The impact of COVID-19 on routine child immunisation in South Africa

doi:10.21203/rs.3.rs-3143159/v1

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Research Article

The impact of COVID-19 on routine child immunisation in South Africa

https://doi.org/10.21203/rs.3.rs-3143159/v1

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Background

The COVID-19 pandemic disrupted immunisation programs worldwide, reversing gains that had brought vaccine-preventable diseases largely under control. This study explored the impact of COVID-19 on the uptake of routine child immunisation services in South Africa.

Methods

We conducted qualitative research using in-depth interviews with 51 purposively selected parents/caregivers of children below the age of five who missed or delayed one or more scheduled immunisation doses in 2020-2022 and with 12 healthcare providers who provided public immunisation services during the pandemic.

Findings

During the pandemic lockdowns, most caregivers perceived the risk of their child being infected with COVID-19 during a clinic visit as more salient than the risk of missing immunisation doses. Caregivers reported minimal exposure to routine immunisation communication, as well as shortages of routine vaccines for children at public health facilities; healthcare workers experienced anxiety and burnout. There was a post-pandemic shift to more active decision-making about immunisation, which had previously been an almost automatic behaviour, leading some caregivers to delay vaccinating their children. There was also evidence of a “bad vaccine” mental model among some caregivers regarding COVID vaccinations, which could lead to doubts about the safety of routine childhood vaccinations.

Interpretation

The shift from default to active decision-making highlights a risk that routine immunisation will backslide in future pandemics. Governments should build resilient health systems at all levels and communicate clearly about the benefits and availability of RIs and the safety of vaccinations in general, alongside supply-side interventions.

Funding

Final Mile Consulting funded this study.

routine immunisation

behavioural science

vaccine-preventable disease

pandemic preparedness

South Africa

Prior to the COVID-19 pandemic, African countries were already lagging in their progress towards achieving the United Nations Sustainable Development Goals of reducing child mortality and ending preventable child deaths,¹ with the highest mortality rates from vaccine-preventable diseases (VPDs) globally among children under five years old.² The COVID-19 pandemic slowed progress even more as efforts to mitigate COVID-19 disrupted maternal and child health services across the continent; 2,3 and transmission fears contributed to reticence to visit health facilities.

Globally, 23 million children missed immunisation doses in 2020.⁴ This is 3.7 million more than in 2019 and the highest number since 2009.⁴ The most significant decline in routine child immunisation was observed in April 2020, when 33% fewer doses of the third diphtheria–pertussis–tetanus-containing vaccine were administered globally compared with 2019, ranging from 9% fewer in the WHO African region to 57% fewer in the Southeast Asia region.⁵ According to the World Health Organisation (WHO), as of April 2022, there were 21 large and disruptive measles outbreaks around the world, with Africa and the East Mediterranean regions reporting the most cases.⁴ The actual number is likely to have been higher due to underreporting caused by the disruption of surveillance systems around the globe caused by the pandemic.

South Africa experienced a decline in the number of children who were fully immunised from 2019 to 2020.⁶ Vaccination rates in seven of the nine provinces waned, with only Northwest province reporting an increase in infants under one year being fully immunised.⁶ Gauteng Province, Africa, reported its first post-COVID-19 outbreak of measles in May 2022.⁷

In this article, we briefly review some previous research into the supply- and demand-side challenges that impacted routine immunisation (RI) services for children during the COVID-19 pandemic. We then present a qualitative study exploring the attitudes and behaviours towards RI among caregivers of children under five years of age and healthcare workers (HCWs) providing RI services in three provinces of South Africa.

