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The Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: a Rapid Review

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The Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: a Rapid Review medRxiv preprint doi: https://doi.org/10.1101/2021.06.25.21259371; this version posted June 30, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-ND 4.0 International license . The Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: A Rapid Review Heneghan C,1 Brassey J,2 Jefferson T.1 (Version 1, 21 June 2021) COLLATERAL GLOBAL Affiliations: 1. The University of Oxford 2. Trip Database Ltd https://www.tripdatabase.com Corresponding author email: [email protected] Abstract Background Vaccines are highly effective for preventing a range of childhood infections. However, there have been concerns about an alarming decline in vaccinations in 2020 due to the COVID-19 pandemic. Methods We performed a rapid review for studies that assessed childhood vaccination uptake during restrictive phases of the COVID-19 pandemic. Results We found 35 published studies that compared changes in the pattern of childhood vaccinations before and during the pandemic. Thirteen were surveys; two mixed-methods surveys and interviews, three modelling studies and 17 retrospective cohort studies with historical controls. We also included ten reports by national or international agencies that had original data on vaccination uptake. Significant global disruptions to vaccine services were reported in Africa, Asia, America (including Latin America and the Caribbean) and Europe. We also found evidence of significant disruption to vaccine uptake for diphtheria tetanus pertussis, BCG, measles and polio. Countries where vaccination rates were already suboptimal had greater drops in uptake and there was evidence of smaller declines in younger children compared to older children. Children born to women who could not read and write were more likely to be incompletely immunized. Various initiatives were used to drive up vaccination rates post restrictions. Conclusions Obstacles to the delivery of vaccination services during the Covid-19 pandemic drove down immunisation rates, especially in disadvantaged people and poorer countries. NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. medRxiv preprint doi: https://doi.org/10.1101/2021.06.25.21259371; this version posted June 30, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-ND 4.0 International license . Carl Heneghan, Jon Brassey, and Tom Jefferson Collateral Global The Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: A Rapid Review June 2021 abstract for inclusion and extracted data into Introduction templates on the study identifier, country, the type of vaccination, the study type, the age of the Vaccines have proven to be highly effective at included populations, the primary methods and the preventing disease and deaths associated with a main results. We did not formally assess quality as range of childhood infections. Many childhood studies were retrospective reviews of records that diseases that used to be common, including involved an active lockdown phase and a historical diphtheria, measles, mumps, rubella, pertussis, control period, surveys or modelling studies. The polio and tetanus, can be prevented by vaccination. quality of included studies was instead assessed The distribution and uptake of vaccines has using an adapted version of the Oxford Centre for improved across the globe. In 2019, 86% of infants Evidence-Based Medicine Levels of Evidence worldwide received three doses of diphtheria, (https://www.cebm.ox.ac.uk/resources/levels-of- tetanus, pertussis (DTP3) vaccines, and childhood evidence/ocebm-levels-of-evidence) immunisation is estimated to prevent 2 to 3 million We also included reports by national or annual deaths from infectious diseases. [1] international agencies that included original data on Despite their effectiveness, the WHO and vaccination uptake. We summarised data UNICEF warned of an ‘alarming decline’ in narratively and reported the outcomes as stated, vaccinations in 2020 due to the COVID-19 including quantitative estimates, where feasible and pandemic. Data from the first four months relevant. We presented the data by disruption of highlighted a substantial drop in the number of services and by diphtheria tetanus pertussis, BCG, children completing three doses of the DTP3 measles and polio vaccine uptake. We also vaccine - the first time in 28 years global reductions extracted up to date numbers from the Global Polio were seen. [2] Eradication Initiative (GPEI) database to assess the UNICEF regards protection from vaccine- latest impact of polio vaccination disruptions in preventable diseases as a child’s fundamental right Afghanistan and Pakistan, where polio is endemic and states that right now is ‘time to vigorously (https://polioeradication.org/). Our review process, monitor the impact on immunisation and plan for strategy and rationale can be accessed at services that reach the most vulnerable once https://collateralglobal.org/article/what-is-a-rapid- restrictions are lifted.’