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Confidential: For Review Only Childhood immunisations in India - impact of COVID-19

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2021-001061

Article Type: Editorial

Date Submitted by the 13-Feb-2021 Author:

Complete List of Authors: Shet, Anita; Johns Hopkins University Bloomberg School of Public Health DeLuca, Andrea; Amputee Coalition of America Dhaliwal, Baldeep; Johns Hopkins University Bloomberg School of Public Health, International Health Banerjee, Preetika; Johns Hopkins University Bloomberg School of Public Health, International Health Carr, Kelly; Johns Hopkins University Bloomberg School of Public Health, International Health Britto, Carl; St John's Research Institute Seth, Rajeev; Bal Umang Drishya Sanstha (BUDS) Basavaraj, GV; Indian Academy of Pediatrics Parekh, Bakul; Indian Academy of Pediatrics http://bmjpaedsopen.bmj.com/ Gupta, Piyush; Indian Academy of Pediatrics Shastri, Digant; Indian Academy of Pediatrics

Keywords: COVID-19, Epidemiology, Health services research

on October 2, 2021 by guest. Protected copyright.

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1 2 3 4 5 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 6 7 8 9 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the Work (as defined 10 in the below author licence), an exclusive licence and/or a non-exclusive licence for contributions from authors 11 who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance 12 with the termsConfidential: applicable for US Federal Government For officers Review or employees actingOnly as part of their official 13 duties; on a worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 14 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, to publish the 15 Work in this journal and any other BMJ products and to exploit all rights, as set out in our licence. 16 17 The Submitting Author accepts and understands that any supply made under these terms is made by BMJ to 18 the Submitting Author unless you are acting as an employee on behalf of your employer or a postgraduate 19 student of an affiliated institution which is paying any applicable article publishing charge (“APC”) for Open 20 Access articles. Where the Submitting Author wishes to make the Work available on an Open Access basis (and 21 intends to pay the relevant APC), the terms of reuse of such Open Access shall be governed by a Creative 22 Commons licence – details of these licences and which Creative Commons licence will apply to this Work are set 23 out in our licence referred to above. 24 25 Other than as permitted in any relevant BMJ Author’s Self Archiving Policies, I confirm this Work has not been 26 accepted for publication elsewhere, is not being considered for publication elsewhere and does not duplicate 27 material already published. I confirm all authors consent to publication of this Work and authorise the granting 28 of this licence. 29 30 31 32 33 34

