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May see outbreaks of diseases like measles, diphtheria if routine immunisations are missed: Deepak Kapur

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With the next National Immunisation Day scheduled for January 17, 2021 and parents still fearing the coronavirus infection, Deepak Kapur, Chairman, Rotary International’s India National PolioPlus Committee talks about why we cannot afford to let the COVID-19 pandemic hamper the progress made by decades of immunisation drives and how the polio vaccination infrastructure that Rotary helped build is now being adapted to the COVID-19 response, in an interaction with Viveka Roychowdhury

COVID-19 has halted routine immunisation programmes, as staff who usually execute these drives, like ASHA workers, have been given COVID duties. What are the other reasons for the disruptions and what could have been done to prevent it? What are the lessons for future disruptions like lockdowns given that COVID-19 will resurge in waves in certain districts?

The COVID-19 pandemic is a multifaceted lethal threat that’s negatively impacting the world’s healthcare systems, economies, and even how we live our lives. It has also adversely affected immunisation programmes everywhere, including in India, as a result of travel restrictions implemented early on to help contain and curb the spread of coronavirus infection.

At the outset of the pandemic, parents were scared, and did not want to risk exposure to the coronavirus while visiting their local health centres and hospitals. Mere survival in this “new normal” became the primary focus, and many parents did not fully understand how missing routine immunisations would allow their child to become more vulnerable to vaccine-preventable diseases such as polio, measles, rubella, etc. What’s more, movement of migrant populations also posed a special challenge to routine immunisation as it led to a significant number of children missing out on immunisation services.

Recognising that immunisation is an essential component of health services and needs to be continued to protect children and pregnant mothers from vaccine- preventable diseases (VPDs), the Ministry of Health and Family Welfare (MoHFW) identified it as an essential health service and released operational guidelines in mid-April that directed states on how to conduct vaccination sessions via enhanced safety protocols.

Since April, these protocols have been further enhanced to allow health workers to conduct safe immunisation sessions even in the face of future disruptions.

Could you give us an idea of the number of children vaccinated every year via routine immunisation and the procedure followed like the Sub National Immunisation Days (SNIDs)?

India’s routine immunisation programme reaches approximately 27 million infants and 29 million pregnant women every year. Around nine million immunisation sessions are held every year in service of full immunisation coverage, protecting children from 12 VPDs including polio, measles, rubella, diphtheria, pertussis, tetanus, etc.

Regarding polio specifically, every year in India there is a National Immunisation Day (NID), typically in January or February, which seeks to immunise all children under the age of five. India’s next NID is scheduled for January 17, 2021.

The NID is generally followed by two Sub National Immunisation Days (SNIDs) that target all children under five in 15-20 states in either May/June or September/October. This year, the first round of SNIDs—since the onset of the global pandemic–was held in September and the second round was completed in early November.

Besides the obvious benefits to individual children and their families, why is it important for children to continue their vaccinations, from a public health perspective?

Routine childhood immunisation is one of the most effective measures we can take to broadly protect our population. By preventing the spread of disease, we also reduce the strain on our healthcare workers and systems, and the ongoing pandemic has reminded us of just how important it is to keep children and new mothers safe and healthy.

We cannot afford to hamper the progress made so far by immunisation drives. Primary vaccines, administered in the first year of a child’s life, are the most important and should not be delayed. An ongoing global public health crisis like this has a direct impact on lowering immunisation coverage against VPDs, and we may see outbreaks of diseases such as measles and diphtheria if routine immunisations are missed.

India’s polio campaign is hailed as a global success. So how much of the polio infrastructure can help in the fight COVID-19? What are the similarities and how to ensure safety of children? What kind of re-training, upskilling of health workers will be required?

India was once considered the toughest context in the world in which to eliminate polio, and it has now been certified polio-free for more than six years. Reaching this milestone proves that a major health threat such as polio can be eliminated even under the most extreme and complex circumstances. Our strategies continue to focus on collaborations with local governments to institute ongoing, routine vaccinations, supplemental immunisation activities (SIAs), and the advancement of new mapping technology to ensure we reach every child.

The polio infrastructure that Rotary helped build is now being adapted to COVID-19 response as: trained personnel conduct contact tracing and surveillance; integrated systems are used to track and record data; and effective messaging on safety precautions is deployed to the public.

