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DOI:
REVIEWARTICLE
ImpactthattheCOVID-­19pandemiconroutinechildhood
vaccinationsandchallengesahead:Anarrativereview
Elena Chiappini1 |Sara Parigi1 |Luisa Galli1 |Amelia Licari2 |Ilaria Brambilla2 |
Maria AngelaTosca3 |Giorgio Ciprandi4 |Gianluigi Marseglia2
1PaediatricInfectiousDiseasesUnit,
DepartmentofHealthSciences,AnnaAbstract
MeyerChildrenUniversityHospital,Aim:Todocumentthedeclineinvaccinationcoverageinthefirstmonthsof2020as
Florence,Italy
2DepartmentofPediatrics,FoundationanindirecteffectoftheCOVID-­19pandemic.
IRCCSPoliclinicoSanMatteo,UniversityMethods:,143arti-
ofPavia,Pavia,Italy
cleswereinitiallyretrieved,outofwhich48wereselectedandincludedinthereview.
3AllergyCenter,IstitutoGianninaGaslini,
Genoa,ItalyResults:Ourreviewretrievedsimilardatainmanycountriesworldwide,and,globally,
4CasadiCuraVillaMontallegro,Genoa,preliminarydatafromthefirst4 monthsof2020indicateadeclineindiphtheria-­
Italy
tetanus-­pertussiscoverage,generallyconsideredthemarkerofvaccinationcoverage
GiorgioCiprandi,ViaBoselli5,16146
services,prioritisingprimaryseriesvaccinationsespeciallyformeasles-rubella­orpo-
Genoa,Italy.
Email:gio.******@,butitalsoletseachcountrydecidewhethertomaintaintheimmunisation
servicesevaluatingthecurrentepidemiologyofvaccine-preventable­diseasesand
Fundinginformation
ThisstudydidnotreceiveanyspecifictheCOVID-­,recoveringofvaccinations
funding
,duringthepandemic,influenzavaccinationshouldbe
promotedasacentralpublichealthmeasure.
Conclusion:Futurechallengeswillbetomaintainthevaccinationprogrammes,es-
peciallyinchildrenyoungerthan2 yearsoldandadolescents,toplantherecovery
ofvaccinationsforsubjectswhopostponedthemduringthelockdown,andtoearly
identifyanyvaccine-­preventablediseaseoutbreak.
KEYWORDS
children,COVID-­19,immunisationcoverage,pandemic,SARS-­CoV-­2,vaccinations
Abbreviations:BCG,bacilluscalmette-­guerin;CDC,centresfordiseasecontrolandprevention;COVID-­19,coronavirusdisease2019;DTP3,diphtheria,tetanus,pertussis;GAVI,global
allianceforvaccinesandimmunisation;HPV,humanpapillomavirus;MERS,MiddleEastrespiratorysyndrome;MMR,measles,mumps,rubella;SARS-­CoV-­2,severeacuterespiratory
syndromecoronavirus2;UNICEF,UnitedNationsinternationalchildren'semergencyfund;WHO,worldhealthorganization.
©2021FoundationActaPæ&SonsLtd
| ;00:1–7.
2 | CHIAPPINIetal.
1 | BACKGROUND
KeyNotes
IndirectdamagefromthecurrentCOVID-­19pandemicinthegeneral
•Thisreviewinvestigatedthevaccinationsituationworld-
population,particularlyinchildren,affectsmanyaspectsofdaily
wideduringtheCOVID-­19pandemic.
,theproportionofseverediseasedirectlyassociated
•Datafrommanycountrieshaveindicatedadeclinein
withSARS-­CoV-­2infectioninthepaediatricpopulationseemstobe
diphtheria-­tetanus-­pertussiscoverage,generallycon-
around1%–­2%,anddeathsareinfrequent1;ontheotherhand,chil-
sideredthemarkerofvaccinationcoverageacross
countries.
lockdown,theprolongedschoolclosures,socialisolationandgen-
•Itisfundamentaltoplantherecoveryofvaccinationsfor
eralimpoverishmentleadtophysicalandpsychologicalabuseinchil-
subjectswhopostponedthem.
families,greaterdifficultyinremoteaccesstotheschooleducation
systemhasbeenalsohighlighted.
