Implementing nationwide measles supplemental immunization activities in Ethiopia in the context of COVID-19: process and lessons learnt

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.

Lessons From the COVID-19 Pandemic Response Implementation: A Case Study of South Sudan and Sierra Leone

INTRODUCTION

The COVID-19 pandemic caused havoc to health systems worldwide and in countries that already had weak health systems. There are lessons to be learned that could contribute to improved response preparedness to future public health emergencies, but there is little documentation on best practices in fragile countries. We describe lessons from South Sudan and Sierra Leone during the COVID-19 response implementation.

METHODS

We conducted a retrospective descriptive analysis of COVID-19 vaccination implementation at national and subnational levels between 2020 and 2022 in South Sudan and Sierra Leone to identify those practices that had a positive impact on public health.

RESULTS

Several interventions were identified that not only improved the COVID-19 situation but also had a positive effect on routine immunizations. The development of a near-real-time vaccination dashboard gave stakeholders a quick look at vaccine implementation, allowing them to make decisions based on current data. The experience acquired from deploying the COVID-19 dashboard has since been applied to the development of a routine immunization dashboard in South Sudan. Surge vaccination was an effective approach to improving COVID-19 vaccination uptake. A measles reactive campaign was conducted during the initial stages of the pandemic when movement was restricted; experience gained from that effort was subsequently applied to COVID-19 mass vaccination initiatives and outbreak reactive campaigns. Additional vaccinators recruited for COVID-19 response also received comprehensive Immunization in Practice training, allowing them to provide routine childhood vaccinations alongside COVID-19 vaccination, contributing to the maintenance of routine vaccination services in both countries.

CONCLUSION

Lessons were learned during the COVID-19 response implementation that have had a positive impact on routine health services. However, it is essential that these effects are maintained and further refined to strengthen the country's preparedness for future public health emergencies and better support the broader immunization service delivery.

Out-of-pocket expenditures and financial risks associated with treatment of vaccine-preventable diseases in Ethiopia: A cross-sectional costing analysis

BACKGROUND

Vaccine-preventable diseases (VPDs) remain major causes of morbidity and mortality in low- and middle-income countries (LMICs). Universal access to vaccination, besides improved health outcomes, would substantially reduce VPD-related out-of-pocket (OOP) expenditures and associated financial risks. This paper aims to estimate the extent of OOP expenditures and the magnitude of the associated catastrophic health expenditures (CHEs) for selected VPDs in Ethiopia.

METHODS AND FINDINGS

We conducted a cross-sectional costing analysis, from the household (patient) perspective, of care-seeking for VPDs in children aged under 5 years for pneumonia, diarrhea, measles, and pertussis, and in children aged under 15 years for meningitis. Data on OOP direct medical and nonmedical expenditures (2021 USD) and household consumption expenditures were collected from 995 households (1 child per household) in 54 health facilities nationwide between May 1 and July 31, 2021. We used descriptive statistics to measure the main outcomes: magnitude of OOP expenditures, along with the associated CHE within households. Drivers of CHE were assessed using a logistic regression model. The mean OOP expenditures per disease episode for outpatient care for diarrhea, pneumonia, pertussis, and measles were $5·6 (95% confidence interval (CI): $4·3, 6·8), $7·8 ($5·3, 10·3), $9·0 ($6·4, 11·6), and $7·4 ($3·0, 11·9), respectively. The mean OOP expenditures were higher for inpatient care, ranging from $40·6 (95% CI: $12·9, 68·3) for severe measles to $101·7 ($88·5, 114·8) for meningitis. Direct medical expenditures, particularly drug and supply expenses, were the major cost drivers. Among those who sought inpatient care (345 households), about 13·3% suffered CHE, at a 10% threshold of annual consumption expenditures. The type of facility visited, receiving inpatient care, and wealth were significant predictors of CHE (p-value < 0·001) while adjusting for area of residence (urban/rural), diagnosis, age of respondent, and household family size. Limitations include inadequate number of measles and pertussis cases.

