Immunization Activities during COVID-19 Pandemic

- by Indian Academy of Pediatrics

Current situation: Circulation of virus causing COVID-19 with increasing number of cases being reported in India

Impact on immunization:

• Disruption in routine immunization

activities due to increased burden on

health infrastructure and resources

• Decreased demand for vaccination

because of physical distancing

requirements and community

reluctance

Potential impact of COVID-19 on health scenario: Current and Future

One of the most important measures: Lockdown and

Restricting community spread

Impact on patients and health related activities

Chronic Patients: Disease management (e.g. Dialysis, cancer care)

Public and Private Immunization: Drop in vaccination both mandatory and recommended

Post COVID possible VPD (Vaccine Preventable Disease) outbreaks

Short term impact: Drop in routine / mandatory vaccination

5.4 5.4

10.8 10.8

Jan-20 Feb-20 Mar-20 Apr-20

Assumptions: Birth cohort (BC): 2.8 Cr per year ( 5.5 lacs new-born per week. 1 year = 52 weeks) | Numbers for primary series vaccines only | 100% immunization rates | IMR not considered for children < 1 year | Missing / Incomplete immunization Jan and Feb: 25%, Mar and Apr: 50%

• Number of unvaccinated children / children with incomplete vaccination added every week : ~ 5.5 lacs

• Babies born in July 2019: Likely to miss the Measles/MMR dose

• Babies born in Jan 2020 and Feb 2020: Likely to miss schedules subsequent DTP-Polio doses due in March and April

• 32.4 lac children will be unvaccinated/partially vaccinated

Potential number of additional children (Lacs): Unvaccinated / Incomplete vaccination

Longer term impact on health scenario: Due to disruption in routine immunization

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Any disruption of immunization services, even for

short periods, will result in an accumulation of

susceptible individuals: Higher likelihood of VPD

outbreak (Especially Measles & Polio)

Such outbreaks may result in:

• VPD-related deaths

• Increased burden on health systems already

strained by the response to COVID-19 outbreak

• Decline in immunization related health indicators

Plan to secure future: Maintain routine immunization as long as COVID-19 response measures permit

Immediate Action Required: Plan for detailed assessment of VPD epidemiology, transmission scenarios of COVID-19, impact in these scenarios and corresponding mitigation measures

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Review current immunization levels and potential future (impact of Covid-19)

Prioritize efforts and resources: Initial focus on epidemic prone VPDs

• VPD surveillance data (measles, polio, H1N1)• Incorporate regional & ICMR knowledge

• Sustain measles elimination and polio eradication• Focus on At-risk population and HCWs

Critical to maintain Polio-free status of India: Increased efforts for checking any sewerage isolation/AFP. Continued use of IPV and bOPV is an absolute must with additional efforts to be deployed on catch-up immunization

Longer term impact of immunization disruption: Higher probability of VPD occurrence

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Vaccinate newborns (as per the national immunization schedule) in maternity hospitals

Follow guidelines on COVID-19 infection prevention during immunization sessions

Prioritize primary series vaccinations for poliomyelitis-containing vaccines, measles-rubella and other combination vaccines

Avoid mass vaccination campaigns until the COVID-19 situation resolves

Prioritize pneumococcal and seasonal influenza vaccines for vulnerable population groups including Healthcare workers

WHO recommendation for Europe: Potential actions for India20th March 2020

Key areas to consider

Epidemiological

situation of COVID-19

and related

mitigation measures

in place

Health system and

immunization

delivery services

characteristics and

constraints

Supply of vaccines:

Timely and in

adequate quantities

Epidemiological risks

of VPDs among the

general population

and specific

vulnerable groups

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Appropriateness of chosen options should be monitored and periodically reassessed (based on impact) as the COVID-19 situation evolves

Potential high level plan: Current and Future

Surveillance , especially for Polio, Measles, etc

01 Issuance of National Guidelines: Separate for Public and Private Sector

Ensure important vaccinations at Birth: Polio-DTP and Measles a PriorityPneumococcal & influenza vaccines

02

Increased surveillance for VPDs: Especially for Polio, Measles, etc

03

Catch up or Intensified Immunization post COVID-19: Similar to Pulse Polio or Mission Indradhanush

04

• Guidelines for ASHA & ANM for Vaccination Dos & DONTs• Media dissemination to reassure parents and HCWs• Private sector may work with OPPI to work on Immunization

• Ensure completion of at Birth vaccines: Maternity homes and Hospitals

• Evaluate alignment with EU guidelines by WHO March 2020• Polio-DTP and Measles vaccination: Absolute Priority

