The COVID-19 impact: What happens when immunization services halt?

Season 2, episode 3

The COVID-19 impact: What happens when immunization services halt?

As the world grapples with the novel coronavirus pandemic, many essential health services have been disrupted. Immunization is one of them. Join experts as they highlight that millions of children are missing out on vaccines and how this could trigger outbreaks of infections and child death due to deadly vaccine preventable diseases.

Guests: 

Dr. Natasha Crowcroft, Director, Centre for Vaccine Preventable Diseases, University of Toronto

Dr. Robin Nandy, Principal Adviser and Chief of Immunization, UNICEF

Producer: Priyadarshini Mitra

Sound Mix: Chandra Bulucon

Episode Transcript 

[00:00:00.93] In the days and weeks ahead, we expect to see the number of cases, the number of deaths, and the number of affected countries climb even higher. WHO has been assessing this outbreak around the clock. And we're deeply concerned. We have therefore made the assessment that COVID-19 can be characterized as a pandemic.

[00:00:33.15] That was WHO Director General Dr. Tedros Adhanom on March 11 confirming some of our worst fears, that the coronavirus disease was now declared a pandemic. Now, more than a month later, COVID-19 has affected every aspect of our daily life. It feels quite surreal.

[00:00:56.76] Schools for more than 90% of the world's children have shut down. Most adults are working from home, international borders are closed, playgrounds have fallen silent. I'm David Morley, President and CEO of UNICEF Canada, and the host of the For Every Child podcast.

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[00:01:26.69] I'm recording this month's episode from a quiet corner in my house. It may sound a bit different compared to how it usually does as each member of our UNICEF Canada family is adjusting to this new reality.

[00:01:41.39] In terms of the disease, COVID-19 has largely spared the children. But it is the children who are the silent victims of this pandemic. We can see the immediate impact in the disruption to their learning, the psychosocial effects of missing interactions with friends and loved ones, staying at home with increased screen time and minimal exercise.

[00:02:06.22] Today's For Every Child episode is going to focus on how the pandemic is impacting the long-term health of our children, and even threatening to reverse gains in health outcomes around the world. We'll discuss the effect COVID-19 is having on immunization. This pandemic is overstretching health systems. Health workers are being diverted to support the outbreak response. And the longer the pandemic continues, the more that essential health services, including vaccinations will be disrupted.

[00:02:45.20] Physical distancing and isolation is also causing vulnerable children to not receive critical vaccines. This will result in an increased risk of outbreaks of infectious diseases, such as measles, polio, and whooping cough.

[00:03:01.21] Think about the children living in countries affected by conflict and humanitarian disasters. They face the greatest risk. To talk a bit more about this, we are joined by Natasha Crowcroft. Natasha is a public health professional specialized in infectious diseases, and immunization, and the director of the Center for Vaccine Preventable Diseases at the University of Toronto.

[00:03:25.72] Natasha, the COVID-19 outbreak reveals what is at stake when communities do not have the protective shield of immunization against an infectious disease. It's a stark reminder of how fast an outbreak can spread without a vaccine to protect people and communities.

[00:03:44.98] Yes, for sure. I think any time there's an outbreak, it's a wake up call to people. A tremendous reminder of why we vaccinate. And we see this with, for example, when there's a measles outbreak, or even one case of measles.

[00:04:00.34] In a high income country, people suddenly respond. And they'll go and get their kids vaccinated, even people who were hesitating about vaccines will often step up when they know that measles is an immediate threat.

[00:04:15.25] And so in the same way, I think this pandemic is that reminder where people will be thinking, well, I wish we had a vaccine, or when can we have a vaccine, or how quickly is it going to be possible. It just changes the way people think.

[00:04:30.34] I am reminded of the pandemic, the last pandemic we had, which was a pandemic H1N1 influenza. And when the vaccine became available for that, people in some places, were lining up around the block to get the vaccine. It didn't last very long that interest. And so it's difficult to predict exactly what will happen. And a lot of what happens depends on how people feel, and how much they trust the authorities. And when people are scared, they don't always behave in predictable ways.

