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When Old Diseases Crash Upon New: Crisis and Opportunity

Authors: Peter Hansen and Grace Chee

The COVID-19 crisis has made the imperative to find safe and effective ways of delivering immunization even more urgent. Immunization is highly impactful and cost-effective. Countries across all income levels include nearly a dozen vaccines in their national immunization programs, which protect against a wide range of diseases and conditions, including measles, polio, tetanus, pneumonia, diarrhea, liver cirrhosis and cancer.  Where vaccine delivery strategies work, many people stop seeing many of the diseases against which they protect and begin to take the benefits for granted.

Key Messages
  • COVID consumes all attention now, but VPDs are actually more transmissible and deadlier: deaths due to resurgence of old diseases are likely to exceed deaths due to COVID
  • As WHO currently recommends suspending immunization campaigns, countries facing greatest risk of resurgence of VPDs are ones that relied on campaigns because they have weak immunization and health systems
  • As a key part of overall COVID response, we must find ways to continue ongoing immunizations efforts while also protecting health workers and assuring caregivers that immunization can be conducted safely– failure to do this will have a devastating effect on people’s health, especially in low and lower-middle income countries
  • We should take the opportunity of this crisis to recognize the urgency of accelerating innovation to strengthen routine immunization as an integral part of primary healthcare systems so health services can reach everyone in need
Put simply: vaccines work. But immunization programs can be severely disrupted during a crisis.

As much of the world focuses on headlines related to development of a new vaccine for COVID-19, that same virus threatens to upend years of hard-won progress and create a resurgence of diseases for which effective vaccines already exist. In fact, illness and deaths resulting from the resurgence of previously controlled diseases, some of which are more transmissible and deadlier, is likely to be significantly greater in many settings than that resulting directly from COVID-19.

This blog prioritizes three actions that are critical for safeguarding health during this global crisis — and beyond.

First, some context. During the Ebola epidemic that struck West Africa in 2014, the number of people who died as a result of measles was significantly greater than the number of people who died as a direct result of illness caused by the Ebola virus. The same pattern has repeated itself in the current Ebola outbreak in the Democratic Republic of Congo. And there is plenty of reason for concern that we will see the same thing with the COVID-19 crisis, but at a far greater scale. A modeling study by researchers at the London School of Hygiene and Tropical Medicine found that for each COVID-19 death prevented by suspending routine immunization, there would be 29-347 future deaths resulting from resurgence of older diseases for which effective vaccines already exist.

The World Health Organization has taken the difficult step of calling for the temporary suspension of mass vaccination campaigns — due to their emphasis on large gatherings and the need to promote social and physical distancing to limit the spread of the coronavirus.

Now, countries have only their routine health care delivery systems to rely on for delivery of vaccines. And yet, the countries that have relied most on vaccination campaigns tend to be the countries with the weakest routine delivery systems and the largest burden of vaccine-preventable diseases. These same countries are now facing the dual challenge of dealing with existing systemic weaknesses as well as acute new challenges. Many caregivers and health workers are afraid and uncertain how to deliver and access services safely, especially with stay-at-home orders in place in many countries and the suspension of public transportation systems. Additionally, staff at all levels, including those who have previously handled immunization, are being diverted to COVID-19 response and surveillance, and funding for operational costs for routine immunization is being diverted to COVID-19 related expenses.

Effectively addressing these issues is our only recourse under the current crisis.

The Chinese word for crisis, weiji, 危机, consists of two characters: the first meaning danger and the second conveying opportunity. Under the COVID-19 crisis, we must not only respond to the current danger, but also seize the opportunity to strengthen service delivery to safeguard health now and in the future in three ways:

  1. Find safe and effective ways to continue ongoing immunization efforts. First and most urgently, countries should not deprioritize delivery of routine immunization to focus on COVID-19 response. Finding safe and effective ways to reach people with existing vaccines should be a core part of every country’s COVID-19 response strategy. For most countries, this will necessitate finding innovative ways to reach people safely through routine delivery systems and other strategies that are linked to the routine system. This will require strong relationships with community leaders, clear communication of the benefits of vaccination and measures taken to ensure safe delivery, and adaptation of delivery approaches to local context and the needs and perspectives of community members. Appropriate distancing, protective equipment and other infection control measures are a necessary part of the response, in line with WHO guidance on maintaining essential health services during the COVID-19 outbreak. National immunization programs need to clearly and proactively communicate with health workers about risks of COVID-19 transmission and benefits of vaccination and address their concerns about safety. They will also need to prepare to respond to rumors and misinformation, and work with communities to build and maintain trust in vaccination and other essential services.
  2. Proactively plan for catch-up of missed individuals. A second critical action is carefully tracking successes and failures in efforts to safely deliver vaccination services during the outbreak, and proactively planning for catching up on vaccinations of communities and individuals that have been missed as soon as it is safe to do so. Catch-up strategies will require a combination of working through the routine delivery system and supplemental activities, with coordination, communication and data capture and use synchronized across the two. Countries also need to continue with their ongoing disease surveillance efforts to enable timely detection of outbreaks and targeted vaccination efforts to limit the spread of outbreaks.
  3. Innovate to strengthen routine delivery systems. In the long term, the most critical priority is strengthening delivery through routine primary healthcare systems, to reach everyone who needs vaccination in an efficient and sustainable manner as part of a holistic approach to improving health throughout a person’s life. It is necessary to rethink how to strengthen primary healthcare systems so they can more effectively reach the millions regularly missed by routine systems prior to the COVID-19 outbreak, and maintain delivery of essential services when other disruptive crises strike in the future.This is clearly not a simple task, but a complex challenge that will require collaboration among a wide range of stakeholders through new ways of working to find innovative solutions. Co-creation approaches at the country-level can help identify the root causes of systemic immunization challenges as well as highlight opportunities to learn from innovations and practices in other settings to tailor solutions for the local context. Peer-to-peer collaborative learning can enable countries to learn from each other about what works (and what doesn’t work) to accelerate progress. Both of these activities will need to be supported by a robust network of global, local and regional experts and institutions who are capable of providing support remotely and helping countries test and adapt solutions. As described in a recent blog by Nathan Blanchet, co-creation approaches can be successfully adapted and implemented virtually when in-person convening is not feasible due to COVID or other reasons—this is critical because strengthening delivery systems is an urgent priority that cannot wait.

Accelerating innovation for safe and effective delivery is important for existing vaccines and for the delivery of a future COVID-19 vaccine, which will require delivery systems and logistics management at an unprecedented scale. Taking action now to strengthen health systems so they can effectively deliver routine and supplemental services to all people in need is essential to limiting the dangers of COVID-19 as well as other diseases.

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