• Intensify VPD surveillance: Especially polio and Measles• Ensure stocking of mandatory vaccines: bOPV, IPV, DTP and

Measles vaccine / MMR

• Catch-up vaccination: Planning for campaigns• Reactivate successful Govt. Programs: e.g. Mission

Indradhanush and Pulse Polio• Vulnerable population: Pneumonia and Influenza vaccination

Parents to be reassured

During this COVID Pandemic:

**vaccination at a later date is manageable

***Message should reach to the public via print media/TV/Radio

In Conclusion

Regular or heightened surveillance to continue for VPDs especially Polio and Measles

Infected or quarantined mothers to be advised to get their children vaccinated, on advise of their treating physician

Ensure continuity of Birth dose BCG, b-OPV & Hep B

COVID-19 govt. recommendation to be followed and social distancing maintained

Advisory to parents to immediately start immunization on receiving Govt. notification / communication

Prioritize primary schedule dosesPrioritize Polio, Influenza, MMR and Pneumococcal vaccination for infantsPrioritize Influenza vaccination for Vulnerable population including HCWs

Missed immunization: Parents to be reassured that subsequent vaccine doses have permissible window to vaccinate

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07 02

06 03

05 04

Thank You

Await next advisory on Vaccinations after relaxation of “Lockdown”.

Will be released soon

Evaluate WHO recommendations* for Interrupted or Delayed Routine ImmunizationAntigen Age of 1st Dose Doses in Primary Series (min

interval between doses)Interrupted primary series Doses for those who start vaccination late Booster

If ≤ 12 months of age If > 12 months of age

BCG As soon as possible after birth 1 dose NA 1 dose 1 dose Not recommended

Hepatitis B As soon as possible after birth (<24h)

Birth dose <24 hrs plus 2-3 doses with DTPCV (4 weeks)

Resume without repeating previous dose

3 doses 3 doses Not recommended

Polio bOPV + IPV 6 weeks (see footnote for birth dose)

4 doses (IPV dose to be given with bOPV dose from 14 weeks of age) (4 weeks)

Resume without repeating previous dose

4 doses (IPV to be given with 1st dose of bOPV)

4 doses (IPV to be given with 1st dose of bOPV)

Not recommended

IPV / bOPV Sequential8 weeks (IPV 1st)

1-2 doses IPV and 2 doses bOPV(4 weeks)

Resume without repeating previous dose

1-2 doses IPV and 2 doses bOPV1-2 doses

IPV and 2 doses bOPV Not recommended

IPV8 weeks

3 doses (4 weeks) Resume without repeating previous dose

3 doses 3 dosesIf the primary series begins < 2 months of age, booster to be given at least 6 months after the last dose

DTP-containing vaccine (DTPCV)

6 weeks (min) 3 doses (4 weeks)

Resume without repeating previous dose 3 doses

3 doses with interval of at least 4 weeks between 1st & 2nd dose, and at least 6 mosbetween 2nd & 3rd dose. (if > 7 yrs use only aP containing vaccine

3 boosters: 12-23 months (DTP containing vaccine); 4-7 years (Td/DT containing vaccine; and 9-15 yrs (Td containing) (if > 7 yrs use only aP containing vaccine).

Pneumococcal (Conjugate) 6 weeks (min)

3 doses (3p+0) with DTPCV (4 weeks) or 2 doses (2p+1) (8 weeks)

Resume without repeating previous dose 2-3 doses

1-5 yrs at high-risk: 2 dosesBooster at 9-18 months if following 2 dose schedule Another booster if HIV+ or preterm neonate

Rotavirus 6 weeks (min)

2 or 3 depending on product given with DTPCV

Resume without repeating previous dose

2 or 3 depending on product>24 months limited benefit

Not recommended

Measles 9 or 12 months (6 months min, see footnote)

2 doses (4 weeks) Resume without repeating previous dose

2 doses2 doses Not recommended

Rubella 9 or 12 months

1 dose with measles containing vaccine

NA 1 dose 1 dose Not recommended

Mumps 12-18 months

2 doses with measles containing vaccine (4 weeks)

Resume without repeating previous dose

Not recommended2 doses Not recommended

Seasonal influenza (inactivated quadrivalent)

6 months (min)< 9 yrs: 2 doses (4 weeks) ≥ 9 yrs: 1 dose

Resume without repeating previous dose

2 doses < 9 yrs: 2 doses ≥ 9 yrs:1 dose Revaccinate annually 1 dose only

Varicella 12-18 months

1-2 (4 weeks – 3 months, depending on manufacturer)

Resume without repeating previous dose

Not recommended 1-2 doses

*Summary of WHO Position Papers dated April 2019