[00:04:59.92] When it comes to humanitarian crises, like say the ones we have in Syria, Yemen, or the Ebola outbreak in the Democratic Republic of Congo, what role does routine immunization play in protecting children and adults?

[00:05:16.33] So talking about humanitarian crisis, routine immunization is incredibly important. Often the very first disease that will emerge in that situation is measles because it's so infectious, and because immunization coverage only needs to drop a little bit in especially when there's a high birth rate it. It just explodes in those sorts of settings, and it can be devastating.

[00:05:39.32] In those humanitarian crises, the emergencies are affecting places where the populations are already in difficulty. They're already in trouble, where children have malnutrition, where the communities are stressed. They may have had to move out or flee terrible situations.

[00:05:59.61] And so the infectious diseases in those settings have the worst impact on the poorest and most vulnerable people in the world. So people who work in that area, one of the first things they do is try and ensure that populations and communities are immunized. And indeed, when the Ebola outbreak, in 2015 in West Africa, was going on because the whole immunization program basically shut down during the outbreak, as predicted that there would be probably more deaths from measles following the outbreak when it was over than had occurred due to Ebola itself.

[00:06:32.64] And so as a result of that, a huge immunization campaign was put in following the Ebola oubreak to try and mitigate that. So these crises come with a huge risk of vaccine preventable diseases. And that's very well-known, and it's one of the first things that is done to protect those communities.

[00:06:53.57] We spoke about measles. Some countries, including Canada had eliminated the disease. What led to its comeback?

[00:07:02.21] There are lots of different reasons in different places around the world. And so in places, in other countries, there are weak immunization systems, or weak health systems, or the crises we've just been talking about. But I think in countries like Canada, then falls in confidence, and in trust have been a much bigger component of what's influenced these outbreaks.

[00:07:26.60] In North America, I think, so Peter Hotez talks about all the influences that have led to vaccine hesitancy, including the vaccination programs of the victims of their own success. You don't see the diseases. You forget why you vaccinate.

[00:07:43.67] And so you really need community champions to try and keep confidence in programs. And there are countries like Nepal, for example, that actually have female volunteers in communities, who help support confidence in immunization. And it's been incredibly successful in that setting.

[00:08:00.66] And I think it would be great to learn from a country like Nepal. There's another idea that this idea of freedom of choice. But it's applied to vaccines in a very indiscriminate way. The idea is that everyone has freedom to choose whether or not they vaccinate their kids, which is best very aligned with that political, again, view of the world of freedom of choice being absolutely key.

[00:08:23.63] But it's seen in a very one dimensional way. So it leaves out freedom of people to expect that their kids will be protected in living in a society like in Canada. And it's a niche idea as well.

[00:08:37.31] Because most parents, if you ask them, will say, well, actually, I don't think people should have choice not to vaccinate their kids if it's going to put my kids at risk. It's a philosophical view that lines up with a certain view of the world, where no one can tell me what to do, and you can't tell me to vaccinate my kid.

[00:08:54.98] And which goes against what we're trying to achieve with immunization, which is herd immunity, and protecting everyone, and protecting the most vulnerable amongst us. Everyone who can participating. Many people can't. So older may not be as well protected because their immune system is getting older.

[00:09:12.26] People who are going through cancer treatment. Young babies are too young to be fully immunized. People with all sorts of immune problems, they need to be protected by everyone else who's healthy. And so those vulnerable people don't have a choice. So the rest of us can step up and help.

[00:09:29.63] And that whole concept of us all being in this together is something that is really key to the success of immunization. Earlier, we were talking about how the COVID-19 outbreak could be a wake up call for vaccines. I think it's also a wake up call for the fact that we're all connected, and an infectious disease is a social diseases, and they spread between people. And so we have to think about other people when we think about vaccines as well.

[00:09:58.19] When you spoke about freedom and rights colliding, you made mention of herd immunity. Can you tell us what it really means, and how it can help protect people against disease?

[00:10:10.37] Herd immunity, this sometimes called a free rider idea, where well I don't need to worry because everyone else will get vaccinated. That is morally a bit repugnant. But from a purely, is it actually technically true?