35 http://bmjpaedsopen.bmj.com/ 36 37 38 39 40 41 42 43 44

45 on October 2, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 Childhood immunisations in India - impact of COVID-19 4 5 Anita Shet1, Baldeep Dhaliwal1, Preetika Banerjee1, Kelly Carr1, Andrea DeLuca2, Carl Britto3, 6 7 Rajeev Seth4, Bakul Parekh5, GV Basavaraj5, Piyush Gupta5, Digant Shastri5 8 9 10 1 11 InternationalConfidential: Vaccine Access Center, Johns For Hopkins Review Blomberg School ofOnly Public Health, 12 13 Baltimore, USA 14 2 Amputee Coalition, Washington DC, USA 15 16 3 St Johns Research Institute, Bangalore, India 17 18 4 Bal Umang Drishya Sanstha, New Delhi, India 19 20 5 Indian Academy of Pediatrics 21 22 23 24 25 26 27 Corresponding Author: 28 29 30 31 Anita Shet, MD. PhD http://bmjpaedsopen.bmj.com/ 32 33 International Vaccine Access Center 34 Johns Hopkins Blomberg School of Public Health, Baltimore, USA 35 36 Email: [email protected] 37 38 39 40 Funding 41 on October 2, 2021 by guest. Protected copyright. 42 The authors gratefully acknowledge partial support from the Johns Hopkins Maternal and Child 43 44 Health Center, India, as well as support from the Indian Academy of Pediatrics. Grant number is 45 not applicable. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 1 60 https://mc.manuscriptcentral.com/bmjpo Page 3 of 6 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 The COVID-19 pandemic has led to major disruptions in the delivery of essential health services 4 5 including routine immunization services in many countries, setting the stage for potentially 6 7 serious population health effects. The WHO reported major disruptions to vaccination services 8 9 in countries around the world, and estimated that approximately 80 million children under the 10 11 age of oneConfidential: were living in countries where Forroutine immunization Review services Only were disrupted, and 12 1 13 could potentially be at risk for developing a vaccine-preventable illness . Evidence from 14 previous epidemics have demonstrated that even temporary interruptions of routine 15 16 immunization services can lead to secondary public health crises, such as outbreaks of vaccine- 17 18 preventable diseases, amplifying morbidity and mortality2. 19 20 21 3 22 Results from a survey of Indian pediatricians amplify a growing chorus around the globe calling 23 24 for a focus on vaccine-preventable illnesses, even as COVID-19 cases grow worldwide. This 25 comes at a pivotal time in India’s ongoing pursuit to improve immunization coverage. The 26 27 national immunization program run by the government of India is one of the largest in the 28 29 world, with an annual reach of over 26 million children and 29 million pregnant women4. 30 31 Mission Indradhanush was launched in 2014 to further extend this reach and achieve full http://bmjpaedsopen.bmj.com/ 32 33 immunization for 90% of children. While remarkable progress has been made, there is evidence 34 of existing inequalities in coverage5. 35 36 37 38 Early in the pandemic, soon after the lockdown was announced, there were major disruptions 39 40 in health services, especially in women and children’s services. Movement restrictions were 41 on October 2, 2021 by guest. Protected copyright. 42 likely to have disrupted strategies utilized by Mission Indradhanush, including community 43 44 mobilization, door-to-door campaigns, and monitoring events. The National Health Mission’s 45 health management and information system reported a substantial decrease in routine 46 47 immunization services relative to the previous year, indicating that in March 2020, at least 48 49 100,000 and 200,000 children missed their BCG and pentavalent (diphtheria, tetanus, pertussis, 50 51 hepatitis B and Hemophilus influenzae type b) vaccines respectively6,7. Researchers modelled 52 53 different scenarios and used the Lives Saved Tool (LiST) to demonstrate that widespread 54 8 55 disruption to health systems could lead to substantial increases in maternal and child deaths . 56 57 58 59 2 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open Page 4 of 6

