International Journal of Contemporary Pediatrics

Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

[Link] pISSN 2349-3283 | eISSN 2349-3291

DOI: [Link]
Original Research Article

Impact of COVID-19 pandemic on routine childhood immunisation

services post lockdown in a tertiary care centre in
Meerut district of western U.P.
Archana D. Agrawal1*, Gaurav Gupta2, Ashu Bhasin1, Abhishek Singh1, Alpa Rathi1

1
Department of Pediatrics, LLRM Medical College and SVBP Hospital, Meerut, Uttar Pradesh, India
2
Department of Surgery, LLRM Medical College and SVBP Hospital, Meerut, Uttar Pradesh, India

Received: 20 December 2020

Accepted: 05 January 2020

*Correspondence:
Dr. Archana D. Agrawal,
E-mail: drarchu1232@[Link]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: The severe acute respiratory syndrome corona virus-2 (SARS CoV-2) disease pandemic has been a threat
to public health and health care system world-wide including routine immunization which has been greatly disrupted
putting children at risk for vaccine-preventable diseases (VPDs). A study with an aim to analyse the impact of COVID-
19 pandemic on routine immunization coverage post lockdown at a tertiary care centre of western UP.
Methods: A retrospective analytical study was conducted at LLRM Medical College, Meerut comparing 3 periods of
year 2020, each of 4 weeks viz: 1-28th of February, 1-28 of August and 1-28 of December.
Results: Total number of vaccine beneficiaries decreased significantly post lockdown from 646 in February to 275 and
419 in August and December respectively. The percent reduction was maximally seen in booster vaccines while birth
dose group was least affected. There was 76.2% and 39.3% reduction in number of children receiving primary doses of
combination vaccines in August and December period respectively as compared to February 2020. We found 68.42%
and 54.39 % reduction in MR-1 beneficiaries in August and December respectively as compared to February 2020.
Conclusions: Significant reduction is found in total number of children receiving immunization during un-lockdown
period, compared to pre-COVID level. This difference was more significant in booster doses compared to birth doses.
We did not find any significant catch up in vaccine beneficiaries by December 2020 despite 7 months of un-lockdown
raising significant concern for public health.

Keywords: COVID-19, Pandemic, Lockdown, VPD, Routine childhood immunisation

INTRODUCTION On 24 March 2020, in response to COVID-19 pandemic,

lockdown was imposed in Meerut district of Uttar Pradesh
The novel coronavirus disease 2019 (COVID-19), which (UP) as a part of nationwide lockdown. The Government
has affected more than 200 countries globally including of India ordered a nationwide lockdown for 21 days which
India, has been declared as pandemic by World Health kept extended in phases till May17.2 As per containment
Organization (WHO) on 11 march 2020 prompting plan of Ministry of Health and Family Welfare (MoHFW),
governments to implement numerous interventions such as the Meerut district was declared as high transmission red
total or partial lockdown, restrictions over public transport, zone area, so complete lockdown continued further for few
shutdown of schools and routine health services to prevent weeks till 31st May 2020.3 Being in red zone routine
the further spread of COVID-19.1 immunization practices were also stopped in Meerut.

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 219
 Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

