National immunisation rates for children under five years have dropped dramatically over the period of South Africa's COVID-19 lockdown, sparking fears of an outbreak of deadly childhood infectious diseases including measles.
The most recent Department of Health figures, released to Spotlight, show that national immunisation coverage in April during level five of the lockdown dropped from 82% in April last year to 61% for April this year. Most concerning is the sharp decrease in the coverage rate of the second dose of measles vaccine from 77% in April last year to 55% in April this year.
The World Health Organisation's (WHO) recommended immunisation coverage rate for countries worldwide is 95%. The larger the percentage of people immunised, the more the population will be protected from deadly outbreaks of infectious diseases.
Measles, a highly contagious disease, remains a serious global threat although a safe and effective vaccine has been available since 1963. The measles virus usually results in a high fever and rash, and can lead to blindness, encephalitis or death.
Dr Lesley Bamford, acting Chief Director of Child, Youth and School Health at the National Department of Health, said immunisation performance indicators were based first, on the number of fully immunised children under one year of age who have had all required immunisations at birth, at six, 10 and 14 weeks and at six months and nine months; and secondly on the number of children who have had their second dose of measles at one year of age. The first dose of measles is given at 6 months.
Bamford said all provinces have been affected with the weakest second dose measles coverage in North West at 43% followed by the Western Cape at 48%. The Western Cape has so far been hardest hit by COVID-19, with more than half of the country's confirmed cases and over two thirds of the country's COVID-19 deaths. The provinces least affected by a drop in immunisation rates for second dose measles were Northern Cape (67%) and Mpumalanga (66%), Bamford said.
"We have been working very hard to get our second dose measles up and it was going up. Now, it has come right down again. The concern is that by protecting kids from COVID-19, by not taken them for immunisations we will have measles outbreaks instead, which for children is much more deadly," she said.
There have been no outbreaks yet, "but remember that during lockdown infections don't spread". "It's in post-lockdown when children start mixing again and schools open that there is a very real risk of outbreaks," said Bamford.
The health department does not collate immunisation figures in the private sector, but they were expected to be down. This was confirmed by a Dischem, the large pharmacy retail store, spokesperson who told Spotlight that its 290 clinics spread across stores countrywide reported steep declines in immunisation coverage.
Lizeth Kruger, Dischem's National Clinic Manager, said immunisations for children under five years had dropped by 8% in March (before the lockdown), 41% in April, 26% in May and 40% in June compared to last year's figures for the same period.
The health department, which has immunisation catch-up plans, is urging caregivers to take children due for routine immunisation and who have missed their shots during lockdown, to health facilities to get their vaccinations. "We are sending out a very strong message that lifesaving immunisations are available. There are no national stock-outs that we are aware of because vaccines are available nationally. We expect our primary health care facilities to be up and running and providing services," Bamford said.
The United Nations Agency for Children (Unicef) recently noted that it is "deeply alarmed by the knock-on effects of the COVID-19 pandemic on children" and the fact that over 117 million children in 37 countries may miss out on their measles vaccination as immunisation campaigns have been stopped in an effort to reduce the risk of spreading the SARS-CoV-2 virus.
Unicef also warned that an additional 6 000 children could die every day from preventable causes over the next six months as the pandemic continues to weaken health systems and disrupt routine services. The estimate is based on a modelling analysis by researchers from the Johns Hopkins Bloomberg School of Public Health, which was published in The Lancet Global Health journal.
Drawn from the worst of three scenarios in 118 low- and middle-income countries, the analysis estimates that there could be another 1.2 million under-five deaths in just six months, due to reductions in routine health service coverage levels and an increase in child wasting. These possible deaths are in addition to the 2.5 million children who already die before their 5th birthday every six months in the 118 countries included in the analysis.
Relatively fragile service
University of the Witwatersrand Vaccinology Professor Shabir Mahdi said that South Africa has "a relatively fragile service despite having an advanced immunisation programme and we are not reaching the global immunisation target of 95% coverage set by the WHO". "So, we cannot afford to risk further under-immunisation of children because if this happens, we are setting ourselves up for an outbreak of life-threatening preventable diseases such as Pertussis, Diphtheria, Rotavirus, Polio and Pneumococcal disease," Madhi said.