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 In India they estimated that an additional 49,000 child deaths and 2,300 maternal deaths in a 4 5 month could be attributable to severely disrupted services8. Applying the current population 6 7 demographic data in India, estimates suggested that eventually over 27 million children will 8 9 miss out on diphtheria tetanus pertussis (DTP) vaccines and other health services, resulting in a 10 9 11 40% increaseConfidential: in child mortality over the next For year . ReviewIf vaccination services Only are not restored and 12 13 barriers to access are not addressed, disparities will become more pronounced and the number 14 of zero-dose children will likely increase. India currently accounts for 2.1 million of the 20 15 16 million unvaccinated and under-vaccinated children globally (11%)10, and the national lockdown 17 18 has shown its potential to further exacerbate this problem. Without targeted campaigns and 19 20 effort, there is a legitimate risk for a reversal of gains made through national programs. 21 22 23 24 Experiences from past outbreaks provide lessons on the indirect impacts which can be even 25 more harmful to health. Analyses from the West African Ebola outbreak in 2014-2015 suggest 26 27 that the increased number of deaths caused by other infections such as measles, HIV and 28 29 tuberculosis attributable to health system failures exceeded deaths from Ebola2,11. A sustained 30 31 period of disrupted immunization can result in the accumulation of susceptible individuals http://bmjpaedsopen.bmj.com/ 32 12 33 which in turn can lead to disease outbreaks . Given the disruptions and the realization of the 34 dire consequences, the Government of India declared immunization an essential health service 35 36 in April 2020, and issued guidelines for states to resume routine immunization services13. In 37 38 June 2020 India began a phased reopening of the economy, and the resumption of 39 40 immunization activities were appropriately structured based on local COVID-19 infection rates 41 on October 2, 2021 by guest. Protected copyright. 42 and restrictions. These activities were based on the WHO guidance urging nations to continue 43 44 providing essential services along with COVID-19 mitigation and treatment measures in order to 45 maintain public trust and minimize morbidity and mortality14. 46 47 48 49 Coordinated campaigns across India targeting children who missed critical routine vaccinations 50 51 during the national lockdown, as well as targeting low-coverage areas, could prevent additional 52 53 public health disasters. Prioriting measles vaccine catch up would be most prudent given the 54 15 55 outbreak potential with even marginal reduction in heard immunity . Planning catch-up 56 57 58 59 3 60 https://mc.manuscriptcentral.com/bmjpo Page 5 of 6 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 campaigns now is essential so providers can minimize the time children are at risk for vaccine- 4 5 preventable diseases. Vaccination catch-up sessions could institute innovative strategies such 6 7 as implementing appointment-only visits, minimizing overcrowding, separating immunization 8 9 visits from sick children visits, prioritizing robust communication efforts which address 10 11 caregivers’Confidential: fears of contracting COVID-19, For and sending Review reminders to caregivers Only of the 12 16 13 importance of routine vaccinations . There is growing evidence that the risk-benefit ratio is 14 decidedly in favor of continuing vaccination services even when considering consequences of 15 16 doing so during the pandemic17. Gaining provider insights on effective strategies is essential to 17 18 establishing context-specific mechanisms to prioritize catch-up for missed vaccines. In 19 20 neighboring country Pakistan, an analysis of predictors associated with immunization during 21 22 their lockdown showed that factors such as higher maternal education, facility-based births, 23 24 and early enrollment into the immunization program were associated with higher immunization 25 uptake18. Interventions targeted at sustaining these predictors could be effective means of 26 27 engaging with caregivers to ensure catch-up for missed vaccines in India as well. 28 29 30 31 The government of India has recently approved COVID-19 vaccines, and the nation has embarked http://bmjpaedsopen.bmj.com/ 32 33 on one of the largest and most ambitious immunization campaigns in the world. Although 34 children will not receive the COVID-19 vaccine at this time, their caregivers and healthcare 35 36 providers who will receive the vaccine, should be provided with targeted messages and 37 38 reminders for childhood routine immunizations. In addition, liaising routine immunization 39 40 campaigns with the COVID-19 vaccine rollout, particularly in hard-to-reach areas would be 41 on October 2, 2021 by guest. Protected copyright. 42 beneficial, given India’s vast human resources and immunization experience. Concerted efforts 43 44 are needed from governing and academic groups to ensure that routine immunization and catch- 45 up programs are implemented to sustain gains in vaccination coverage and provide a robust 46 47 blueprint for the national roll-out of the COVID-19 vaccine. 48 49 50 51 Patient and Public Involvement: No patients were involved 52 53 54 55 56 57 58 59 4 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open Page 6 of 6