The immunization services had to bear the brunt of these hepatitis B, diphtheria, tetanus, pertussis, Polio, H.
unprecedented circumstances and various on-site and influenza B, rotavirus, pneumococcus, measles and
community immunization services were severely affected. rubella.7
Delayed or missed vaccination can make children
susceptible to preventable diseases and may also affect We divided the vaccines in 5 groups as below.
herd immunity.4 Vaccine-preventable diseases (VPD)
remains an important issue that requires adherence to Children receiving birth dose vaccine including BCG,
recommendations to prevent severe illnesses in children. Hepatitis B and OPV- 0 dose. Children receiving primary
According to WHO, VPD is a threat to 80 million children doses of combination vaccine including pentavalent, OPV,
under one year worldwide because of disruption in IPV, PCV and rotavirus vaccine. Children receiving MR-
healthcare services due to COVID-19 pandemic.5 To avoid 1 and vitamin A. Children receiving MR-2 with DPT 1
the impact of disruption in immunization, as per MoHFW booster and vitamin A. Children receiving DPT booster 2.
guidelines, vaccination of institutionally delivered
newborn was started.6 Further since July 2020, proper Comparative study was done between February and
routine immunization sessions were started on daily basis. August data that is pre COVID and unlockdown-1 and
Multiple factors like phasic unlock down, fear of catching February and December i.e., unlockdown-2 and
COVID-19 infection from hospitals, unavailability of appropriate statistical tests were applied.
public transport and lack of awareness regarding priority
of routine immunization have adversely affected health RESULTS
seeking behaviour and routine immunization visits to
health care facilities. Some data regarding the impact of The present study shows that during the un-lockdown
lockdown on immunisation coverage is available but period the absolute number of children receiving routine
published data showing immunisation coverage during immunization was significantly lower in August 2020
post lockdown period is still scarce. So, we conducted a (n=275) and also in December 2020 (n=419) as compared
study with an aim to analyse the impact of COVID-19 to the pre COVID period of February 2020 (n=646); with
pandemic on routine childhood immunization during the the p-value of 0.0002 and 0.007 respectively using
post lockdown period over last 6 months in phasic manner unpaired t test of equal variance (Table 1, Figure 1). Table
in a tertiary care centre of district Meerut of western UP. 2 shows the comparison among different vaccines group
between February 2020 and August 2020 with percent
METHODS reduction and p value. Table 3 shows the comparison
among different vaccines group between February 2020
It was a retrospective analytical study carried out at SVBP and December 2020 with percent reduction and p value.
hospital attached with LLRM Medical College Meerut in
the state of UP, a centre catering COVID as well as non- Table 1: Vaccination received during February,
COVID patients during this pandemic. We divided the August and December study period.
study group in 3 phases over an equal duration of 4 weeks-
Variables February August December
Pre-COVID phase: 1-28th February 2020. Birth dose* 258 186 217
Combination
Unlockdown-1: two months after the lockdown was 257 61 156
vaccine**
withdrawn i.e. 1-28th August 2020. MR-1 57 18 26
MR-2+DPT-1 51 8 12
Unlockdown-2: six months after the end of lockdown i.e.1- DPT-2 23 2 8
28th December 2020. Total 646 275 419
*Birth dose includes BCG, OPV and Hepatitis B.
All children attending immunization clinic of paediatric **Combination Vaccine includes Pentavalent, IPV, Rota Virus
OPD age 0 days to 5 years were included in the study and Pneumococcal vaccines
group. Data was collected from hospital records including
name, date, age, sex, vaccine administered and entered in There was 27.91% reduction in number of children
Microsoft excel version 2016. Calculations were done and receiving birth dose in August 20 (n=186) as compared to
data was analysed to see total number of children receiving February 20 (n=258) with the p value of 0.002. Whereas,
vaccines for all the three periods on weekly basis to study in December 2020 the number of infants (n=217) receiving
any change in trend of number of vaccine beneficiaries birth those approached nearly to pre COVID time of
over time and also aggregated count over 4 weeks February 2020 (n= 258) with reduction of just 15.89%
duration. (p=0.15).

The hospital follows National immunization schedule Similarly, there was an alarming decline in the number of
which targets 11 VPDs beginning at birth and beneficiaries receiving primary doses of combination
subsequently at 6, 10 and 14 weeks, 9 months, 16-24 vaccines, with a 76.26% reduction in number of children
months and 5 years. The vaccines are against tuberculosis,

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 220
 Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

in August 2020 (n=61) as compared to February 2020

(n=257) with p value of 0.00001.

Although the number of vaccines started showing increase

in trend in December 2020 as compared to August 2020,
still there was significantly lower vaccination with
reduction of 39.3% in December 2020 (n=156) as
compared to February 2020 (n=257) and the difference is
a still statistically significant (p value=0.002) (Figure 2,
Figure 3).

Table 2: Vaccine comparison between February and

August study period.

% P Figure 1: Total vaccines during February, August and

February August December 2020 study period.
change value#
27.91
Birth dose* 258 186 0.026
(↓)
Combination 76.264
257 61 0.00001
Vaccine** (↓)
68.42
MR-1 57 18 0.01
(↓)
DPTb1+MR- 84.31
51 8 0.0005
2 (↓)
90.90
DPTb2 23 2 0.003
(↓)
57.43
Total 646 275 0.0002
(↓)
*Birth dose includes BCG, OPV and Hepatitis B.
**Combination Vaccine includes Pentavalent, IPV, Rota Virus
and Pneumococcal vaccines. #P value determined by unpaired t
test of equal variance.

Table 3: Vaccine comparison between February and Figure 2: Comparison of vaccination status between
December study period. February 2020 and August 2020.

