Childhood immunization services accessibility and utilization during the COVID-19 pandemic in Africa.

Dear Editor,

According to the WHO, more than 30 million children under five years of age still suffer from vaccine-preventable diseases (VPDs) every year in Africa. Of these, over half a million die from VPDs annually, representing approximately 58% of global VPD-related deaths. Pre-COVID-19, the immunization programs in most African countries were gaining traction with diseases such as polio and maternal and neonatal tetanus nearing eradication and elimination respectively. As such, the consequences of COVID-19 related disruptions in childhood immunization service delivery will be catastrophic. Granted, most countries in Africa are anticipating an increased risk of a resurgence of VPDs that were controlled or eliminated. To anticipate the consequences related to suboptimal control of VPDs in children following the COVID-19 pandemic, there is a need to assess the extent of these disruptions in the region. In this letter, we present preliminary findings of a review aimed at synthesizing the available evidence on the accessibility and utilization of child immunization services (CIS) in Africa during the COVID-19 pandemic period.

PubMed, Google Scholar, and Africa Journals Online (AJOL) databases were searched for relevant studies. Details on the results of title, abstract and full text screening are presented in Fig. 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. Ten studies met the inclusion criteria (Table 1). Data were independently extracted from eligible studies.

Fig. 1

PRISMA flow diagram.

Table 1

Characteristics of included studies.