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 REFERENCES 4 5 6 7 1. McHomvu E, Mbunda G, Simon N, et al. Diagnoses made in an Emergency Department in 8 9 rural sub-Saharan Africa. Swiss Med Wkly 2019; 149: w20018. 10 11 2. TakahashiConfidential: S, Metcalf CJ, Ferrari MJ, Foret al. Reduced Review vaccination and Only the risk of measles 12 13 and other childhood infections post-Ebola. Science 2015; 347(6227): 1240-2. 14 15 3. Shet A, Dhaliwal B, Banerjee P, et al. COVID-19-related disruptions to routine vaccination 16 services in India: perspectives from pediatricians. medRxiv 2021: 2021.01.25.21250040. 17 18 4. Bhandari N, Mazumder S, Taneja S, Sommerfelt H, Strand TA. Effect of implementation of 19 20 Integrated Management of Neonatal and Childhood Illness (IMNCI) programme on 21 22 neonatal and infant mortality: cluster randomised controlled trial. BMJ 2012; 344: e1634. 23 24 5. Naish S, Dale P, Mackenzie JS, McBride J, Mengersen K, Tong S. Climate change and 25 dengue: a critical and systematic review of quantitative modelling approaches. BMC 26 27 Infect Dis 2014; 14: 167. 28 29 6. World Health Organization. Integrated Management of Childhood Illness: a WHO/UNICEF 30 31 initiative, WHO Bulletin, Supplement 1 to volume 75. 1997. http://bmjpaedsopen.bmj.com/ 32 33 7. Tulloch J. Integrated approach to child health in developing countries. Lancet 1999; 354 34 35 Suppl 2: Sii16-20. 36 8. Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect effects of the 37 38 COVID-19 pandemic on maternal and child mortality in low-income and middle-income 39 40 countries: a modelling study. The Lancet Global health 2020; 8(7): e901-e8. 41 on October 2, 2021 by guest. Protected copyright. 42 9. Armstrong Schellenberg JR, Adam T, Mshinda H, et al. Effectiveness and cost of facility- 43 44 based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet 2004; 45 46 364(9445): 1583-94. 47 10. Ghatak D, Zaitchik, B., Kumar, S., Matin, M., Bajracharya, B., Hain, C., & Anderson, M. . 48 49 Influence of Precipitation Forcing Uncertainty on Hydrological Simulations with the NASA 50 51 South Asia Land Data Assimilation System. Hydrology, 5(4), 57. 2018. 52 53 11. Elston JW, Cartwright C, Ndumbi P, Wright J. The health impact of the 2014-15 Ebola 54 55 outbreak. Public Health 2017; 143: 60-70. 56 57 58 59 5 60 https://mc.manuscriptcentral.com/bmjpo Page 7 of 6 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 12. Truelove SA, Graham M, Moss WJ, Metcalf CJE, Ferrari MJ, Lessler J. Characterizing the 4 5 impact of spatial clustering of susceptibility for measles elimination. Vaccine 2019; 37(5): 6 7 732-41. 8 9 13. Curry J, McGregor C, Tracy S. A communication tool to improve the patient journey 10 11 modelingConfidential: process. Conf Proc IEEE Eng For Med Biol Review Soc 2006; 1: 4726-30. Only 12 13 14. May CR, Mair F, Finch T, et al. Development of a theory of implementation and 14 integration: Normalization Process Theory. Implementation science : IS 2009; 4: 29. 15 16 15. Masters NB, Eisenberg MC, Delamater PL, Kay M, Boulton ML, Zelner J. Fine-scale spatial 17 18 clustering of measles nonvaccination that increases outbreak potential is obscured by 19 20 aggregated reporting data. Proc Natl Acad Sci U S A 2020; 117(45): 28506-14. 21 22 16. Oyo-Ita A, Wiysonge CS, Oringanje C, Nwachukwu CE, Oduwole O, Meremikwu MM. 23 24 Interventions for improving coverage of childhood immunisation in low- and middle- 25 income countries. The Cochrane database of systematic reviews 2016; 7(7): Cd008145. 26 27 17. Abbas K, Procter SR, van Zandvoort K, et al. Routine childhood immunisation during the 28 29 COVID-19 pandemic in Africa: a benefit-risk analysis of health benefits versus excess risk 30 31 of SARS-CoV-2 infection. The Lancet Global health 2020; 8(10): e1264-e72. http://bmjpaedsopen.bmj.com/ 32 33 18. Chandir S, Siddiqi DA, Mehmood M, et al. Impact of COVID-19 pandemic response on 34 uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic 35 36 immunization registry data. Vaccine 2020; 38(45): 7146-55. 37 38 39 40 41 on October 2, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 6 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from