CONCLUSIONS

The OOP expenditures induced by VPDs are substantial in Ethiopia and disproportionately impact those with low income and those requiring inpatient care. Expanding equitable access to vaccines cannot be overemphasized, for both health and economic reasons. Such realization requires the government's commitment toward increasing and sustaining vaccine financing in Ethiopia.

Impact of the Early Stages of the COVID-19 Pandemic on Coverage of Reproductive, Maternal, and Newborn Health Interventions in Ethiopia: A Natural Experiment

Background

The COVID-19 pandemic and response have the potential to disrupt access and use of reproductive, maternal, and newborn health (RMNH) services. Numerous initiatives aim to gauge the indirect impact of COVID-19 on RMNH.

Methods

We assessed the impact of COVID-19 on RMNH coverage in the early stages of the pandemic using panel survey data from PMA-Ethiopia. Enrolled pregnant women were surveyed 6-weeks post-birth. We compared the odds of service receipt, coverage of RMNCH service indicators, and health outcomes within the cohort of women who gave birth prior to the pandemic and the COVID-19 affected cohort. We calculated impacts nationally and by urbanicity.

Results

This dataset shows little disruption of RMNH services in Ethiopia in the initial months of the pandemic. There were no significant reductions in women seeking health services or the content of services they received for either preventative or curative interventions. In rural areas, a greater proportion of women in the COVID-19 affected cohort sought care for peripartum complications, ANC, PNC, and care for sick newborns. Significant reductions in coverage of BCG vaccination and chlorohexidine use in urban areas were observed in the COVID-19 affected cohort. An increased proportion of women in Addis Ababa reported postpartum family planning in the COVID-19 affected cohort. Despite the lack of evidence of reduced health services, the data suggest increased stillbirths in the COVID-19 affected cohort.

Discussion

The government of Ethiopia's response to control the COVID-19 pandemic and ensure continuity of essential health services appears to have successfully averted most negative impacts on maternal and neonatal care. This analysis cannot address the later effects of the pandemic and may not capture more acute or geographically isolated reductions in coverage. Continued efforts are needed to ensure that essential health services are maintained and even strengthened to prevent indirect loss of life.

Impact of the COVID-19 pandemic on utilisation of facility-based essential maternal and child health services from March to August 2020 compared with pre-pandemic March-August 2019: a mixed-methods study in North Shewa Zone, Ethiopia

INTRODUCTION

Health systems are often weakened by public health emergencies that make it harder to access health services. We aimed to assess maternal, newborn and child health (MNCH) service utilisation during the first 6 months of the COVID-19 pandemic compared with prior to the pandemic.

METHODS

We conducted a mixed study design in eight health facilities that are part of the Birhan field site in Amhara, Ethiopia and compared the trend of service utilisation in the first 6 months of COVID-19 with the corresponding time and data points of the preceding year.

RESULT

New family planning visits (43.2 to 28.5/month, p=0.014) and sick under 5 child visits (225.0 to 139.8/month, p=0.007) declined over the first 6 months of the pandemic compared with the same period in the preceding year. Antenatal (208.9 to 181.7/month, p=0.433) and postnatal care (26.6 to 19.8/month, p=0.155) visits, facility delivery rates (90.7 to 84.2/month, p=0.776), and family planning visits (313.3 to 273.4/month, p=0.415) declined, although this did not reach statistical significance. Routine immunisation visits (37.0 to 36.8/month, p=0.982) for children were maintained. Interviews with healthcare providers and clients highlighted several barriers to service utilisation during COVID-19, including fear of disease transmission, economic hardship, and transport service disruptions and restrictions. Enablers of service utilisation included communities' decreased fear of COVID-19 and awareness-raising activities.

CONCLUSION

We observed a decline in essential MNCH services particularly in sick children and new family planning visits. To improve the resiliency of fragile health systems, resources are needed to continuously monitor service utilisation and clients' evolving concerns during public health emergencies.

