COVID-19's lost generation of unvaccinated children
Authors: Damian Walker, Subhash Chandir
Journal: The Lancet Global Health (2021)

In their modelling study, Kaja Abbas and colleagues (October, 2020)1Abbas K Procter SR van Zandvoort K et al.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.Lancet Glob Health. 2020; 8: e1264-e1272Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar state that routine childhood immunisation is "at risk of suspension" and "should be sustained in Africa as much as possible… during the COVID-19 pandemic". It is now more than 6 months since the paper was first posted as a working paper, approximating the 6-month COVID-19 risk period modelled by the authors. We now know that immunisation programmes in Africa (and beyond) were severely disrupted.2WHOPulse survey on continuity of essential health services during the COVID-19 pandemic: interim report.https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1Date: 27 August 2020Date accessed: October 22, 2020Google Scholar The authors' two scenarios show how uncertain our understanding is of the pandemic's indirect health effects on immunisation services. The deaths due to the disruption of routine immunisation were estimated to be between 25 584 ([194 388 + 10 282] × 12·5%) in the low-impact scenario and 701 828 in the high-impact scenario. That is a 27-times difference, driven exclusively by whether catch-up activities occur. Countries with electronic immunisation registries can provide insights into how many children who missed out during lockdowns are eventually vaccinated.3Chandir S Siddiqi DA Setayesh H Khan AJ Impact of COVID-19 lockdown on routine immunisation in Karachi, Pakistan.Lancet Glob Health. 2020; 8: e1118-e1120Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar For example, in Pakistan's Sindh province with a population of 48 million, of 424 371 children who missed vaccinations during the lockdown (March 23 to May 9, 2020), 62% were vaccinated by September. The catch-up vaccinations used the defaulter lists from the electronic immunisation registry to trace and vaccinate the children. However, although the programme is successfully tracing and vaccinating some of the missed children, the data from Pakistan show a continuously expanding pool of missed children since the lockdown period. Most African countries do not have electronic immunisation registries,4Namageyo-Funa A Samuel A Bloland P Macneil A Considerations for the development and implementation of electronic immunization registries in Africa.Pan Afr Med J. 2018; 30: 81Crossref PubMed Scopus (10) Google Scholar so the numbers of children who were unvaccinated because of the pandemic and who die prematurely will remain unknown. We applaud Abbas and colleagues1Abbas K Procter SR van Zandvoort K et al.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.Lancet Glob Health. 2020; 8: e1264-e1272Summary Full Text Full Text PDF PubMed Scopus (188) Google Scholar for taking a benefit–risk approach that compares health benefits to COVID-19 mortality risk. There is a need for more modelling efforts that look at both sides of the equation instead of reporting separate sets of estimates that are of little use to policymakers and programme managers. It is crucial that modellers revisit the assumptions in their papers in light of new evidence about the effects of the virus, compliance with policy measures, and the indirect health effects. Failure to do so might mean that inaccurate or misleading estimates continue to circulate. However, until large household surveys are done, estimation of the full extent of the COVID-19 impact on childhood immunisation will continue to be a stab in the dark. Our inability to generate a realistic estimate of the number of missed children will lead to suboptimal planning and implementation of catch-up efforts, leaving behind a generation of under-immunised and zero-dose children. We declare no competing interests. Impact of COVID-19 lockdown on routine immunisation in Karachi, PakistanThe swift spread of COVID-19 has upended health systems and affected all health services. The disruption of routine immunisation services could start secondary outbreaks of vaccine-preventable diseases and also worsen the longstanding inequity in immunisation coverage, especially in rapidly urbanising cities. Karachi, the capital of Sindh province and the largest megacity in Pakistan, is home to more than 16 million people.1 Despite the city's status as the industrial hub of the country, Karachi has seen a decline in the delivery of health-care services over the past decade. Full-Text PDF Open AccessCOVID-19's lost generation of unvaccinated children – Authors' replyWe thank Damian Walker and Subhash Chandir for their letter in response to our benefit–risk analysis on sustaining routine childhood immunisation in African countries during the COVID-19 pandemic.1 Full-Text PDF Open Access