%
February December P value#
change
15.89
Birth dose* 258 217 0.15
(↓)
Combinatio 39.30
257 156 0.0012
n vaccine** (↓)
54.38
MR-1 57 26 0.042756
(↓)
DPTb1+MR 76.470
51 12 0.0045
-2 (↓)
65.22
DPTb2 23 8 0.02
(↓)
35.13
Total 646 419 0.007
(↓)
*Birth dose includes BCG, OPV and Hepatitis B. **Combination Figure 3: Comparison of vaccination status between
Vaccine includes Pentavalent, IPV, Rota Virus and February 2020 and December 2020.
Pneumococcal vaccines. # P value determined by unpaired t test
of equal variance
It was observed that for the primary booster doses of DPT
with MR-2 there was a drastic reduction in the number of
There was 68.42% reduction in August 2020 (n=18) for vaccine beneficiaries in August 2020 which was not
MR-1 beneficiaries as compared to February 2020 (n=57) picked up even by the end of this year. Percentage
(p=0.01). Similar trend was observed in December 2020 reduction in August was 84.3% (n=8) compared to
(n=26) also with percentage reduction of 54.39% from February (n=51) with the p value of 0.0005. In December
February 2020 and it was still statistically significant also the percent reduction was 76.4% (n=12) and
(p=0.04). p=0.0004. (Figure 2, Figure 3)

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 221
 Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

While studying weekly trends in the total number of versus combination vaccine=257). This was in coherence
children receiving vaccines, the four weeks of August with the finding of Patel et al in Gujrat.8
depict a gradual decline in the number of children which
may actually reciprocate to increasing fear due to flare up Whereas, Helen et al in England studied change in trend of
of COVID positive cases in the community (Figure 4). aggregated weekly counts of first hexavalent and MMR
vaccine, found a general decrease in hexa-valent
vaccinations delivered in 2020 compared with 2019, but
without any evidence of further rate of decline with the
introduction of physical distancing measures and in later
weeks this number even increased as compared to 2019.11

In all 8 out of 34 (23.52%) infants received BCG along

with their first pentavalent dose in August month as against
3 of 114 babies (2%) during pre-COVID period. Later
during December, this delay improved and only 3 of 59
(5%) babies received BCG with first pentavalent vaccine.
It is again highlighted that after so much of work in
immunization field, birth dose vaccination coverage is still
lacking in many peripheral regions. In comparison to
Figure 4: Comparison of Weekly trend of number of August, the children receiving combination vaccine
vaccines between February, August and December increased in December by 60%; still the gap was
2020. statistically significant in comparison to pre-COVID
(February) levels.
There is increasing trend in the number of children
attending immunization clinic in the last month of the year A major setback has been there for measles and rubella
but still it is far from the pre-COVID targets. (MR-1) vaccine as the coverage dropped to only 18
beneficiaries during the entire four weeks of August with
DISCUSSION reduction of 68.42% in comparison to February, it later
improved in December in comparison to August period (26
The present study shows that during the unlock-down versus 18) but still far from pre-COVID target. Helen et al
period absolute number of all beneficiaries receiving found 19% reduction in first 3 weeks of lockdown
routine immunization was lower in August as well as in compared to 2019 which rose later despite continuation of
December in the year 2020 as compared to February lockdown.11 Similarly, Patel et al showed reduction of MR
[Link] results were shown by a study conducted in vaccination count by 78.57% in the month of May 2020
Gujarat by Patel et al where they compared the period of compared to 2019.1,8 Also surprisingly, we found 4 of 18
lockdown with same period of previous year.8 Also, (22.2%) children receiving MR-1 in August month were
similar results have been documented in a study of Saudi so delayed for vaccination that they received pentavalent
Arabia, Pakistan and England.9-11 vaccination along with MR-1 dose, while in December 2
of 26 children received pentavalent vaccine with MR-1.
The least affected group was children receiving birth doses
as after the guidelines of Ministry of Health and Family The worst hit category was of the children receiving
Welfare on 15th April, our hospital resumed booster doses of DPT-b1 and MR-2 with a decline of 84%
administration of birth doses to all institutionally delivered in the month of August and 76% in the month of December
babies and by December end it has reached almost to the showing that there was poor catch up even till the last four
Pre-COVID numbers. Our hospital being a referral centre weeks of the year. Whereas, other vaccines like BCG and
for COVID deliveries too and also as many private combination vaccines have shown improving trend to a
practitioners were not conducting deliveries at their place, larger extent by the end of this year.
number of deliveries were not significantly decreased
because of lockdown in our centre.6 It also highlights that for the children of older age group,
the parents are still avoiding routine immunization (RI)
Patel et al has also shown a significant decrease in sessions which is a cause of great concern for the
vaccination of birth doses in the month of May 2020 resurgence of VPD epidemics as well as it is mitigating the
during lockdown compared to May 2019.8 positive impact of MR campaign conducted in 2018-19 in
India. Similar findings were also observed during ebola
From our study it is clear that there was massive decline in outbreak in 2014.
the number of beneficiaries receiving primary doses of
combination vaccines in August (n=61) as compared to Sun et al, conducted a study in West Africa post EBV
February (n=257) and also as compared to BCG outbreak and compared vaccination coverage of
beneficiaries in the month of August (n=186) itself. While pentavalent and Measles pre outbreak, during the outbreak
in February these number were almost same (BCG=258 and post MCHW campaign found a decrease of 29.6% in

