Balancing the needs for child health during COVID-19
The COVID-19 pandemic has generated many tough trade-offs for governments around the world. Ethiopia has not been spared from this and the debate was between weighing the risks involved in carrying out immunization campaigns for children and running the risks of an increased number of COVID-19 infections as a result of this campaign. A total of 1,466 measles cases had been reported in 104 woredas between January and May 2020 alone. The proportion of children under five years of age impacted by COVID-19 is less than one per cent, whereas, children under five years constitute around 47 per cent of measles cases. Global evidence indicates that measles kills around 2.3m under 5 years children every year globally.
In Ethiopia, it has not taken long to make a decision about this trade off. Together with our colleagues at WHO, we strongly advocated that the balance was clearly in favour of continuity of primary health care services, especially child vaccination. The local evidence for this was clear: so far only 180 children, out of a total population of roughly 17.5 million children nationwide, have tested positive for the COVID 19 virus. By contrast, we know that in Ethiopia more than 62,000 children can die from vaccine-preventable diseases each year. Moreover, global experience from Ebola outbreaks indicates that more children died from suspending services than from Ebola itself. All these factors point firmly to the conclusion that while the COVID-19 pandemic constitutes a serious public health concern, primary health care services such as Routine Immunization must continue without interruption.
Even before the COVID-19 pandemic hit Ethiopia, the country had seen an increase in vaccine-preventable disease outbreaks. In 2019, there were 142 measles outbreaks, and 4,003 confirmed measles cases, substantially more than in 2018. The effects of the COVID-19 virus had made a bad situation worse, by stretching health services to also cover this new need. By the third week of April 2020, already ten of 11 regions and chartered cities had reported COVID-19 positive cases, and a further ten zones are affected by the circulating-Vaccine Derived Polio Virus (cVDPV). This is due to low immunity levels among children, related to low coverage of routine vaccination, with 1.2 million children in Ethiopia having not been immunized at all.
The integrated measles and polio vaccination campaigns scheduled for April 2020 year were initially postponed due to the COVID-19 pandemic. However, our thought was that recovering lost ground will be challenging, and it will be very difficult for Ethiopia to catch up on the number of children unimmunized (according to scientific evidence, the immunization coverage will be reduced by at least 18.5 per cent in case vaccination services are not provided). This is due to factors such as reduced workforce, as healthcare workers are reassigned to COVID-19 isolation and treatment centres, and shortage of Personal Protective Equipment (PPE) supplies. Mothers and caregivers may also be afraid to visit health facilities, a tendency which was particularly evident in Ethiopia at the start of the outbreak in March and April.
It is on these grounds that we joined forces with our colleagues at WHO to advocate with the Ministry of Health for the continuation of essential primary health care services, including the resumption of the measles campaign. We based our advocacy on existing evidence and also on our readiness to support the campaign whether through provision of Personal Protective Equipment, communication, and supervision. Hence, on 30 June, a nationwide mass measles vaccination campaign began, although its launch in Addis Ababa and Oromia was delayed due to civil unrest in several areas. COVID-19 preventative measures were integrated thoroughly into the campaign, with UNICEF providing masks and hand sanitizers for all health workers. Volunteers were recruited to enforce physical distancing at vaccination centres and mobilize community. Health workers who protected themselves by wearing face masks. Clients were made to cover their faces and, in some towns, had their temperature checked; where temperature measurement was not available, clients were screened by asking whether they have signs and symptoms of respiratory symptoms. Hand sanitizer was available at all sites for vaccinators and caretakers. At health facilities, handwashing facilities were prepared. Vaccination campaign sites reduced crowds through careful community mobilization and management. The campaign took place over a longer period - two weeks rather than one - in order to avoid overcrowding at the centres. In most places, vaccination was provided outdoors in order to avoid clustering in spaces where the risk of virus transmission is generally greater. UNICEF stationed 50 technical assistants throughout the country to facilitate activities, along with staff from CDC and WHO.
See video on the measles campaign in Ethiopia - here
The campaign was a success; healthcare workers reported high demand from caregivers and most regions reached their immunization targets. By 27 July, about 14,345,997 of the targeted 15 million children had been vaccinated (96 per cent coverage), saving the lives of many children, carrying out a campaign under unusual circumstances.
In some places, local officials used the occasion to integrate additional services such as screening for malaria, scabies and trachoma, and in at least one woreda in Amhara (Tselemet woreda), Vitamin A supplementation took place alongside the measles vaccine.
Routine Immunization is only one part of the health services. There are other health services equally important such as maternities, antenatal care services and other essential services such as growth monitoring for children and treatment of children with severe acute malnutrition. Experience from past epidemics shows that health systems typically struggle to maintain routine health services. There is still a shortage of PPE for healthcare workers in Ethiopia, estimated at a cost of about US$21 million for three months (currently most PPE is going to treatment and isolation centres).
As we move ahead and as COVID-19 starts to take its toll in Ethiopia through the increased number of cases, our plan next is to carry out the polio vaccination campaign in the 304 woredas that are reporting vaccine derived polio cases. We hope to work with the Ministry of Health and our colleagues at WHO and other partners to get this campaign organized in September. There is surely plenty of work at our hands here in Ethiopia to ensure that the gains made for children and their well-being over the past decade are not reversed!