Author, Year	Study Design	Data Sources	Data Collection Tool	Key findings on child immunization during COVID-19
Kassie et al.4	Comparative study	Facility health records for each service component.	Checklist extracted from the Ethiopian Demographic and Health Survey,2016 (EDHS, 2016)	Decrease in overall newborn immunisation service utilisation by 28.5% from the pre-COVID-19 numbers to the COVID-19 period.
Balogun et al.9	descriptive Cross-sectional study	Clients: women of reproductive age who had just received RMNCH services at the heatlh facilities.	Structured questionnaire used to conduct exit interviews.	Childhood immunisation was the most frequently received service (42.02%) since the COVID-19 outbreak.
Wanyana et al.5	cross-sectional quanitative	Provincial level MCH indicators extracted from the Rwanda Health Management Information System (HMIS).	Not specified but assume the data was exported to a spreadsheet then to SPSS for statistical analysis.	Significant decreases noted in the following vaccinations; BCG, polio zero, polio 1, polio 2, diptheria, tetanus, pertussis, hepatitis B and hemophilus influenza (DTP_HepB_Hib) 1, DTP_HepB_Hib 2, pneumococcus 1, pneumococcus 2, rotavirus 1 and rotavirus 2
BCG and polio zero vaccination services utilization decreased in three out of five provinces.
Despite the overall decline in service utilization, the utilisation in the Southern Province of measles and rubella (MR) 1 vaccination services increased with variations probably due to the continuation of community-based interventions in the region.
Adelekan, 2021	cross-sectional study	Health workers (head nurses/midwives) in health facilities.	Semi-structured interviewer-administered questionnaire	Slight decline in childhood immunisation during COVID lockdown by about 3% from pre pandemic levels.
Further decline in childhood immunisation by about 10% after the lockdown.
The changes in childhood immunisation varied with states.
Gebreegziabher et al.2	Cross-sectional	Routine health management information system (HMIS) database form the Addis Ababa Health Bureau	HMIS data entered into Redcap database.	There was a decrease in Pentavalent-1 vaccination (0.3%), Pentavalent-3 vaccination (4.7%) and fully vaccination (0.6%) in the first 8 months of the COVID −19 pandemic (March-October 2020) compared to the previous 8 months (July 2019- February 2020) average perfomance. This could have been due to the deisre to reduce COVID-19 spread in health facilities and the repurposing of health workers may have led to hesitation to continue routine immunisation services in health facilities during the early period of the COVID-19 pandemic.
Pentavalent-3 vaccination recipients began to decrease during January to March 2020 with accelerated reduction in the period April to June 2020 following the national lockdown.
The trend in Measles first dose vaccination across quarters remained above the pre-pandemic baseline level, although a slight positive decrement trend was observed during the periods January–March 2020, July–September 2020 and October–December 2020. Accelerated increment was observed in the period April–June 2020 following lockdown. This may have been due to the nationwide home to home campaign that was conducted in June 2020 in Ethiopia
Pires, 2021	Mixed-methods research, descriptive, cross-sectional, retrospective	Quantitative data: facility monthly official statistics and MCH statistics department.
Qualitative data: interviews with HCWs, traditional birth attendants, clients of MCH services.	Quantitative data: Microsoft Excel
Qulaitative data: interview guide used for recorded interviews	There was a 20% decline in childhood vaccinations and an 18% decrease in children completely vaccinated in the intervention area during the three months of COVID-19 pandemic in 2020 when compared to the same period in 2019 all without statistical significance.
In the non-intervention area, there was a 16% decrease in children completely vaccinated fot the same periods all without statistical significance.
In non-intervention area there was a decrease of 16% in the number of children completely vaccinated all without any statistical significance.
Clients and TBAs indicated that they continued to attend health services, mostly to get vaccinations for their childern as vaccines were no longer available through community outreach programs.
Shapira et al.3	interrupted time series design	Panel data from monthly service volumes from health facilities reported into the national HMIS.	Not specified	Child vaccination had the largest declines in several countries as evidenced by the drop for at least 1 month in all countries except DRC in the number of children who received the thrid dose of the pentavalent.
Cumulative reduction in child vaccination in the March-July 2020 period ranged from 2% in cameroon to 17% in Mali with the largest disruptions recorded in April and May.
In countries like Liberia and Somalia, there were no significant diffrences in numbers of vaccinated childern from pre-COVID levels byu June 2020.
The number of BCG vaccinations adminstered showed a similar pattern but with smaller reductions on average,, with three of seven countries reporting a significant shortfall in gtotal BCG vaccinations delivered.
The model does not observe subsequent significant positive increases that would suggecst a catch-up from earlier vaccination reductions in five of the eight countries where the overall 5-month decline is significantly below zero.
Vaccination services, relying to a larger extent on outreach campaigns relative to other services, may likely to have been more impacted by activity restrictions introduced to mitigate the virus's spread.
Shikuku, 2020	cross – sectional	Facility level data extracted from the Kenya Health Information System (KHIS)	Microsoft Excel Spreadsheet	There were no significant changes in the mean total hospital attendance per month for immunization services during a 4-month period (March – June 2019) pre-COVID-19 compared with during the equivalent 4-month period peri‑COVID-19 pandemic.
Trends across month showed a reduction in hospital attendance in April 2020 for all the hospital services followed by a sustained increase in May and June 2020 for pentavalent immunization compared with the similar equivalent pre-COVID-19 period
Burt, 2021	Observational study	Facility level electronic medical records (EMR) from Kawempe district, Kampala	Microsoft Excel Spreadsheet	All antenatal and vaccination services ceased in lockdown for 4 weeks.
Since the lifting of the lockdown, there have been a significant reduction (960 fewer) in monthly attendances .
There was no change in the rate of children receiving Bacille Calmette-Guerin (BCG) at birth, oral polio, pneumococcal or rotavirus vaccines since the end of lockdown, although fewer children were reported to be attending the immunization clinic.
The increase in the rate of measles vaccinations attributable to a catch-up campaign after a long stock out.
Hategeka7	time series	Facility level Health Management Information System (HMIS)	Not specified	Vaccinations were largely not affected by COVID-19 in Kinshasa
The Gombe health zone had few facilities (n = 3) that reported vaccination consistently during the study period, subgroup analyses to undestand the effect of the lockdown policy on vaccinations in the zone.
The fact that vaccinations were not affected likely to be explained by the fact that most vaccinations are delivered at health centers which were not affected by lockdowns as comapred to hospitals.