Linked vaccination coverage surveys plus serosurveys among Ethiopian toddlers undertaken three years apart to compare coverage and serologic evidence of protection in districts implementing the RED-QI approach

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A seroprotective tetanus titer indicates a toddler has received pentavalent vaccine.

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Serosurveys document increased seroprevalence post-measles vaccination campaigns.

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Vaccination coverage/serosurveys can assess interventions to improve immunizations.

In low and middle-income countries, estimating the proportion of vaccinated toddlers in a population is important for controlling vaccine-preventable diseases by identifying districts where immunization services need strengthening. Estimates measured before and several years after specific interventions can assess program performance. However, employing different methods to derive vaccination coverage estimates often yield differing results.

Methods

Linked vaccination coverage surveys and seroprotection surveys performed among ~300 toddlers 12–23 months of age in districts (woredas), one per region, of Ethiopia (total, ~900 toddlers) in 2013 to estimate the proportion vaccinated with tetanus toxoid (a proxy for pentavalent vaccine) and measles vaccine. The surveys were followed by implementation of the Reaching Every District using Quality Improvement (RED-QI) approach to strengthen the immunization system.

Linked coverage/serosurveys were repeated in 2016 to assess effects of the interventions on vaccination coverage. Indicators included “documented coverage” (vaccination card and/or health facility register records) and “crude coverage” (documented plus parent/caretaker recall for children without cards). Seroprotection thresholds were IgG-ELISA tetanus antitoxin ≥0.05 IU/ml and plaque reduction neutralization (PRN) measles titers ≥120 mIU/ml.

Findings

Improved markers in 2016 over 2013 include coverage of pentavalent vaccination, vaccination timeliness, and fewer missed opportunities to vaccinate. In parallel, tetanus seroprotection increased in the 3 woredas from 59.6% to 79.1%, 72.9% to 83.7%, and 94.3 to 99.3%. In 2015, the Ethiopian government conducted supplemental measles mass vaccination campaigns in several regions including one that involved a project woreda and the campaign overlapped with the RED-QI intervention timeframe; protective measles PRN titers there rose from 31.0% to 50.0%.

Interpretation

The prevalence of seroprotective titers of tetanus antitoxin (stimulated by tetanus toxoid components within pentavalent vaccine) provides a reliable biomarker to identify children who received pentavalent vaccine. In the three study woredas, the RED-QI intervention appeared to improve immunization service delivery, as documented by enhanced pentavalent vaccine coverage, vaccination timeliness, and fewer missed vaccination opportunities. A measles mass vaccination campaign was followed by a markedly increased prevalence of measles PRN antibodies. Collectively, these observations suggest that wider implementation of RED-QI can strengthen immunization, and periodic linked vaccination surveys/serosurveys can monitor changes.

Impact that the COVID-19 pandemic on routine childhood vaccinations and challenges ahead: A narrative review

Aim

To document the decline in vaccination coverage in the first months of 2020 as an indirect effect of the COVID‐19 pandemic.

Methods

We performed a literature review in medical databases. Overall, 143 articles were initially retrieved, out of which 48 were selected and included in the review.

Results

Our review retrieved similar data in many countries worldwide, and, globally, preliminary data from the first 4 months of 2020 indicate a decline in diphtheria‐tetanus‐pertussis coverage, generally considered the marker of vaccination coverage across countries. World Health Organization recommends maintaining vaccination services, prioritising primary series vaccinations especially for measles‐rubella or poliomyelitis, but it also lets each country decide whether to maintain the immunisation services evaluating the current epidemiology of vaccine‐preventable diseases and the COVID‐19 local transmission scenario. Successively, recovering of vaccinations should be planned. Moreover, during the pandemic, influenza vaccination should be promoted as a central public health measure.

Conclusion

Future challenges will be to maintain the vaccination programmes, especially in children younger than 2 years old and adolescents, to plan the recovery of vaccinations for subjects who postponed them during the lockdown, and to early identify any vaccine‐preventable disease outbreak.