Impact of the COVID-19 lockdown on routine vaccination in Pakistan: a hospital-based study

COVID-19 related disruption and resilience in immunisation activities in LMICs: a rapid review

OBJECTIVES

We conducted a rapid review to determine the extent that immunisation services in low-income and middle-income countries (LMICs) were disrupted by the COVID-19 pandemic and synthesised the factors that can be used to build resilience in future.

DESIGN

Rapid review reported in accordance with the Preferred reporting for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

DATA SOURCES

PubMed and Web of Science were searched through 6 October 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included studies that focused on disruption to immunisation activities due to the COVID-19 pandemic in LMICs. Outcomes included routine vaccine coverage, supplementary immunisation activities, vaccine doses, timing of vaccination, supply chain changes, and factors contributing to disruption or resilience.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers used standardised methods to search, screen and code studies. Quality assessment was performed using a modified version of the Critical Appraisal Skills Programme for qualitative research. Findings were summarised qualitatively.

RESULTS

Of 4978 identified studies, 85 met the eligibility criteria. Included studies showed declines in immunisation activities across LMICs related to the COVID-19 pandemic. These included reductions in achieved routine coverage, cancellation or postponement of campaigns and underimmunised cohorts. Immunisation was most disrupted in the early months of the pandemic; however, recovery varied by country, age-group and vaccine. Though many countries observed partial recovery in 2020, disruption in many countries continued into 2021. It has also been noted that clinician staff shortages and vaccine stock-outs caused by supply chain disruptions contributed to immunisation delays, but that concern over COVID-19 transmission was a leading factor. Key resiliency factors included community outreach and healthcare worker support.

CONCLUSIONS

There is limited information on whether reductions in vaccination coverage or delays have persisted beyond 2021. Further research is needed to assess ongoing disruptions and identify missed vaccine cohorts.

Measles Vaccine Coverage and Disease Outbreaks: A Systematic Review of the Early Impact of COVID-19 in Low and Lower-Middle Income Countries

Objectives: We aimed to evaluate changes to measles-containing vaccine (MCV) provision and subsequent measles disease cases in low- and lower-middle income countries (LICs, LMICs) in relation to the COVID-19 pandemic. Methods: A systematic search was conducted of MEDLINE, OVID EMBASE and PubMed records. Primary quantitative and qualitative research studies published from January 2020 were included if they reported on COVID-19 impact on MCV provision and/or measles outbreak rates within LICs and LMICs. Results: 45 studies were included. The change in MCV1 vaccination coverage in national and international regions ranged -13% to +44.4% from pre-COVID time periods. In local regions, the median MCV1 and overall EPI rate changed by -23.3% and -28.5% respectively. Median MCV2 rate was disproportionally impacted in local areas during COVID-interruption time-periods (-48.2%) with ongoing disruption in early-recovery time-periods (-17.7%). 8.9% of studies reported on vaccination status of confirmed measles cases; from these, 71%-91% had received no MCV dose. Conclusion: MCV vaccination coverage experienced ongoing disruption during the recovery periods after initial COVID-19 disruption. Vaccination in local area datasets notably experienced longer-term disruption compared to nationally reported figures.

A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan-The Impact on Zero-Dose Children and Polio Coverage

Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

Impact of COVID-19 on routine childhood immunisations in low- and middle-income countries: A scoping review

Routine vaccines are critical to child health. The COVID-19 pandemic significantly impacted essential health services, particularly in low-and middle-income countries (LMICs). We reviewed literature to determine the impact of COVID-19 on service delivery and uptake of routine childhood immunisation in LMICs. We reviewed papers published between March 2020 and June 2022 using a scoping review framework, and assessed each paper across the World Health Organisation health system strengthening framework. Our search identified 3,471 publications; 58 studies were included. One-quarter of studies showed routine childhood immunisation coverage declined (10% to 38%) between 2019 to 2021. Declines in the number of vaccine doses administered (25% to 51%), timeliness (6.2% to 34%), and the availability of fixed and outreach services were also reported. Strategies proposed to improve coverage included catch-up activities, strengthening supply chain and outreach services. Re-focusing efforts on increasing coverage is critical to improve child health and reduce the likelihood of disease outbreaks.

