While the world is scrambling to develop a COVID-19 vaccine, the rate at which existing life-saving vaccines for other diseases are being used in South Africa has declined.
The decline has largely been blamed on the COVID-19 pandemic and the associated lockdown. Now, as many lockdown measures have been eased and COVID-19 infection and mortality numbers have declined from peaks in July, government has set in motion plans to catch up on the immunisation backlog.
Spokesperson for the National Department of Health, Popo Maja, tells Spotlight that a nationwide catch-up drive aimed at children under the age of five is set to start on 1 November. He adds that provinces are expected to catch up on all missed immunisations by the end of March 2021.
Decline in immunisation coverage between April and August
Spotlight previously reported that there had been a 21 percentage point decline in immunisation coverage, going from 82% in April 2019 to 61% in April 2020.
Maja says between April and August, there had been a 10% decline in primary vaccinations for children under the age of one, with a significant decline in nine provinces.
The picture doesn't get any better when looking at the breakdown according to metros.
"Seven out of eight metropolitan municipalities were not able to vaccinate at least 80% of their children with all primary antigens," says Maja. "42 (81%) districts did not reach the target in 2020 during the lockdown period as compared to 22 (42%) of districts during the same period in 2019."
"Sitting on a time bomb"
South Africa's immunisation rates before lockdown were not ideal to begin with, according to the Director of Vaccines for Africa (a non-profit academic unit) Prof Gregory Hussey.
"We're sitting on a time bomb basically... Before it was bad, but now it's worse. If for any reason there is (for example) a measles or rotavirus epidemic, we're in trouble, big trouble. And COVID-19 is not going to go away," he says.
Data from the latest edition of the District Health Barometer shows that South Africa's immunisation coverage for children under the age of one was only at 81.9%, falling short of the global immunisation target of 90%.
Hussey adds that while children were mostly spared the devastation of COVID-19, the impact of COVID-19 for them is going to be seen in other infectious diseases.
Hussey says lockdown has protected children to a certain extent because they were not interacting with other children, and thus there was no opportunity for infections to spread. However, he cautions that there will be a rise in infections as the country opens up.
This can already be seen, as a recent NICD statement shows an increase in the circulation of a common childhood illness, Respiratory Syncytial Virus.
According to a Maternal and Child Health Specialist at UNICEF South Africa, Dr Yin Yin Aung, children who are not receiving their immunisations during lockdown could also have a secondary effect. She explains that when children do not immunisations at clinics, they also do not get de-worming treatment, Vitamin A supplements, information about nutrition, nor the appropriate treatment if they have infection or diarrhoea.
She adds that UNICEF, along with the World Health Organization (WHO), helps the National Department of Health dealing with backlogs in immunisations and other child health interventions.
"It is critical that no child is left behind. So, this is the aim of this catch up drive, to get all the children protected against preventable diseases," says Aung. Her advice to parents and caregivers whose children missed their immunisations is to go to a clinic with the child's Road-To-Health Booklet and catch up on immunisation and other health services.
Prof Susan Goldstein, a public health specialist and Deputy Director of PRICELESS (a unit of the South African Medical Research Council), is blunt in her assessment of what would happen without a successful immunisation catch-up plan. "There are going to be more children who die," she says. "We have a fantastic immunisation schedule... which has saved thousands and thousands of lives. When the children are not fully immunised, the possibility of outbreaks immediately occurs."
Goldstein assures parents that taking children to get vaccinated, even if it is after the age stated in the Road-To-Health booklet, is safe. "It doesn't matter if it's a bit late, just get them immunised. It's safe to do so and it will protect your child," she says.
The Catch-up Drive
Maja explains that the National Department of Health, together with UNICEF, the WHO and the Clinton Health Access Initiative (CHAI) had been planning a focused intervention called 'Project Jiki'izinto' to improve immunisation performance in eight Metropolitan Municipalities and six low-performing districts.
However, due to the negative impact of COVID-19 on immunisations, the plan will now cover all 52 districts with an integrated child health catch-up drive.
