Reasons for reductions in routine childhood immunisation uptake during the COVID-19 pandemic in low- and middle-income countries: A systematic review

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Abstract

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a substantial decline in routine immunisation coverage in children globally, especially in low- and middle-income countries (LMICs). This study summarises the reasons for disruptions to routine child immunisations in LMICs. A systematic review (PROSPERO CRD42021286386) was conducted following PRISMA 2020 guidelines. Six databases were searched: MEDLINE, Embase, Global Health, CINAHL, Scopus and MedRxiv, on 11/02/2022. Observational and qualitative studies published from January 2020 onwards were included if exploring reasons for missed immunisations during the COVID-19 pandemic in LMICs. Study appraisal used National Heart, Lung, and Blood Institute and Critical Appraisal Skills Programme tools. Reasons for disruption were defined with descriptive codes; cross-sectional (quantitative) data were summarised as mean percentages of responses weighted by study population, and qualitative data were summarised narratively. A total of thirteen studies were included describing reasons behind disruptions; 7 cross-sectional (quantitative), 5 qualitative and 1 mixed methods. Seventeen reasons for disruptions were identified. In quantitative studies (total respondents = 2,853), the most common reasons identified were fear of COVID-19 and consequential avoidance of health centres (41.2%, SD ±13.3%), followed by transport challenges preventing both families and healthcare professionals from reaching vaccination services (11.1% SD ±16.6%). Most reasons stemmed from reduced healthcare-seeking (83.4%), as opposed to healthcare-delivery issues (15.2%). Qualitative studies showed a more even balance of healthcare-seeking (49.5%) and healthcare-delivery issues (50.5%), with fear of COVID-19 remaining a major identified issue (total respondents = 92). The most common reasons for disruption were parental fear of COVID-19 and avoidance of health services. Health systems must therefore prioritise public health messaging to encourage vaccine uptake and recovery of missed immunisations.

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The PRISMA 2020 statement: an updated guideline for reporting systematic reviews

Matthew J L Page, Joanne E McKenzie, Patrick Bossuyt … (2025)

The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement, published in 2009, was designed to help systematic reviewers transparently report why the review was done, what the authors did, and what they found. Over the past decade, advances in systematic review methodology and terminology have necessitated an update to the guideline. The PRISMA 2020 statement replaces the 2009 statement and includes new reporting guidance that reflects advances in methods to identify, select, appraise, and synthesise studies. The structure and presentation of the items have been modified to facilitate implementation. In this article, we present the PRISMA 2020 27-item checklist, an expanded checklist that details reporting recommendations for each item, the PRISMA 2020 abstract checklist, and the revised flow diagrams for original and updated reviews.

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PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews

Matthew J Page (2021)

The methods and results of systematic reviews should be reported in sufficient detail to allow users to assess the trustworthiness and applicability of the review findings. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement was developed to facilitate transparent and complete reporting of systematic reviews and has been updated (to PRISMA 2020) to reflect recent advances in systematic review methodology and terminology. Here, we present the explanation and elaboration paper for PRISMA 2020, where we explain why reporting of each item is recommended, present bullet points that detail the reporting recommendations, and present examples from published reviews. We hope that changes to the content and structure of PRISMA 2020 will facilitate uptake of the guideline and lead to more transparent, complete, and accurate reporting of systematic reviews.

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Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

Timothy Roberton, Emily Carter, Victoria Chou … (2020)

Summary Background While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food. Methods We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9·8–51·9% and the prevalence of wasting is increased by 10–50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months. Findings Our least severe scenario (coverage reductions of 9·8–18·5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39·3–51·9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9·8–44·7% in under-5 child deaths per month, and an 8·3–38·6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18–23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths. Interpretation Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come. Funding Bill & Melinda Gates Foundation, Global Affairs Canada.

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Author and article information

Contributors

Alexandra M. Cardoso Pinto:

ORCID: https://orcid.org/0000-0001-5852-4841

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Sameed Shariq: Role: Formal analysisRole: InvestigationRole: ValidationRole: Writing – review & editing

Lasith Ranasinghe:

ORCID: https://orcid.org/0000-0003-2281-2352

Role: InvestigationRole: ValidationRole: Writing – review & editing

Shyam Sundar Budhathoki:

ORCID: https://orcid.org/0000-0002-8614-1087

Role: MethodologyRole: Writing – review & editing

Helen Skirrow:

ORCID: https://orcid.org/0000-0002-4383-0616

Role: MethodologyRole: ValidationRole: Writing – review & editing

Elizabeth Whittaker: Role: ConceptualizationRole: SupervisionRole: Writing – review & editing

James A. Seddon: Role: ConceptualizationRole: SupervisionRole: Writing – review & editing

Suman Majumdar: Role: Editor

Journal

Journal ID (nlm-ta): PLOS Glob Public Health

Journal ID (iso-abbrev): PLOS Glob Public Health

Journal ID (publisher-id): plos

Title: PLOS Global Public Health

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 2767-3375

Publication date (Electronic): 24 January 2023

Publication date Collection: 2023

Volume: 3

Issue: 1

Electronic Location Identifier: e0001415

Affiliations

[1 ] School of Medicine, Imperial College London, London, United Kingdom

[2 ] Academic Foundation Doctor, Imperial College London, London, United Kingdom

[3 ] Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom

[4 ] Department of Infectious Disease, Imperial College London, London, United Kingdom

[5 ] Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa

Burnet Institute, AUSTRALIA

Author notes

Shyam Sundar Budhathoki is an Academic Editor for PLOS Global Public Health but was not involved in any editorial decisions for this manuscript. All other authors have declared that no competing interests exist.

* E-mail: alexandra.cardoso-pinto18@ 123456imperial.ac.uk

Author information

Alexandra M. Cardoso Pinto https://orcid.org/0000-0001-5852-4841

Lasith Ranasinghe https://orcid.org/0000-0003-2281-2352

Shyam Sundar Budhathoki https://orcid.org/0000-0002-8614-1087

Helen Skirrow https://orcid.org/0000-0002-4383-0616

Article

Publisher ID: PGPH-D-22-01417

DOI: 10.1371/journal.pgph.0001415

PMC ID: 10021156

PubMed ID: 36963003

SO-VID: d0488079-a93b-41cc-9058-54aa2c065a0e

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 31 August 2022

Date accepted : 20 December 2022

Page count

Figures: 6, Tables: 3, Pages: 17

Funding

Funded by: Imperial College Open Access Fund

Award Recipient :

ORCID: https://orcid.org/0000-0001-5852-4841

Alexandra M. Cardoso Pinto

Funded by: MRC/DFID Concordat agreement

Award ID: MR/R007942/1

Award Recipient : James A. Seddon

This study was supported by Imperial College Open Access Fund in the form of open access publication funding. This study was also supported by UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement (MR/R007942/1) in the form of a Clinician Scientist Fellowship awarded to JS. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Reasons for reductions in routine childhood immunisation uptake during the COVID-19 pandemic in low- and middle-income countries: A systematic review

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Abstract

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Novel Coronavirus Disease COVID-19

Most cited references 41

The PRISMA 2020 statement: an updated guideline for reporting systematic reviews

PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews

Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

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