Supply-side issues impacting routine immunisation

Pandemic-related disruption of RI services was observed across all WHO regions, with varying degrees of interruption to RI sessions, health workforce availability, and vaccine supply.⁵ COVID-19 reduced the number of HCWs available to offer RI services as they were reallocated to other departments, missed work due to sickness or possible COVID-19 exposure, or even died from COVID-19.⁸

A synthesis of WHO data from 170 countries in 2019 and 2020 found the leading causes of RI service disruption to be the absence of personal protective equipment (PPE) for HCWs, decreased availability of HCWs, travel restrictions, and insufficient vaccines and vaccine-related supplies.⁵ RI services were further negatively impacted when health workers relying on public transport struggled to get to work as a result of disruptions, fare increases, and complete withdrawal of transport services.⁹

In the African region, WHO data were available for 30 of 47 member states. Among those countries reporting, there were signs of disrupted RI sessions in 17 (57%), with fixed-post services partially suspended in two countries and outreach services wholly or partially suspended in 17 countries. Reports for seven (23%) of 30 countries indicated challenges with vaccine supply.⁵

Demand-side issues impacting RI

Disruptions in demand for immunisation services were observed in all WHO regions in April 2020. In the African region, 11 (37%) of 30 countries reported challenges with vaccine demand because of fear of COVID-19 exposure, transportation barriers, and misinformation.⁵ Parents refused to bring their children to vaccination centres due to fear of COVID infection; some mothers preferred to give birth at home, which meant the first vaccine doses were missed.¹⁰ Fear of contagion, combined with a lack of information or misinformation concerning both vaccinations and COVID-19, increased vaccine hesitancy.^10,11 Families’ reluctance to attend healthcare services to receive childhood measles vaccines may have led to an increase in the number of unvaccinated children and further increased rates of measles.¹²

A risk–benefit analysis of reopening immunisation clinics during the pandemic found that for every death attributable to COVID-19 acquired at immunisation clinics in Africa, 84 deaths from VPDs could be prevented.¹³ These data underscore the more significant risk posed by vaccine-preventable child diseases to the population and the health system overall.

Lessons from the Ebola Outbreak

Experiences from past epidemics, such as the West African Ebola disease outbreak in 2014–15, hold lessons for maintaining vaccinations during severe crises. The suspension of vaccination programmes and decrease in vaccination coverage resulted in more deaths from measles than from Ebola, and some parents reduced their use of health services because of community perceptions of an increased risk of contracting Ebola.¹⁴ The Ebola outbreak weakened a struggling national immunisation program, and postoutbreak recovery took significant time; together, these factors likely accounted for the increased number of measles cases reported.¹⁴ The Ebola experience demonstrates the need to continue RI during a pandemic to avoid devastating consequences for communities and the health system overall.

We conducted an explorative qualitative study in September 2022 in urban, peri-urban, and rural locations within Gauteng, KwaZulu-Natal, and Mpumalanga provinces in South Africa. In-depth interviews were conducted with 51 parents or caregivers of children below the age of five who missed or delayed one or more scheduled immunisation doses in 2020–22. South African Demographic and Health Survey data were used to identify locations with a high concentration of children under five in the respective provinces. Door-to-door recruitment was conducted using a screening tool that identified consenting caregivers or parents of children under five who utilise public health RI services. Caregivers who do not routinely immunise their children were not recruited. A total of 12 HCWs who provided public health immunisation services during the pandemic period were recruited from online platforms and interviewed. Interviews were conducted by telephone by trained moderators using a validated discussion guide that explored barriers to RI uptake during and following COVID-19 lockdowns in South Africa.

The survey gathered descriptive demographic data on the participants and asked them about their beliefs and behaviors regarding RI for their children before, during, and after the COVID-19 pandemic. Participants were asked whether they had visited healthcare facilities for RI during the pandemic, their reasons for not doing, or why those who went had been unsuccessful in getting their children immunised. Questions also covered their perceptions of HCWs’ and community members’ attitudes towards RI, their understanding of government communications about RI during the pandemic, and their own perceptions of the importance of RI. Participants were also asked about their beliefs in the efficacy of RIs and the efficacy of COVID-19 vaccines.

Data analysis

Qualitative interviews were translated, transcribed, coded in Excel, and thematically analysed. We applied thematic data analysis in an iterative process, going back and forth between the data and the themes to refine and develop our analysis. Distinct themes and pathways of RI emerged. Descriptive participant demographic data were calculated using R software.

