Fieldset
A ‘devil’s choice’: Balancing childhood immunisation with preparing for COVID-19

Italian nurse Barbara shares how the spread of COVID-19 has the potential to disrupt life-saving vaccination campaigns around the world, causing a worrying "double burden" for healthcare systems that could cost young lives

“Dalla padella alla brace” — out of the frying pan and into the fire — is what we say in Italian when you must choose between two options that both have undesirable outcomes.

As we all face the current COVID-19 global pandemic, our thoughts turn to the health of our families and our own struggles. As we bunker down, we also see how the normal and everyday morphs into something previously unthinkable, as we try to understand and process how a global pandemic impacts on our day to day work.

The repercussions on the youngest lives could be devastating

As a nurse who has worked in hospitals in Europe and low and middle-income countries including the Democratic Republic of Congo, South Sudan, Iraq and Bangladesh, I am simply terrified by what’s happening in health centres in those places, as they come under enormous strain from the arrival of people sick with COVID-19.

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Barbara has worked as a nurse with MSF for over eleven years in the Democratic Republic of Congo, Colombia, Haiti, Iraq, South Sudan, Ethiopia and Bangladesh.
Barbara has worked as a nurse with MSF for over eleven years in the Democratic Republic of Congo, Colombia, Haiti, Iraq, South Sudan, Ethiopia and Bangladesh.

And yet, as someone who works for Medecins Sans Frontieres/Doctors Without Borders (MSF) specifically on immunisation in developing countries, I’m more terrified by what’s not happening in those same health centres.

In many parts of the world, parents already struggle to get their children the life-saving vaccinations they need to protect them against deadly diseases such as measles, whooping cough, or diarrhoeal diseases that claim hundreds of thousands of young lives each year.

Measles

Due to a global resurgence, there have been ongoing outbreaks of measles in countries like the Democratic Republic of the Congo and Nigeria. In 2018, measles killed more than 140,000 people, mostly children under the age of five.

We can foresee a “double burden” on health systems: the COVID-19 pandemic coupled with outbreaks of vaccine-preventable diseases

Measles can be prevented with vaccination, as can numerous other diseases — and hopefully, one day, COVID-19 as well — but it requires children having the chance to be vaccinated. And now the COVID-19 crisis is compounding the situation, putting child immunisation programmes all over the world at serious risk of being suspended or halted.

The repercussions on the youngest lives could be devastating.

Critical services

In late March, the World Health Organization (WHO) issued guidance to help countries protect critical immunisation services during the COVID-19 pandemic, “so that ground is not lost in the fight against vaccine-preventable diseases.” 

The main message of the new guidance is that “countries should take what steps they can to sustain immunisation programmes and prevent unnecessary loss of life.”

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Joseph Drobho Giria holds his two-year-old daughter, Bhileru Drobho, who suffers from measles, in the measles unit run by MSF at Biringi Hospital, Ituri Province, northeastern Democratic Republic of Congo, on 06 November 2019
Joseph Drobho Giria holds his two-year-old daughter, Bhileru Drobho, who suffers from measles, in the measles unit run by MSF at Biringi Hospital, Ituri Province, northeastern Democratic Republic of Congo, on 06 November 2019

While recommendations highlight the importance of appropriate protective measures to avoid transmission of this coronavirus, it also emphasises that if immunisations are disrupted, this could cause an even greater burden on health systems in countries.

By reducing disease spread, preventive vaccinations will not only reduce the need for medical consultations in health facilities, which may be overburdened with patients with COVID-19, but they will also prevent the emergence of new epidemics, which are difficult to manage in contexts of limited medical resources.

A double burden

In MSF medical programmes, we have seen situations like this play out before. During humanitarian emergencies or natural disasters, the disruption of immunisation services, even for brief periods, can lead to increased numbers of unvaccinated children and raise the probability of outbreak-prone diseases, such as measles or meningitis. Such outbreaks may result in increased illness or death predominantly in young infants and other vulnerable groups.

So today, we can foresee a “double burden” on health systems: the COVID-19 pandemic coupled with outbreaks of vaccine-preventable diseases.

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Health staff at the Al Sabah hospital in Juba, South Sudan attend a training supported by MSF ahead of the expected arrival of COVID-19 patients
Health staff at the Al Sabah hospital in Juba, South Sudan attend a training supported by MSF ahead of the expected arrival of COVID-19 patients

Just last week, my MSF colleagues and I had a strategic discussion on how COVID-19 responses in countries where we work could have worrying effects on children’s health, such as suspension of mass vaccination campaigns, halting childhood nutrition programmes, and the conversion of maternity wards into COVID-19 wards.

Vaccines save lives. And I don’t say that because a modelling study told me so, but because I have seen it again and again

Other groups have already made some distressing forecasts. The Measles and Rubella Initiative, which includes the American Red Cross, US Centers for Disease Control and Prevention (CDC), UNICEF, and WHO, stated that over 117 million children in 37 countries are at risk of missing out on measles vaccines in the face of COVID-19. They say that measles immunisation campaigns have already been delayed in 24 countries, and campaigns planned for later in 2020 may not be implemented in an additional 13 countries.

Vaccines save lives

A recent modelling study tried to give a scale of the beneficial health impact from sustaining routine childhood immunisations in a region like Africa.

One of the scenarios they ran looked at a 6-month period in 2020 and estimated that continued immunisations could prevent 715,000 deaths in children from the time of vaccination until they are 5 years old. Measles and whooping cough each made up about one-third of the vaccine-preventable deaths in these estimates.

Vaccines save lives. And I don’t say that because a modelling study told me so, but because I have seen it again and again in the eleven years I have been working in this field.

Difficult decisions

Of course, all countries must take serious COVID-19 precautions and actions to protect their communities and health workers. It’s crucial. Yet at the same time, diseases that can be prevented by vaccination can be just as deadly and should continue to be addressed robustly — children shouldn’t have to miss out on being protected.

These aren’t easy decisions to make, but while maintaining immunisation services as much as possible right now may seem like an extra burden, the situation will be even worse if countries have to deal with both COVID-19 and one or more outbreaks of another disease, be it measles, meningitis, cholera or a whole host of others.

It is currently World Immunization Week 2020 (24–30 April), the theme for which is “#VaccinesWork for All.” In the face of COVID-19, which also affects us all, we must not stop ongoing efforts to ensure that life-saving vaccines reach all of the youngest and most vulnerable members of our families and communities.

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