WHO: Guiding principles for immunization activities during the COVID-19 pandemic Interim guidance – 26 March 2020

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WHO: Guiding principles for immunization activities during the COVID-19 pandemic
Interim guidance – 26 March 2020
**As the COVID-19 pandemic evolves, this document and accompanying FAQ will be revised as necessary. **

Due to the global circulation of the virus causing COVID-19 and the current pandemic, there is risk of disruption to routine immunization activities due to both COVID-19 related burden on the health system and decreased demand for vaccination because of physical distancing requirements or community reluctance. Disruption of immunization services, even for brief periods, will result in increased numbers of susceptible individuals and raise the likelihood of outbreak-prone vaccine preventable diseases (VPDs) such as measles.1 Such VPD outbreaks may result in increased morbidity and mortality predominantly in young infants and other vulnerable groups, which can cause greater burden on health systems already strained by the COVID-19 response. The high potential for VPD outbreaks makes it imperative for countries to maintain continuity of immunization services wherever services can be conducted under safe conditions. Prior disease outbreaks and humanitarian emergencies have underscored the importance of maintaining essential health services such as immunization, and effectively engaging communities in planning and service delivery. 2,3 Yet the complexity and global reach of the COVID-19 response with respect to mandatory physical distancing (also referred to as social distancing) and economic impact on households is unprecedented for public

This document provides guiding principles and considerations to support countries in their decision-making regarding provision of immunization services during the COVID-19 pandemic and is endorsed by the WHO’s Strategic Advisory Group of Experts on Immunization. It is complemented by a range of WHO technical materials on response and mitigation measures for COVID-19.4 Each country will need to make individual risk assessments based on the local dynamics of COVID-19 transmission, immunization and health system characteristics, and current VPD epidemiology in their setting.


Guiding Principles
1. Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where feasible.5 Immunization delivery strategies may need to be adapted and should be conducted under safe conditions, without undue harm to health workers, caregivers and the community.6

2. VPD surveillance should be maintained and reinforced to enable early detection and management of VPD cases, and where feasible, contribute to surveillance of COVID-19.

3. National authorities will need to continuously monitor the dynamics of COVID-19 in their country or region. National Immunization Technical Advisory Groups (NITAGs) have an important role in providing advice with respect to the maintenance, adaptation, suspension and/or reinstatement of immunization services.

4. If provision of immunization services is negatively impacted by COVID-19, countries will need to design strategies for catch-up vaccination for the period post COVID-19 outbreak and make plans which anticipate a gradual recovery. Implementation of catch-up will require strategies to track and follow-up with individuals who missed vaccinations, assess immunity gaps, and re-establish community demand. Innovation and creativity will be required.


5. Based on the current understanding of transmission of the COVID-19 virus and recommendations for physical distancing, mass vaccination campaigns should be temporarily suspended. Countries should monitor and re-evaluate at regular intervals the necessity for delaying mass vaccination campaigns.

6. The conduct of outbreak response mass vaccination campaigns will require a careful risk-benefit analysis on a case-by-case basis, assessing risks of a delayed response against the risks associated with an immediate response, both in terms of morbidity and mortality for the VPD and the potential impact of further transmission of the COVID-19 virus.

7. Where feasible, influenza vaccination of health workers, older adults, and pregnant women is advised.7


Considerations for Routine Immunization and VPD Surveillance
:: The decision to maintain immunization services will be influenced by local mandates for physical distancing and guided by health system context, the local burden of VPDs, the status and anticipated status of local COVID-19 transmission (classified as no cases, sporadic, clusters, or community transmission), and factors such as population demographics and migration patterns.

:: Where health system capacity is intact and essential health services are operational (e.g., adequate human resources, adequate vaccine supply), fixed site immunization services and VPD surveillance should be executed while maintaining physical distancing measures and appropriate infection control precautions, equipped with the necessary supplies for those precautions.8

:: The appropriateness of implementing alternative strategies (e.g. outreach or mobile services), as well as activities requiring community interaction for VPD surveillance, must be assessed in the local context and should be adapted to ensure the safety of the health workers and community. Innovative methods for vaccination delivery should be explored to optimize service delivery.

:: Where the provision of limited services is feasible, immunization of vulnerable populations at increased risk of morbidity and mortality due to VPDs should be prioritized for vaccination against outbreak-prone diseases such as measles, polio, diphtheria and yellow fever.


