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 Table of Contents  
Year : 2022  |  Volume : 24  |  Issue : 3  |  Page : 25-29

Facilitators and Barriers to Infant Immunization during COVID-19 Pandemic

1 Department of Medicine, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
3 Station Health Organisation, Mumbai, Maharashtra, India
4 Health Organisation, INS Kadamba, Karnataka, India

Date of Submission03-Oct-2021
Date of Acceptance20-Nov-2021
Date of Web Publication01-Apr-2022

Correspondence Address:
( Dr). Shabeena Tawar
Station Health Organisation, Mumbai - 400 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_126_21

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Introduction: The world is enveloped with the coronavirus disease 2019 (COVID-19) Pandemic with modern medicine and public health facing their most significant challenges ever posed. As the number of COVID-19 cases increased worldwide, an important issue of concern was the continuation of routine immunization services for children. This study has been conceptualized to assess the effect of the COVID-19 pandemic on infant Immunization. Materials and Methods: This study was a descriptive study conducted in an urban community amongst healthy children <1-year-old from January 2018 to September 2021. Immunization records of infants were obtained from data generated during each immunization session and strength, weakness, opportunity, and threat analysis was done using a questionnaire. Results: During the study, a total of 3518 vaccinations were done, a total of 3010 vaccinations (85.5%) were done on time, and the total delayed vaccinations were 508 (14.5%). The difference among the years was statistically significant, with the highest delay in the year 2020 (P < 0.001). However, in the year 2021, the number of vaccinations carried out from April to September was 568, with delayed vaccination of only 10.9%. Conclusion: The Armed Forces childhood immunization program could be sustained during the COVID-19 pandemic due to a multitude of contributing factors such as adherence to national guidelines that prioritized vaccination, infrastructure, and availability of trained workforce and most importantly commitment to strict COVID appropriate behavior.

Keywords: COVID-19, immunization, vaccination, essential health services, delayed

How to cite this article:
Tawar S, Yadav AK, Garg S, Bhaskar V, Swain SK. Facilitators and Barriers to Infant Immunization during COVID-19 Pandemic. J Mar Med Soc 2022;24, Suppl S1:25-9

How to cite this URL:
Tawar S, Yadav AK, Garg S, Bhaskar V, Swain SK. Facilitators and Barriers to Infant Immunization during COVID-19 Pandemic. J Mar Med Soc [serial online] 2022 [cited 2022 Sep 25];24, Suppl S1:25-9. Available from: https://www.marinemedicalsociety.in/text.asp?2022/24/3/25/342373

  Introduction Top

Immunization is an effective way of controlling infection due to communicable diseases as it is the key to strengthen the host defenses and prevent children from acquiring infections. It is also known that one of the greatest benefits that a country can offer to its population is protection from infectious diseases.[1]

The world is enveloped with the coronavirus disease 2019 (COVID-19) Pandemic since the beginning of 2020. Public health and modern medicine are facing their most unprecedented challenges posed to mankind after almost a century. The onset of the Pandemic forced the imposition of a lockdown. This implied that only the most essential and emergency medical services were offered to the public resulting in the disruption of many preventive and curative health services. As the number of COVID-19 cases increased worldwide, the endpoint of lockdowns and restrictions were not in sight. With this, the most important issue of concern was the continuation of immunization services for Infants. It has been speculated that disrupted immunization services, may not only have short term but also long-term ramifications which may only be evident with time.

It is known that disruptions in routine immunization if left unaddressed is poised to halt and even reverse the global progress achieved in vaccine delivery.[2],[3] Despite the short term and long-term ramifications that disruption of immunization can have it is one of the least publicized consequences of the COVID pandemic.[4] As per the WHO guiding principles, “Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where ever feasible.”[5]

Not just the low-income countries[6],[7],[8] faced a risk of drop and disruption in immunization services, a decline in immunization coverage in early stages of the Pandemic was also seen in the High-income countries.[9],[10],[11]

The country went into complete lockdown with only essential health services to continue on March 25, 2020. With no guidelines already in place and COVID threats lurking all over, the decision to continue or discontinue immunization services was a challenge in itself. It was decided to continue with immunization services given the unique setting of the Armed Forces and the availability of both infrastructure and trained workforce. Although the Armed Forces have kept the continuation of Routine Immunization a high priority throughout the early days of the Pandemic, the turnout of infants for immunization was at variance with the pre COVID data.

Therefore, this study was conducted to assess the effects of COVID-19 pandemic on Infant Immunization and to derive conclusions on further strategies.