Confidential: For Review Only Childhood immunisations in India during the COVID-19 pandemic

Journal: BMJ Paediatrics Open

Manuscript ID bmjpo-2021-001061.R1

Article Type: Editorial

Date Submitted by the 25-Mar-2021 Author:

Seth, Rajeev; Bal Umang Drishya Sanstha (BUDS) http://bmjpaedsopen.bmj.com/ Basavaraj, GV; Indian Academy of Pediatrics Parekh, Bakul; Indian Academy of Pediatrics Shastri, Digant; Indian Academy of Pediatrics Gupta, Piyush; Indian Academy of Pediatrics

Keywords: COVID-19, Epidemiology, Health services research

https://mc.manuscriptcentral.com/bmjpo Page 1 of 8 BMJ Paediatrics Open

35 http://bmjpaedsopen.bmj.com/ 36 37 38 39 40 41 42 43 44

45 on October 2, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

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1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 Childhood immunisations in India during the COVID-19 pandemic 4 5 Anita Shet1, Baldeep Dhaliwal1, Preetika Banerjee1, Kelly Carr1, Andrea DeLuca2, Carl Britto3, 6 7 Rajeev Seth4, Bakul Parekh5, GV Basavaraj5, Digant Shastri5, Piyush Gupta5 8 9 10 1 11 InternationalConfidential: Vaccine Access Center, Johns For Hopkins Review Blomberg School ofOnly Public Health, 12 13 Baltimore, USA 14 2 Amputee Coalition, Washington DC, USA 15 16 3 St Johns Research Institute, Bangalore, India 17 18 4 Bal Umang Drishya Sanstha, New Delhi, India 19 20 5 Indian Academy of Pediatrics 21 22 23 24 25 Corresponding Author: 26 27 28 29 Anita Shet, MD. PhD 30 31 International Vaccine Access Center http://bmjpaedsopen.bmj.com/ 32 33 Johns Hopkins Blomberg School of Public Health, Baltimore, USA 34 Email: [email protected] 35 36 37 38 Author contributions 39 40 AS prepared the first draft of the manuscript. BD, PB, AD and DS provided critical review and 41 on October 2, 2021 by guest. Protected copyright. 42 input. All authors reviewed the manuscript and approved the final version for submission. 43 44 45 Funding 46 47 This work was supported by the Johns Hopkins Maternal and Child Health Center, India, and the 48 49 Indian Academy of Pediatrics. Grant number is not applicable. 50 51 52 53 Competing Interests Statement 54 55 The authors declare no competing interests. 56 57 58 59 1 60 https://mc.manuscriptcentral.com/bmjpo Page 3 of 8 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 4 5 Ethics Statement 6 7 This editorial article represents the opinions of the authors, and no ethical review was sought. 8 9 10 11 Patient Confidential:and Public Involvement For Review Only 12 13 Patient and Public Involvement: No patients were involved 14 15 16 Exclusive License 17 18 I, the Submitting Author has the right to grant and does grant on behalf of all authors of the 19 20 Work (as defined in the below author licence), an exclusive licence and/or a non-exclusive 21 22 licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has 23 24 agreed a CC-BY licence shall apply, and/or iii) in accordance with the terms applicable for US 25 Federal Government officers or employees acting as part of their official duties; on a 26 27 worldwide, perpetual, irrevocable, royalty-free basis to BMJ Publishing Group Ltd (“BMJ”) its 28 29 licensees and where the relevant Journal is co-owned by BMJ to the co-owners of the Journal, 30 31 to publish the Work in BMJ Paediatrics Open and any other BMJ products and to exploit all http://bmjpaedsopen.bmj.com/ 32 33 rights, as set out in our licence. 34 35 36 The Submitting Author accepts and understands that any supply made under these terms is 37 38 made by BMJ to the Submitting Author unless you are acting as an employee on behalf of your 39 40 employer or a postgraduate student of an affiliated institution which is paying any applicable 41 on October 2, 2021 by guest. Protected copyright. 42 article publishing charge (“APC”) for Open Access articles. Where the Submitting Author wishes 43 44 to make the Work available on an Open Access basis (and intends to pay the relevant APC), the 45 terms of reuse of such Open Access shall be governed by a Creative Commons licence – details 46 47 of these licences and which Creative Commons licence will apply to this Work are set out in our 48 49 licence referred to above. 50 51 52 53 Word Count 54 55 1189 words 56 57 58 59 2 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open Page 4 of 8

