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Why the Post-Pandemic Year Must Focus on Routine Child Immunisation

Why the Post-Pandemic Year Must Focus on Routine Child Immunisation

A child receives the oral polio vaccine in Lucknow, November 2009. Photo: RIBI Image Library/Flickr, CC BY 2.0.

Chennai: Although Union finance minister Nirmala Sitharaman claimed to have boosted India’s ‘health and wellbeing’ budget by 137% in the 2021 budget, experts warn that in the post-pandemic year, the government must focus on routine child immunisation and surveillance programmes – or India could face another outbreak of a vaccine-preventable disease (VPD).

A team of researchers from the International Vaccine Centre, Indian Academy of Paediatrics and other institutes surveyed paediatric healthcare providers in 21 states and two UTs. Their study, conducted in April-June and September 2020, showed that 33.4% and 7.8% of respondents reported a near-complete suspension of vaccination services in the respective periods.

In July last year, the WHO had warned of a worrying drop in the number of lifesaving vaccines children had access to. The government also admitted to parliament that the number of hepatitis B doses administered at birth had dropped 19% and the number of vaccination sessions in health facilities, 31%, from April to June 2020.

Even before the pandemic, a study by the Delhi government in November 2018, involving data pertaining to 10.2 million people, reported that over 2 lakh children aged 0-5 years in the national capital hadn’t been vaccinated for diseases like measles, mumps and typhoid.

Cancelled vaccination sessions

Dr Srinivas G. Kasi, convener of the Advisory Committee on Vaccines and Immunisation Practices, Indian Academy of Paediatrics, said that during the lockdown, the demand for vaccines crashed as people didn’t have access to transport facilities and were also afraid, especially in cities. Overall, routine immunisation took a backseat at most primary, secondary and tertiary health centres.

Dr Aquinas Edassery, founder of Swasthya Swaraj, a healthcare NGO in Kalahandi, one of the most backward districts in Odisha, said that even when there weren’t many cases of COVID-19, antenatal and newborn care suffered very much.

“The entire coverage of crucial vaccines is less than 10% at Thuamul Rampur, a block with 78 villages and a primitive tribal population of 50,000,” she said.

Odisha’s immunisation coverage was 87.3% in 2018-2019. According to National Health Mission data for April-June 2020, around 6,098 infants received BCG vaccines compared to 6,197 children in 2019 in Kalahandi. But Dr Edassery said she has observed that underreporting is rampant, especially since disaggregated data from tribal hamlets is either unavailable or isn’t solicited.

According to Swasthya Swaraj’s data, a screening for childhood tuberculosis revealed by accident that only 30% of children aged 0-3 months had received the BCG vaccine in 2019.

In an order dated April 15, 2020, the Union home ministry issued guidelines on immunisation practices to be adopted with respect to buffer, containment and green zones. But the sub-centres became proactive only much later.

According to the fifth National Family Health Survey, vaccination coverage has improved in the country relative to the fourth round. Of the 22 states and UTs, only Kerala, Lakshadweep and Goa reported decline in vaccination, whereas coverage increased by as much as 20% in Assam, Gujarat, Nagaland, Mizoram and Karnataka.

A study published in The Lancet Global Health journal in July 2020 reported that for every one excess death attributed to a COVID-19 infection acquired during routine clinic visits for vaccination in Africa, 84 deaths in children could have been prevented by sustaining routine childhood immunisation. In the previous month, the London School of Hygiene and Tropical Medicine had issued a measles outbreak warning, with 200 plus cases of which more than half were children younger than 5.

In Bihar, where around two lakh children are vaccinated a month, parents cancelled 93,000 immunisation sessions from March to May 2020, with only 4,575 children being vaccinated in April. Torrential floods during the pandemic further affected routine immunisation programmes in 136 blocks. When the waters receded, the state machinery used the COVID-19 house-to-house surveillance database, prepared by ASHA workers, to catch up on routine immunisation.