  Materials and Methods Top

This study was a record-based descriptive study conducted in an urban community among healthy infants <1 year old. The study was carried amongst infants born to Armed Forces Population comprising of service personnel and their families who were stationed at Mumbai during the study period. The study was conducted from April 2020 to December 2020. The questionnaire was administered during this period. The data was also collated from records from January 2018 to September 2021. The immunization sessions were carried out at family Clinics which were located within the community and not inside the hospital. The inclusion criteria were all infants below 1 year of age who visited family clinics for vaccination and were presently residing in Mumbai. Exclusion criteria were children above 1 year of age and those who registered but did not take any vaccination. Immunization records were obtained from data generated weekly at the end of each immunization session, and monthly reports of total children vaccinated that is forwarded to Local Health Authorities.

All recorded infants due for immunization were taken from the records. Those whose immunization was delayed for more than 2 weeks were classified as delayed immunization for the month. An SMS was sent to parents of infants who missed the immunization session and hence, they reported and got vaccinated within a maximum period of 2 weeks. The year- wise eligible population was calculated from the Family Planning data and the total women who had registered for institutional delivery.

A questionnaire was prepared to carry out a strength, weakness, opportunity, and threat (SWOT) analysis to assess the strengths, weaknesses, opportunities, and threats in undertaking the immunization sessions. The questionnaire comprised mostly open-ended questions that generated a list of statements. The questionnaire was administered to various stakeholders such as parents, administrators and health care workers. The assessment was undertaken on four key facets: immunization coverage, policies/knowledge about rules, available infrastructure, and workforce.

The data were collated in MS Excel. The percentage for the delayed immunization was calculated for each month. The Chi-square test for linear trend was used. The data were analyzed using StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC. The P < 0.05 was considered as statistically significant.

  Results Top

A total of 3518 vaccinations were done under the national immunization schedule for the infants from January 2018 onward. A total of 3010 vaccinations (85.5%) were done on time. The total delayed immunization was 508 (14.5%). The year-wise total vaccination and delayed vaccination is given in [Figure 1]. The percentage of delayed immunization is 10.2%, 15.7%, 18.9%, and 13.6% for the year 2018, 2019, 2020 and 2021 respectively. The difference among the years was statistically significant, with the highest delay in the year 2020 (P < 0.001). The month-wise delay among the years is shown in [Figure 2]. The highest proportion of delay occurred from April to September in 2020 [Figure 2]. We divided the period into three parts: First wave (April to September), inter-wave period (October to December) and January to March. During the first wave of the pandemic in 2020, only 282 vaccinations were carried out compared to 498 and 500 vaccinations carried out in 2018 and 2019 respectively, in the corresponding months. The percentage of delayed vaccinations is also 25.2% compared to 8.8% and 18.2% in 2018 and 2019 respectively [Table 1].
Figure 1: Year- wise delay in vaccination

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Figure 2: Month-wise proportion of delayed vaccination

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Table 1: Comparison of different periods of the pandemic

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However, in the year 2021, though the second wave started in March and peaked in June, the number of vaccinations carried out from April to September was 568 with delayed vaccination as 10.9%.

From October to December, there was statistically no difference in the delayed vaccination or number of vaccinations [Table 1]. Between January and March, there was no statistical difference in the years 2018, 2019, 2020, and 2021 though there was less vaccination in the year 2020 [Table 1].

Hepatitis 'B', Oral Polio Vaccine (OPV) and Bacillus Calmette–Guérin (BCG) were administered to all children born in the hospital. The coverage of Hepatitis B was 83.16%, 90.26% and 82.73% for the year 2018–2019, 2019–2020 and 2020–2021, whereas the coverage of OPV and BCG at birth was 92.33%, 91.22%, and 77.89% respectively for the 3 years under study [Table 2].
Table 2: Comparison of institutional vaccine coverage in last 3 years

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A total of 79 participants were approached for the questionnaire. 72 (91.13%) responses were obtained. 07 (8.86%) out of 79 did not respond. The responses are mentioned in [Table 3]. SWOT analysis was undertaken to assess the strengths, weaknesses, opportunities, and threats in undertaking the immunization sessions. The assessment brought out facets that acted as facilitators and barriers to routine immunization [Table 4].
Table 3: Responses to the questionnaire

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Table 4: Strengths, weaknesses, opportunities, and threats analysis of the existing immunization program

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  Discussion Top

As per the WHO almost 2.3 crore children[12] could not receive childhood vaccines in the year 2020 due to disruption of health services due to COVID-19 pandemic across the world. The first wave period was a period of great uncertainty wherein the disease was poorly understood. The health workforce was also diverted toward COVID control and public health activities of contact tracing and quarantine. No clear guidelines on immunization were present at that time. The WHO took out its first advisory[5] on immunization during the pandemic on May 22, 20. We also found in our study that during this period majority of the vaccinations were delayed (25.2%).

