The COVID-19 pandemic has affected and disrupted the health services delivery at all levels of the Nepalese health system. Immunisation is an essential health service delivery for every country. The addition of new vaccines and immunisation schedules, a complex supply chain involving multiple stakeholders at an international and national level, cold chain infrastructure and public healthcare delivery structure and process makes immunisation a micro-system in itself . Effective management of immunisation both during normal and disaster time shows the resilience and strength of the health system. In this present study, we explored delivery of the national immunisation service during COVID-19 pandemic and the nature and extent of impact of COVID-19 pandemic on childhood immunisation services.
Overall, our study shows that despite many barriers, both providers and users perceived that childhood immunisation service delivery continued during the COVID-19 pandemic; however, there was a disruption of services at specific points/periods during COVID-19 pandemic. There was an attempt to trace those children who missed their regular immunisation during the COVID-19-related disruption by the service providers. Despite such attempts, a lack of a real-time dynamic immunisation database and temporary migration and movement of families during COVID-19 pandemic affected the tracing of all the children missing immunisation.
The members involved in immunisation delivery at the peripheral level and the parents reported inadequate biosafety practice during COVID-19 pandemic. They highlighted the issues such as lack of PPE, poor compliance to COVID-19 SOP measures by the service users. In addition, the inadequate healthcare system that is malign with infrastructure shortage and lack of effective management and a lackadaisical attitude regarding the health service delivery during pandemic might have contributed to inadequate preparedness and cushioning of the health system and healthcare staff during the COVID-19 pandemic [25, 26].
In the current study, even though the childhood immunisation service deliveries were affected during the early phase of COVID-19 pandemic in Nepal, the ground level members of the immunisation team, i.e., FCHVs, ANMs were delivering the service in the later period. In addition, although the regular immunisation service and the mass immunisation campaign were continued intermittently, taking appropriate precautionary measures, only a smaller number were brought for vaccination shots because of the fear of COVID-19 transmission. Almost consistent findings were observed in Saudi Arabia and the United States, where the reasons for low vaccine coverage were the fear of contracting COVID-19 at healthcare facilities, restrictions in movements for the public, limitations within healthcare facilities, and unavailability of vaccination services during lockdown [27, 28]. Indeed, the additional potential reasons mentioned above may have led to fewer children attending the vaccination service in Nepal. In addition, in case of the current study, this might also be due to lack of effective communication about the operation of vaccination centers during COVID-19 pandemic. The effective tracking of the missed children and administering the missed doses of vaccines is crucial. Failure to do so might lead children to the resurgence of vaccine-preventable diseases (VPDs) . A study in Africa has reported that the benefits of routine childhood vaccination outweigh the risk of COVID-19 transmissions and death and focused on continuing the vaccination process amid COVID-19 pandemic .
The service providers reported a lack of specific guidelines on child vaccination during COVID-19 and communication gaps and issues in mobilisation of the healthcare workforce. The guidelines for conducting routine childhood immunisation safely during the COVID-19 pandemic have been developed by organisations such as Centers for Disease Control and Prevention (CDC), and WHO [31, 32] and countries such as New Zealand  have implemented their version of guidelines to follow for vaccination during COVID-19. However, a tailored guideline focusing on conduction of the child vaccination in Nepal seems to lack action, which might have led to chaos and immunisation service disruption. Nevertheless, this study showed a need to adopt such guidelines for Nepal and effectively implement and communicate them to all health service delivery levels.
In this study, the FCHVs reported that reassurance from colleagues was not present during COVID-19 pandemic. In Nepal, the vaccination programs greatly rely on FCHVs, and they were vulnerable to higher exposure to COVID-19 due to added burden in service delivery. In addition, the top-down bureaucratic culture that does not consider the concerns of the peripheral level service delivery staff might have led to such a situation. The front-line peripheral level staff such as the FCHVs and the ANMs are essential part of immunisation services, and the health system needs to cushion these precious staff from such exposure. The health system needs to be reassuring and use all the available resources at its disposal to create a safe working environment for such staff during COVID-19 and any future pandemics.
It was reported that the family and social life of the healthcare workers were affected much because of COVID-19 in the current study. A scoping review showed that the healthcare workers faced emotional challenges and stress in dealing with the patients and carrying out their regular functions amid COVID-19 pandemic . In addition, it was observed that transportation restrictions, fear of being exposed to virus, illness, paucity of PPEs and ineffective infection prevention and control were reasons for insufficient healthcare workers in different countries [35,36,37]. Furthermore, even though healthcare workers were trying their best to provide services from their end, literature shows the experience of social stigma against healthcare workers in different countries, including Nepal . However, no participants reported this as an issue in our study.
Our findings showed that parents realised the importance of vaccination and brought their children for vaccination despite COVID-19 fear. These parents also tried to stick to the COVID-19 safety measures. This result was similar to a study conducted in Saudi Arabia, where parents’ positive attitudes about child vaccination were observed . In contrast, another study in Saudi Arabia reported that many parents were not concerned about vaccination delay . The variation in results may be associated with the awareness level of parents, since a significant association between positive attitude towards vaccination and parents’ education was reported .
This study also observed that many children who migrated from their temporary stay to permanent addresses during COVID-19 pandemic got their scheduled vaccines in their respective villages. The participants did not report the negative impact on vaccine logistics. Even during the lockdown, public health officials hindered the vaccine delivery from central to district stores. In lack of PPE, delivery of some of the regular healthcare services were affected at local levels, but the local governments of that specific areas took care of the proper vaccine delivery and distribution at local levels. In contrast to this result, in astudy in Africa, it was observed that the COVID-19 causes logistical constraints to vaccine supply and delivery to the service points . The undisturbed logistics to vaccine supply and delivery in Kathmandu valley may be because of the availability of sufficient vaccines required within the country for the time being and no travel restrictions for vehicles carrying vaccines. It could also be because our study site was near the district store of vaccines. Hence, one of the limitations of this study is that we cannot generalise the findings of this study to the entire country.
From a health system perspective, childhood immunisation service delivery must be adapted to COVID-19 safety (biosafety) requirements and other future disasters and pandemics. Health services delivery during the pandemic and other disasters is challenging; however, essential health services such as immunisation need to continue even during a pandemic. The biosafety measures were inadequate, and there were lapses in the supply of PPE and other health supplies, proper training of the health workers, operation guidance and proper cushioning of healthcare workers, especially the front line and much vulnerable FCHVs. Furthermore, the lack of a real-time immunisation database and inability to track the number of families migrating temporarily during COVID-19 pandemic, especially from urban areas, also shows the need to improve database tracking and effective linking of local population database to the national childhood immunisation program. Despite the tremendous pressure from COVID-19 on health service delivery, the logistics aspect of the national immunisation program kept the vaccine supply chain ongoing. It shows the strength of the national immunisation program and continuous effort of all the stakeholders towards strengthening the program. Nepal should build on this strength of the national immunisation program and address the system (supply) side inadequacies for a sustainable childhood immunisation program.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.