We present the respondent characteristics and then a thematic analysis of the responses. Table 1 shows some demographic characteristics of the caregiver respondents. One-third (n = 17, 33%) resided in each province (Gauteng, KwaZulu-Natal, and Mpumalanga). Most were between the ages of 26 and 40 years (n = 38, 75%). Income levels varied, with 22% (n = 11) reporting household income below R3,000, 20% (n = 10) earning R3,000–5,999, and 43% (n = 22) earning R6,000–9,999.

Table 1

Caregiver characteristics
	N (%)
Province
Gauteng	17 (33·3%)
KwaZulu-Natal	17 (33·3%)
Mpumalanga	17 (33·3%)
Age
18–25 years old	9 (17·6%)
26–40 years old	38 (74·5%)
41–60 years old	4 (7·8%)
Household income
No income	5 (9·8%)
R1 - R1 399	2 (3·9%)
R1 400 - R1 999	2 (3·9%)
R2 000 - R2 999	2 (3·9%)
R3 000 - R5 999	10 (19·6%)
R6 000 - R9 999	22 (43·1%)
R10 000 - R19 999	6 (11·7%)
R20 000 - R39 999	2 (3·9%)

Caregivers’ reasons for not visiting health facilities and returning from clinics without being given RI immunisation are shown in Table 2, categorised by province, age, and income level. Fear of contracting COVID-19 was the most common reason for not seeking RI services, while lack of immunisation staff and stock shortages were the most common reasons for not receiving the sought RI doses.

Table 2

Reason for missed doses, per demographics against participant characteristics.
Variables	Did not visit the facility, due to community announcement of COVID restrictions	Did not visit the facility, due to fear of contracting COVID-19	Did not visit the facility, due to lack of time	Other personal reasons	Returned from clinic due to immunisation stock shortage	Returned from clinic due to lack of immunisation staff
	N = 4	N = 18	N = 1	N = 2	N = 20	N = 6
Province
Gauteng	1 (25%)	6 (33·3%)	0 (0%)	1 (50%)	7 (35%)	2 (33·3%)
KwaZulu-Natal	2 (50%)	7 (38.9%)	0 (0%)	0 (0%)	6 (30%)	2(33·3%)
Mpumalanga	1 (25%)	5 (27.8%)	1 (100%)	1 (50%)	7 (35%)	2 (33·3%)
Age
18–25 years old	0 (0%)	5 (27.8%)	1 (100%)	0 (0%)	1 (5%)	2 (33.3%)
26–40 years old	4(100%)	11 (61.1%)	0 (0%)	2 (100%)	18 (90%)	3 (50%)
41–60 years old	0 (0%)	2 (11.1%)	0 (0%)	0 (0%)	1 (5%)	1 (16.7%)
Income
No income	0 (0%)	2 (11·1%)	0 (0%)	0 (0%)	3 (15%)	0 (0%)
R1 - R1 399	0 (0%)	0 (0%)	0 (0%)	0 (0%)	2 (10%)	0 (0%)
R1 400 - R1 999	0 (0%)	1 (5·6%)	0 (0%)	0 (0%)	1 (5%)	0 (0%)
R10 000 - R19 999	0 (0%)	3 (16.7%)	1 (100%)	0 (0%)	2 (10%)	0 (0%)
R2 000 - R2 999	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (5%)	1 (16·7%)
R20 000 - R39 999	1 (25%)	0 (0%)	0 (0%)	0 (0%)	0 (0%)	1 (16·7%)
R3 000 - R5 999	2 (50%)	5 (27.8%)	0 (0%)	1 (50%)	2 (10%)	0 (0%)
R6 000 - R9 999	1 (25%)	7 (38.8%)	0 (0%)	1 (50%)	9 (45%)	4 (66·7%)

Thematic findings

1. Prepandemic immunisation behaviors

a. Routine immunisation (RI) is a norm among South Africans.

