The current COVID-19 pandemic has deflected attention away from other health priorities. However, the coronavirus is far from the only virus people that are fighting. In what is often called the “Global South”, measles, yellow fever, Ebola and others continue to cause death and disability, especially among the youngest members of society. Vaccines for these viruses already exist and are supported by the Global Alliance for Vaccines and Immunization (Gavi). Over the last two decades coverage levels for many diseases have been increasing. This is why it is so worrying, argues Paulina Kellersmann, that the COVID19 outbreak is jeopardizing immunization efforts.
The challenges that COVID19 has generated for other health issues are dramatic. To name just a few, it has brought healthcare systems to the brink of collapse, while border closures and reduced air traffic make it difficult for governments to fly in vaccines. Already, twenty one low- and middle-income countries are facing vaccine shortages for measles, polio and human papillomavirus (HPV). Ironically, transport restrictions may also end up impacting on the delivery of future COVID-19 vaccines. The pandemic also poses a less direct threat to immunization through its financial implications: funding is being redirected to the fight against COVID-19 and economic downturn will leave governments with fewer budgets to spend on vaccines.
The consequence of these trends could be as significant as the coronavirus itself. Mass immunization campaigns and new vaccine introductions have had to be cancelled or postponed. At least 14 Gavi-supported vaccination campaigns have already been delayed. They were supposed to immunize more than 13 million people against polio, measles, cholera, HPC, yellow fever and meningitis. Failing to do so is likely to lead to hundreds of thousands of people getting sick.
The WHO has responded to this threat by encouraging fixed-site immunization – i.e. offering vaccination services that people must travel to access – but this will only solve a small portion of the problem. The corona pandemic naturally lowers demand for routine vaccination for a number of reasons. Most obviously, people avoid healthcare facilities for fear of catching the virus or are prevented from doing so by lockdowns. Additionally, citizens’ confidence in health systems is likely to fall when they see health authorities and medical staff struggling to deal with the current crisis. Lower trust levels may then encourage dissuade people from attending clinics.
With so many people unvaccinated, the risk for measles, polio and other outbreaks is high. In many low-income countries, these represent as much of a threat to life as COVID-19. The threat from measles is especially large as it is extremely contagious, spreading with a reproductive number typically estimated at 12-18. The virus had already returned to the African continent even before corona struck. The largest outbreak is currently in the Democratic Republic of Congo (DRC), where 6,000 people have died. This was largely because vaccination coverage had fallen to very low levels as a result of a number of reasons, one of which was that the health system was also also focussed on fighting Ebola. The experience from DRC makes news about measles mass vaccination campaigns being suspended in Nigeria, Ethiopia, Chad and South Sudan particularly worrisome: these campaigns were supposed to vaccinate 21 million children.
Against this background, Gavi and its partners should support governments to ensure all feasible immunization takes place and all cancelled campaigns are rescheduled and implemented as soon as the situation allows for it. Keeping track of the children that have been missed is crucial, so that everyone can be vaccinated in the future, minimizing long-term harm. But for this to happen, plans for vaccination roll-outs need to be made now.
The problem of pandemics is not new – it was similar for SARS, MERS, the swine flu, Ebola and Zika, which were also followed by calls for better pandemic preparedness. But those viruses did not affect rich, powerful countries to the extent that COVID-19 does now, and so global attention was much lower. There is a potential for the response to coronavirus to be very different, and Gavi has reacted by setting up vaccine stockpiles for several diseases. Yet more needs to be done.
To detect disease outbreaks early, for instance, we need better surveillance systems and international cooperation on data collection. A cost-effective solution to extend surveillance nets could be improving access to primary healthcare. Clinics are the first contact point when people fall ill, and so local medical staff can detect outbreaks quickly – but only if a sufficient health system exists, and this requires further investment.
Other challenges for immunization
Coronavirus will not be the last major health crisis the world faces, and so we need to start learning the lessons of the past, both about how to respond to viruses and about how to do a better job of making sure that we can provide other important health services during pandemics.
One major challenge is conflict and fragility. Gavi reports that the share of fragile states who rely on it for support has almost doubled over the last decade, from 15% to 27%, with 60% being on the African continent. Implementing vaccination campaigns or continuing routine immunization is difficult in these contexts, for example due to political instability or weakened health systems. The consequence of this is that vaccination rates are around 10% lower in fragile compared to non-fragile settings. Distribution of COVID-19 vaccines in conflict areas will likewise be a challenge that can only be overcome through careful preparation.
Gavi’s immunization efforts are also threatened by increasing vaccine hesitancy. Ironically, while many children in the Global South do not yet have access to vaccines, some parents also intentionally refuse them. To successfully tackle their concerns and misperceptions, more research on the determinants and origins of people’s mistrust is needed. In Central Africa, for example, colonial medical campaigns are (partly) to blame for low trust levels. Dealing with vaccine hesitancy will likely also be an issue once COVID-19 vaccines become available. Speculations about mandatory vaccination and vaccine misinformation are already stirring up resentment and skepticism.
The graduation of Gavi aid recipient countries is a further challenge to immunization coverage. As countries cross the income threshold and become ineligible for vaccine aid, many have been struggling to self-finance their vaccination programs. This is especially worrisome since several of the world’s most populous countries (India, Nigeria and Pakistan) are set to graduate over the next few years. Gavi predicts that by 2030, 70% of all under-immunized children will be living in middle-income countries. If these children are the ones most in need of vaccines, failing to supporting the countries they live in simply because they have passed an arbitrary income threshold could be a fatal mistake. Basing Gavi-eligibility on a broader set of criteria – such as vaccination coverage, disease prevalence, poverty and inequality indices – rather than just income should therefore be considered.
The middle-income countries must also not be forgotten during the current pandemic. Not poor enough to be supported by Gavi, and not rich enough to spend the same on vaccines as the US, the UK or Germany, these countries might be the last in line for COVID-19 vaccines. Despite the billions of dollars pledged for the Coronavirus Global Response on May 4 to ensure universal access to future vaccines, it remains to be seen how affordable vaccines and how equitable vaccine distribution will be in the end.
The end of the coronavirus will not be the end of this story, however. There will be another pandemic, with similar effects, in the future. The time to start planning for that is now.
Paulina Hedwig Marie Kellersmann is studying in the MSc. Development Economics programme at the University of Göttingen, Germany, and is particularly interested in global health, food security and rural development.
