Operational Considerations for Immunization Services 

during COVID-19 in Non-US Settings Focusing on 

Low-Middle Income Countries

Accessible version: www.cdc.gov/coronavirus/2019-ncov/global-covid-19/maintaining-immunization-services.html

cdc.gov/coronavirus

www.cdc.gov/coronavirus/2019-ncov/global-covid-19 CS 318280-A 08/03/2020

Background

Immunization services have been disrupted significantly during 

the COVID-19 pandemic, threatening the achievements in the 

eradication and elimination of major vaccine-preventable diseases 

(VPDs) like polio and measles. More than 80 million children under 

the age of one are estimated to be affected by disruptions in routine 

immunization services in more than 68 countries and are at risk of 

polio, measles, diphtheria, pertussis, tetanus, hepatitis B, Hemophilus 

influenza type b, pneumococcus, and rotavirus infections (1). As of 

June 1, 2020, approximately 125 mass vaccination campaigns against 

polio, measles, meningitis A, yellow fever, typhoid, cholera, and 

tetanus had been postponed. 

In many countries, immunization services have been disrupted 

as a result of:

• Unavailability of healthcare workers as a result of their deployment 

to the COVID-19 response.

• Lack of personal protective equipment (PPE) to conduct 

immunization activities during COVID-19.

• Healthcare workers’ fear about contracting COVID-19. 

• Lack of vaccines due to closure of country borders as a result 

of COVID-19.

• Reduced demand for immunization services due to unwillingness 

or inability of parents to leave their homes due to fear of COVID-19.

Purpose

The purpose of this document is to provide operational 

considerations for the implementation of immunization services 

during the COVID-19 pandemic in non-US settings. Its intended

users are CDC country offices, immunization program managers,

and staff from partner immunization programs. These considerations 

are meant to supplement—not replace—any local health and

safety laws, rules, and regulations.

This document provides a summary of global guidance on 

immunization services during COVID-19 as of June 12, 2020. 

It complements and provides reference to more detailed technical 

guidance from the World Health Organization, UNICEF, and the

Global Polio Eradication Initiative including: 

• Guiding principles for immunization activities during the 

COVID-19 pandemic: interim guidance

• Frequently Asked Questions: Immunization in the context of 

COVID-19 pandemic

• Framework for decision-making: implementation of mass 

vaccination campaigns in the context of COVID-19: Interim 

guidance

• Polio eradication programme continuity: implementation in the 

context of the COVID-19 pandemic

Implementation of vaccination sessions

during COVID-19 

• Immunization services are essential and should be maintained 

whenever possible during the COVID-19 pandemic to prevent 

outbreaks of vaccine-preventable diseases (VPDs) and protect 

children (2,3). 

• Immunization delivery strategies need to be adapted depending 

on the VPD risk and COVID-19 situation in each country 

(see Table) (3–6).

• National Immunization Technical Advisory Groups (NITAGs) should 

be involved in decision making with regards to scheduling and 

implementation of routine immunization services and mass 

vaccination campaigns. 

• Healthcare workers should regularly inform communities about 

the status and availability of routine immunization services and 

mass campaigns. Regular communication will help to reduce 

confusion about availability and purpose of immunization 

services, increase awareness of the necessary precautions in 

place at the immunization session site to prevent SARS-CoV-2 

transmission and prepare community members who need to 

attend the vaccination session. 

• It is likely that measures to reduce SARS-CoV-2 transmission and 

ensure the health and safety of both health workers and clients 

will remain in place for some time. Special considerations for 

setting up the vaccination site and maintaining good infection 

prevention and control (IPC) practices should be followed (4) 

(see Annex in Framework for decision-making: implementation 

of mass vaccination campaigns in the context of COVID-19:

 Interim guidance for detailed IPC and PPE recommendations)

» Recommendations for vaccination site:

 Conduct vaccination in a well-aerated area and implement 

frequent disinfection focusing on high-touch surfaces, using 

products effective against SARS-CoV-2.
 Reconfigure waiting rooms to allow for at least 2 meters 

(6 feet) distance between people and limit entry to only 

one companion per vaccination recipient. In situations 

where people will form lines, encourage people to stay 

at least 2 meters (6 feet) apart by providing signs or other 

visual cues such as tape or chalk marks.

 Consider increasing the duration of the vaccination session 

and/or number of vaccination sites so that people can 

maintain physical distancing of at least 2 meters (6 feet).

