Covid-19-related Immunization Disruptions in Rajasthan: A Retrospective Observational Study
Location: Rajasthan (all districts)
Sample: 2,144 children
Timeline: August – October 2020
J-PAL Initiatives providing funding: Cash Transfers for Child Health (CaTCH)
Target group: Children from low-income households who turned 12 months old between January and October 2020 and therefore, were due all their key-first year immunizations either in the months before, during or after the Covid-19 lockdown.
Outcome of interest: Immunization; Health Outcomes
Covid-19 dimensions: Healthcare service delivery gaps
Mode of data collection: Computer-assisted Telephone Interviewing (CATI) / phone surveys
Nature of activities: Data collection (surveys); Use of administrative data
Research paper(s): Covid-19 Related Immunization Disruptions in Rajasthan, India: A Retrospective Observational Study
The Indian government suspended immunization services during its nationwide lockdown, announced in March 2020, following the onset of the Covid-19 pandemic. Immunization outreach services resumed in May 2020, with an emphasis on making up for losses by targeting children who had missed their routine vaccinations during the lockdown. The effectiveness of these efforts and whether immunization coverage recovered post-lockdown remains unknown. However, this knowledge will be critical for adapting and targeting immunization policy in the coming months.
This project examined immunization disruptions during the lockdown (March to May 2020) in Rajasthan, India, and the extent to which the government’s subsequent efforts at catch-up immunization were successful at reaching children from low-income households who had missed routine first-year vaccinations due to healthcare disruptions.
Researchers collected retrospective primary data through phone surveys (August to October 2020) on the immunization status of children who turned a year old between January and October 2020. They compared the immunization status of children due immunizations during the lockdown to older and younger cohorts that were due their immunizations before or after the lockdown and were less likely to be affected by it. The key outcomes analyzed were:
- The timeliness of the administration of the Measles1 vaccine (due at 9 to 12 months) and;
- The completion of all first-year immunization milestones by the time of the survey.
Researchers document that while health system disruptions caused children to miss immunization milestones during the lockdown, a substantial proportion were reached through the government’s catch-up efforts in the months following the easing of lockdown restrictions. However, catch-up remained incomplete four to five months after the lockdown was lifted: children who turned a year old during the lockdown remained significantly less likely to have completed the required first-year immunizations even as catch-up efforts ensured that cohorts who were due for vaccinations in June 2020 or later had returned to pre-lockdown immunization levels.
Children from socioeconomically disadvantaged backgrounds and areas which experienced the strictest lockdown restrictions experienced larger declines in immunization coverage. Findings indicate that immunization providers should target immunization outreach efforts, including home visits, at children who turned 9 to 12 months old during the lockdown. Without targeted efforts to identify and reach these missed children, a large share of children may remain unvaccinated, turning back decades of progress against infectious diseases.
Households faced substantial barriers to immunizing their children during the lockdown. Overall, 31 percent of children experienced Covid-19-related immunization disruptions. Fear of contracting Covid-19 (20 percent), cancellation of scheduled immunization sessions (15 percent), and travel barriers (10 percent) were the most commonly reported causes of disruption.
Children missed routine first year immunizations during the lockdown, but many were reached through the government’s catch-up drive after restrictions were lifted. Children who were due to receive the Measles1 vaccine during the lockdown were significantly less likely to get it on time (at or before 9 months) and were more likely to receive it later (between 10 and 12 months) than children who were due to receive it before the lockdown was announced.
Children who were due to receive vaccinations during the lockdown remained significantly less likely to be fully immunized four to five months after it was lifted. By the time of the survey, children who were due to receive their immunizations during the lockdown were 14 percent less likely to have received all key first-year vaccinations than older cohorts due their vaccinations before the lockdown was announced. They were also 9.7 percent less likely to have completed them than younger cohorts who were due their immunizations in June 2020 or later, after the lockdown was lifted. Immunization coverage among the youngest cohorts was similar to the pre-lockdown levels.
Children from poorer, less educated, and lower caste households, as well as those residing in areas with the strictest and longest lockdowns, experienced larger declines in immunization.
Aggregate administrative data are insufficient to assess the effectiveness of catch-up. An analysis of the publicly available data collected by the government’s Health Management Information system (HMIS) shows a large uptick in the total number of children who were fully immunized in May and June 2020, reflecting the government’s catch-up efforts. However, survey findings from this study demonstrate that these post-lockdown increases did not fully offset immunizations missed during the lockdown, particularly among groups that are underserved by the health system. Ensuring successful catch-up requires careful monitoring and disaggregated data to identify and reach the specific individuals, groups, and cohorts with missed immunizations.