[3] We, therefore, set out to review/. synthesise the published literature on the impact of the COVID-19 pandemic restrictions on vaccination coverage for children. Results Methods Figure 1 reports the Identification of Childhood Vaccination studies via databases. From 389 We performed a rapid review using a flexible records identified, we found 35 published studies framework for restricted systematic reviews. [4] For that compared changes in the pattern of childhood the initial search, we restricted the results to peer- vaccinations before and during the pandemic. 32 reviewed articles using the LitCovid database. studies assessed evidence from 22 countries: LitCovid is a curated literature hub for tracking up- Afghanistan, Bangladesh, China, Germany, India, to-date scientific information about SARS-CoV-2 Indonesia, Japan, Kuwait, The Netherlands, (https://www.ncbi.nlm.nih.gov/research/coronaviru Portugal, Rwanda, Scotland, Senegal, Sierra s/). It is a comprehensive resource on the subject, Leone, South Korea, Spain (16 countries, one study providing central access to relevant articles in each); England, Ethiopia, Italy, Pakistan, Saudi PubMed. We searched for various terms/phrases Arabia (five countries, two studies each). For the associated with childhood vaccinations, e.g., USA, there were six studies. Three studies reported ‘vaccines’, ‘vaccination’ or ‘immunisation’ and on multiple countries: two were done in Africa ‘children’ or ‘infants’. We screened the title and [Masresha 2020 and Abbas K 2020] and one in 1 medRxiv preprint doi: https://doi.org/10.1101/2021.06.25.21259371; this version posted June 30, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-ND 4.0 International license . Carl Heneghan, Jon Brassey, and Tom Jefferson Collateral Global The Impact of COVID-19 Restrictions on Childhood Vaccination Uptake: A Rapid Review June 2021 South-East Asia and the Western Pacific monthly average number of vaccine doses provided (SEAR/WPR) [Harris 2021]. from January to June compared with 2018 and In terms of methods, thirteen studies were 2019. [Masresha BG 2020]. In Ethiopia, 633 surveys; two were mixed-methods surveys and children and their mother/caregiver were interviews, three studies were models (one interviewed from Jul 22 to Aug 7, 2020. Based on provided data on a retrospective cohort), and 17 their recall, plus vaccination cards, 350 (57%) were retrospective cohort studies. children finished all recommended vaccines. We also included ten reports by national or Vaccination coverage during the outbreak was international agencies that had original data on 12.5% lower than before the outbreak. [Miretu DG vaccination uptake: one each for Blue Cross, the 2021] Nuffield Trust, PAHO and Public Health England, two reports for UNICEF (one jointly with PAHO) and Asia four WHO reports. (See TABLE 2) Twenty percent of child immunisation services in Disruption to services Bangladesh were cancelled in April 2020 and 25% in May. The most significant disruption occurred in Data collated by the WHO, UNICEF, Gavi, and the remote subdistricts: Hijla (57%), Agailjhara (25%) Sabin Vaccine Institute show that pandemic and Mehendiganj (20%). Improved coverage restrictions substantially reduced the delivery of appeared in the post-disruption months (July to immunization services in at least 68 countries October 2020), with about 99% of immunisation affecting over 80 million children under the age of sessions held. [Rana S 2021] In India, survey data one. [UNICEF 2020] According to the WHO’s first of paediatric healthcare providers from April to June pulse interim survey published in August 2020, and September 2020 reported a greater than 50% 16/91 (18%) of countries reported severe/complete drop in vaccination services by 83% of the disruption of routine mobile immunization services, respondents in June (n=424 respondents) and 33% and 10% reported disruption to static routine in September (n=141). [Shet 2021] In Indonesia, immunisation services. About half of the countries 42% (480/1137) of survey
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