Considerations for Mass Vaccination Campaigns
:: Based on the current understanding of the transmission modes of the COVID-19 virus and the recommended prevention measures of physical distancing, it is advised to temporarily suspend the conduct of mass vaccination campaigns due to the increased risk of promoting community circulation. Countries should monitor and re-evaluate at regular intervals the necessity for the delay of mass vaccination campaigns.

:: Under circumstances of a VPD outbreak, the decision to conduct outbreak response mass vaccination campaigns will require a risk-benefit assessment on a case by case basis and must factor in the health system’s capacity to effectively conduct a safe and high-quality mass campaign in the context of the COVID-19 pandemic. The assessment should evaluate the risks of a delayed response against the risks associated with an immediate response, both in terms of morbidity and mortality for the VPD and the potential impact of further transmission of the COVID-19 virus.


:: Should an outbreak response vaccination campaign be pursued, stringent measures are required to uphold standard and COVID-19 infection prevention and control, adequately handle injection waste, protect health workers and safeguard the public.

:: Should an outbreak response vaccination campaign be delayed, a periodic assessment based on local VPD morbidity and mortality, as well as regional and international epidemiology will be required to evaluate risk of further delay.


Consideration for Re-establishing Immunization Services
:: In circumstances where immunization services must be diminished or suspended, countries should reinstate and reinvigorate immunization services at the earliest opportunity to close immunity gaps, once reduced local transmission of the COVID-19 virus permits primary health care services to resume.

:: If resources for catch-up are limited, catch-up immunization activities should place priority on outbreak-prone VPDs such as measles, polio, diphtheria, and yellow fever.

:: Countries should implement effective communication strategies and engage with communities to allay concerns, enhance community linkages and re-establish community demand for vaccination.

1 Suk et al. Post-Ebola Measles Outbreak in Lola,Guinea, January–June 2015. Emerging Infectious Diseases. 2016; 22(6):1106-1108.
2 http://www.jogh.org/documents/issue201802/jogh-08-020601.htm
3 Vaccination in Acute Humanitarian Emergencies: A Framework for decision-making
4 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance
5 COVID-19: Strategic Planning and Operational Guidance for Maintaining Essential Health Services During an Outbreak. 20 March 2020.
6 https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125
7 WER, 23 November 2012, 23 No. 47, 2012, 87, 461–476 https://www.who.int/wer/2012/wer8747.pdf?ua=1
8 https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control

© World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.
WHO reference number: WHO/2019-nCoV/immunization_services/2020.1


Related documents
:: Guidance for health-care workers during COVID-19
:: COVID-19: Operational guidance for maintaining essential health services during an outbreak



Polio Eradication in the context of the COVID-19 pandemic
Summary of urgent country and regional recommendations from the Polio Oversight Board meeting of March 24, 2020
The COVID-19 pandemic response requires worldwide solidarity and an urgent global effort. The Global Polio Eradication Initiative (GPEI), with thousands of polio workers, and an extensive laboratory and surveillance network, is positioned and ready to ensure that our resources are used by countries in their preparedness and response. The COVID-19 emergency means that many aspects of the polio eradication programme will be—and in some areas are already– substantially affected.

In light of these considerations, the Polio Oversight Board (POB) of GPEI recommends:
1. All polio eradication country programmes prioritize support for the response to COVID-19. Specifically, for the next 4-6 months, GPEI assets (technical expertise, surveillance and community networks, and logistics capacity) at all levels (global, regional, national, and local levels) should be made available to support the global response to COVID-19. GPEI staff supporting COVID-19 front line activities, must be provided with the necessary training, materials, equipment and logistics to do so safely. Additionally, if required, GPEI financial management systems could be used to support the channelling of COVID-19 funding for the pandemic response.

2. Critical functions related to Polio Acute Flaccid Paralysis and Environmental Surveillance should remain a priority and governments should do all they can to ensure they continue, to closely monitor the circulation of wild and vaccine-derived polioviruses. As much as possible, these surveillance activities should be paired with COVID-19 surveillance and data systems upgraded to support this expanded portfolio of work. To facilitate this work, the provision of personal protective equipment for surveillance officers should be prioritized.

