Impact of COVID-19 on Immunization Services for Maternal and Infant Vaccines: Results of a Survey Conducted by Imprint - The Immunising Pregnant Women and Infants Network

"To address the current uncertainty reflected by this short study and experienced by healthcare providers, clearer and more tailored communication is urgently needed..., particularly for LMICs."

Research indicates that the consequences of interruptions to routine immunisation programmes due to the COVID-19 pandemic have the potential to be widespread, with at least 80 million children under the age of one estimated to be at risk from vaccine-preventable diseases (VPDs) due to such disruptions. To understand immunisation service interruptions caused by the COVID-19 pandemic, the researchers captured the local experiences of members of the IMmunising PRegnant women and Infants NeTwork (IMPRINT), a network of clinicians and scientists who investigate the biological and implementation challenges to the use of vaccines in pregnancy and the early postnatal period. With its 290 members based in 51 countries worldwide, IMPRINT provided the researchers with insight into the "collateral damage" caused by COVID-19, specifically related to the delivery of local and national immunisations, allowing for a comparison of the situation in high-income countries (HICs) versus low- and middle-income countries (LMICs).

Conducted over a 2-week period in April 2020, the online survey included discrete questions to quantify the extent of disruption, as well as free-text options to explore the reasons behind reported disruptions. Of the 48 responses received (representing healthcare providers and researchers at the grassroots level of vaccine delivery from 18 different countries), the majority (75%) were from LMICs. Overall, survey respondents conveyed a feeling of uncertainty due to the pandemic, independent of the setting, which extended into many services in their countries, including those related to routine immunisations. Of all respondents, 50% or more reported disruption in either maternal or infant/toddler vaccine delivery in their country.

Thematic analysis identified 3 key themes behind immunisation disruption, which are illustrated in figures within the paper:

1. "Access" issues - e.g., logistical barriers related to lockdowns;
2. "Provider" issues - e.g., staff shortages; and
3. User "concern" - e.g., fear of acquiring COVID-19 at immunisation appointments and broader vaccine hesitancy.

Access and provider issues were more commonly reported by LMIC respondents. In contrast, "concern" issues were reported more frequently as a barrier in HICs; however, the phrases "conspiracy theory" and "anti-vaccine (or anti-vaxx) sentiment" were mainly associated with some LMICs. ("This may be consistent with the wave of vaccine hesitancy...and broader mistrust currently spreading across this region, with regards to both COVID-19 illness and potential COVID-19 vaccine trials to be undertaken in the future...")

Participant free-text responses on regional, national, and international guidelines revealed, in part, that:

• Participants from LMICs primarily referenced World Health Organization (WHO) international guidelines, with some answers describing how their governments had adapted these recommendations to their setting.
• Other measures or recommendations described were geared toward the local or community level. Participants from LMICs gave more anecdotal evidence - for example, "sensitization and awareness creation of caregivers also to report suspect cases for COVID-19 in their communities..." and "recommendations around use of SMS [text messaging] reporting to monitor and track session implementation across the health facilities" (both by Nigerian respondents).
• Participants from HICs referenced more official communications to parents or families, quoting advice issued by general practitioners or community clinics: "We are trying to reassure families that appointments are being staggered and social distancing is being practiced in the waiting areas and increased cleaning practices are in practice". Links were provided by some respondents to information sent to parents highlighting the consequences of delayed vaccination; no similar examples of parental communication were provided by LMIC respondents.

Recommendations to emerge from the study include:

• Gear efforts to communicate policies and convey key messages to pregnant women and parents, especially those in LMICs - emphasising the importance of attending routine vaccination services, despite the COVID-19 pandemic.
• Especially for parents based in LMICs, focus strategies on more community engagement to improve immunisation uptake.
• Deliver accurate and up-to-date advice using user-friendly approaches (for example, via social media), given the importance of accurate online messaging during the pandemic.
• Develop communication strategies to tackle misinformation, which has been a worldwide concern during the pandemic. ("To date, the pandemic has largely been interpreted as an imported problem. This perception has in some places hampered acceptance of preventative measures...and might impact on future immunization campaigns, if a vaccine is tested and finally introduced.")
• Optimise logistics, both at a local and national level.
• Prioritise vaccination services at local, regional, and national levels: "General efforts explaining the safety measures implemented need to be communicated, in combination with the message that vaccination matters and saves lives, pandemic or not."
• Focus on developing alternative, innovative, and, in some cases, context-specific strategies to overcome or circumvent disruptions to service provision. "Local measures should...ensure safety and practicality, but still be sufficiently flexible to rapidly adapt to the evolving situation..." - e.g., a trial of "trace and immunise" systems, particularly using a digital interface.

The researchers conclude that further quantification of routine vaccination disruption is needed, alongside health service prioritisation, logistical support, and targeted communication strategies to reinforce routine immunisations during the COVID-19 response. In fact, a repeat survey is already planned. It will aim to increase the response rate, particularly from countries now at the epicentre of the pandemic, and to explore further how to manage the challenges of immunisation disruption. It would also be helpful to assess if: lessons have been learned, further recommendations or guidelines have been published at the national or local level (or alterations to the existing ones), and the implementation of novel strategies has helped to overcome identified barriers.