Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit–risk analysis of health benefits versus excess risk of SARS-CoV-2 infection

LSHTM CMMID COVID-19 Working Group

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Abstract

Background: National immunisation programmes globally are at risk of suspension due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing COVID-19 pandemic. We aimed to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through visiting routine vaccination service delivery points. Methods: We considered a high-impact scenario and a low-impact scenario to approximate the child deaths that could be caused by immunisation coverage reductions during COVID-19 outbreaks. In the high-impact scenario, we used previously reported country-specific child mortality impact estimates of childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever to approximate the future deaths averted before 5 years of age by routine childhood vaccination during a 6-month COVID-19 risk period without catch-up campaigns. In the low-impact scenario, we approximated the health benefits of sustaining routine childhood immunisation on only the child deaths averted from measles outbreaks during the COVID-19 risk period. We assumed that contact-reducing interventions flattened the outbreak curve during the COVID-19 risk period, that 60% of the population will have been infected by the end of that period, that children can be infected by either vaccinators or during transport, and that upon child infection the whole household will be infected. Country-specific household age structure estimates and age-dependent infection-fatality rates were applied to calculate the number of deaths attributable to the vaccination clinic visits. We present benefit–risk ratios for routine childhood immunisation, with 95% uncertainty intervals (UIs) from a probabilistic sensitivity analysis. Findings: In the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa. The benefit–risk ratio for the vaccinated children is 85 000 (4900–546 000), for their siblings (<20 years) is 75 000 (4400–483 000), for their parents or adult carers (aged 20–60 years) is 769 (148–2700), and for older adults (>60 years) is 96 (14–307). In the low-impact scenario that approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10); if the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000). Interpretation: The deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children. Routine childhood immunisation should be sustained in Africa as much as possible, while considering other factors such as logistical constraints, staff shortages, and reallocation of resources during the COVID-19 pandemic. Funding: Gavi, the Vaccine Alliance; Bill & Melinda Gates Foundation.

Original languageEnglish
Pages (from-to)e1264-e1272
JournalThe Lancet Global Health
Volume8
Issue number10
DOIs
Publication statusPublished - Oct 2020

Bibliographical note

Funding Information:
We thank Nicholas Grassly (Imperial College London), Raymond Hutubessy (WHO), and Anthony Scott (London School of Hygiene & Tropical Medicine) for helpful discussions. We thank the reviewers for their valuable feedback on previous versions of the manuscript. This study was supported in part by Gavi, the Vaccine Alliance (KA, AC, MJ), the Bill & Melinda Gates Foundation (OPP1157270 to KA, AC, MJ; INV-003174 to MJ), the Vaccine Impact Modelling Consortium (KA, AC, MJ), Elrha Research for Health in Humanitarian Crises/UK Department for International Development (KvZ), UK Department of Health and Social Care (16/137/109 to MJ), UK Department for International Development/Wellcome Trust (Epidemic Preparedness Coronavirus research programme 221303/Z/20/Z to KvZ), and the Wellcome Trust (208812/Z/17/Z to SFl; 210758/Z/18/Z to SFu).

Funding Information:
We thank Nicholas Grassly (Imperial College London), Raymond Hutubessy (WHO), and Anthony Scott (London School of Hygiene & Tropical Medicine) for helpful discussions. We thank the reviewers for their valuable feedback on previous versions of the manuscript. This study was supported in part by Gavi, the Vaccine Alliance (KA, AC, MJ), the Bill & Melinda Gates Foundation (OPP1157270 to KA, AC, MJ; INV-003174 to MJ), the Vaccine Impact Modelling Consortium (KA, AC, MJ), Elrha Research for Health in Humanitarian Crises/UK Department for International Development (KvZ), UK Department of Health and Social Care (16/137/109 to MJ), UK Department for International Development/Wellcome Trust (Epidemic Preparedness Coronavirus research programme 221303/Z/20/Z to KvZ), and the Wellcome Trust (208812/Z/17/Z to SFl; 210758/Z/18/Z to SFu). Editorial note: the Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Publisher Copyright:
© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

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