3. All polio activities which come in contradiction to global guidance on physical distancing, such as house-to-house or other immunization activities using oral or injectable vaccines1, should be suspended to avoid placing communities and frontline workers at unnecessary risk, and facilitate rapid and effective COVID-19 response in countries. Specifically,
a. All preventive polio campaigns should be postponed until the second half of 2020.

b. Endemic countries, and non-endemic countries planning to conduct outbreak responses campaigns, should postpone all campaigns (mOPV2, bOPV) until June 1, 2020 and then reevaluate based on the status of the COVID-19 pandemic. Any country wishing to proceed with polio vaccination campaigns should only implement such campaigns after a thorough assessment of risk of COVID-19 transmission among frontline workers and communities and potential impact on immunization programs. Vaccines currently approved for preventative SIAs and outbreak response will be shipped, unless a country has decided to postpone that campaign. New vaccine requests will be considered on a case-by-case basis.

4. Efforts to obtain an Emergency Use Listing recommendation for novel Oral Polio Vaccine type 2 (nOPV2), must continue at full speed. The preparation for nOPV2 roll-out, across the range of technical, communications, policy and manufacturing activities should also continue. Engagement with countries around initial use of nOPV2 will continue, as appropriate to their specific COVID-19 situation, with the goal of deploying nOPV2 for outbreak response during the second half of 2020.

5. While halting important polio eradication activities is necessary, it will result in increased spread of disease and number of children paralyzed by wild and circulating vaccine-derived polioviruses. This will require a scale up of polio eradication efforts once the COVID-19 situation has stabilized. Without compromising support to the COVID-19 response, country programmes should take the opportunity during the pause in vaccination campaigns to improve other elements of the program such as strategic planning and performance management processes. Finally, GPEI and country programmes must develop a comprehensive set of context-specific strategies and a plan for resumption of operations.
This guidance and the timelines will be reviewed by the Strategy Committee on a bi-weekly schedule given the rapidly changing situation with COVID-19.

1 Guiding principles for immunization activities during the COVID-19 pandemic, endorsed by SAGE, can be found here: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/maintaining-essential-health-services-and-systems



Statement by UNICEF Executive Director Henrietta Fore on the disruption of immunization and basic health services due to the COVID-19 pandemic
NEW YORK, 26 March 2020: “Around the world, the COVID-19 pandemic is overstretching health services as health workers are diverted to support the response.

“Physical distancing is leading parents to make the difficult decision to defer routine immunization.

“Medical goods are in short supply and supply chains are under historic strain due to transport disruptions. Flight cancellations and trade restrictions by countries have severely constrained access to essential medicines, including vaccines.

“As the pandemic progresses, critical life-saving services, including immunization, will likely be disrupted, especially in Africa, Asia and the Middle East where they are sorely needed.
“At the greatest risk are children from the poorest families in countries affected by conflicts and natural disasters.

“We are particularly concerned about countries that are battling measles, cholera or polio outbreaks while responding to COVID-19 cases, such as Afghanistan, the Democratic Republic of Congo, Somalia, the Philippines, Syria and South Sudan. Not only would such outbreaks tax already stretched health services, they could also lead to additional loss of lives and suffering. At a time like this, these countries can ill-afford to face additional outbreaks of vaccine-preventable diseases.

“The message is clear: We must not allow lifesaving health interventions to fall victim to our efforts to address COVID-19.

“UNICEF is committed to supporting basic health care and immunization needs in the worst affected countries, and to doing so in a way that limits the risk of COVID-19 transmission. We are working hard to ensure adequate vaccine supplies are available in countries that need them. We are in close communication with global vaccine suppliers to ensure production is not disrupted and supply is managed in the best possible manner under these difficult circumstances. We are also providing greater support to governments to continue the supply of vaccines during this pandemic.

“In the days to come, governments may have to temporarily postpone preventive mass vaccination campaigns in many places to ensure that the delivery of immunization services does not contribute to COVID-19 spread, and to follow recommendations on physical distancing.
“UNICEF strongly recommends that all governments begin rigorous planning now to intensify immunization activities once the COVID -19 pandemic is under control. These vaccination activities must focus on children who will miss vaccine doses during this period of interruption and prioritize the poorest and most vulnerable children. To successfully roll-out vaccines against COVID -19 when they become available, we need to ensure that our immunization programmes remain robust and can reach those that will need these vaccines the most.

“Immunization remains a life-saving health intervention. As the world’s biggest buyer and supplier of vaccines, UNICEF will continue to play a pivotal role in supporting governments’ current and future immunization efforts.”