The Impact of COVID-19 on Routine Child Immunisation in South Africa

"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 COVID-19 pandemic disrupted routine immunisation (RI) programmes worldwide. In South Africa, the number of children fully immunised at 1 year of age declined by 4.3% between 2019 and 2020. This article presents a qualitative study exploring attitudes and behaviours towards RI among caregivers of children under 5 years of age and healthcare workers (HCWs) providing RI services in 3 provinces of South Africa.

The article begins by briefly reviewing some previous research into the supply- and demand-side challenges that impacted routine immunisation (RI) services for children during the COVID-19 pandemic. Pandemic-related disruption of RI services was observed across all World Health Organization (WHO) regions, with varying degrees of interruption to RI sessions, health workforce availability, and vaccine supply. Disruptions in demand for immunisation services were also 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.

The researchers carried out an explorative qualitative study in September 2022 in urban, peri-urban, and rural locations within Gauteng, KwaZulu-Natal, and Mpumalanga provinces in South Africa. They conducted in-depth interviews with 51 parents or caregivers of children 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.

In terms of prepandemic immunisation behaviours, the interviews revealed that RI was a default behaviour in South Africa, driven by entrenched social norms built over generations, strong provider recommendations, and easy access to RI through intensive outreach campaigns. Thus, little thought was involved for caregivers and parents in deciding to vaccinate their children. The immunisation programme 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.

That said, long waiting times, stock shortages, lack of education/information about RI, negative HCW attitudes, and fear of stigma and judgment all impacted care-seeking before and after COVID-19. Despite these problems, uptake of RIs was high prior to the pandemic; in 2019, 83.9% (95% confidence interval (CI): 82.9-84.9) of children received all basic vaccinations up to age 1 year. 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).

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. 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. There were shortages of routine vaccines for children at public health facilities, and HCWs experienced anxiety and burnout.

As outlined here, there was a post-pandemic shift to more active decision-making about immunisation, which resulted in 3 pathways for RI uptake when the lockdowns were lifted: the path of persistence, the path of procrastination, and the path of doubt. Of these three pathways, only the path of persistence led to consistent RI uptake. An unvaccinated status quo emerged for the 2 other groups. "Procrastinating" caregivers intended to immunise their children but consciously or unconsciously 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."

Based on the findings, the researchers suggest that "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..." Furthermore, governments should build resilient health systems and focus on understanding and engaging procrastinating and doubtful caregivers. Clear communication about RI benefits and vaccine safety is crucial, as misinformation can lead to distrust in new vaccines.