We found that immunisation was a default behavior driven by social norms built over generations, coupled with provider recommendations and easy access to RI through high-touch campaigns, so little thought was involved for caregivers and parents in deciding to vaccinate their children. The immunisation program commanded a high degree of trust in the community. Few participants were concerned about the efficacy, effectiveness, and potential adverse effects of child vaccines. The “Road to Health” immunisation card provided an effective way for caregivers to keep track of scheduled appointments. Prior to the COVID-19 pandemic, the system brought predictability and effective planning of supplies and resources for HCWs.

“It was better because we weren’t full because no one just came in randomly. Everyone knows their date; that today is this child’s date. You can’t wake up today and just decide to take the child for immunisation, or maybe after a month or after a year. You have to go according to your date.” (HCW, Enrolled Nurse, KwaZulu Natal)

When immunisation doses ran short, caregivers would often be provided with an alternative date within two weeks. Delays and skipped doses were the exceptions, not the norm. Caregivers who did not immunise their children reported that they were often viewed negatively by the community and by HCWs.

Minor problems with RI uptake existed prior to COVID-19 but were managed.

Waiting times, stock shortages, lack of education, negative HCW attitudes, and fear of stigma and judgment all impacted care-seeking before and after COVID-19. Many participants complained about how long it took to access clinic services, including RI. This was exacerbated by stock shortages, the inconvenience of which impacted motivation to keep children’s immunisations up to date. Working mothers reported that it was especially difficult to make multiple visits when there were stock shortages, resulting in missed doses.

“Previously, they would make sure that if they have a shortage of anything, that they would call around, they would communicate with you so that you are able to get it as soon as possible." (female, 26–40 years old, Gauteng)

Lack of information about the importance of RI in general, the purpose of specific doses and their side effects also reduced commitment to RI. Prior negative experiences with HCWs and mistrust in the public health system in general undermined confidence in RI services before and after the pandemic. Fear of being judged by HCWs and other women discouraged some young mothers from seeking postnatal care.

“I would not go to the clinic when I have a problem with a child. I’d rather go to the doctor. Nurses make it hard for us to want to learn, to want to know something, because they are rude.” (female, 18–25 years, Mpumalanga)

Despite these problems, uptake of RIs was high prior to the pandemic; in 2019, 83.9% (95% CI: 82.9–84.9) of children received all basic vaccinations up to age 1 year, i.e., up to measles 1. Vaccination coverage for children fully vaccinated (received all age-appropriate vaccinations from birth to 18 months) was 76.8% (95% CI: 75.4–78.2).¹⁵

2. Disruption of immunisation during the pandemic

1. Caregivers faced a dilemma appraising the risk of COVID-19 exposure vs the risk of their child developing a vaccine-preventable disease.

The salience of COVID-19 outweighed the risk of missing doses that prevent VPDs. Health facility attendance during peak lockdown periods was low, with most caregivers avoiding public health facilities for fear of potential COVID-19 exposure. They doubted whether adequate infection control measures were in place to protect themselves and their children from infection. Participants reported a range of missed RI visits, from delays of mere weeks to multiple missed RI visits over two years.

“it was truly scary because I was also scared, I was also afraid that she might even get COVID at the clinic” (female, 26–40 years, Mpumalanga)

Other participants were still determining whether immunisation services were even available during the lockdowns, as they did not hear explicit messaging about this from the South African president or in the media. A perception that the health system prioritised COVID-19 over RI and child health kept some mothers from bringing their children, since they believed they would be turned away from facilities, even when that was not the case.

b. Government communication on routine immunisation was insufficient.

Government communication to the public on the continuation of RI services during the lockdown period was not extensive, resulting in a widely held perception that RI was neither urgent nor a government priority. While the Department of Health and relevant institutions (such as the National Institute for Communicable Diseases) understood that RI services must continue and the Department of Health issued guidelines for the safe delivery of immunisation services during the pandemic, this understanding did not cascade to the public. Caregivers anticipated that the president’s regular televised COVID-19 briefings would provide explicit guidance, but between March 2020 and March 2021, only one State of the Nation address explicitly addressed the importance of seeking RI.