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 The COVID-19 pandemic has led to major disruptions in the delivery of essential health services 4 5 including routine immunisation services in many countries, setting the stage for potentially 6 7 serious population health effects. The WHO reported major disruptions to vaccination services 8 9 in countries around the world, and estimated that approximately 80 million children under the 10 11 age of oneConfidential: were living in countries where Forroutine immunisation Review services Only were disrupted, and 12 1 13 could potentially be at risk for developing a vaccine-preventable illness . Evidence from 14 previous epidemics have demonstrated that even temporary interruptions of routine 15 16 immunisation services can lead to secondary public health crises, such as outbreaks of vaccine- 17 18 preventable diseases, amplifying morbidity and mortality2. This commentary explores the 19 20 possible effects of the COVID-19 pandemic on routine immunisations in India. 21 22 23 3 24 Results from a survey of Indian pediatricians amplify a growing chorus around the globe calling 25 for a focus on vaccine-preventable illnesses, even as COVID-19 cases grow worldwide. This 26 27 comes at a pivotal time in India’s ongoing pursuit to improve immunisation coverage. The 28 29 national immunisation program run by the government of India is one of the largest in the 30 31 world, with an annual reach of over 26 million children and 29 million pregnant women4. http://bmjpaedsopen.bmj.com/ 32 33 Mission Indradhanush was launched in 2014 to extend this reach and achieve full immunisation 34 for 90% of children and the program was further intensified in 20194,5. While remarkable 35 36 progress has been made, there is evidence of existing inequalities in coverage6. 37 38 39 40 Early in the pandemic, soon after the lockdown was announced, there were major disruptions 41 on October 2, 2021 by guest. Protected copyright. 42 in health services, especially in women and children’s services. Movement restrictions were 43 44 likely to have disrupted strategies utilized by Mission Indradhanush, including community 45 mobilization, door-to-door campaigns, and monitoring events. The National Health Mission’s 46 47 health management and information system reported a substantial decrease in routine 48 49 immunisation services relative to the previous year, indicating that in March 2020, at least 50 51 100,000 and 200,000 children missed their BCG and pentavalent (diphtheria, tetanus, pertussis, 52 7,8 53 hepatitis B and Hemophilus influenzae type b) vaccines respectively . Researchers modelled 54 55 different scenarios and used the Lives Saved Tool (LiST, a mathematical modeling tool to 56 57 58 59 3 60 https://mc.manuscriptcentral.com/bmjpo Page 5 of 8 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 estimate the impact of program coverage of maternal, newborn, and child health on mortality 4 5 at a country level9) to demonstrate that widespread disruption to health systems could lead to 6 7 substantial increases in maternal and child deaths10. In India they estimated that an additional 8 9 49,000 child deaths and 2,300 maternal deaths in a month could be attributable to severely 10 10 11 disruptedConfidential: services . Applying the current Forpopulation Review demographic data Only in India, estimates 12 13 suggested that eventually over 27 million children will miss out on diphtheria tetanus pertussis 14 (DTP) vaccines and other health services, resulting in a 40% increase in child mortality over the 15 16 next year11. If vaccination services are not restored and barriers to access are not addressed, 17 18 disparities will become more pronounced and the number of zero-dose children will likely 19 20 increase. India currently accounts for 2.1 million of the 20 million unvaccinated and under- 21 12 22 vaccinated children globally (11%) , and the national lockdown has shown its potential to 23 24 further exacerbate this problem. Without targeted campaigns and effort, there is a legitimate 25 risk for a reversal of gains made through national programs. 26 27 28 29 Experiences from past outbreaks provide lessons on the indirect impacts which can be even 30 31 more harmful to health. Analyses from the West African Ebola outbreak in 2014-2015 suggest http://bmjpaedsopen.bmj.com/ 32 33 that the increased number of deaths caused by other infections such as measles, HIV and 34 tuberculosis attributable to health system failures exceeded deaths from Ebola2,13. A sustained 35 36 period of disrupted immunisation can result in the accumulation of susceptible individuals 37 38 which in turn can lead to disease outbreaks14. Given the disruptions and the realization of the 39 40 dire consequences, the Government of India declared immunisation an essential health service 41 on October 2, 2021 by guest. Protected copyright. 42 in April 2020, and issued guidelines for states to resume routine immunisation services15. In 43 44 June 2020 India began a phased reopening of the economy, and the resumption of 45 immunisation activities were appropriately structured based on local COVID-19 infection rates 46 47 and restrictions. These activities were based on the WHO guidance urging nations to continue 48 49 providing essential services along with COVID-19 mitigation and treatment measures in order to 50 51 maintain public trust and minimize morbidity and mortality16. 52 53 54 55 56 57 58 59 4 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open Page 6 of 8

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 Coordinated campaigns across India targeting children who missed critical routine vaccinations 4 5 during the national lockdown, as well as targeting low-coverage areas, could prevent additional 6 7 public health disasters. Prioriting measles vaccine catch up would be most prudent given the 8 9 outbreak potential with even marginal reduction in heard immunity17. Planning catch-up 10 11 campaignsConfidential: now is essential so providers can For minimize Review the time children Only are at risk for vaccine- 12 13 preventable diseases. Vaccination catch-up sessions could institute innovative strategies such 14 as implementing appointment-only visits or designated walk-in clinics for healthy children, 15 16 minimizing overcrowding, separating immunisation visits from sick children visits, prioritizing 17 18 robust communication efforts which address caregivers’ fears of contracting COVID-19, and 19 20 sending reminders to caregivers of the importance of routine vaccinations18. In addition, 21 22 healthcare strategies such as the Integrated Management of Newborn and Childhood Illnesses 23 24 (IMNCI) can strengthen their focus on immunisation. Empowering community health workers to 25 trace children who missed vaccination appointments, can help restore baseline vaccination 26 27 levels. Catch-up vaccinations can also be given to children in contact healthcare facilities for 28 29 acute or chronic illnesses19. There is growing evidence that the risk-benefit ratio is decidedly in 30 31 favor of continuing vaccination services even when considering consequences of doing so http://bmjpaedsopen.bmj.com/ 32 20 33 during the pandemic . Gaining provider insights on effective strategies is essential to 34 establishing context-specific mechanisms to prioritize catch-up for missed vaccines. In 35 36 neighboring country Pakistan, an analysis of predictors associated with immunisation during 37 38 their lockdown showed that factors such as higher maternal education, facility-based births, 39 40 and early enrollment into the immunisation program were associated with higher immunisation 41 on October 2, 2021 by guest. Protected copyright. 42 uptake21. Interventions targeted at sustaining these predictors could be effective means of 43 44 engaging with caregivers to ensure catch-up for missed vaccines in India as well. A pulse survey 45 from the WHO indicated partial disruption of essential health services beyond immunisations in 46 47 many regions of the world, particularly in lower-income countries22, which prompted a strong 48 49 call to arms for health systems and governments to ‘build back better’ to incorporate health 50 51 system resilience, and maintain the provision of essential health services during and after the 52 23 53 COVID-19 pandemic . 54 55 56 57 58 59 5 60 https://mc.manuscriptcentral.com/bmjpo Page 7 of 8 BMJ Paediatrics Open

