COVID-19 Immunisations and Health Services & Systems – The Way Forward

A Public Health Perspective from Angola

We have learned a lot since the initial discovery of COVID-19 in late 2019. The causative pathogen was quickly identified as a coronavirus and named SARS-CoV-2. Researchers rapidly sequenced the genome, and with an ever-growing body of knowledge based on pathophysiological, clinical and epidemiological observations, the diagnostic and case management capabilities of health systems for treating COVID-19 improved worldwide.

At the same time, the body of misinformation and conspiracy theories around the disease grew. Some movements denied the very existence of the disease. The public received an enormous amount of information, amplified by media coverage featuring “experts” and members of academia and opinion-makers. Social media was almost omnipresent, disseminating information without any controls for quality or scientific validity. Bringing this context to light – even if in brief – provides insight into some of the reasons why access to routine health services. including but not limited to vaccinations, has suffered such a significant decline.

All sectors of medical care in Angola showed a similar pattern: a reduction in care provided and an increase in mortality from various conditions.

Lockdowns were imposed around the world as a response to the pandemic. It is not the place of this article to discuss the motivations behind this decision but rather consider the impacts. The lockdowns added layers of difficulty to routine medical services for a variety of reasons. First, there was a reduction in the medical sector workforce in various countries. Second, the restrictions on movement and the fear transmitted through the media caused delays in seeking medical care for routine ailments.

We can take as an example an unpublished survey on death by acute respiratory diseases carried out by members of the University in Benguela in central Angola. This survey examined extra deaths during the very first weeks of national lockdown and identified a sharp decline compared with the previous year – more than 30% – of inpatient admissions for all forms of disease, as well as a significant rise of case fatality ratio for acute respiratory infections. This steep decline in inpatient admissions can reasonably be attributed to a delay in seeking care. At the same time, the increase in case fatality rates likely resulted from the unchecked progression of conditions that were too severe to be effectively treated once finally attended to.

All sectors of medical care in Angola showed a similar pattern. Anecdotal evidence from many primary care health care facilities in Angola describes a sharp decline in outpatient and emergency visits across the region and for various conditions. A similar pattern was seen in the private sector. Some small clinics had to close their doors altogether given the extreme drop in the number of patients – almost to zero in some cases. This drastically reduced healthcare revenues.

Preventive child health services were affected, and vaccination was frequently postponed. For example, nationwide polio and measles vaccination were cancelled or delayed, and restrictions on movement presented barriers to access to the locations where routine vaccinations were provided. This is consistent with the situation described in the Collateral Review paper ‘Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: A Rapid Review’ by Carl Heneghan et al., which clearly demonstrates that the access to and coverage of childhood vaccinations dropped across the globe.

The case of Angola is especially clear. In a World Bank (WB) and GAVI funded project currently being implemented in Angola, a USD 9.7 million dedicated funding grant has been in place since the end of 2019 to implement interventions in 13 municipalities with pre-pandemic reduced vaccination coverage. The purpose of the project is to increase the reach of integrated health services to include vaccinations. However, this project has yet to result in any relevant increase compared with the previous month, and vaccination uptake is far below the coverages of 2017. The general trend was a decline of immunisation coverage since 2018, with a significant decrease from the moment the country began emergency status and entered the process of lockdown.

Health care systems have no choice but to reorganise themselves, and in Africa and Angola specifically.

Even if we can speculate on the reasons behind this drop in coverage (some seem self-evident, such as the fear of infection by SARS-CoV-2), it appears that we do not know all of the determinants driving it. The influence of news and word-of-mouth from the internet, as well as lack of quality information from the health sector, may have resulted in vaccine shunning. We can also consider potential influences of diversion of health service resources into COVID-19 focussed care, a decline in the availability of regular treatments due to the procurement of COVID-19 related vaccines and treatments, and a generalised paralysis of health systems in the country limiting access.

The response to this public health emergency revealed general weaknesses of health services in almost all countries, including a focus to avoid the collapse of health systems and poorly designed responses diverted resources – human, financial and time – from the routine care of other diseases. Communication weakness regarding COVID-19 from governments and international organisations, such as the WHO, led to public confusion and lack of acceptance of the proposed measures such as hand washing, physical distancing, and mask utilisation.

These factors may help us understand more deeply why people – including mothers and caregivers – have become “afraid of vaccination”.

At present, there is no hard data to understand all the impacts that this situation has had on infant mortality. However, we do know that very recently in Angola, there were severe outbreaks of febrile illness in Luanda and Benguela which led to deaths of children and adults because not enough medicines were available at the primary care level, and local providers were overwhelmed with following up on COVID-19 cases and asymptomatic contacts.

This illustrates how important it is that we study and seek to understand – quickly – how to improve vaccine acceptance for all vaccines (not just COVID-19) and how the global pandemic of misinformation impacts Africa.

Only then can African Health professionals design and implement interventions adapted to solve those constraints. Otherwise, we risk spending money and time on business-as-usual (campaign after ineffective campaign), potentially losing opportunities to increase vaccination coverage.

In the aftermath of the COVID-19 emergency, the most probable scenario is living long-term with the virus. Health care systems have no choice but to reorganise themselves, and in Africa and Angola specifically, the weakened health systems face enormous challenges. In some cases, they are already on the brink of collapse due to chronic divestment in health and the economic crisis caused by the COVID-19 pandemic response. All the same, the new era of living with COVID-19 brings the opportunity to address, at a systems level, the improvement of health systems in Africa, which would lead to the enhancement of immunisation coverage and reduction of under-five mortality.

Joao C. Blasques de Oliveira, MD is a Public Health Specialist & International Health consultant in Angola and has generously contributed his expertise and unique perspective to Collateral Global.

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