“I do not think that the government did anything. There was no communication whatsoever. They feel more that the pregnant ladies and the antenatal department has top priority.” (female, 26–40 years, Gauteng)

Several addresses conveyed an unintended message that people should not seek routine health services during the lockdowns:

“Apart from people who need to travel to and from work or who need to seek urgent medical or other assistance during this time, everyone will be required to remain at home” (President Cyril Ramaphosa, 13 July 2020)

As a result, many caregivers were uncertain whether they should seek RI during COVID-19 lockdowns if they were available and whether it was safe to use RI services.

“When the president was talking on TV, he said, ‘The hospitals and clinics are only for emergencies.’ So I did not go to the clinic. They did not turn me away—I did not go…. One should only go to the clinic for emergencies. So you wouldn’t go to inject the baby, they would send you back [as the clinic only served] people who were very sick.” (female, 26–40 years, KwaZulu-Natal)

c. Public health facilities experienced shortages of child immunisations during peak COVID

Children missed scheduled vaccines due to prolonged shortages at facilities stemming from global supply chain disruptions. Accurate information was rarely provided about when doses would be available, making it difficult for caregivers to plan accordingly. Motivated caregivers made multiple visits or travelled to different public health facilities in search of missing child doses. Other caregivers who did not regard RI so urgently deferred immunisation until their next scheduled visit or planned to resume RI at a later milestone period, such as school entry.

“I think I took him two times, but the first time I [only] managed to get some of the vaccines that I was due for, and then others I was told were out of stock. I had to turn back home. In addition, then, the second time, they told me they still had shortages. They told me to come back and try again, and they still had a shortage of that vaccine...” (female, 26–40 years old, Mpumalanga)

“You find that the clinics that are nearby also have nothing. You can refer them to a clinic. When you check with the clinics, they also say they don’t have it. When they also check with the hospital we don’t have it… The next time their appointment is due, we might have it.” (HCW, enrolled nurse, KwaZulu Natal)

Some caregivers could afford to go to private pharmacies to access RIs. Shortages were a barrier for some employed caregivers who felt unable to take additional leave for multiple visits to immunise their children or were not willing to pay privately for a service they could access for free.

d. HCWs suffered burnout and anxiety at the height of the pandemic.

Health providers experienced a range of challenges during the height of the pandemic, such as increased workloads and stress from being short-staffed, task-shifting, contracting COVID-19, having to isolate, and the fear of transmitting the infection to family members. These factors impacted HCWs’ motivation levels and caused burnout, which manifested in their treatment of caregivers.

“Whoever is attending to you at the clinic does not want to spend too much time with you; They tend to do their job [more] haphazardly than what they did in the past.... obviously with the understanding that they have a fear of COVID… So I think then they just feel that the quicker that they are done with you, the better.” (female, 26–40 years, Gauteng)

“I was at the point of finding another job because I was tired of being overworked; it was also emotionally draining.” (HCW, enrolled nurse, Gauteng)

Many caregivers felt children were “invisible” as the response shifted towards COVID-19 infection. They often perceived HCWs to be more distant and inattentive than before the pandemic, with consultations often shortened to limit face-to-face time contact between patients and providers. Some caregivers were treated poorly by HCWs for missing doses, irrespective of the reason, such as concern about COVID-19.

3. Post-pandemic immunisation trends

e. A shift to more “active” decision-making around routine immunisation

Caregivers returned to health facilities at different paces. Compared with before the pandemic, COVID-19 triggered new, “active” decision-making processes resulting from the visible threat of COVID-19 and knowledge gaps about the importance of child immunisation. The motivating factor for seeking and avoiding RI was often the same: to keep children safe and protected from illness. However, before COVID-19, immunisation decisions were driven by social norms and default behavior where little thought was involved, just action. In contrast, COVID-19 fears, high restrictions on movement, and a perception that RI was a nonemergency service created a context where vaccination required an active decision, resulting in some parents opting out of scheduled doses. A new norm to avoid nonessential health visits emerged.