Interestingly, we did not find any difference in either vaccination coverage or percentage of delayed vaccination in the period, following the first wave or during the second wave. The Armed forces immunization program is a robust system, and its resilience was tested during this pandemic. Right from documentation, placing demands for vaccine, timely collection to the administration of vaccines in a setting of COVID required intensive preparation and planning by health care workers and administrators towards ensuring timely conduct of sessions and sensitization of community to come forward for the same as brought out in our SWOT analysis. Armed Forces policies were based on WHO and MoHFW guidelines and tailor-made as per specific local requirements.

Immunization registry data have shown a significant drop in all vaccinations during the pandemic.[13] It is also known from studies[14] that timely and complete vaccination confers benefits and protects across the entire childhood. This protection is greatly reduced if the vaccination schedule is delayed or incomplete. In our study, 85.5% of vaccinations were done on time and only 14.5% of vaccinations were delayed.

The immunization sessions in our setting could be carried on, despite lockdown due to various factors such as the utilization of trained workforce from within resources available, this was achieved by assistance from the hospital in providing Nursing staff who were staying within the community for the conduct of immunization to tide over unavailability that would have occurred if we were to depend only on staff who were commuting from different locations. A rapid review and synthesis of the literature on immunization[15] carried out in the year 2020, showed that travel restrictions on health care workers were one of the most significant reasons that largely slowed the pace of immunization.

Active Liaison with the Municipal corporation ensured a smooth supply chain throughout the Pandemic, which was also an enabling factor that helped continue our vaccination programme. A Swedish survey revealed that disruption in the supply chain[16] has been cited as one of the most significant factors that slackened vaccination in most places.

As shown in [Table 2], the coverage of birth dose of BCG and Hepatitis was 90.26% in 2019–2020 and 82.73% in the year 2020–2021. These vaccines could continue to be administered at these coverage rates as the hospital was operational throughout. However, differential coverage was observed due to the Armed Forces population being a floating population with numbers varying each year. WHO news release of July 15, 2021[12] highlighted the drop in BCG coverage to 85% in India which is the lowest in many years, the coverage in 2019 being 95%.

There were obstacles in the form of perception of parents and anxiety associated with stepping out of homes and contracting COVID. The undermined adversity associated with missed immunizations could be averted by reiterating the importance of immunization and addressing the perturbation of the community by way of health education. Fear of contracting COVID[17] has been cited as one of the significant reasons for disruption in immunization. Based on MOHFW guidelines,[18] it was decided to continue the immunization sessions in outreach clinics within the community.

During the World Immunization Week, WHO also showed concern over the resurgence of diseases that can be prevented. It advocated that countries need to prioritize the continuation of RI services and if suspended, catch up must be rescheduled as soon as possible.[19] With this concern uppermost in mind, Armed Forces also continued with their immunization programme during the COVID Pandemic. As the study was a record-based study, there is a limitation of probably missing out on some data regarding a few infants who took vaccination at peripheral outreach centres and whose numbers were not reflected in our data.

  Conclusion Top

The magnitude of spread being surreal and unprecedented, there was a lot of anxiety in the minds of parents about bringing children out for routine vaccination. The Armed Forces childhood immunization programme could be sustained during the COVID-19 pandemic due to a multitude of contributing factors such as adherence to national guidelines that prioritized vaccination, infrastructure, availability of trained workforce, and most importantly adherence to strict COVID appropriate behavior.

Health education, repeated electronic messages, community participation and pooling of resources, helped in being able to maintain the resilience of the program and conduct Immunization as per schedule. Method to achieve sustained vaccine coverage in our study can work as a template for settings experiencing reduced childhood immunization.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