Out of the 10 studies found eligible for data synthesis, seven studies reported decreased utilization of CIS. One study conducted in Ethiopia reported a 0.3% and 4.7% decrease in pentavalent-1 vaccination and pentavalent-3 vaccination during the first 8 months (March – October 2020) of the pandemic, respectively. This study also reported that there was an overall 0.6% decrease in the number of fully vaccinated during the same period compared to the previous 8 months (July 2019 – February 2020) average performance. A multi-country study conducted in eight sub-Saharan African countries reported that child vaccination had the largest decline in several countries. This study shows that there was a drop in the number of children who received the third dose of the pentavalent vaccination for at least 1 month in all countries except DRC. The reported cumulative reduction in child vaccination from March-July 2020 ranged from 2% in Cameroon to 17% in Mali, with the largest reductions recorded in April and May 2020. In Liberia and Somalia, there were no significant differences in numbers of vaccinated children from pre-COVID levels to June 2020. Other studies conducted in Ethiopia and Rwanda reported a significant decrease in CIS during the COVID-19 pandemic.

Apart from a decrease in the rate of attendance and utilization of child immunization services during the COVID-19 pandemic, delivery of these services was also limited due to the prioritization of COVID-19 patients. Out of the 10 included studies in this review, only three6, 7, 8 reported disruptions on the delivery of CIS from the health care providers’ perspectives. Based on the findings of a cross-sectional study in Nigeria, there was a slight decline of three percent in the delivery of CIS. A nearly 10% decline in the number of facilities offering CIS services was observed after the lockdown in Nigeria. About 96.0% to 100% of the selected primary health centers (PHCs) offered CIS before lockdown, while during the lockdown, only 85% were offering the services. During the lockdown, the decline in CIS differed by region. After the lockdown, the level of CIS amongst some facilities remained at lockdown levels while at other PHCs it declined from the lockdown levels. On the other hand, another study in Kinshasa in the DRC reported no significant differences between the pre-COVID and during COVID rates of child vaccinations while vaccination services ceased in lockdown for 4 weeks in Kampala, Uganda.

A study conducted in Nigeria investigated challenges in access and satisfaction with reproductive, maternal, newborn, and child health services during the COVID-19 pandemic. The study reported that about 56% of the participants had no challenge accessing reproductive, maternal, neonatal, and child health (RMNCH) services since the COVID-19 outbreak. However, the remaining 44% of the participants reported a least one challenge with accessing RMNCH services. Close to a third could not access service because they could not leave their houses during the lockdown and about 18% could not access service because there was no transportation during the lockdown. About 3% of the participants mentioned other challenges such as the high cost of transportation, fear of contracting COVID-19 since patients with COVID-19 were also receiving care in the facility, and the mandatory use of facemasks at the facility.

The emergence of the novel severe acute respiratory syndrome coronavirus 2 (COVID-19) resulted in an unprecedented public health crisis. Before the rollout of COVID-19 vaccination programs, measures to mitigate the risks of COVID-19 relied on limiting personal contact, hand hygiene, wearing face masks, and movement restrictions. These measures also disrupted health services such as CIS. This review revealed that there was a decrease in utilization of CIS in most sub-Saharan African countries during the COVID-19 pandemic. The decline in immunization rates differed according to the vaccine and the regions of the countries. This review also revealed that the delivery of CIS was disrupted in some countries, while in some CIS completely ceased during the lockdown, yet in others, there were no significant changes. In some countries, the number of facilities offering CIS decreased. Furthermore, this review revealed that some people in some countries had difficulty accessing CIS due to several reasons. Countries in Africa should therefore monitor childhood immunization trends during the COVID-19 pandemic so that they can implement catch-up vaccination activities for those who would have missed their doses as soon as is practically possible.

Funding

This study was not funded.

Declaration of Competing Interest

None declared.