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 222
 Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

Penta-3 and decrease of 25.9% in measles coverage during December month too for the same reason and to study
pandemic which rose post campaign but not to statistically further change in the number of vaccine beneficiaries.
significant level.12
CONCLUSION
A massive decrease has been found in DPT 2nd booster
coverage which is due at 5 years of age as per National There has been a significant negative impact of COVID-
immunization schedule, re-emphasizing the parents lack of 19 pandemic on attendance of children availing routine
concern for booster doses as against the fear of exposure immunization services even after 6 months of un-
to COVID infection. Similar findings were reported by lockdown. The major setback has been seen for booster
Patel et al.8 doses of Measles, Rubella, and DPT followed by
pentavalent vaccines. BCG and other vaccines
Many studies have shown that VPD outbreaks especially administered at birth are nearly approaching pre-COVID
measles epidemics often follow humanitarian crises. levels.
Measles is one of the most transmissible infections, and
immunization rates tend to be lower than for other Studies are further needed to estimate the number of
Extended Program of Immunization (EPI) vaccines, due in susceptible cohort of under-5 children who urgently need
part to the older age at which measles vaccine must be catch up vaccination. This surveillance data will further
administered i.e. 9 months versus 6 weeks or younger for guide for planning and implementation of strategies to
the first dose of other vaccines. For this reason, explosive bridge the existing vaccination gap and to prevent the risk
measles outbreaks are often an early result of health system of upcoming VPD epidemics. This is need of hour that
failure. Outbreaks have followed disruptions due to war, high-quality supplementary immunization activities
natural disasters and any other calamities.13 Analyses from should be conducted at district level and nationwide and
the 2014-2015 Ebola outbreak suggests that the increased routine immunization should be strengthened to protect the
number of deaths caused by measles, malaria, HIV/AIDS hard-earned positive impact of MR campaign conducted in
and tuberculosis attributable to health system failures India in 2018-19.
exceeded deaths from Ebola.14,15
ACKNOWLEDGEMENTS
The benefits of immunization far outweigh the risk
associated with it. In a benefit-risk analysis of health Our sincere thanks to Dr Vanya, Dr. Sujata, Dr. Sunil and
benefits versus excess risk of SARS-CoV-2 infection, in sister Poonam for making available to us, all the past
Africa, it was estimated that in a high mortality scenario, hospital records.
for every one excess COVID-19 death attributable to
SARS-CoV-2 infections acquired during routine Funding: No funding sources
vaccination clinic visits, 84 (95% CI; 14-267) deaths in Conflict of interest: None declared
children could be prevented by sustaining routine Ethical approval: The study was approved by the
childhood immunization.16 WHO and thereafter MoHFW Institutional Ethics Committee
has declared immunization as an essential health care
activity even during covid-19 pandemic.17 REFERENCES