Duetothefearofcontractingtheinfectioninthehospital,ac-measles,varicella,rubella,MMR,MMRV,poliomyelitis,diphtheria,
cesstotheemergencyroomhasbeenpostponedforchildrenwithtetanus,pertussis,Haemophilusinfluenza,Hib,HepatitisB,HBV,
,visitstoDTP,BCG,influenza,-
someItalianpaediatricemergencyroomsdecreasedbymorethanlishedinEnglishreferringtoroutineimmunisationprogrammesdur-
80%,withdelaysindiagnosingevenseverediseasesand,atleastiningtheCOVID-­,non-­relevant
onecase,alsoresultinginachild'-­relatedillnesses
Moreover,thefearofcontractingtheinfectionhasledthepop-wereexcluded,aswellasthosereferringtoanti-­SARS-­CoV-­2vac-
ulationtopostponetheuseofotherhealthservices,sothat,(ECandSP)independentlyperformedthelitera-
example,amongtheindirecteffectsofthepandemic,adeclineinturesearches.
,4Overall,143articleswereinitiallyretrieved,outofwhich48
OnMarch2020,,wesum-
thedocumentGuidanceonroutineimmunizationservicesduringmarisethekeyfindingsfromreviewedmanuscripts,highlightingthe
COVID-19­pandemicintheWHOEuropeanRegiontoprovidesupportmajorresults.
inthedecisiontomaintainornotthevaccinationactivityduringthe
-
mentandprovidestheguidingprinciplestominimisetheexposure3 | RESULTS
toCOVID-­-
| Adeclineofvaccinecoverageingeneralhas
seriesvaccinationsespeciallyformeasles-­rubella-­orpoliomyelitisbeenreportedworldwide
massvaccinationcampaignsinhigh-­risksettingsandvaccinateneo-Globally,theWorldHealthOrganization(WHO),UnitedNations
nates,accordinglytothenationalimmunisationschedule,inmater-Children'sFund(UNICEF)andtheWorldAllianceforVaccineand
,eachcountryImmunisation(GAVI,acooperationofpublicandprivateentities
shoulddecidewhethertomaintaintheimmunisationservicesevalu-withtheaimofimprovingaccesstoimmunisationinpoorcountries)
atingthecurrentepidemiologyofvaccine-­preventablediseases,theestimatedthatatleast80 millionchildrenareatriskofvaccination-­
COVID-­19transmissionscenario,thecorrespondingcontainmentpreventablediseasesduetotheCOVID-­,75%
furtherreiteratedinasubsequentdocument,Guidingprinciplesforvaccinationcampaigns3,4;intheWHOEuropeanRegion,duringthe
immunizationactivitiesduringtheCOVID-19­pandemic,whichempha-firstmonthsoftheCOVID-­19pandemic,routinevaccinationswere
sisesthehighriskofvaccine-­preventablediseaseoutbreaksincaseinterruptedin22%ofinfants7[Table 1].
immunisationcoveragefellundersub-­,500childrenaged0–­11 years
resultedinoneinthreeparentspostponingtheirchildren'svaccina-
tionsduringthefirstmonthsofCOVID-­
2 | METHODSaffectedagegroupwasthe0–­2 years,withadecreaseinhexava-
lent,measles-­mumps-­rubella-­varicella(MMRV),anti-­meningococcal
Aliteraturereviewwasperformedthroughmedicaldatabases,in-andanti-­
cludingMEDLINEbyPubMed,EMBASE,GoogleScholar,Scopusthevaccinationcentres’safetyplayedaroleintheparents’decision
,in42%ofcases,the
Usedkeywordswereasfollows:SARS-­CoV-­2,COVID-­19,corona-vaccinationcentrepostponedtheappointment,andthecentrewas
virus,vaccinecoverage,vaccine,children,infant,trainedimmunity,closedin13%
CHIAPPINIetal. | 3
TABLE1 MainfindingsofstudiesinvestigatingvaccinationcoverageduringthefirstmonthsofCOVID-­19pandemic
Country/RegionReference#Decreaseinvaccinationcoverage—­mainfindings
Worldwide375%of82countriesallovertheworldhavetemporarilysuspendedmassvaccination
campaignsduringthelockdown
Europe522%ofinfantsinterruptedvaccinations
