Qualiten Insight

Vaccination and immunization programs are necessary to control and eradicate many fatal diseases. COVID-19 pandemic and resulting lockdowns have impacted the regular immunization programs globally. Global stakeholders and healthcare agencies need to quickly revamp the immunization programs to tackle the reemergence of other infectious diseases.

Key Areas: Public Health | Immunology | Infectious Diseases

Series: Public Health – News & Analysis

COVID-19 vaccinations have once again proved the importance of immunization programs to fight against public health diseases. Immunization is a cost effective reliable intervention to prevent many fatal diseases [1]. Diseases like smallpox and rinderpest have been eradicated due to successful immunizations, while some other diseases like polio and measles are on the verge of eradication [2-3]. Successful immunization prevents nearly 4-5 million deaths every year. Despite this, in 2018, the global incidence rate for vaccine-preventable diseases was 2.1 million [4-5].

World Health Organization (WHO) and various healthcare agencies run systematic routine immunization programs around the globe to eradicate many diseases [6]. However, infectious disease outbreaks have been observed during natural calamities such as flood and earthquakes [7]. Natural disasters often lead to the collapse of healthcare facilities, disruption of immunization programs, diverted medical attentions, etc. [7]. Similarly, during the complex emergencies, large-scale displacements and humanitarian crisis also hinder the health services for the public resulting in diseases outbreaks [8]. Epidemics can create similar situation and there is always a fear of other diseases causing outbreak during these epidemics [9]. During 2014-16 Ebola outbreak in Guinea, Liberia and Sierra Leone, almost as many people died with other infectious diseases as Ebola because of limited healthcare facilities [10].

Similar pattern is being observed during the COVID-19 pandemic. There are reports of polio and measles outbreaks in some countries, while patients suffering from other diseases like tuberculosis and HIV are also being affected due to COVID-19 becoming the primary focus of governments, healthcare agencies and healthcare workers [11-14].

Factors affecting routine immunization and disease outbreaks

Following factors affected the routine immunization programs during the COVID-19 emergency:

• Shifting attention of government and healthcare agencies from routine immunization to dealing with challenges posed by pandemic.
• Routine vaccination programs were also halted or delayed to avoid infection or transmission of the COVID-19 virus. In April 2020, WHO suggested temporary suspension of mass immunization programs to reduce transmission of COVID-19 [15].
• Lockdown and quarantine resulted in people being unable to visit healthcare facilities for vaccination.
• Many people avoided hospitals and other healthcare facilities for immunizations and treatments because of fear of getting exposed to the COVID-19 virus [16].
• COVID-19 being the primary focus, and lack of diverse healthcare facilities in hospitals resulted in other infectious disease patients being marginalized.
• In countries with limited resources, the lockdown also resulted in humanitarian crisis and displacements of migrant workers from urban areas [17].
• Disrupted air travel and border closures by the governments have resulted in vaccine shortage in many underdeveloped countries [18].

Immunization status before COVID-19

Even without the pandemic, immunization status was far from perfect. According to United Nations Children’s Fund (UNICEF), while 14 million children do not get any vaccination, another 6 million children do not get complete sets of vaccinations for preventable diseases like measles and polio [19]. These life-threatening diseases, which are mostly vaccine preventable, caused death of over 2 million people in 2018 [5]. HIV, tuberculosis, hepatitis, malaria, tropical diseases, and sexually transmitted infections were projected to kill about 4 million people in 2020, well before COVID-19 deaths were factored [9]. Global conditions of the major infectious diseases before COVID-19 are as following:

• Tuberculosis (TB) kills nearly 4000 people every day and 1.5 million people yearly [20]. In 2017, nearly 10 million people developed TB, whereas half a million people were infected with drug-resistant-TB [21].
• Measles is one of the most contagious virus with the “reproduction number” of 12-18, i.e., the number of people infected by a single individual (reproduction number for COVID-19 coronavirus is 2-3) [22-23]. Measles is a virus which was on the verge of eradication with declining numbers but still it has resulted in death of over 140,000 lives in 2018 and it also caused an outbreak in 2019 in Democratic Republic of the Congo, which was the largest outbreak documented after introduction of measles vaccine in 1963 [15, 24].
• Dengue infection saw the rise of 2.4 million in 2010 to over 4 million in 2019 and led thousands of deaths [25].
• WHO has also predicted an increase in mortality due to malaria in malaria endemic regions [26]. In 2019, Malaria resulted in over 400,000 deaths [27].
• Overall infectious diseases caused over 5.1 million deaths in 2019 [27].

COVID-19 effects on other immunization programs

While addressing the 2020 annual World Immunization Week (24-30 April) WHO Director-General Dr. Tedros Ghebreyesus warned about resurgence of vaccine-preventable diseases due to halt or suspension of immunization programs [28]. Experts have also feared losing fights against other infectious diseases with the world focusing on COVID-19. Similar concerns were raised by vaccine alliance – Global Alliance for Vaccines and Immunization (GAVI), which highlighted shortage of vaccines in 21 countries due to border closure and suspended air travels [18]. Furthermore, many hospital-based care for patients were marginalized due to limited health facilities. Vaccination coverage and vaccine dosage declined due to COVID-19. Understanding the ramifications of the collapse of immunization programs would require further research, but some relevant research has already been published and the major takeaways from these studies are as following:

• According to Measles & Rubella Initiative, in 24 countries, measles immunization campaign was delayed and there are chances of over 117 million children missing out on measles vaccine in 37 countries [29].
• Temporary suspension of the immunization programs has risked the lives of at least 80 million children under the age of one from over 68 countries [30].
• Researchers have also highlighted approximately 75% decline in vaccine orders by doctors to vaccinate since the start of 2020, when first COVID-19 patient was identified in USA [31].
• In USA, there was a notable decline in ordering of both non-influenza and measles-containing vaccine after declaration of COVID-19 emergency in March 2020 [32].
• Due to fear of getting exposed to COVID-19 virus, there was 57% decline in parents taking their children to health centers for vaccination [16].
• Similar patterns were observed across the globe with vaccination coverage dropping to over 50% [16].

Resulting Outbreaks and Projections

As mentioned earlier, the resulting effects of the COVID-19 on health services and immunization programs can only be estimated with further research. However, we already started witnessing challenges and projections which are caused due to disrupted healthcare programs:

• Polio and diphtheria cases have been recorded in Pakistan and Afghanistan in large numbers [12]. Four times more polio cases were observed in polio endemic countries like Pakistan and Afghanistan [33].
• According to UNICEF report, over 2 million children under the age of five could die in next year due to COVID-19’s impact on healthcare [19].
• As women are less likely able to access healthcare during this pandemic, additional 200,000 stillbirths could occur [19].
• Over 120,000 children could be infected by HIV due to disrupted prevention services [19].
• Democratic Republic of the Congo declared 11th outbreak of Ebola in 2020 and there are still Ebola outbreaks in the African regions [34].

Conclusion

COVID-19 pandemic has shown our vulnerabilities and exposed our burdened healthcare system. There is an immediate need to invest more globally in healthcare and research. With proper funding to healthcare organizations and research, the marginalization for other disease patients at the time of such emergencies could be mitigated. Additionally, COVID-19 has once again proved the effectiveness of immunization with COVID-19 vaccination programs in full swing to curb this deadly pandemic. Similar strategies and focus should be implemented to complete other immunization programs with the vaccines already available to eradicate the vaccine-preventable diseases. Furthermore, proper funding for programs like PREDICT would help project any further pandemics, which would ensure better response during such emergencies [35].

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