"The catch-up drive will be conducted in all districts for children under five years of age. However, twelve priority districts have been identified - these districts have the highest number of under-vaccinated children and include seven of the eight metropolitan municipalities," he says.
This catch up drive, Maja says, aims to restore and intensify routine immunisation services, and provide catch-up doses to children who have missed vaccinations. It will also aim to strengthen the provision of catch-up immunisations going forward.
He adds that the drive will also be used as a platform for providing other child health services, including Vitamin A supplementation, de-worming, growth monitoring and HIV services.
The 12 priority districts will have their catch up drives first, running from 1 November to 31 January 2021, Maja explains. The other districts' drives will run from January 2021 until 31 March 2021.
Maja says that the drive will form part of the Side-by-Side Campaign, which is "a national mass communication campaign which aims to empower and support caregivers and families to provide the full range of care that children require for optimal growth and development".
How the provinces will implement the plan
Maja says provinces were "officially requested" to submit implementation plans and that virtual meetings are held regularly to "assist provinces to plan for the nationwide integrated child health catch-up drive".
"Documents including a concept document, a Field Guide and other tools have been developed and shared with provinces to provide guidance in planning for the catch-up drive," he says.
Spotlight asked the Provincial Departments of Health in KwaZulu-Natal, Gauteng, the Eastern Cape and the Western Cape about their catch-up plans.
The Eastern Cape and KwaZulu-Natal departments had not responded by the time of publication, despite many efforts to contact them.
Spokesperson for the MEC for Health in Gauteng, Kwara Kekana, says that their plan still needs to be presented to the National Department of Health for approval, but is in progress.
Kekana adds that there had been a significant decline in immunisation coverage in the province during lockdown. In the period spanning from 21 April to June, immunisation coverage had declined by 9 percentage points, compared to the same time period in the previous year, decreasing from 86.5% to 77.5%.
Kekana says that there is a plan which she refers to as a macro plan, in progress that will be conducted in a phased manner, starting in November.
She adds that the first phase of the drive will be conducted in Ekurhuleni, Johannesburg, and Tshwane, while the second phase, starting in December 2020, will be in Sedibeng and the West Rand.
Communications Officer for the Western Cape Department of Health, Byron La Hoe, tells Spotlight that the province had already implemented a plan in August to catch up on the missed immunisations. He adds that lockdown had caused a 22% reduction in immunisations in the province's facilities in April this year, compared to April 2019.
The plan, according to La Hoe, is based on information provided by the WHO in March to guide efforts "to conserve optimal immunisation cover through the provision of Catch-Up Outreach services".
"The information was customised/translated for the Western Cape and shared with services by means of a formal circular," he explains.
The catch-up drives are conducted in high-risk areas, he explains, such as areas where immunisation cover might be low, and where there is potential risk for an outbreak.
La Hoe says to ensure all children are immunised, health facilities are following up with parents who missed appointments. And to make the public aware of the need for children to have up-to-date vaccinations, the province launched the #VaccinesWork communication campaign in August.
"The core message is to inform parents that important childhood immunisations are available to children who have fallen behind due to the coronavirus pandemic," says La Hoe. "Parents are also reminded to make their appointments and bring their healthy children to the clinics for these free immunisations."
He adds that, at the time of the interview, the Western Cape Department of Health had received no formal communication regarding child immunisation from the National Department of Health.
"To date, the Western Cape Department of Health has not received any formal communication directed to management to action a standardised National Catch-up," he says. "However, the department is committed to ensuring that effective catch-up interventions take place in the province, and the sharing of data and information with the national Department of Health."
National Vaccination Coverage Survey to be released soon
In March 2019 it was announced that a National Vaccination Coverage Survey would be conducted to provide a more comprehensive overview of immunisation coverage in the country. The last immunisation survey was done in 1994.
According to one of the study authors, Prof Rosemary Burnett, the survey has been conducted successfully and will hopefully be released to the National Department of Health by the end of the month. Burnett declined to comment on the findings until then.
Maja confirmed that the survey findings will be released before the end of 2020.