In the recent past, 25-year-old Zahra Mohamud* had visited the Hawadle maternal and child health centre in Hargeisa regularly to have her older son Ibrahim* vaccinated against the most common childhood diseases. However, since the COVID-19 outbreak in Somalia, Zahra has been afraid to take her 7-month-old second son Jama* for routine vaccination at the centre fearing that she or her children might be infected with COVID-19. Her fear was perhaps justified as in health facilities in low-income countries, physical distancing and handwashing is not always possible, and not everyone can necessarily afford to buy masks.

“I have heard so many COVID-19 prevention messages that have advised us to avoid gathering in public places,” Zahra said. “Now I am afraid we could get COVID-19 from a health facility too.” Zahra explained that she would only visit a health facility if she thought it was safe. “Many parents are staying at home and not getting their children vaccinated,” added Zahra.

Even in countries with well-functioning health systems, families share the same fears as Zahra’s, and are afraid of contracting COVID-19 from health facilities which has resulted in a low uptake of regular health services.

Unfortunately, if caregivers like Zahra stop visiting health facilities to seek regular health services, children will bear the consequences of these decisions. A joint analysis of WHO and UNICEF country offices shows that by the end of June 2020, an estimated 108 000 children under one year of age in Somalia might have missed out on their first dose of measles vaccines, and close to 96 000 might have missed out on their third doses of pentavalent vaccines. In the long term, this could translate to children living compromised lives, with low immunity, and become more prone to catching and spreading infectious diseases. This can pose a threat to the country, region and world.

Plummeting routine immunization rates in children

In 2020, Somalia set a target of 620 000 children aged under one year for routine immunization to receive vaccines against childhood tuberculosis, polio, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenza type B and measles. This means around 55 000 children under one year of age should be vaccinated each month. However, due to the COVID-19 pandemic, Somalia has witnessed a drop in immunization, both in outreach by health service providers and uptake by parents/caregivers. Vaccination coverage for pentavalent 1, for instance, has decreased by 10% from January to June 2020, compared to the same period in 2019.

Data gathered by the WHO and UNICEF country offices show that immunization rates plummeted from January to May 2020, rising slightly again in June, possibly due to lockdowns being eased and people being able to move more freely.

COVID-19 spurs changes in programming

In 2020, the Federal Government of Somalia was forced to postpone all planned, regular large-scale health campaigns that aimed to offer eligible children measles and polio vaccines, vitamin A supplements and deworming tablets in their homes. This included 2 rounds of polio campaigns aimed at stopping the spread of circulating vaccine-derived poliovirus (cVDPV2), by reaching around 1.6 million children under the age of 5 in the southern and central regions of Somalia, and an integrated measles-polio campaign in Banadir, targeting around 300 000 children to protect them from measles and the paralyzing effects of polio.

Being proactive to avoid regressing

In a country already living with threats such as the locust invasion, recurring extremes of drought and floods, and insecurity in some states, the health system across Somalia is still fragile and health resources are limited.

If regular immunization is not continued and stepped up in the coming months, Somalia stands a high chance of reversing some of the health gains made in child health in the last few decades. The country risks witnessing outbreaks of vaccine preventable diseases, with additional children prone to contracting diphtheria, pertussis, tetanus, measles and circulating vaccine-derived polioviruses.

To avoid this situation, Dr Mamunur Malik, WHO Representative in Somalia, reaffirmed WHO's commitment to redouble efforts to protect children from these vaccine-preventable diseases.

“The slowdown in routine immunization rate is a stark reminder to all of us on what could unwind in the coming months. Protecting the lives of children against preventable diseases should not be compromised while we respond to COVID-19. If we miss out on such a high number of children receiving life-saving vaccines, we face another public health dilemma. The outbreaks from other vaccine-preventable diseases will unfold and reverse other health gains,” Dr Malik explained. “WHO Somalia is working with the Ministry of Health, UNICEF and GAVI to resume routine immunization services and conduct accelerated immunization activities in the hotspots, to boost children’s immunity in these high-risk districts and communities.

“Evidence shows that children from displaced, evicted and other vulnerable families already have limited access to life-saving vaccinations. With a virus like COVID-19 in the picture, they are more likely to miss out on required immunization if we don’t intervene now,” said Dr Malik.

“We are first earmarking areas that need more attention. Due to its population density, frequent movement of people and the largest number of internally displaced camps in Somalia, Banadir is the most vulnerable region for the swift spread of all kinds of vaccine-preventable diseases, followed by Lower and Middle Shabelle,” said Dr Farid Muhammad, Medical Officer for the Expanded Programme on Immunization at the WHO country office in Somalia.

Ongoing efforts to improve vaccination coverage

To maintain expected standards of safety within health facilities, so that caregivers like Zahra feel safe during visits, WHO has been working with the Somali Government and partners such as the UNICEF to provide personal protective equipment (PPE) to health care providers in all public and private health facilities. Health facilities are being equipped with hand sanitizers for both health care seekers and providers to use. These facilities are also being advised to organize triaging stations so that high-risk health care seekers are recognized.

Other measures being taken include assessment of the current state of routine immunization, incorporating COVID-19 prevention in plans, and the capacity development of Somalia’s health workforce.

“Training health personnel is integral in stopping the spread of diseases,” said Dr Umar Al-Umra, Medical Officer, EPI and Health System Strengthening, WHO Somalia. “WHO is working with the health ministries to assess skill gaps and conduct EPI training sessions for health personnel including COVID-19 prevention in these sessions.”

So far, 3345 community health workers have been trained and deployed as members of integrated community surveillance and rapid response teams to address the COVID-19 pandemic. These teams are disseminating messages on the importance of routine immunization and encouraging parents to vaccinate their children against vaccine preventable diseases. At the same time, WHO has teamed up with partners to increase risk communication around COVID-19, so people understand how to keep safe.

WHO aims to boost immunization and surveillance activities further by continuing efforts to roll out supportive supervision where possible. In addition to these interventions, WHO and partners will work to strengthen surveillance of vaccine-preventable diseases and roll out an immunization strategy for urban areas, where large numbers of people live close to each other.

Note: GAVI, the Vaccine Alliance, provides support to WHO’s EPI programme in Somalia.

*name changed to protect identity.