Implications of COVID-19 and "super floods" for routine vaccination in Pakistan: The reemergence of vaccine preventable-diseases such as polio and measles

With multiple waves and variants, the coronavirus disease 2019 (COVID-19) pandemic has affected routine vaccination programs globally. Its impact is also visible in Pakistan as routine health services continue to be disrupted. Consequently, thousands of children have emerged as vulnerable in the face of vaccine-preventable diseases (VPDs), which have already started causing outbreaks in the country. Infections with polio and measles have been significantly reported, especially during the last few years. This reemergence of both diseases is posing great challenges for the country at local, national, and global levels. These impacts are being multiplied by the 2022 flooding - called "super floods" - in the country. Hence, relevant stakeholders, such as the Pakistani government and the World Health Organization (WHO), need to revisit the entire vaccination program to address and resolve issues occurring at the management or local levels. It is highly important to pay attention to the context that provides a fertile ground to negatively affect vaccine uptake.

Disruptions to routine childhood vaccinations in low- and middle-income countries during the COVID-19 pandemic: A systematic review

Background

The COVID-19 pandemic has disrupted routine childhood vaccinations worldwide with low- and middle-income countries (LMICs) most affected. This study aims to quantify levels of disruption to routine vaccinations in LMICs.

Methods

A systematic review (PROSPERO CRD42021286386) was conducted of MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on the 11th of February 2022. Primary research studies published from January 2020 onwards were included if they reported levels of routine pediatrics vaccinations before and after March 2020. Study appraisal was performed using NHLBI tool for cross-sectional studies. Levels of disruption were summarized using medians and interquartile ranges.

Results

A total of 39 cross-sectional studies were identified. These showed an overall relative median decline of -10.8% [interquartile range (IQR) -27.6%, -1.4%] across all vaccines. Upper-middle-income countries (upper-MICs) (-14.3%; IQR -24.3%, -2.4%) and lower-MICs (-18.0%; IQR -48.6%, -4.1%) showed greater declines than low-income countries (-3.1%; IQR -12.8%, 2.9%), as did vaccines administered at birth (-11.8%; IQR -27.7%, -3.5%) compared to those given after birth (-8.0%; IQR -28.6%, -0.4%). Declines during the first 3 months of the pandemic (-8.1%; IQR -35.1%, -1.4%) were greater than during the remainder of 2020 (-3.9%; IQR -13.0%, 11.4%) compared to baseline.

Conclusion

There has been a decline in routine pediatric vaccination, greatest in MICs and for vaccines administered at birth. Nations must prioritize catch-up programs alongside public health messaging to encourage vaccine uptake.

Systematic review registration

Identifier: CRD42021286386.

Post-genomic platform for development of oligonucleotide vaccines against RNA viruses: diamond cuts diamond

The coronavirus pandemic has starkly demonstrated the need to create highly effective vaccines against various viral diseases. The emerging new platforms for vaccine creation (adenovirus vectors and mRNA vaccines) have shown their worth in the fight against the prevention of coronavirus infection. However, adenovirus vectors and mRNA vaccines have a serious disadvantage: as a rule, only the S protein of the coronavirus is presented as an antigen. This tactic for preventing infection allows the ever-mutating virus to escape quickly from the immunity protection provided by such vaccines. Today, viral genomic databases are well-developed, which makes it possible to create new vaccines on a fundamentally new post-genomic platform. In addition, the technology for the synthesis of nucleic acids is currently experiencing an upsurge in demand in various fields of molecular biology. The accumulated experience suggests that the unique genomic sequences of viruses can act as antigens that trigger powerful humoral and cellular immunity. To achieve this effect, the following conditions must be created: the structure of the nucleic acid must be single-stranded, have a permanent 3D nanostructure, and have a unique sequence absent in the vaccinated organism. Oligonucleotide vaccines are able to resist the rapidly changing genomic sequences of RNA viruses by using conserved regions of their genomes to generate a long-term immune response, acting according to the adage that a diamond cuts a diamond. In addition, oligonucleotide vaccines will not contribute to antibody-dependent enhanced infection, since the nucleic acid of the coronavirus is inside the viral particle. It is obvious that new epidemics and pandemics caused by RNA viruses will continue to arise periodically in the human population. The creation of new, safe, and effective platforms for the production of vaccines that can flexibly change and adapt to new subtypes of viruses is very urgent and at this moment should be considered as a strategically necessary task.