As the world continues to suffer the burden of the COVID-19 pandemic, upskilling nurses and paramedic workers has been critical to the functioning of our health care systems. In India, healthcare workers have been upskilled and trained on COVID-19 infection prevention guidelines to safely administer vaccines and protect communities from the pandemic.

Do we have the extreme cold chain facilities that some COVID-19 vaccines require? How are agencies like the Rotary Foundation engaging with this issue?

India’s cold chain systems can maintain vaccines at minus 8 to minus 10 degrees Celsius and we need minus 30 degrees Celsius to be able to maintain COVID-19 vaccines. The government is identifying warehouses and preparing its proprietary Electronic Vaccine Intelligence Network (eVIN) that digitises vaccine stocks and monitors cold chain temperatures to ensure quality and efficacy are not lost to temperature variations. Health centres are geo-tagged and sensors in refrigerators and freezers storing vaccines automatically inform a central database when temperatures change, signalling that the equipment needs to be repaired or replaced.

Regarding Rotary’s role in cold chain expertise, the infrastructure Rotary and its Global Polio Eradication Initiative (GPEI) partners established in India for the polio eradication programme has already been used to assist in the transportation and dissemination of other critical vaccines, such as for measles, hepatitis B, and Japanese encephalitis, and now, may be useful in the deployment of a COVID-19 vaccine.

As Chairman of Rotary’s India National PolioPlus Committee from 2001, what have been the learnings from the country’s progress on polio and Mission Indradhanush which can be implemented against COVID-19? Especially as it will be a two-dose ‘new’ vaccine and will need follow up and monitoring for adverse events?

Eradicating polio worldwide has been Rotary’s goal for more than 30 years, and the organisation is committed to supporting the Government of India’s mission to sustain the polio-free status of the region and extending the polio infrastructure and knowledge to protect millions of children from other diseases including COVID-19.

Rotary took a lead in bringing multiple stakeholders including political leaders, UN organisations, and NGOs and non-profits together for polio eradication. To that end, the Indian government must apply a similar approach for a COVID-19 vaccine by convening organisations such as Gavi, the Vaccine Alliance; the World Health Organisation (WHO); the Coalition for Epidemic Preparedness Innovations; and other civil society and humanitarian organisations. The Indian government must also work with the private sector in order to establish protocols to ensure our population has quick, cost-effective, and equitable access to a forthcoming vaccine.

The task will be momentous with significant challenges, but with planning, coordination, and cooperation among stakeholders, the mission is achievable.

As part of unlocking of states, we have been able to restart immunisation, but they have not been as successful. What are your insights from SNID rounds this year (September & November) across states? What explains the dip in coverage?

There is a renewed focus on routine immunisation, following an initial disruption resulting from lockdown restrictions that were first implemented in April 2020. Routine immunisation services in the non-containment and buffer zones have resumed. The first round of SNIDs was held in September across 11 states including Bihar, Delhi, Gujarat, Haryana, Maharashtra, Punjab, Rajasthan, Jharkhand, West Bengal, Uttarakhand, and Chandigarh (UT).

The immunisation coverage was sub-optimal, with a nearly 23 per cent dip in the total number of children vaccinated compared to the total number of children vaccinated during an SNID round held in September 2019. A second round of SNIDs was conducted on November 1 in Delhi, West Bengal and remaining pockets of states covered in previous round, and data on number of children reached is not yet available.

According to MoHFW data, the number of people reporting for immunisation has been fewer than in years past, over fears surrounding COVID-19. With that in mind, the Government of India, along with Rotary and other members of the India Expert Advisory Group (IEAG), is working to educate communities about COVID-19 and is continuously reviewing operational guidelines to help mitigate fears that would prevent parents from ensuring their children receive routine immunisations.

How can healthcare policy makers and public health professionals defuse the fear of infection, due to COVID-19 as well as the latent mistrust among certain communities for vaccines?

It is important to be prepared to rapidly dispel misinformation and rumours that may lead to vaccine refusal. As misinformation spreads within seconds on social media, correct information must also be readily available and disseminated quickly: it is necessary to track vaccine safety concerns and prepare informational campaigns to counter false information.

As Rotary deployed esteemed community influencers, engaged celebrities, and raised awareness for polio immunisation and encouraged vaccine acceptance, healthcare policy makers and public health professionals must now update this playbook to reflect today’s digital age in order to build trust and adoption of a COVID-19 vaccine as it becomes available.

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