Main types of pandemic-related effects on RI and approaches to mitigation

The COVID-19 pandemic affected key determinants of vaccination—facility readiness, intent to vaccinate and community access8 9—as well as how these drivers interact together to support timely, effective vaccine services worldwide (table 1). On their own, each of these disruptions could negatively impact vaccination rates; in combination, they formed substantial obstacles to RI programmes as a whole.

In Nepal, about 50% of immunisation centres ceased operations during the initial onset of lockdown measures at the end of March 2020; furthermore, cases among healthcare workers would cause clinics to abruptly suspend services. In mid-April 2020, a nationwide measles–rubella campaign was suspended due to safety concerns. Measles outbreaks occurred in 4 of Nepal’s 77 districts, which were thought to be related to such disruptions.

For Senegal, with mass gatherings prohibited in mid-March 2020, vaccination activities and mobilisation efforts led by Badiènou Gokh and other community-based health workers had to be postponed. Human papillomavirus (HPV) vaccine delivery was halted as schools, Senegal’s main platform for HPV vaccination, closed. At facilities, health worker availability became constrained by concurrent deployment for COVID-19 management and response. Senegal also saw patient attendance fall, which was attributed to a combination of movement restrictions, concerns about COVID-19 exposure, and/or rumours about COVID-19 and vaccine reliability.

In Liberia, growing vaccine hesitancy emerged as a major challenge, with rumours rapidly spreading about COVID-19 vaccines being tested on citizens. Concerned about potential longer-term consequences of vaccine misinformation, Liberia temporarily halted facility-based outreach services. Uptake of RI services also declined during the earlier days of Liberia’s state of emergency, while health facility staff also faced inadequate supplies of personal protective equipment (PPE).

These represent only a fraction of RI disruptions experienced in 2020,1 2 4 10 underscoring the importance of swiftly implementing catch-up activities and closing gaps in coverage. WHO has issued recommendations on providing immunisation services during the pandemic,11–14 with its guidance evolving alongside world’s evidence base on COVID-19 and how to weigh the relative risks of SARS-CoV-2 transmission against the costs of service disruption. In late March 2020, for countries with surging infections and without active measles or polio outbreaks, WHO recommendations viewed exposing healthcare workers and community members to the novel coronavirus as greater than temporarily postponing mass campaigns.11 As the world’s understanding of COVID-19 improved and the magnitude of service disruptions began to surface,2 WHO issued follow-up guidance on implementing mass vaccination campaigns12 and principles for maintaining or resuming RI.13 14

How countries have then acted—adapting such guidelines for local needs or developing their own mitigation strategies against COVID-19 disruptions based on prior experience or some combination of each—has become an area of great interest. Drawing from experiences in Nepal, Senegal and Liberia, as well as desk research, we identified six main components to approaches for addressing pandemic-related effects on RI (table 2).

First, prioritising the continuity of RI services, at both national and local levels, was a key component. This was particularly evident in Nepal, where the Ministry of Health and Population directed its Family Welfare Division to implement safety protocols and to adapt service provision as necessary to maintain RI services amid the country’s extended lockdown period (ie, end of March through most of July 2020).

Second, implementing communications and outreach activities were vital for addressing misinformation and strengthening trust in both COVID-19 guidance and RI activities. Such work was the cornerstone to Liberia’s mitigation approach, with a vaccine perception study identifying myths about COVID-19, limited trust in both new and old vaccines, and delays in vaccination timeliness as the primary barriers to uptake. In collaboration with key partners, Liberia’s Expanded Programme on Immunization (EPI) then developed a multistage communications plan, mapping key messages to target audiences, communication channels, and impact metrics for short-term, medium-term and long-term objectives.

Third, identifying alternative delivery options beyond health clinic settings was critical for promoting service continuity during the COVID-19 pandemic. For instance, Senegal’s RI programme began offering vaccine sessions at alternative hours, including after work and during weekends, and community health workers conducted home visits for HPV vaccination after school-based services became unavailable amid widespread closures.

Fourth, instituting IPC and distancing measures while modifying service provision practices has been fundamental for maximising the safe continuance or resumption of vaccination services. Nepal, Senegal and Liberia each adapted WHO guidelines to national and local settings, conducted IPC trainings and procured PPE for vaccinators.

Fifth, leveraging current—or setting up—systems to track missed doses and target catch-up efforts remains crucial for RI recovery efforts. In Senegal, healthcare workers have been using contact records maintained at district offices to text or phone parents whose children missed immunisation visits. In the absence of such information, short-term delays in completing vaccination schedules could quickly turn into more persistent coverage gaps and higher risk for vaccine-preventable disease.

Sixth, conducting catch-up RI services and campaigns as soon as SARS-CoV-2 transmission risks could be mitigated is imperative to addressing pandemic-related disruptions. For instance, Nepal resumed its nationwide measles–rubella mass campaign in June 2020 after a 1.5-month pause,15 and by August 2020, Liberia had conducted periodic intensification of RI in at least 11 districts.

Not every approach was used or perhaps needed in each country, just as COVID-19 has affected RI services in different ways across settings. For instance, Liberia’s EPI had to weigh the potential consequences of rapidly deteriorating vaccine confidence and trust against temporarily suspending facility-based outreach services in April 2020. Their pivot to identifying obstacles to vaccine uptake and establishing their risk communications strategy before resuming services again involved distinct planning and implementation approaches from those required elsewhere. In Nepal, large numbers of people would still show up at immunisation centres to vaccinate their children during lockdown periods; while high vaccine acceptance and service-seeking typically would be welcome, during the ongoing COVID-19 pandemic, such turn-out could heighten potential virus exposure and transmission risk in the absence of clear distancing measures and IPC protocols. As such, Nepal had to carefully coordinate immunisation sessions to maximise safety, especially when the rotavirus vaccine was introduced in July 2020. For Senegal, adapting modes of RI delivery was central to mitigating COVID-related effects on immunisation, especially when typical RI platforms—community-based outreach and school-based services—were not viable during nationwide gathering restrictions and closures. In response, community health workers have gone house-to-house for vaccination visits and have sought to provide greater flexibility in visit timing. What unites these diverse settings and programmes is the recognition that each level of vaccination barriers or facilitators must be addressed, from patient acceptance and trust to community access; the willingness to adapt to and test alternative approaches; and the overarching dedication to providing RI to all.

It is worth noting that pandemic-related impacts on RI may not be wholly known for months or even years to come. Similarly, the longer-term success of past and present efforts to maintain or resume RI remains unclear; this is particularly true as epidemic trajectories continue to change and now many countries are rapidly deploying COVID-19 vaccines alongside new virus variants and corresponding surges. Going forward, it is crucial to better understand implementation dimensions of modified RI services, including acceptability, feasibility, costs and effectiveness,16 17 especially as EPI programmes consider if and how to resume prepandemic operations. As more data are collected, analysed and disseminated, through the EGH partnership, we hope to continue collating lessons learnt about programmatic strategies and innovations that countries implemented to sustain vaccine delivery during the COVID-19 crisis.