[00:10:26.42] Well, when you get vaccinated, you protect others through herd immunity, but you also get individual protection. If you decide not to be vaccinated, and to rely on everybody else being vaccinated, there's an element of protect. But all it takes is for you to take one aeroplane trip with somebody else who's got measles on the plane, or if you live in a city where I live Toronto, which is the most diverse city in the world with people who have come from all over the world, and travel all over the world.

[00:10:56.40] You could just be walking through your local supermarket, and be exposed to measles because somebody has just come back from somewhere. So it's a very short sighted idea to rely on herd immunity. You really need both.

[00:11:08.88] What would you say are already some key learnings from COVID-19 on how we can be better prepared to handle such a crisis?

[00:11:17.70] Probably the biggest key learning, which isn't necessarily something new, but I think is something to think about right now is, can we really please stop forgetting the lessons of the past? It's so easy when there isn't an outbreak going on to think, oh, everything's OK. And we don't need to do anything.

[00:11:36.39] And time and again, that's been shown to be wrong. During the SARS outbreak in 2003 in Toronto, everybody was regretting the cuts to public health that had meant that the system wasn't strong enough to deal with that outbreak. And yet when the new Ontario government came in 2018, one of the decisions they made was to cut public health in Ontario. We need public health, and we need well-funded, well-resourced.

[00:12:05.22] Public health that's able to respond to these kinds of crisis. Part of that system has to be investing in public trust, which means that the public health organizations need to be independent enough of government to be trusted by the population and with leaders that people believe in. And we've seen some great examples during COVID-19.

[00:12:27.12] Leaders such as Dr. Bonnie Henry in Vancouver, and people like that make a huge difference to the population. Someone that they feel is telling them the truth won't tell them things won't reassure them falsely.

[00:12:39.30] Another thing we're learning already is how important it is to invest in applied science. And that means we need science within our health care and public health systems. We need research be going on integrated into the response. And for the people with scientific skills to be included in those organizations and in the leadership.

[00:12:56.91] Because when you have a big new outbreak like this, there are so many questions that we need to be able to answer. And the other thing that's really coming out is how prescient it was to set up organizations such as CEPI, the Coalition for Epidemic Preparedness and Innovations which is a global organization that is helping to drive forward the development of vaccines and other innovations.

[00:13:22.53] And they need to work very closely with researchers. And it's been unprecedented the speed at which things are moving forward in this pandemic. And that's very pleasing to see. It's never going to be fast enough. But it's so much faster than it's ever been in human history.

[00:13:40.63] So what are the measures that are needed to maintain immunization during emergencies?

[00:13:46.17] It's certainly a challenge to keep immunization programs going during emergencies. I would say that it starts before the emergency starts. Every country needs to have robust public health systems. And the stronger they are, the better, and the more resilient they'll be to get through an emergency.

[00:14:03.97] I think having political support, non-partisan support for immunization and solidarity within nations, as well as between nations, that high level of support is really important. So that it is possible to have a ceasefire between two sides that have absolutely no time for each other, and still get in there, and do an immunization program if you can get the right political support.

[00:14:28.20] We absolutely take it for granted. And in a country like Canada, it's one of the things I think is incredibly pleasing that the leaders, whatever their political party in general support immunization. And I think the other thing that helps people get through emergencies is good communication systems that inspire trust and confidence, and that are rapid and transparent.

[00:14:49.89] So example, the Dengvaxia, the dengue vaccine issue in the Philippines, where an issue to do with a new vaccine that was used in the Philippines undermine trust in the whole immunization program. And so you really need good communication systems that will inspire people to maintain confidence in the immunizations.

[00:15:10.54] And then another thing I think people don't maybe talk about as much is how important the laboratory systems are, and these are often a bridge between the health care system and the public health system getting laboratory data even during a crisis can be absolutely critical to figuring out what is going on. So those are some of my thoughts. It's not easy. It's very complex, and it requires something we're talking about a lot at the center for vaccine preventable diseases. At the University of Toronto is the need for interdisciplinary approaches people working together in order to make sure that during emergencies, we do the right thing.

[00:15:51.70] Thank you, Natasha. Like you said, only when all people work together in responding to a crisis can we hope for a solution. In our interconnected world, diseases are not limited by geographic borders. We are all in this together.

