key: cord-0807024-z4lzn2tx authors: Bardají, Azucena; Bassat, Quique; Matsinhe, Graça; Aguado, Teresa title: COVID-19 in Africa and collateral effects on health systems and their immunization programs date: 2020-10-09 journal: Vaccine DOI: 10.1016/j.vaccine.2020.10.014 sha: 5fa9e7ba9b331b678366445379b0409383562789 doc_id: 807024 cord_uid: z4lzn2tx nan Epidemics caused by emergent and re-emergent pathogens have historically shown a devastating impact in the health and well-being of populations, particularly those with lesser resources and capacity to respond. Increased travel and global mobility have contributed to higher risk and speed in the spread of such epidemics. In 2014-2015, the Ebola epidemic in West Africa directly caused over 10,000 deaths, but the increased number of deaths caused by malaria (n=6,818), HIV/AIDS (n=1,091), tuberculosis (n=2,714), and measles (between 2,000-16,000) attributable to health systems failures exceeded deaths from Ebola. [1, 2] Similarly, the response to meningococcal meningitis pandemics in sub-Saharan Africa early in the 1990's, paralyzed routine health care systems and exhausted international stocks of vaccines, leading to increases in morbidity and mortality beyond those merely attributable to meningitis. [3] As of mid-September 2020, and after 9 months of COVID-19 pandemic, SARS-CoV-2 confirmed cases surpasses 28 million, with nearly a million deaths globally; 51% of cases are reported in the Americas, followed by 17% in Europe. [4] As COVID-19 continues to spread globally, it is less uncertain what scenario low-and middle-income countries will face while a rapid increase of cases is being seen. At this stage, all countries are officially affected by COVID-19 in the African region, with 1,365,689 cumulated cases and 33,047 deaths reported. [5] The damage of COVID-19 is adding to the deadly impact that main endemic diseases such as malaria (380,000 deaths), [6] HIV/AIDS (440,00 deaths), [7] and tuberculosis (608,000 deaths) [8] poses annually on the region. Though COVID-19 cases in this region currently account for 5% of cases world-wide, the real existing cases in the continent are probably underrepresented given the limited testing capacities. These have been increasing up to 50% per week since the beginning of the pandemic, [5] indicating that the rapid spread of COVID-19 in Africa may mirror the fast escalation of the pandemic in today's most severely affected regions. In high income countries, the COVID-19 pandemic is still having a dramatic impact on morbidity and mortality and abruptly disrupting health systems. Certainly, its effects have been numerous on governments decision making regarding control policies for mitigating the effects of the epidemic. A fast increase of COVID-19 cases in Africa, not restricted to few countries as in the case of Ebola but widely affecting the continent, is yet having a massive and unprecedented impact on their entire health systems and populations. [9, 10] Many of the limited resources and infrastructures in these countries are being necessarily redirected to emergency measures for clinical care and epidemic control. Though the pandemic may present with particular characteristics in the continent, given the younger average age of populations or differences in transmissibility dynamics, implications and consequences on health systems may be similarly dramatic due to the already existing weaknesses on healthcare and limited capacity in epidemic response. There is certainly also the indirect impact of COVID-19 in the already observed drop in utilization of key health programs such as maternal and reproductive health services, child health programs, or HIV and malaria control activities, which may turn into increased morbidity and mortality, especially among the most vulnerable. [10] Disruptions due to COVID-19 pandemic are also expected to have particularly upsetting consequences in the region on key activities such as immunization programs. [11] On March 26 th , the World Health Organization issued new guidelines,[12] endorsed by the Strategic Advisory Group of Experts (SAGE) on Immunization, aimed at sustaining immunization activities during the COVID-19 pandemic, and recommended to temporarily suspend preventive immunization campaigns in places where there is no active outbreak of a vaccine-preventable disease given the risk of inadvertently contributing to foster transmission of COVID-19. Gavi, the Vaccine Alliance, confirmed its support to countries on COVID-19 response, committing the provision of the necessary vaccines to support catchup mass vaccination campaigns once lockdowns finish. [13] However, suspension of mass vaccinations for measles, polio and other diseases, all significant contributors to child mortality, may hinder the acquisition of immunity (individually but most notably also community-wide), render African children vulnerable, and undoubtedly trigger other lifethreatening outbreaks. [14] A good example of this possible scenario is the increased measles mortality in DRC, with around 7,000 deaths from over 375,000 confirmed cases, during the recent 2018 Ebola epidemic. [15] It may also translate into hard-to-reverse setbacks in polio eradication if COVID-19 extends to those areas and populations concentrating last-mile efforts. [16] Furthermore, ongoing research efforts for a number of studies and clinical trials are being affected by interruptions and delays, further jeopardizing the generation of much needed data originating from this region. [17] The impact of COVID-19 in Africa on immunizations goes beyond mass vaccination strategies. WHO, GAVI, and other organizations have stressed that safeguarding immunization services was of critical importance. [18] But sustaining routine immunizations faces inevitably threats and challenges. The emergency measures that result in social isolation and confinement of the population aggravate the situation, as they affect health services seeking behaviour and demand for health services. Disruptions in the Expanded Programme on Immunizations (EPI) services might also be observed because of staff diverted to respond to COVID-19 urgent needs. [19] Delays and stock-outs of routine EPI vaccines may occur too, due to obstacles in supply chain related to lock-down of borders and transports, unavoidably leading to reduced vaccination coverage. [20] Significantly, frontline health workers may also be primarily affected, [21] further hindering the vulnerability of the communities they are serving. Moreover, despite the unquestionable contribution of the outreach activities (mobile brigades) to the increase of vaccination coverage, with the progression of the pandemic many African countries may eventually decide to temporarily suspend also these activities to reduce the risk of transmission of COVID-19 in the community. Failure to carry out outreach activities, exacerbate the inaccessibility to basic health services including immunization, making these populations less and less served and consequently widening the equity gap and increasing the vulnerability to vaccine-preventable diseases. It is thus essential, while mitigating and controlling the effects of current pandemic in the region, to provide support to maintain and underpin vaccination programs and surveillance, both in fixed posts and outreach, as well as mass immunisation campaigns and prompt catch-up activities once emergency measures are progressively relaxed. There is also an opportunity to reinforce preparedness at global level, anticipating the likely scenario of subsequent waves of COVID-19, of devastating consequences for the poorest resource regions. Azucena Bardají* (MD, PhD), Quique Bassat (MD, PhD), Graça Matsinhe (MD, MPH), Teresa Aguado (MSc Biol and Pharm, PhD) *Corresponding author: azucena.bardaji@isglobal.org Effects of Response to 2014-2015 Ebola Outbreak on Deaths from Malaria, HIV/AIDS, and Tuberculosis, West Africa. Emerg Infect Dis Reduced vaccination and the risk of measles and other childhood infections post-Ebola Approved by the Guidelines Review Committee. 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