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

Type Journal Article Author Kaja Abbas Author Simon R. Procter Author Kevin van Zandvoort Author Andrew Clark Author Sebastian Funk Author Tewodaj Mengistu Author Dan Hogan Author Emily Dansereau Author Mark Jit Author Stefan Flasche Author Rein M. G. J. Houben Author W. John Edmunds Author Christian Julian Villabona-Arenas Author Katherine E. Atkins Author Gwenan M. Knight Author Fiona Yueqian Sun Author Megan Auzenbergs Author Alicia Rosello Author Petra Klepac Author Joel Hellewell Author Timothy W. Russell Author Damien C. Tully Author Jon C. Emery Author Hamish P. Gibbs Author James D. Munday Author Billy J. Quilty Author Charlie Diamond Author Carl A. B. Pearson Author Quentin J. Leclerc Author Emily S. Nightingale Author Yang Liu Author Akira Endo Author Arminder K. Deol Author Adam J. Kucharski Author Sam Abbott Author Christopher I. Jarvis Author Kathleen O'Reilly Author Thibaut Jombart Author Amy Gimma Author Nikos I. Bosse Author Kiesha Prem Author Stéphane Hué Author Nicholas G. Davies Author Rosalind M. Eggo Author Samuel Clifford Author Graham Medley URL https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30308-9/abstract Volume 8 Issue 10 Pages e1264-e1272 Publication The Lancet Global Health ISSN 2214-109X Date 17/07/2020 Extra Publisher: Elsevier PMID: 32687792 Journal Abbr The Lancet Global Health DOI 10.1016/S2214-109X(20)30308-9 Library Catalog www.thelancet.com Language English Abstract Background National immunisation programmes globally are at risk of suspension due to the severe health system constraints and physical distancing measures in place to mitigate the ongoing COVID-19 pandemic. We aimed to compare the health benefits of sustaining routine childhood immunisation in Africa with the risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through visiting routine vaccination service delivery points. Methods We considered a high-impact scenario and a low-impact scenario to approximate the child deaths that could be caused by immunisation coverage reductions during COVID-19 outbreaks. In the high-impact scenario, we used previously reported country-specific child mortality impact estimates of childhood immunisation for diphtheria, tetanus, pertussis, hepatitis B, Haemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, measles, meningitis A, rubella, and yellow fever to approximate the future deaths averted before 5 years of age by routine childhood vaccination during a 6-month COVID-19 risk period without catch-up campaigns. In the low-impact scenario, we approximated the health benefits of sustaining routine childhood immunisation on only the child deaths averted from measles outbreaks during the COVID-19 risk period. We assumed that contact-reducing interventions flattened the outbreak curve during the COVID-19 risk period, that 60% of the population will have been infected by the end of that period, that children can be infected by either vaccinators or during transport, and that upon child infection the whole household will be infected. Country-specific household age structure estimates and age-dependent infection-fatality rates were applied to calculate the number of deaths attributable to the vaccination clinic visits. We present benefit–risk ratios for routine childhood immunisation, with 95% uncertainty intervals (UIs) from a probabilistic sensitivity analysis. Findings In the high-impact scenario, for every one excess COVID-19 death attributable to SARS-CoV-2 infections acquired during routine vaccination clinic visits, 84 (95% UI 14–267) deaths in children could be prevented by sustaining routine childhood immunisation in Africa. The benefit–risk ratio for the vaccinated children is 85 000 (4900–546 000), for their siblings (<20 years) is 75 000 (4400–483 000), for their parents or adult carers (aged 20–60 years) is 769 (148–2700), and for older adults (>60 years) is 96 (14–307). In the low-impact scenario that approximates the health benefits to only the child deaths averted from measles outbreaks, the benefit–risk ratio to the households of vaccinated children is 3 (0–10); if the risk to only the vaccinated children is considered, the benefit–risk ratio is 3000 (182–21 000). Interpretation The deaths prevented by sustaining routine childhood immunisation in Africa outweigh the excess risk of COVID-19 deaths associated with vaccination clinic visits, especially for the vaccinated children. Routine childhood immunisation should be sustained in Africa as much as possible, while considering other factors such as logistical constraints, staff shortages, and reallocation of resources during the COVID-19 pandemic. Short Title Routine childhood immunisation during the COVID-19 pandemic in Africa