 People with pre-existing medical conditions should have 

separate vaccination sessions.

 Separate vaccination sites from curative services by using 

different locations or allocating different hours. 

 Alcohol-based hand sanitizer with a minimum of 60% alcohol 

or a hand washing station with soap and water, paper towels, 

and trash can (hands-free) need to be available and should 

be used by every person entering the vaccination site and by 

healthcare workers to perform hand hygiene after every client.

 Maintain 2 meters (6 feet) distance when possible between 

people at the vaccination site. 

 Prior to entry into the vaccination site, screen vaccination 

recipients and companions for COVID-19 symptoms and 

exposure risk. Those who screen positive should be offered a 

mask then referred to the relevant part of the health system 

for further COVID-19 evaluation. If feasible offer vaccination 

at the COVID-19 evaluation site or, if not feasible, postpone 

vaccination for 14 days after symptom resolution or 2 

negative tests conducted at least 24 hours apart.

» Recommendations for vaccinators 

 Vaccinators should not come to the vaccination session if 

they have symptoms suggestive of COVID-19 or have been 

exposed to a person infected with SARS-CoV-2. Please see 

return to work guidance for healthcare professionals for 

further details on when vaccinators can return to work. 

 Maintain hand hygiene after interaction with each client/

vaccine recipient by washing hands with soap and water for 

at least 20 seconds or using hand sanitizer with a minimum of 

60% alcohol.

 Vaccinators should wear masks throughout the vaccination 

session, especially in areas with widespread community 

transmission of COVID-19.

 Catch-up vaccination

• Disruption to routine immunization services and reduced demand 

for these services will lead to missed vaccinations. However, the 

recommended immunization schedule should always be initiated 

at the earliest opportunity. 

• To close immunity gaps created by any disruption to routine 

immunization services, countries need to plan for and implement 

catch-up vaccination at routine immunization services (fixed, 

outreach, mobile, and school-based). Some countries may also 

choose a ‘campaign’ style “periodic intensification of routine 

immunization” (PIRI) approach to provide more intensive and 

large-scale opportunity to receive any nationally recommended 

vaccines that have been missed (7). 

• A catch-up vaccination policy or guideline and a catch-up 

schedule are essential components of an immunization program. 

Development or revision of catch-up policy or guidance should 

be done in collaboration with the NITAG and be officially 

disseminated to all healthcare staff involved in managing and 

delivering immunization services. Guidance on target age ranges, 

number of doses for each vaccine, minimum intervals between 

doses of the same vaccine, reminder that there is no need to 

repeat previous doses, and where and how to report vaccine doses 

that are given outside the recommended age range should be 

included.

• The WHO recommendations for interrupted or delayed 

immunization will help inform development of catch-up policy 

and guidelines. Examples of catch-up vaccination schedule for the 

United States is available from CDC. 

• Missed vaccine doses that are provided to individuals outside the 

recommended age range should still be recorded on the homebased record (HBR) of vaccination and reported through the 

usual immunization information system. Doses should always be 

recorded in accordance with the number of doses in sequence, 

regardless of age. 

• Engagement with communities and implementation of 

communication strategies are essential to re-establish community 

demand for vaccination and increase awareness that it is not 

too late to vaccinate. Key messaging should be on increasing 

awareness that individuals are still eligible to come for missed 

vaccinations, that late vaccination still provides a high level 

of protection against disease, continued high safety of late 

vaccinations, and ensuring that individuals know when and where 

immunization services are currently being provided as well as the 

safety precautions being taken for delivery of services.
Table. Framework for provision of various immunization services during the COVID-19 pandemic 

by degree of community transmission of COVID-19*

None to minimal community 

transmission of COVID-19.

Minimal to moderate

Community transmission of 

COVID-19.

Substantial community 

transmission of COVID-19.

Evidence of isolated cases 

or limited community 

transmission, case 

investigations underway, no 

evidence of exposure in large 

communal setting.

Sustained transmission with 

high likelihood or confirmed 

exposure within communal 

settings with potential for 

rapid increase in cases.

Large scale community 

transmission, multiple cases 

within communal settings 

(e.g. healthcare facilities, 

schools, workplaces, mass 

gatherings, etc.)

Immunization Delivery platform

Routine immunization (RI) 

platform (fixed, outreach, 

school, mobile)

(3,5)

Fixed RI sessions and 

newborn (BCG, OPV, HepB) 

vaccination should continue. 

