Maintaining Essential Services in the Time of COVID-19: Vaccination Delivery in Low- and Middle-Income Countries

As many low- and middle-income countries (LMICs) face alarming projections of the number of COVID-19 cases and deaths they can expect in the coming months, the pressure to meet spiralling health system needs is strong, especially for hospital-based medicine. But to avoid major deteriorations in key markers—such as maternal and child mortality—essential health services must not be overlooked. Many countries face challenges that go beyond providing adequate resources for essential services in health systems that already faced overwhelming demands before the pandemic began. These include the real impact that physical distancing measures and declining incomes are having on demand for health services.

As we observe World Immunisation Week, the implications of COVID-19’s spread for routine childhood vaccination delivery are already becoming clear. Gavi, the Vaccine Alliance, reports that 14 national campaigns against vaccine-preventable diseases such as polio, measles, and cholera have already been postponed. As a result of this, 13.5 million people in some of the most challenging settings worldwide will miss out on vaccination. Yet, as recent modelling work using data from Africa shows, the health benefits accrued from childhood vaccination vastly outweigh the risk of contracting, and dying from, COVID-19 during immunisation clinic visits.

This blog considers childhood vaccination delivery in the context of COVID-19, and proposes how to sustain, and ideally expand, delivery in the face of tightening resource constraints.

COVID-19 is already posing practical challenges to vaccination delivery in LMICs

Childhood vaccination is one of the most cost-effective interventions in the armoury available to public health policymakers and practitioners in LMICs. However, there is already strong evidence that COVID-19 is having a detrimental effect on all aspects of vaccination delivery:

• Routine vaccination is heavily dependent on complex global supply chains that have experienced significant disruption since the turn of the year because of controls on cross-border movement of goods. Besides obvious effects on distribution, this disruption also affects vaccine manufacture, because of sourcing and operational challenges in obtaining packaging, supplies, and ingredients due to lockdown measures, flight cancellations, and trade restrictions.
• Lack of access to personal protective equipment has prompted strikes and even legal action by healthcare workers in a number of LMICs and demonstrates that services may be vulnerable to shortages in healthcare workers available to deliver vaccination.
• Physical distancing measures imposed to control the spread of COVID-19 limit opportunities for physical vaccination delivery. WHO now recommends the suspension of mass vaccination campaigns as part of efforts to control COVID-19 spread.
• Although data from LMICs are in short supply, there is evidence elsewhere that people are not accessing care at pre-crisis levels: the English National Health Service reported a 30 percent decline in emergency department attendances in March 2020 compared to the same month in 2019—attributed to the combined effects of fear and physical distancing measures.

What effect might disruptions have on vaccination coverage and health outcomes?

Although physical distancing measures buy time in the short term as they reduce the spread of vaccine preventable diseases (VPD), we know from previous epidemics—including that of Ebola in 2014-2016—that with decreased vaccination comes an increased risk of VPD spread. Lessons learned from this include:

• The duration and intensity of disruption can have profound implications for coverage of essential vaccinations. In Sierra Leone, there was a 25-30 percent reduction in coverage for two key childhood vaccinations (MCV and Penta3) over the first nine months of the epidemic. Modelling work showed that a 50 percent reduction in measles vaccination across Guinea, Liberia, and Sierra Leone would result in a 19 percent increase in the number of unvaccinated children after 18 months’ disruption, and a 35 percent increase in mortality compared to no outbreak.
• The timing of disruption also matters. Although data are piecemeal, findings from conflict-affected settings show that disruptions at or immediately around the time of birth can significantly increase the risk of newborns and infants failing to receive key primary dose vaccinations.
• Finally, we know that even under normal circumstances, wealthier, urban populations are better able to afford and access vaccination. These inequalities in coverage are likely to widen as the economic effects of physical distancing measures intensify. This risk is particularly acute for vulnerable populations in LMICs—including refugees and those who are internally displaced.

What steps can Gavi take to mitigate the effects of the COVID-19 pandemic on vaccine delivery?

Gavi’s scheduled replenishment in the middle of this year presents a vital opportunity to review the scope and level of financial support for vaccine purchasing and delivery in LMICs in these challenging times, especially given forward projections that suggest these countries will see some of the biggest shortfalls in vaccination coverage in the coming years. Here are some ideas for Gavi to consider:

• Review transition planning and eligibility criteria for support. Gavi has already announced $200m in health system strengthening support to a series of low-income countries, but, in view of current developments, the timeframe for co-financing and phase-out plans for vaccination support in lower-middle-income countries should be revisited.
• Use Gavi’s Alliance structure to assure budgetary protection for Expanded Program on Immunization (EPI) programs and/or vaccines. As conditions for the large-scale budget support that is in the process of being deployed are developed, Gavi should use its structure to work with the World Bank and other multilateral development banks to protect public expenditure on EPI vaccines and delivery programs. Vaccination programs are an essential public health expenditure that should ideally be financed largely by a government’s own spending even in low-income countries—and an essential part of pandemic preparedness as well.
• Use the Alliance to enable and promote pooled demand and advance purchasing commitments for key EPI vaccines. This is a good time to support middle-income countries of all kinds to buy into UNICEF and/or Gavi purchasing partnerships at a tiered price for key EPI vaccines. In particular, appropriate volumes of MMR and IPV/nOPV vaccine need to be purchased, manufactured, and distributed as a priority. Until now, these vaccines have been relatively affordable, and most countries have purchased them on their own. But given the level of manufacturing capacity that will likely need to be diverted to production of a COVID-19 vaccine in the medium- to long-term, demand for MMR/pentavalent vaccines and IPV will need to be clearly defined by each country if they are to avoid shortages and price hikes. It may also be necessary for demand to be pooled and protected.
• Emphasise investment in strengthened and integral vaccine-preventable disease surveillance for health systems facing COVID-19. Effective surveillance is critical for monitoring purposes, and is particularly important in resource-constrained settings in identifying high-risk populations, or areas where system performance is poor, to support vaccination targeting. Strong VPD surveillance systems offer ready platforms for helping to track the spread of COVID-19. In this area, the pandemic presents an opportunity for Gavi to address shortfalls in its approach to global health security and improve surveillance systems, and take a fuller approach to VPD surveillance.