[00:16:11.47] In spite of the circumstances, I want all our listeners to know that our UNICEF team is working tirelessly in response to coronavirus both at home and around the world, whether it's delivering protective gear and supplies to health workers in countries that need it the most, or working with the Canadian government to advocate for children.

[00:16:35.02] Robin Nandy, chief of immunization at UNICEF is amongst those working closely on our COVID-19 response globally. Robin, can you tell us a bit more about it?

[00:16:47.14] As you know, UNICEF is a global presence, and pretty much all low, and middle income countries around the world. We work in multiple sectors. But I'm going to focus my responses largely on the health sector response.

[00:17:06.94] We are engaged in the COVID response in three ways. One is the immediate response supporting the government with essential supplies. Very importantly, UNICEF is a big player in our global supply of health and supplies for other social sectors through our supply division in Copenhagen. We want to maintain the continuity of essential supplies, drugs, vaccines, and so on, personal protective equipment for health care workers.

[00:17:39.19] We are also the lead agency for risk communication and community engagement. As with social media, a lot of misinformation as well, making sure that everybody has access to appropriate information, accurate information. We work with our colleagues at WHO on case detection, surveillance largely through the community, health networks, support also goes to appropriate case management, and essential supplies. Oxygen concentrators very important in managing cases of COVID.

[00:18:14.98] That's direct COVID support. But we are also equally concerned about what we call the secondary impact of the COVID outbreak. So the diversion of attention, the diversion of resources, human resources to the COVID response is very appropriate at that time. But there trade-offs, because you could basically shift attention away from other basic health services like maternal newborn health services, treatment of common illnesses that are life threatening for children, pneumonia, diarrhea, and malaria, continuity of immunization services. Because we don't want these countries to be outbreak of vaccine preventable diseases like measles along with or soon after the COVID outbreak.

[00:19:06.64] And then the third part is the principle of system strengthening. And whatever we do now in the COVID response, we need to be mindful of how it contributes to building the health system more broadly for any future, such threats outbreaks are unpredictable for sure. But what is definitely predictable is the fact that COVID-19 is not going to be the last such threat that we face.

[00:19:36.31] Every year, UNICEF reaches almost half the world's children with life-saving vaccines. What impact are we seeing COVID-19 having specifically on immunization due to border closures, and travel restrictions?

[00:19:50.95] There has been no halt in manufacturing of vaccines. That is continuing. Some of our industry partners, maybe their capacity has dropped because of work absenteeism, and so on, and so forth. So the vaccine supplies are going on.

[00:20:04.84] I think what we are tracking very closely is the movement of these supplies from the manufacturer to the country of use because of flight cancellations, and so on. But even that, we are getting around through using alternate routes, chartering planes, where needed, and so on, and so forth.

[00:20:22.34] However, from a programmatic side, we are following guidance from WHO, which is endorsed by the strategic advisory group of expert on immunization, which basically recommends continuing immunization services whenever possible within the constraints of the health system that is stretched with the COVID response. We also understand that even if health facilities continue to offer vaccinations, it might be very difficult for parents to bring their kids for immunization.

[00:20:54.58] So we have temporarily suspended all campaign style delivery of immunization. Campaigns are an extremely effective way in which we reach large number of children in a short space of time. Not having these campaigns it means that we do compromise what we call population immunity among kids. This could give rise to the risk of vaccine preventable diseases, particularly those that are communicable, or transmissible like measles.

[00:21:26.88] And you would have seen the statement from the Measles & Rubella Initiative that the suspension of measles campaigns itself will likely deprive as many as 114 million kids from measles vaccine. So I mean, it's extremely important that we track this, not after the COVID outbreak is over, starting now.

[00:21:51.84] The tracking of kids that have missed routine doses, and the kids that have missed campaigns because of delays and already start planning in terms of how to target ensuring essential supplies. We are seeing a big hit that the world economies are facing with the COVID outbreaks. And this would be even further compounded if there are other outbreaks that are superimposed on the COVID outbreak.