Outreach and mobile 

sessions can continue if 

there is no evidence of local 

transmission. 

School-based vaccination 

can continue if schools are 

open and are allowing such 

activities. 

Fixed RI sessions and 

newborn (BCG, OPV, 

HepB) vaccinations should 

continue. 

Outreach, mobile and 

school-based vaccination 

might need to be suspended 

depending on local situation. 

Fixed RI sessions and 

newborn (BCG, OPV, 

HepB) vaccinations should 

continue. 

Suspend outreach, 

mobile and school-based 

vaccination and re-evaluate 

the situation weekly by 

conducting a risk-benefit 

analysis. **

Mass vaccination campaign 

(preventative supplementary 

immunization activity, 

outbreak response 

immunization, PIRI***)

(4,6,7)

Mass campaigns can 

continue while maintaining 

standard IPC measures and 

using PPE.

Assess the risks and 

benefits** of the mass 

vaccination campaign 

based on local VPD 

morbidity. Consider 

modified approaches to 

vaccine delivery and If 

campaign is conducted 

provide appropriate PPE and 

implement standard IPC to 

prevent COVID-19 spread. 

Mass vaccination campaigns 

should be temporarily 

suspended and re-evaluate 

the situation weekly by 

conducting a risk-benefit 

analysis** assessing risk 

of delayed campaign on 

morbidity and mortality 

of the VPD and potential 

to increase COVID-19 

transmission.

VPD surveillance (5) VPD surveillance activities 

should continue as usual.

At a minimum surveillance 

for VPDs with eradication 

and elimination goals should 

continue. Identify critical 

VPD surveillance activities 

that need to continue. 

Active surveillance can be 

maintained if surveillance 

officers are provided with 

PPE.

Identify critical VPD 

surveillance activities 

that need to continue. 

Community-based 

surveillance should be 

suspended.

* For all activities, standard IPC measures need to be followed irrespective of the degree of community transmission

** See Figure 1 in Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19: Interim guidance

*** PIRI: periodic intensification of routine immunization consists of an intensified “campaign style” immunization sessions and can be used 

for catch-up vaccination
References:

1. Gavi, WHO, and UNICEF. At least 80 million children at risk of disease as COVID-19 disrupts vaccination efforts, warn Gavi, WHO and UNICEF. 

Available at: https://www.gavi.org/news/media-room/least-80-million-children-risk-disease-covid-19-disrupts-vaccination-efforts (Accessed 

May 28, 2020)

2. World Health Organization. Maintaining essential health services: operational guidance for the COVID-19 context: Interim guidance 1 June 

2020. Geneva: World Health Organization. Available at: https://www.who.int/publications-detail/10665-332240 (Accessed June 2, 2020)

3. World Health Organization. Guiding principles for immunization activities during the COVID-19 pandemic: Interim guidance 26 March 2020. 

Geneva: World Health Organization. Available at: https://apps.who.int/iris/bitstream/handle/10665/331590/WHO-2019-nCoV-immunization_

services-2020.1-eng.pdf (Accessed May 21, 2020)

4. World Health Organization. Framework for decision-making: implementation of mass vaccination campaigns in the context of COVID-19: 

Interim guidance 20 May 2020. Geneva: World Health Organization. Available at: https://www.who.int/publications-detail/framework-fordecision-making-implementation-of-mass-vaccination-campaigns-in-the-context-of-covid-19 (Accessed May 21, 2020)

5. World Health Organization and United Nations Childrens’ Fund. Immunization in the context of COVID-19 pandemic: Frequently asked 

questions. 16 April 2020. Geneva: World Health Organization. Available at: https://apps.who.int/iris/bitstream/handle/10665/331818/WHO2019-nCoV-immunization_services-FAQ-2020.1-eng.pdf (Accessed May 21, 2020)

6. World Health Organization. Polio eradication programme continuity: implementation in the context of the COVID-19 pandemic: interim guide 

May 2020. Geneva: World Health Organization. Available at: http://polioeradication.org/wp-content/uploads/2020/03/COVID-POL-programmecontinuity-planning-20200325.pdf (Accessed May 28, 2020)

7. World Health Organization. Periodic Intensification of Routine Immunization: Lessons learned and implications for action. Geneva: World Health 

Organization 2009. Available at: https://www.who.int/immunization/programmes_systems/policies_strategies/piri_020909.pdf?ua=1&ua=1

(Accessed June 2, 2020)