Active decision-making also revealed severe information gaps around the importance of RI, the deadly child diseases they protect against, the often-disabling effects of VPDs, and the potential consequences of RI inaction.

“I just take my child to the clinic, they do whatever then I come back, but I don’t know [what] the procedure [is], how it works, what is it for […] They [should] tell us that […] today your kids are going to get this injection, but they don’t say that... It is just that there's no communication between nurses and mothers or patients.” (female, 26–40 years, KwaZulu-Natal)

“What will happen to a child that doesn’t get immunised? Nothing. [...] Children that I have seen who don’t get immunised but they are growing, they are alright. They have no problem.” (female, 26–40 years old, Gauteng)

f. A new “bad vaccine” mental model has emerged for some

All vaccines (especially for children) were traditionally considered “good”, but a “bad vaccine” mental model (a set of strongly held beliefs reinforced through experience) emerged over the course of the COVID-19 pandemic. Participants distinguished between COVID-19 vaccines (often viewed as unfamiliar, unproven, developed too quickly, ineffective, and causing side effects and other adverse events) and other vaccines such as child immunisations that are perceived as familiar, safe, effective, and trusted. Despite this conscious distinction, mistrust of established vaccines arises when more end-users subscribe to the “bad vaccine” model. As the boundaries between the two mental models blur, the safety and efficacy of all vaccines may be called into doubt, resulting in vaccine hesitancy, distrust, and avoidance.

“We weren’t sure of anything regarding COVID. Remember, on social media, Twitter, and Facebook, the messages they sent, I think, is what made us scared… We believe in media more than trying things out for ourselves… People say, ‘Don’t go get vaccinated; you will die; people are dying.’ A lot of people listen to that. They did not want to get vaccinated. I didn’t feel convinced about taking it. The reasons behind taking it were not very valid for me…. [However, people] know that the child vaccine doesn’t have anything wrong, it’s made so that the child is fine. [Interviewer: Was the COVID one not made for people to be fine?] No ways—the COVID one is scary.” (female, 18–25 years, KwaZulu-Natal)

Our research confirms that the COVID-19 pandemic disrupted routine immunisation services in South Africa in multiple ways. Similar to other studies, we found that the most common reason for disruption in RI uptake was parental fear of COVID-19 and consequent avoidance of health services.^3,16 Health systems need to invest significantly in behavioural research and prioritise risk communication and community engagement to encourage vaccine uptake and recovery of missed immunisations.¹⁶ The focus of studies on pandemic preparedness is skewed towards supply-side issues, but the demand side of RI is equally fragile in the face of pandemic-scale shocks.

The active decision-making for child vaccination that emerged during the pandemic resulted in three pathways for RI uptake when the lockdowns were lifted: the “path of procrastination”, the “path of doubt”, and the “path of persistence” (Fig. 1). Of these three pathways, only one – the path of persistence – led to consistent RI uptake. An unvaccinated status quo emerged for the two other groups, which missed immunising their children as scheduled. “Procrastinating” caregivers intended to immunise their children but consciously or nonconsciously delayed doing so, despite viewing RI in a positive light, or they did not act after experiencing service delivery and other barriers. For the “doubtful”, COVID-19 triggered doubts about the necessity and safety of RI, with some caregivers feeling hesitant about vaccines, prompted or reinforced by emerging concerns about COVID-19 vaccines. Long-held norms were tested in the face of uncertainty brought on by the pandemic, and decision-makers may need to anticipate these shifts and different pathways towards vaccination.

The decline in routine immunisation coverage increased the risk of outbreaks of VPDs, such as measles, cholera, polio, and diphtheria. Decision-makers should reinforce risk salience for deadly childhood diseases and vaccines as effective tools to protect children against deadly diseases. Furthermore, government communication should reinforce the urgent importance of vaccination, especially in anticipation of potential pandemic disruption.

For now, the “bad” vaccine mental model is limited to COVID-19 vaccines, but it could have implications for other vaccines in the future. The global gains against VPDs are at risk of being lost in the cloud of uncertainty, misinformation, and emerging “bad” vaccine mental models.