Italy8Oneinthreechildrenpostponedvaccinations;0–­2 yearsoldwerethemainlyaffected
group
Tuscany(Italy)%reductioninparents’compliancewithmandatoryvaccination(hexavalentand
MMRVvaccines),andevenmore(%)withnon-­mandatoryvaccinations
Spain10Vaccinationcoveragedeclinedby5%–­60%dependingonchildren'sageandtypeof
-­gratuityvaccines
England12MMRvaccinationcoveragedecreasedby20%duringthefirstthreeweeksofthe
lockdown
LothianareaofScotland13Stableattendanceatchildhoodimmunisationclinicsduringlockdown,sinceseveral
adaptationsweremade
Netherlands14Limitedimpactontheroutineinfantvaccinations,especiallyaftercatch-­up
vaccinationprogramme,withareductioninMMRparticipationby1%–­2%
%intheadministrationofthemeaslesvaccineduringthefirstfour
monthsof2020;vaccinationsagainsthepatitis,meningitis,polioandrotavirusalso
showedadecreasingtrend
%
NewYork17,18InApril2020,62%decreaseinvaccineadministrationinchildrenaged<24 months,
and96%decreaseinthoseaged2–­18 
ordersduringMarchandApril2020,ordersduringthesecondhalfofMayand
Junewererelativelycomparabletothosefromthesameperiodin2019
%,withan83%dropamongchildrenage5
drop-­off,with65%lowercoveragein2020
LatinAmerica4Vaccinationcoveragehadalreadysufferedacollapseduringthelastdecade,andit
willnowsufferanevengreaterdeclineduetotheCOVID−19pandemic
Brazil27Reductionindemandforvaccineroomsduringthepandemic,eventhoughtheservice
,Brazil
occupiedthefirstplaceattheTop10 listofMeaslesIncidenceRateperMillion
Asia4OverthepastdecadeAsiamadeenormousprogressintermsofvaccinationcoverage,
andnowrisksseeingjeopardisedalltheworkdonebecauseofthepandemic
Indonesia24About84%ofimmunisationserviceshavebeenblockedbythepandemic;20%of
theserelatedtomeaslesandrubella
Pakistan23,%declineinthedailyaveragetotalnumberofvaccinations,withthehighest
Singapore26Herdimmunityagainstmeaslesreducesto74%–­84%among12-­month-­to2-­year-­olds
Japan27ThenationalHaemophilusinfluenzaevaccinationratedecreasedto73%in2020,and
anincrementaldiseaseburdenwasobserved
KoreaRepublic28Vaccinationrateinchildrenaged0–­35 monthsdidnotdecreasesignificantly;for
childrenaged4–­6 %–­%
Afghanistan22Increaseinpoliomyelitiscases
SaudiArabia30,%
%–­%comparedtopreviousyears
Africa35ForeveryonedeathattributabletoSARS-­CoV−2infectionsacquiredduringroutine
vaccinationclinicvisits,therecouldbe84(14–­267)deathsinchildrenprevented
bysustainingroutinechildhoodimmunisationinAfrica
SierraLeone32Decreaseamong50%–85%­invaccineadministration
Sub-­SaharanAfrica(153513/15countriesshowedadeclineinthemonthlyaveragenumberofvaccinedoses
countries)provided,with6countrieshavingmorethan10%decline
(Continues)
4 | CHIAPPINIetal.
TABLE1 (Continued)
Country/RegionReference#Decreaseinvaccinationcoverage—­mainfindings
Kenia36FromDecember2020,theprobabilityofalargemeaslesoutbreakwillincreaseto
38%(19–­54),46%(30–­59)and54%(43–­64)assuminga15%,50%and100%
reductioninmeaslesvaccinationcoverage
Ethiopia37Nationwidefollow-­upmeaslespreventivevaccinationcampaign,scheduledforApril
2020,waspostponed
drewupdetailedguidelinestolimittheriskoftransmittingSARS-­administrationshavestartedtoincreaseintheUnitedStates,espe-
CoV-­2duringvaccination,but46%ofvaccinatingphysiciansde-ciallyforyoungerchildren,thankstotheimplementationofpublic
,
Thesedatawereinlinewithanothersurvey,carriedoutinTuscany,includingtheactivere