Tackling the covid disruption of regular childhood immunization

It is mid-morning and families throng around the mobile clinic parked in the remote village in northern India. The immunization team is readying to provide covid vaccines to adolescents and adults, along with catch-up vaccines to children who missed vaccinations during the pandemic.

Two years on, the devastation caused by Sars-CoV-2 is obvious. Millions of deaths, hundreds of millions of infections an uncounted number afflicted by ‘long-haul covid’. National economies stopped cold. India recorded over half a million covid deaths, the world’s third highest after the US and Brazil. But there were many uncounted casualties, and the real toll is likely to be at least 8 times higher, which suggests that India lost at least 4 million lives to covid. The pandemic also devastated families in ways that we won’t see clearly for a number of years. As national healthcare delivery systems were disrupted, childhood immunizations fell by the wayside. The tragedy is that they didn’t have to.

Researchers estimate that about 30 million children may have missed routine vaccines in 2020, an increase of more than 25% over pre-pandemic years. In parts of the world with a high burden of vaccine-preventable diseases, immunization services declined by more than half. The staggering scale of these disruptions is a grim portent of vaccine-preventable disease outbreaks in the future. Outreach services were affected much more than clinic-based service delivery. Such interruptions can result in a large immunity gap that takes away the protective layer of herd protection against deadly diseases; as these surge because of lapsed immunizations against measles, pneumonia and other illnesses, still more lives would be at risk.

India began vaccinating people against covid in January 2021 in one of the world’s largest vaccination drives. The country fired up its vaccine makers, activated a ubiquitous vaccine app, and served 1.8 billion jabs to snaking queues of people in the busiest cities and the remotest hamlets. Determined armies of vaccinators trudged arduous kilometres on foot, cycle, motorbike or makeshift vans to meet daily targets. However, routine childhood immunizations did not get the same attention. This is now changing. Many groups along with local governments have re-established mobile services for families in remote villages. Covid vaccines are provided to eligible folk along with catch-up vaccines to children who missed vaccinations.

Integrating routine vaccinations along with covid vaccine delivery is a strategy that is gaining support across the globe. As countries take strides to close the covid vaccine equity gap, a renewed focus on routine immunization is vital. Recognized as one of the best investments in public health, the vaccines we have against 26 deadly infectious diseases can together prevent an estimated 2.5 million child deaths each year and probably 4-5 million deaths each year among all age groups combined.

The pandemic exposed our society’s strengths and failings with brutal exactitude. We achieved pocket-sized rapid covid testing kits, near-miraculous treatments for covid, highly-effective covid vaccines and the delivery globally of over a billion doses given through Covax. Yet, essential health-service failures around the world have been sobering.

The pandemic’s disruption of routine immunization has been catastrophic. Coverage is back at 2009 levels, setting progress backward by ten years. Experiences from past epidemics, such as the west African Ebola disease outbreak in 2014–15, when suspension of vaccination programmes and a coverage drop resulted in more deaths from measles than Ebola, provided stark lessons.

Health facility closures and public fears of covid infection were key reasons for children missing out on vaccines. Other factors include severe lockdowns, health worker shortages and supply chain disruptions. Vaccine hesitancy, considered a major pre-pandemic threat, is now a real factor compounding the covid-related decreased protection against vaccine-preventable illnesses. Pre-covid, an alarming drop in vaccine confidence had already seen rises in measles cases in low- and high-income settings. A worsening immunity chasm could give the measles virus space to make significant evolutionary leaps that can render today’s vaccine less effective.

In resuming regular immunization, apart from its bundling with covid efforts, roles are played by public outreach to address vaccine hesitancy, the creation of data-driven immunization systems, sustained financial support from local and global stakeholders and restructured health systems to weather future pandemics. Sustainability—with drives that carry on through adversity—is key to success, as articulated by the Immunization Agenda 2030.

Meanwhile, the team in that Indian village vaccinates the last child for the day. Although she is too young for a covid vaccine, which her parents got, she is protected against measles, pertussis, diphtheria and many other diseases now.

Covid waves and resource shifts towards covid-vaccine delivery cannot be allowed to eclipse routine immunizations. Childhood vaccinations need to be brought out of the shadows and back into the spotlight for a brighter post-covid future for everybody.

Anita Shet & Rose Weeks are, respectively, a paediatrician and director of the Maternal and Child Health India Center at Johns Hopkins Bloomberg School of Public Health; and director of communication at the Johns Hopkins International Vaccine Access Center