"Children are at greater risk of dying from vaccine preventable disease than contracting COVID-19 in the clinics and if anything, we know that children are at a very nominal risk of developing very severe COVID-19 disease."
The South African Medical Research Council's (SAMRC) Professor Karen Hofman said South Africa has 5.8 million children under 5 years of age and while this group is not at high risk for infection of COVID-19 disease, their health is of particular concern. In a co-authored article in The Conversation she said: "This group appears to be less susceptible to COVID-19. But, if the country doesn't pay attention, the death rate for these children will soon increase because of measles outbreaks."
Hofman is the SAMRC's Director for Health Economics and Decision Science at Wits University.
Measles is a highly contagious disease that mostly affects children under the age of 5. "The basic reproductive number of measles in a susceptible population is between 12 and 18. This means that on average every person with measles will infect between 12 and 18 people," Hofman said.
By way of comparison the reproductive number of symptomatic cases of SARS-CoV-2 is estimated to be between 2 and 3.5, she said.
Why numbers are down
Bamford said that at no time did the department of health discourage caregivers from coming to clinics for immunisation. She said at the beginning of the lockdown (March 27) some facilities and provinces stopped immunising, so caregivers with children could not access health services.
"We are not really sure yet exactly why children were not immunised. We surmise it's a combination of supply problems with facilities not encouraging immunisation because of lack of availability, people may not have been able to access the health facilities, and they may have been too scared to go," Bamford said.
Antenatal care visits for pregnant women went from 78% in April 2019 to 71% this April which was not "a huge drop". "This suggests services were being provided and pregnant women could access them. The drop should reflect a combination of people unwilling to go for fear of infection with the SARS-CoV-2 virus or they could have had difficulties in getting to health facilities.
Professor Greg Hussey, Vaccines for Africa director at the University of Cape Town, agreed that there is a real danger that with dropping immunisation rates due to lockdown measures, infectious diseases will spike when children integrate at crèches and schools.
"The problem with mass immunisation campaigns in the country is that they are not truly community-based as in door-to-door. The campaigns are clinic and school-based, which means gatherings of people with the risk of infection," he explained. "Children should attend clinics which need to be made safe (with infection-control procedures and social distancing in place) from the possibility of infection with COVID-19," Hussey said. "People have had to find ways to deal with this virus. They have had to find intuitive opportunities. Not enough people are thinking about what needs to be done."
Bamford said community health workers who help identify children who are not immunised and refer them to facilities, have also been involved in the COVID-19 response. "But hopefully, there is a shift away from testing and screening and community health workers will be refocussing on adding routine work that include maternal and child health and immunisations," she said.
Screening of pupils at 23 000 schools countrywide will begin and there won't be capacity for immunisation at schools, said Bamford. "That is why community health workers are really important because they can go to households to check Children's Road to Health cards," Bamford said.
The department of health has a Side by Side-campaign which is based on a new Road to Health booklet which is based on five themes aimed at a reduction in mortality of under five years olds. The department also has an extensive SABC radio campaign in the official languages and plans to campaign for immunisation via the health department's successful MomConnect WhatsApp service where pregnant mothers get health messages and where they can send compliments and complaints.
Asked whether caregivers' concerns about children contracting the SARS-CoV-2 may lead to vaccine hesitancy in future, Bamford said: "We don't have any evidence of new hesitancy. However, there is a potential risk that COVID-19 fears may transform into scepticism about medical treatment. But this depends on how coverage of a new vaccine for COVID-19 plays itself out. A vaccine is likely to be our only hope, so if we do get a vaccine, this could be a potential boost for all vaccines."
She said vaccine hesitancy in South Africa "is mainly a middle-class phenomenon" and "there is this misconception that immunisations are only for poor people who live in unhygienic conditions". "Quite a few of our measles outbreaks have occurred in private schools," Bamford said.
Vaccine hesitancy did occur in the majority of the population but "in small pockets" and the issues were more related to accessing vaccines. "Coverage tends to be very good in the early months when caregivers are very aware and it is in the front of their minds to take the children for immunisation but life happens and people forget to get second doses," she said.