Author: Eka Paatashvili
Over this last year, countries around the world have been forced to focus most of their efforts on fighting the COVID-19 pandemic, potentially leaving other health priorities, including routine immunization, to fall by the wayside. To understand COVID-19’s full impact on routine immunization, we must look at how countries have modified routine immunization service delivery and financing and trends in vaccine coverage. We must then consider future systemic improvements to further strengthen immunization programs and increase their resiliency in the face of future shocks to the system.
The experiences of Armenia, Georgia, and Uzbekistan provide an opportunity to understand the key challenges that countries in the European region have encountered with maintaining routine immunization during the COVID-19 pandemic and the strategies they implemented to address these challenges. Here are some of the key takeaways.
Restoring and maintaining essential health services
In all three countries, it was challenging to maintain essential health services, including immunization, while mitigating the impact of the pandemic. While immunization services were never stopped or paused in any of these countries, they did experience reductions in coverage and delays in vaccination at some point during 2020.
- In Armenia, compared with 2019, the 1-year-old target group coverage dropped by 0.2%, the 2-year-old target group dropped by 2%, and the 6-year-old target group dropped by 1.5%. The key challenge to timely vaccination, which has dropped by 60%, was due to the war and the fear of getting COVID-19 when visiting clinics.
- Uzbekistan mostly maintained its 97-98% national vaccination coverage rate, with immunization coverage dropping 1.5-2% lower during the summer crisis.
- Georgia experienced a drop of 7-8% in its national immunization coverage. There was 5-6% decrease for Hexa-1 and Hexa-3 vaccines among children under 1-year of age, however, a higher decrease was observed for booster doses. For the newly introduced HPV vaccine, coverage reached only 23% in 2020.
March and April 2020 made up the most difficult period of the pandemic for these countries. The lack of PPE, restricted public transportation, as well as general fear and uncertainty around COVID-19 among the general population and health care workers, resulted in reduced utilization of vaccination services. And yet, none of these countries experienced a VPD outbreak.
The efforts of the EPI and health program providers, including tailored catch-up strategies and supportive supervision activities, helped the countries restore vaccine coverage rates, overcoming the reductions in coverage that occurred during the initial stage of the pandemic.
- Armenia used daily monitoring of routine vaccination countrywide, which helped to quickly identify the current vaccination dynamics and respond to bottlenecks.
- Georgia focused on the micro-planning approach, where public health authorities supported primary health care (PHC) clinics in identifying and dealing with individual missed opportunities for vaccination. In addition, to ensure better access to the immunization services and flexibility for families that had moved to rural areas, children could receive vaccination regardless of their place of residence.
- Uzbekistan actively operated mobile outreach groups for the regions under transportation restrictions. This approach enabled them to gather beneficiaries at medical facilities and schools for their routine vaccinations. When needed, mobile groups also used home visits to deliver immunization services.
Putting safety first
To adapt to the increased safety risks and lockdown strategies, the countries followed WHO’s recommendations during the development and introduction of national guidelines, along with assessment checklists, to help safely maintain immunization services. In addition to setting updated sanitary-epidemiological norms, the new regulations defined specific vaccination hours to separate patient flow. The regulations, applied to both public and private sectors, were initially found to be difficult to follow by service providers. To help ease the transition to these new protocols, public health authorities provided trainings, supportive materials, and regular monitoring meetings face-to-face as well as online. To reduce the risk of infections, Georgia implemented a new system with online appointments and remote counseling by phone.
Due to safety concerns, the National CDCs of Armenia and Georgia avoided large-scale catch-up campaigns during World Immunization Week in April 2020. In contrast, Uzbekistan followed WHO’s recommendations on distance, sanitization, and PPE requirements to safely conduct immunization campaigns for the HPV second-dose vaccination in March and large MMR catch-up campaigns in June. Both vaccination campaigns in Uzbekistan reached 97-98% coverage.
Prioritizing routine immunization financing
Historical prioritization of immunization was a key factor in securing immunization funding in the region. Despite the financial hardships imposed by COVID-19, Georgia and Uzbekistan have so far been able to secure their full routine immunization program budgets. Due to the war, Armenia had to cut all health care program budgets, including the immunization program which experienced its first reduction in 16 years. However, Armenia did not believe there was an effect on immunization program activities.
Armenia and Georgia kept Gavi post-transition funds for routine immunization catch-up activities rather than taking advantage of the opportunity to redirect them to COVID-19 needs. Uzbekistan did reprogram Gavi funds to procure sufficient personal protective equipment (PPE), however this seems to have had no impact on routine immunization.
Overcoming vaccine procurement and supply constraints
Due to international travel restrictions and local transportation bans, the countries were anticipating delays in vaccine shipment and delivery. At the beginning of the pandemic, Armenia did experience stock issues, including a national stock-out of hep-A and meningococcus vaccines and a late shipment of flu vaccines from UNICEF. Similarly, Uzbekistan had to delay HPV vaccination. While Georgia did not experience any interruption in the procurement and supply of routine vaccines, there were other barriers with commercial vaccines like hep-A, meningococcus, and chickenpox vaccines that had to be addressed. The countries have since been able to resolve these acute supply constraints.
Sharing and shifting responsibilities due to overburdened health workforce
Since the start of the pandemic, the country EPI teams have been involved in COVID-19 response activities and, more recently, COVID-19 vaccination preparedness and implementation became their direct responsibility. This has placed additional responsibilities on already overburdened EPI personnel.
Later, the increased workload and spread of infection among frontline medical workers and epidemiologists became a serious concern impacting immunization service provision. Uzbekistan suffered a significant loss of health worker capacity during a summer outbreak, requiring the Ministry of Health to engage other doctors, specialists, and public health workers in the provision of PHC and immunization services.
Withstanding vaccine hesitancy and demand hurdles
As social media in Armenia and Georgia showed significant resistance to COVID-19 vaccines, both countries anticipated an increase in hesitancy for routine immunization. In Georgia, a knowledge, attitudes, and practices (KAP) survey revealed low, but growing, COVID-19 vaccine acceptance – from 33% in August to 46% in November 2020. Fortunately, this hesitancy to COVID-19 vaccines did not transfer to hesitancy for routine immunization, and demand for routine vaccines resumed as restrictions began to ease. In Uzbekistan, hesitancy was not a concern for the COVID-19 or routine vaccines.
In summary, while the dynamics of the pandemic differed across Armenia, Georgia, and Uzbekistan, all three countries have largely been able to maintain their routine immunization programs by focusing on safety, maintaining financing, overcoming supply constraints, shoring up the health workforce, supportive supervision and performing targeted catch-up campaigns when needed. As countries around the world implement COVID-19 vaccines, they may face new challenges and opportunities with maintaining routine immunization services. There is a need to stay focused on core functions and activities such as those highlighted in Armenia, Georgia, and Uzbekistan, while exploring opportunities for service delivery improvements and innovation. For example, countries can explore how technologies can replace education and outreach visits and face-to-face communication with parents. Countries will also be eager to understand how PHC services can effectively integrate massive COVID-19 vaccination of their adult populations without disrupting childhood vaccinations. LNCT hopes to provide further opportunities for countries to learn from each other’s experiences with maintaining routine immunization during the COVID-19 pandemic.
Do you have a story about overcoming challenges to routine immunization during the pandemic to share? We invite you to post it in the comments, below!