How can global and local actors support continuity of immunisation services in LMICs?

• Unlock logistics and supply chain bottlenecks by committing to remove movement restrictions on essential vaccination supplies, and facilitating international transport via specialized mechanisms being setup for COVID-19 supplies. Firm commitments are needed from governments, to allow the unrestricted movement of essential vaccination supplies (both supplies for vaccine manufacturing and for vaccine distribution within countries), and from airlines and air cargo companies, to provide priority to international shipments for Gavi and the UNICEF Supply Division. In cases where vaccine supplies in a country are extremely limited and special measures are needed, the emergency supply chain coordination mechanism—set up by WHO and the World Food Programme for COVID-19 supplies—could be utilized for expedited international and regional shipments of vaccines.
• Prioritise vaccination delivery as an essential health service, for everyone. This means:
  • Making the case for vaccination in the context of an ever-increasing number of competing pressures, and protecting the budget and spending on vaccination at all costs. There is much research evidence on which to draw, and a growing body of guidance from actors including WHO emphasising the need to prioritise above all primary series vaccinations for outbreak-prone diseases such as measles, polio, and diphtheria.
  • Monitoring vaccination trends to help decision-makers quickly identify pockets of vulnerability or low coverage, and target vaccination delivery appropriately.
  • Using innovative service delivery models, ranging from vaccinating in clinical areas segregated from those treating people with suspected COVID-19, through to community outreach clinics—where PPE supplies and other infection control measures permit.
  • Giving a robust commitment to ensuring vulnerable populations—such as refugees and internally displaced persons for whom cramped living conditions and compromised nutritional status accentuate the risk of VPD spread—are not left behind.
• Strengthen communication on the importance of vaccination. A central lesson of the West African Ebola outbreak was that the fragility of public trust in health institutions had major effects on people’s willingness to take up vaccination services. Fear and suspicion of health services as possible locations of COVID-19 transmission are likely to prove just as much of a concern to those seeking routine vaccinations and any future candidate COVID-19 vaccine. In addressing this, local decision-makers should have deliberate community engagement strategies, and can draw also on a plethora of simple, low-cost tools, and behavioural techniques for reducing vaccine hesitancy.
• Rationalise existing programs, by reviewing vaccination schedules and/or pausing the introduction of new vaccines. It may also become necessary to reconsider whether it is really cost-effective to continue to deliver all the vaccines included in routine schedules. These decisions must be locally driven and informed by ongoing re-evaluation of evidence.
• Begin planning now for catch-up vaccination campaigns, which will be critical to address shortfalls linked to COVID-19 disruption, evidence for which is steadily accumulating. While campaigns are regularly carried out in LMICs to help drive up coverage, nothing on the scale and scope of what will be required once physical distancing measures are lifted has ever been attempted before. Global and local actors will need to start putting systems in place now to rapidly roll out catch-up campaigns, and ensure that financing for this work can be unlocked quickly (for which Gavi’s role will again be central).  
• Consider demand-side incentives for vaccination. As the costs associated with seeking care increase and incomes fall, countries may consider using cash transfer programs as a vehicle to promote and expand vaccination coverage. In addition to the significant body of evaluation on cash transfer programs, microtransfers only for full vaccination coverage demand also seem worthy of further consideration (see New Incentives in northern Nigeria with a forthcoming evaluation showing that small demand-side incentives can play a major role in achieving full immunization coverage in very poor settings).

Concluding thoughts

In the rush to address the health system effects of COVID-19, it is vital that decision-makers, global and local, prioritise childhood vaccination delivery. Challenges resulting from the disruptive effects of COVID-19 are manifold but the consequences of failing to ensure this essential service is maintained are likely to be drastic.

We have outlined a series of measures that can be taken to help mitigate these effects, spanning financing, strengthened supply chain management, and planning early for catch-up campaigns, among many others. But decision-makers also need to start thinking now about what it might take to procure and implement rapid roll-out of COVID-19 vaccination at scale—even though all the evidence points to a viable vaccination being at least 12-18 months away. There are broad and exceptionally complex issues to consider in this space, including (but not limited to) the question of financing roll-out without compromising commitment to core childhood vaccinations, and delivery models that will likely need to target a different demographic to routine childhood immunisation. Detailed and considered treatment of these questions, including through pragmatic research, will need to be a priority in the months ahead.