Advisory Committee on Vaccine and Immunization 1. Cucinotta D, Vanelli M. WHO Declares COVID-19
Practises (ACVIP) recommends even for practitioners that a Pandemic. Acta Biomed. 2020;91(1):157-60.
all routine vaccinations be administered as scheduled, even 2. COVID-19 pandemic lockdown in India.
during the COVID-19 pandemic as it is an essential health [Link]
activity.18 lockdown_in_India. Accessed on 28 December,
2020.
Limitations 3. Containment plan-MoHFW. [Link].
Last accessed on 16 May, 2020.
Our centre being a tertiary level referral centre for both 4. Centers for Disease Control and Prevention: Risks of
COVID and non COVID in western UP, parents may be Delaying or Skipping Vaccines. Available at:
afraid of catching COVID infection and so might have [Link]
diverted to some other periphery centres for vaccination. vaccinate/[Link]. Accessed on
During lockdown as routine OPD and immunization 28 December, 2020.
services were not available, people may not be aware of 5. World Health Organization. At least 80 million
restarting immunization services and so turnover might be children under one at risk of diseases such as
low in the month of August. This was taken care by diphtheria, measles and polio as COVID-19 disrupts
repeatedly informing the society through telemedicine and routine vaccination efforts warn GAVI, WHO, and
newspaper. Also, the services were restarted since July and UNICEF. Available at: [Link]
we collected data for analysis in the month of August to room/detail/22-05-2020-at-least-80-million-
avoid this gap. We collected and analyzed the data for children-under-one-at-risk-of-diseases-such-as-
diphtheria-measles-and-polio-as-covid-19-disrupts-

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 223
 Agrawal AD et al. Int J Contemp Pediatr. 2021 Feb;8(2):219-224

routine-vaccination-efforts-warn-gavi-who-and- the wake of Ebola. Science. 2015;347(6227):1240-

unicef. Accessed on 15 June, 2020. 42.
6. [Link] 14. Elston JWT, Cartwright C, Ndumbi P, Wright J. The
[Link]. Last accessed on health impact of the 2014–15 Ebola outbreak. Public
28 December, 2020. Health. 2017;143;60-70.
7. National Immunization Schedule (NIS) for Infants, 15. Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvani
Children and Pregnant Women. AP. Effects of response to 2014–2015 Ebola
[Link] outbreak on deaths from malaria, HIV/AIDS, and
ponents/Immunization/report/National_%20Immuni tuberculosis, West Africa. Emerging infectious
zation_Schedule.pdf. Last accessed on 28 December, diseases. 2016;22(3):433.
2020. 16. Abbas K, Procter SR, van Zandvoort K, Clark A,
8. Patel P, Vasavada H, Patel SV, Patel K, Rathva P. A Funk S, Mengistu T et al. COVID-19 Working
Study of the Impact of Lockdown on Vaccination Group. Routine childhood immunisation during the
Coverage at a Tertiary Care Center. Ped infec dis. COVID-19 pandemic in Africa: a benefit-risk
2020;2(2):43-50. analysis of health benefits versus excess risk of
9. Alsuhaibani M, Alaqeel A. Impact of the COVID-19 SARS-CoV-2 infection. Lancet Glob Health.
Pandemic on Routine Childhood Immunization in 2020;8(10):e1264-e1272.
Saudi Arabia. Vaccines (Basel). 2020;8(4):581. 17. World Health Organization. Guiding principles for
10. Chandir S, Siddiqi DA, Setayesh H, Khan H. Impact immunization activities during the COVID-19
of COVID-19 lockdown on routine immunisation in pandamic.
Karachi, Pakistan. 2020;8(9):e1118-120. [Link] Last
11. McDonald HI, Tessier E, White JM, Woodruff M, accessed on 25 December, 2020.
Knowles C, Bates C et al. Early impact of the 18. Indian Academy of Pediatrics. Advisory Committee
coronavirus disease (COVID-19) pandemic and onVaccinesand Immunization Practices (ACVIP).
physical distancing measures on routine childhood ACVIP Guidelines on Immunization during COVID
vaccinations in England, January to April 2020. Euro 19 Pandemic. [Link]
Surveill. 2020;25(19):2000848. ADVISORY-ACVIPGuidelines-on-Immunisations-
12. Sun X, Samba TT, Yao J, Yin W, Xiao L, Liu F et al. [Link]. Last accessed
Impact of the Ebola outbreak on routine on 25 September, 2020.
immunization in western area, Sierra Leone - a field
survey from an Ebola epidemic area. BMC Public Cite this article as: Agrawal AD, Gupta G, Bhasin
Health. 2017;17(1):363. A, Singh A, Rathi A. Impact of COVID-19 pandemic
13. Takahashi S, Metcalf CJE, Ferrari MJ, Moss WJ, on routine childhood immunisation services post
Truelove SA, Tatem AJ et al. Bryan T. The growing lockdown in a tertiary care centre inmMeerut district
risk from measles and other childhood infections in of western U.P. Int J Contemp Pediatr 2021;8:219-24.

International Journal of Contemporary Pediatrics | February 2021 | Vol 8 | Issue 2 Page 224