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 The government of India has recently worked on several strategies for health systems 4 5 strengthening, including incorporating a coordinated program for public health surveillance, 6 7 which will help monitor outbreaks of vaccine-preventable diseases among other diseases24. In 8 9 the context of the pandemic, the government of India has approved COVID-19 vaccines, and the 10 11 nation hasConfidential: embarked on one of the largest For and most Review ambitious immunisation Only campaigns in the 12 13 world. Although children will not receive the COVID-19 vaccine at this time, their caregivers and 14 healthcare providers who will receive the vaccine, should be provided with targeted messages 15 16 and reminders for childhood routine immunisations. In addition, liaising routine immunisation 17 18 campaigns with the COVID-19 vaccine rollout, particularly in hard-to-reach areas would be 19 20 beneficial, given India’s vast human resources and immunisation experience. Concerted efforts 21 22 are needed from governing and academic groups to ensure that routine immunisation and catch- 23 24 up programs are implemented to sustain gains in vaccination coverage and provide a robust 25 blueprint for the national roll-out of the COVID-19 vaccine. 26 27 28 29 30 31 http://bmjpaedsopen.bmj.com/ 32 33 34 35 36 37 38 39 40 41 on October 2, 2021 by guest. Protected copyright. 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 6 60 https://mc.manuscriptcentral.com/bmjpo BMJ Paediatrics Open Page 8 of 8

1 bmjpo: first published as 10.1136/bmjpo-2021-001061 on 14 April 2021. Downloaded from 2 3 REFERENCES 4 5 6 7 1. World Health Organization, News: At least 80 million children under one at risk of diseases 8 such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts, warn 9 Gavi, WHO and UNICEF. 22 May 2020. Available at: https://www.who.int/news/item/22-05- 10 Confidential:2020-at-least-80-million-children-under-one-at-risk-of-diseases-such-as-diphtheria-measles- For Review Only 11 and-polio-as-covid-19-disrupts-routine-vaccination-efforts-warn-gavi-who-and-unicef. 2020. 12 13 2. Takahashi S, Metcalf CJ, Ferrari MJ, et al. Reduced vaccination and the risk of measles and 14 other childhood infections post-Ebola. Science (New York, NY) 2015; 347(6227): 1240-2. 15 3. Shet A, Dhaliwal B, Banerjee P, et al. COVID-19-related disruptions to routine vaccination 16 services in India: perspectives from pediatricians. medRxiv 2021: 2021.01.25.21250040. 17 4. Gurnani V, Haldar P, Aggarwal MK, et al. Improving vaccination coverage in India: lessons 18 from Intensified Mission Indradhanush, a cross-sectoral systems strengthening strategy. BMJ 19 (Clinical research ed) 2018; 363: k4782. 20 5. Intensified Mission Indradhanush 2.0: Coverage report. 25 September 2020. Available at: 21 https://imi2.nhp.gov.in/report/coverage Accessed 20 November 2020. 22 23 6. Srivastava S, Fledderjohann J, Upadhyay AK. Explaining socioeconomic inequalities in 24 immunisation coverage in India: new insights from the fourth National Family Health Survey 25 (2015-16). BMC pediatrics 2020; 20(1): 295. 26 7. National Health Mission Health Management Information System, Ministry of Health and 27 Family Welfare, Government of India. Available at: https://nrhm- 28 mis.nic.in/SitePages/Home.aspx. Accessed on 15 November 2020. 29 8. Rukmini S. How covid-19 response disrupted health services in rural India. Mint. 2020. 30

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