A health worker administers polio drops to a child during a polio vaccination campaign in Karachi. — AFP/File

Routine immunisation in the time of Covid: What should happen next?

We cannot put the undone business of immunisation aside, especially in times of crisis.
Published May 7, 2020

As we navigate the pandemic, it is important to take a moment from the immediacy of the Covid-19 crisis and turn our hands to how it has affected the most critical piece that contributes to the viability of our health care system — vaccine delivery.

Historically, vaccines have helped control some of the deadliest and most debilitating infectious diseases in the world. Some of these illnesses that still affect Pakistan include measles, polio, and rota virus associated diarrhoea. Beyond their oft cited benefits, vaccines also avert frequent medical visits, expensive diagnostic tests, treatments, hospitalisations, and their attendant complications, such as hospital associated infections.

Collectively, vaccines lead to tangible savings in the healthcare expenditure and are also the most globally available health intervention known to us. Nine out of 10 babies in the world get their first dose of the pentavalent vaccine that is responsible for protection against five pernicious illnesses. And this has been realised largely due to access to universal and primary healthcare.

Pakistan has a sprawling primary healthcare system, comprising of 5,000 basic health units, 600 rural health centres, 7,500 other first-level care facilities and over 100,000 lady health workers, providing a range of services, including vaccination.

Also read: Children at risk of missing out on essential routine immunisation amid Covid-19

With Coronavirus and the resultant lockdowns, this machinery is badly disrupted. Fixed immunisation (or vaccination) centres located within basic health units are unable to cater to their catchment populations. In cases where government has outsourced vaccination to public and private hospitals and clinics, administrative focus has shifted to the control of the Covid-19 outbreak. Most focal points of vaccination now paint a picture of emptiness. As the reporting of cases and deaths from Covid-19 increase, so does the fear and panic that has been preventing parents from bringing their children for preventative services, including vaccination. This has far reaching effects on many vaccine preventable illnesses, but I present here the example of measles, a scourge resulting in high fever, measly looking rash, and associated concurrent infections and poor nutrition.

In 2019, there were nearly 2,000 cases of measles reported — this was when six out of 10 children had received a measles vaccine in 2018. While official vaccine estimates are not available for 2019 yet, nearly 500 cases were confirmed in Pakistan until February 2020, much higher than the numbers for Jan-Feb 2019. There has been no further official reporting of new cases since then on account of the lockdown but it is already anticipated that the numbers will run into tens of thousands, magnified largely due to low vaccination rates in the first quarter of the year. These will be exponentially increased as lockdown and social distancing measures are eased. Apart from effects on individuals and households, inundating of health systems already fracturing under the impact Covid-19 is anticipated.

So what measures can be adopted to prevent such a dire situation? While this may appear a stop gap measure, a coordinated approach with stakeholders from the World Health Organisation, the Unicef, the Expanded Programme on Immunisation, the academia, and healthcare workers is required. We also have to prepare for the possibility that this pandemic may stay with us for a prolonged period and hence ensure that our children get the required vaccination in a timely manner.

Immunisation delivery strategies also need to be reimagined at the fixed and outreach levels. The EPI and provincial health departments have launched a variety of app based digital immunisation registries. Such registries can be leveraged to identify those who have missed their vaccines due to the current crisis and provide opportunities to them so they can catch up.

More on this: Are children largely spared from Covid-19? Think again

In order to carry out effective and safe outreach, it is critical that vaccinators are provided with appropriate personal protective equipment (PPE). Child health policy expert and a health specialist at Unicef, Dr Ayaz Hussain, says that a majority of Unicef's Covid-19 related funding to Pakistan will be spent on providing of PPE to vaccinators. They have already dispatched 14 metric tonnes of personal protective equipment to Pakistan, including gloves, masks, and hand sanitisers. It is now up to the provincial governments to utilise this equipment efficiently and to restart immunisation.

At the same time, surveillance of vaccine preventable diseases needs to be re-initiated immediately. This can identify pockets of infection early on and enable targeted control efforts. Using the same mechanisms as those involved in Covid-19, surveillance can save a lot of additional resources and complement identification of both Covid-19 and vaccine preventable illnesses, a win-win.

Similarly, as routine federal immunisation services are maintained, a consolidated effort is required at the provincial levels to initiate a dialogue with pediatricians, family physicians, and other healthcare partners for maintaining and adapting immunisation services.

"There are concerns with vaccines' supply from the EPI," says Mehreen Raza, a specialist in pharmacy services and immunisation delivery at the Aga Khan University Hospital. Shortages are impacting routine vaccinations for children, even when parents brave the fear and the lockdown and go to the vaccination clinics. Therefore, vaccine supply chains need to be restored and Global Alliance of Vaccine Initiative (GAVI) and EPI can play a strong role here.

Read further: Missed children

On the demand side, new and effective communication strategies are required to engage with parents and communities and assuage concerns about risks of bringing child to immunisation centres versus the risk of future vaccine preventable illness related morbidity in its absence. The Pakistan Paediatric Association in partnership with child advocacy organisations can play a major role here. The demand for immunisation must be increased.

Lastly, it is critical to systematically monitor the pandemic to ensure a timely normalisation of services back to their previous state or, even better, adapt from the lessons learnt in this pandemic to completely restructure the immunisation milieu of the country.

We cannot put the undone business of immunisation aside, especially in times of crisis. Radical measures of lockdown will be truly effective in decreasing overall morbidity and mortality if done not at the cost of our future generations.