National Vaccination Policy. India: Ministry of Health and Family Welfare Government of India; 2011. Available from:https://main.mohfw.gov.in/sites/default/files/108481119000.pdf. [Last accessed on 2021 Dec 05].  Back to cited text no. 1
Vaccines Work at All Ages, Everywhere. WHO, WHO Recommendations for Routine Immunizations. Immunization, Vaccines and Biologicals; 2018. Available from: https://www.who.int/immunization/en/. [Last accessed on 2021 Dec 04].  Back to cited text no. 2
Dixit SM, Sarr M, Gueye DM, Muther K, Yarnko TR, Bednarczyk RA, et al. Addressing disruptions in childhood routine immunisation services during the COVID-19 pandemic: Perspectives from Nepal, Senegal and Liberia. BMJ Glob Health 2021;6:e005031.  Back to cited text no. 3
Nelson R. COVID 19 disrupts vaccine delivery. The impact of the ongoing pandemic of coronavirus 2019 on immunization campaigns in low- and middle-income countries is concerning. Lancet 2020;20:546.  Back to cited text no. 4
COVID-19: Strategic Planning and Operational Guidance for Maintaining Essential Health Services During an Outbreak; March 20, 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance. [Last accessed on 2021 Nov 16].  Back to cited text no. 5
WHO. WHO | More than 117 Million Children at Risk of Missing Out on Measles Vaccines, as COVID-19 Surges; 2020. [Last accessed on 2021 Dec 04].  Back to cited text no. 6
WHO. At Least 80 Million Children Under one at Risk of Diseases such as Diphtheria, Measles and Polio as COVID-19 Disrupts Routine Vaccination Efforts. Warn Gavi: WHO and UNICEF; 2020. [Last accessed on 2021 Dec 05].  Back to cited text no. 7
Chandir S, Siddiqi DA, Mehmood M, Setayesh H, Siddique M, Mirza A, et al. Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: An analysis of provincial electronic immunization registry data. Vaccine 2020;38:7146-55.  Back to cited text no. 8
Santoli JM, Lindley MC, DeSilva MB, Kharbanda EO, Daley MF, Galloway L, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:591-3.  Back to cited text no. 9
McDonald HI, Tessier E, White JM, Woodruff M, Knowles C, Bates C, et al. Early impact of the coronavirus disease (COVID-19) pandemic and physical distancing measures on routine childhood vaccinations in England, January to April 2020. Euro Surveill 2020;25:2000848.  Back to cited text no. 10
Europe WHO. Guidance on Routine Immunization Services during COVID-19 Pandemic in the WHO European Region; March 20, 2020 (produced by WHO/Europe). A4 Prelims English Restricted Distribution. Available from: http://who.int. [Last accessed on 2021 Feb 16].  Back to cited text no. 11
WHO. More than 117 Million Children at Risk of Missing Out on Measles Vaccines, as COVID-19 Surges; 2020.Available from:https://www.who.int/news/item/22-05-2020-at-least-80-million-children-under-one-at-risk-of-diseases-such-as-diphtheria-measles-and-polio-as-covid-19-disrupts-routine-vaccination-efforts-warn-gavi-who-and-unicef. [Last accessed on 2021 Nov 23].  Back to cited text no. 13
Cecil E, Bottle A, Ma R, Hargreaves DS, Wolfe I, Mainous AG 3rd, et al. Impact of preventive primary care on children's unplanned hospital admissions: A population-based birth cohort study of UK children 2000-2013. BMC Med 2018;16:151.  Back to cited text no. 14
Olorunsaiye CZ, Yusuf KK, Reinhart K, Salihu HM. COVID-19 and child vaccination: A systematic approach to closing the immunization gap. Int J MCH AIDS 2020;9:381-5.  Back to cited text no. 15
Falkenstein Hagander K, Aronsson B, Danielsson M, Lepp T, Kulane A, Schollin Ask L. National Swedish survey showed that child health services and routine immunisation programmes were resilient during the early COVID-19 pandemic. Acta Paediatr 2021;110:2559-66.  Back to cited text no. 16
Saso A, Skirrow H, Kampmann B. Impact of COVID-19 on immunization services for maternal and infant vaccines: Results of a survey conducted by imprint – The immunising pregnant women and infants network. Vaccines (Basel) 2020;8:556.  Back to cited text no. 17
Immunization Services during and Post COVID-19 Outbreak: MHA Order Dated 15 April 2020, with Revised Consolidated Guidelines. Available from: https://www.mha.gov.in/sites/default/files/MHA%20order%20dt%2015.04.2020%2C%20with%20Revised%20Consolidated%20Guidelines_compressed%20%283%29.pdf. [Last accessed on 2021 Sep 30].  Back to cited text no. 18
WHO News Release Geneva, Hard Fought Gains in Immunization Coverage at Risk without Critical Health Services, Warns WHO; 23 April, 2020. Available from: https://www.who.int/news-room/detail/23-04-2020-hard-fought-gains-in-immunization-coverage-at-risk-without-critical-health-services-warns-who. 21. [Last accessed on 2021 Oct 01].  Back to cited text no. 19


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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