“Bihar has now been brought on track to 2019 records,” said Dr Syed Hubbe Ali, a health specialist with UNICEF Bihar. Another independent assessment by Care India in rural Bihar, of 15,687 children aged 20-23 months, reported 80% coverage with respect to full immunisation.

Resources diverted for COVID-19 vaccines

Vandana Prasad, a technical advisor with the Public Health Resource Network, said that Integrated Child Development Services and anganwadi centres still remain in a disrupted state in some parts of the country. K. Somashekhar, state president of the ASHA Workers Union of Karnataka, said that during the pandemic, around 80% of routine immunisation efforts had come to a halt.

Frontline workers like ASHA workers and auxiliary nurse midwives (ANMs) were focused on containment efforts, and were set back by the government diverting resources away from routine services. Of the 2.38 lakh ANMs in the country involved in providing various health services, including vaccination, the government had wanted around 1.54 lakh to be involved in the COVID-19 vaccine rollout.

Jan Swasthya Sahyog public health physician Dr Yogesh Jain’s primary concern is that the fall in immunisation could be compounded by the COVID-19 vaccination drive – since both programmes share the same workforce and infrastructure. “Vaccines can be delayed but not deferred, as the child remains vulnerable and unprotected until the immunisation is done,” he said.

The cohort of those who missed routine vaccination during the pandemic is huge, and experts have been warning that the government needs to mount special ‘catch-up’ programmes, especially now that COVID-19’s prevalence is also falling.

“Such programmes require elaborate administration, monitoring, supervision, modification of lists, mobilisation and tracking mother-chair pairs to prevent outbreak of VPDs,” Dr Kasi said.

Virologist and former professor of virology at the Christian Medical College, Vellore, T. Jacob John also insisted on proper surveillance. “Risk-benefit balance between coronavirus and measles must be determined, and depending on the results, catch-up immunisations can be undertaken, and if necessary, in campaign mode,” he told The Wire Science.

A nationwide pulse polio immunisation drive took place from January 31 to February 2 this year. After Pakistan and Afghanistan reported a surge in the number of poliovirus type-2 infections, India – declared polio-free in 2014 – had to be wary. Deepak Kapur, head of the Pulse Polio Committee at Rotary International, said supplementary immunisation for polio had suffered in the last year, with a dip during the two catch-up immunisation rounds in September and November 2020.

Some states doing better

Dr Prabir Chatterjee, director of the State Health Resource Centre of Chhattisgarh, said that unlike the national scenario, Chhattisgarh in particular hadn’t experienced a significant drop in child immunisation in the April-June period because the state government had instructed sub-centres to continue routine work. So from April to June, 2020, the number of infants given OPV 0 and BCG vaccines was both 93% and the fraction of fully immunised children (9-11 months), 97%, according to the Health Management Information System.

Dr Vinay Kumar, joint director (immunisation), Chennai, said Tamil Nadu had also managed 99% coverage of the pentavalent vaccine. Per the Directorate of Public Health and Preventive Medicine, the annual vaccine coverage for TdM vaccine was 94%.

According to the 2011 census, there are 63 million child migrants in India; they lack early childhood care and support services, with no periodic government enumeration of migrant workers and their families. So as such, it was significant that Jharkhand was one of few states to have launched an immunisation drive for 44,191 children of migrant workers.

A senior official from the Union health ministry’s department of immunisation said full immunisation coverage in 2020 was around 85%. “We plan to have two rounds of Intensified Mission Indradhanush catch-up immunisations in February and March to reach out to children who missed getting immunised,” the official said. “Our [measles rubella] surveillance did reflect some states that had reported episodes of measles and we reviewed the situation.”

Pradeep Haldar, deputy commissioner (immunisation), in the ministry said vaccination coverage by most states in 2020 did manage to be at par with the previous year – except a few areas that had to be locked down. “One of the biggest challenges in the immunisation programme of India is the increased internal migration,” he said.

Nalini Ravichandran is based in Chennai and has written for The WireMongabay India and Culturico. Previously, she was with The New Indian Express, Chennai, and Mail Today, New Delhi.

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