It is crucial to maintain RI services during any future pandemic, using appropriate infection prevention and control measures to ensure the safety of HCWs and patients. Governments and international organisations need to work together to ensure that RI programs are sustained and that vaccine supplies are available to those who need them. To address supply-side issues during a pandemic, plans that optimise buffer stock to account for anticipated shortages are needed. In addition, private‒public partnerships should be considered to buffer shortages. Governments must train HCWs in coping with burnout and provide access to psychologists/counsellors for those affected.

An integrated pandemic response that ensures the continuity of endemic disease control efforts and maternal and child health services and catch-up campaigns for essential disease prevention and control activities is urgently needed. Postpandemic recovery plans must also include structural changes in public health systems to ensure the rebuilding of resilient systems that can support effective epidemic response while at the same time ensuring the continuity of essential health services.²

Adamu et al. advocate for adopting a systems-based approach that conceptualises all components of the system as interrelated entities.¹ Integrating systems thinking and implementation science in health planning and decision-making could help African countries gain a better understanding of the influence of COVID-19 on health programmes, such as childhood immunisation, and facilitate the implementation of multifaceted evidence-based strategies in complex practice settings.¹

Routine immunisation is a widely accepted practice among South Africans, characterised by high levels of trust in the immunisation programme, driven by generational norms and provider recommendation. During the COVID-19 pandemic, caregivers faced the dilemma of appraising the risk of COVID-19 exposure against the risk of their child developing a deadly VPD—a decision that resulted in missed RI visits for many infants and children. The shift from default to active decision-making highlights a significant risk that RI will likewise backslide in future pandemics. Governments, particularly in low- and middle-income countries, should anticipate this future risk by building resilient health systems at the community, primary healthcare, subnational and national levels.

The three pathways for vaccination uptake that our study identified can help decision-makers plan support for those who will remain consistent in immunisation. However, significant effort needs to be placed into understanding and engaging procrastinating and doubtful caregivers. The more vaccine misinformation spreads, the greater the risk that other new vaccines may fall within the distrusted “bad vaccine” mental model in the future. Therefore, pandemic preparedness must emphasise clear communication about the benefits and availability of RIs and the safety of vaccinations in general, alongside supply-side interventions.

HCW Healthcare workers

PPE Personal protective equipment

RI Routine immunisation

VPD Vaccine-preventable disease

WHO World Health Organisation

Ethical approval

Ethical approval was granted by the University of the Witwatersrand Human Research Ethics Committee (H22/11/38). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all participants, following the ethical guidelines set by Witwatersrand Human Research Ethics Committee. Participants received detailed information about the study's purpose, procedures, risks, and benefits. They had the right to withdraw without consequences. Written consent was obtained, ensuring confidentiality and participant autonomy.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was funded by Final Mile Consulting. The company's board members had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

Authors’ contributions

SM, AA and SS were responsible for the conceptual design of the study. SM, AA, SS, RN, LM, and RP contributed to the review of drafts. All authors have approved the final manuscript. SM, AA, and LM collected data. RN, LM, SM, and AA cleaned and analysed the data. SS, RP, LM, RN, and SM guided data collection, cleaning, and analysis. SM, AA, and SS wrote the paper, and all authors reviewed the manuscript.

Acknowledgements

The study was run by Final Mile staff and undertaken in collaboration with the Provincial Departments of KwaZulu-Natal, Gauteng, and Mpumalanga. The authors thank all their implementing partners and study participants in South Africa.

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No competing interests reported.

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The impact of COVID-19 on routine child immunisation in South Africa

Status:

Version 1

Abstract

Figures

Introduction

Background

Supply-side issues impacting routine immunisation

Demand-side issues impacting RI

Lessons from the Ebola Outbreak

Methods

Data analysis

Results

c. Public health facilities experienced shortages of child immunisations during peak COVID

3. Post-pandemic immunisation trends

e. A shift to more “active” decision-making around routine immunisation

f. A new “bad vaccine” mental model has emerged for some

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1