[00:22:21.03] If these interruptions are unavoidable, as we try to contain the spread of the pandemic, how can we make sure the vulnerable children, especially those living in emergencies are still able to maintain their immunization coverage? Will there be catch up immunization measures undertaken once these COVID-19 related restrictions are lifted?

[00:22:43.41] The good thing that we have in immunization now is very robust partnerships like the Gavi alliance, like the Measles & Rubella Initiative. We are all working collectively across organizations like the World Health Organization, like the US CDC to already start planning to mitigate the impact of these disruptions that COVID-19 has had on Immunization programs.

[00:23:10.86] Of course, in humanitarian situations, in countries impacted by conflict, in countries with weak systems, we are particularly concerned because the health system is already stretched, and we are trying to use whatever tools and tactics that we have to try and monitor the impact of disrupted immunization children track the kids that are missed doses, so that we can act very quickly as soon as the social restrictions are lifted.

[00:23:42.09] These catch up activities could be in the form of intensified outreach services through routine or through campaigns. We all realize that they will probably be a need for bigger campaigns to conduct these catch up both geographically, as well as the age range of children that we target, given that these disruptions are likely to last a few months at least. This will require resources, government resources, external resources.

[00:24:10.77] The Gavi alliance is due for replenishment early June. And it's really important that the immunization needs are not forgotten as the world battles against COVID-19. In immunization, we have more robust data compared to other parts of the health sector.

[00:24:34.63] And we know that most of the unvaccinated kids now reside in either conflict affected areas among the urban poor in slums, or in remote rural areas. And we have tried and tested strategies to reach kids in all these areas. I'm confident that with good proactive planning, adequate attention both technical and political, and adequate resources, we can mitigate the impact.

[00:25:04.95] It's good to hear you say with confidence that we can mitigate the impact of COVID-19. Robin, is there any final message you have for our listeners?

[00:25:14.91] Every adversity that we face teaches us things. This particular pandemic is a stark reminder of how vulnerable we are as a community, as a nation, as a world. And you've seen relatively affluent countries have suffered from the COVID outbreak, even countries with reasonably good health systems.

[00:25:40.90] So I think a robust health system and primary health care level moving to secondary and tertiary care, all levels are extremely important, and need to be maintained and invested in secondly, I think while we have had relative success in addressing vaccine preventable diseases, we still need to be cognizant that approximately 20 million kids each year miss out on essential vaccination or vaccination. So we are missing out the most vulnerable, the most underserved children.

[00:26:14.94] And on the other hand, there is a clamoring for a COVID vaccine. It's good to remind ourselves that just having the vaccine, having the tool in our hand is not adequate. And we need the health system, and the delivery system to get these vaccines to the populations that need them most.

[00:26:35.91] It's still 12 to 18 months away. But I think it's not the discovery of it, but is actually the delivery of it that is extremely critical.

[00:26:46.08] Infectious diseases don't know boundaries. They don't care whether a person is rich or poor. They don't care what nationality they are, what ethnicity, what religion they are.

[00:26:55.90] And so diversity like this needs to really reinforce our human values, and make sure that we do the right thing for our communities, for our countries, for the rest of the world. And I think we've come a long way. The way the scientific community has come together developing diagnostics, testing treatments, developing vaccines for COVID.

[00:27:24.12] We had the first vaccine candidate going into trial roughly 70 days after the start of the outbreak. This is pretty unprecedented.

[00:27:33.19] So the Global Health Partnership is extremely critical. We all play our part. We all work based on our comparative advantage. And I think this collective effort and partnership is going to be critical to address both COVID, as well as any future threats that we face.

[00:27:55.32] April 24 to 30 is World Immunization Week. The science is clear, vaccines are safe and effective life saving tools that prevent the spread of infectious diseases. This will not be the last outbreak we face.

[00:28:12.09] We need to build on our past and current experiences to better prepare for future disease outbreaks and pandemics in all countries, but especially, those with weaker health systems. As our speaker said, strong primary health care is the foundation.

[00:28:32.70] And I want to end this podcast today with a thank you. A thank you to all our health care professionals, our frontline workers, those who've made sure that we keep well, and keep moving when the world has been forced to a halt. Thank you all for listening.

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