In Liberia: Low Immunization Rates During COVID-19 Rebound in 2022
MONROVIA – At the Duport Health Facility, located in Paynesville City, Montserrado County, in April 2023, Esther Kerkula waited patiently in a small reception area with her young baby girl. She believes mothers who stayed away from health facilities during the height of COVID-19 should not be blamed. “Everyone was afraid. Even if I had baby, I would also stay away. But now, COVID-19 has gone and a lot of women are bringing their babies to the hospitals for vaccination.”
More young mothers with babies joined Esther in the waiting room and the facility got busier as the morning progressed. Esther added, “Vaccines really are one of the best ways to protect children against any disease.”
Liberian Health authorities have since noted a significant decrease in the utilization of routine immunization services during the COVID-19 outbreak. Most notably, over 2020-2021 there was a 5% reduction in the administration of Penta3, usually given to protect children from five life-threatening diseases – Diphtheria, Pertussis, Tetanus, Hepatitis B and Haemophilus influenzae type B. There was also a decrease of 7% in measle vaccinations.
The Program Manager for Liberia’s Expanded Program on Immunization, Adolphus Clarke, said, “These percentages represent data from Liberia’s 725 health facilities administering routine immunization services. Before COVID-19 in 2019, the coverage for the third dose of Penta3 was 87% and then the first dose of measles was 85%. During the COVID-19 period, the coverage of Penta3 dropped to 82% while the coverage of measles also dropped to 78%.”
The WHO – UNICEF Best Estimate (WUENIC) latest report on Liberia states, “The disruption in immunization services led to the resurgence of Vaccine-Preventable Diseases (VPD). The WHO’s 2023 publication noted between November 17, 2021 and September 18, 2022, there were 6,789 confirmed measles cases with 79 deaths from 62 out of 93 health districts across the 15 counties in Liberia. There were 883 cases of pertussis with no death from three counties.
Clarke blamed the situation on the misconception about COVID-19 which stopped caregivers and parents from taking their children to health facilities for routine immunization. “People have their own perception of what a vaccine will do or not,” he said. “Because we were in the COVID period, people took that same misinformation about COVID-19 vaccine and brought it to the routine vaccination.”
Liberia experienced its first confirmed COVID-19 case on March 16, 2020, and up to May 17, 2023, there were 8,090 confirmed cases with 294 deaths. A total of 3.9 million persons have been fully vaccinated and Liberia is ranked second in Africa with a fully vaccinated coverage rate of 84%.
A resident of Ganta, Nimba County, Ruth Yinih, said, “I had baby at that time. My baby is three-years-old now. We were misinformed about the virus. People who had a cold and even headache were quarantined. No one really knew about this strange virus they called COVID-19. How can you go to the hospital under such conditions? I bought a lot of medicines from the drugstore for my family.”
A senior health technician at the Christian Extension Ministry Clinic, a private health facility in Buchanan, Grand Bassa County, Andrew Wolo Tarr, said the health system was engulfed with misinformation and misinterpretation about the pandemic, thus instilling fear in the public to attend health facilities. “There were incorrect messages floating around about the virus. In fact, at some point, the pandemic was politicized – even on radio talk shows, people would call and provide false information. It actually scared away people from health facilities.”
The Executive Director of Public Health Initiative, a civil society organization and Chairperson of Liberia Coordinating Mechanism, the governance board of the Global Fund against TB, HIV, and Malaria in Liberia, Joyce Kilikpo, noted, “There was lots of information on social media such as Facebook, WhatsApp, and even YouTube. Some of the mis-information was that COVID-19 came through vaccinations and that people can get it from the hospital. This brought negative perception about vaccines in general… Parents stayed away from hospitals and kept their children from being vaccinated.”
“As civil society organization, we are identifying children who missed out on important immunization services during COVID-19 period at the community level to ensure that they are vaccinated. We identify them in the communities and call the vaccinators. This is not sufficient because we can’t reach everywhere – we need to do a lot of things including media engagements.”
Liberia is divided into 15 counties but the four counties of Nimba, Lofa, Grand Bassa and Montserrado, serve as microcosms of what happened to vaccination rates during COVID-19 pandemic and Liberia’s overall vaccination recovery process. The four counties have an estimated population of 2,823,558. There are 32 health districts and 22 zones, 543 health facilities, 192 public and 339 private health clinics. Of the 543 health facilities, only 341 offer immunization services.
Data gathered from the various county health systems showed that prior to the COVID-19 pandemic in 2019, 93,492 children received Penta3 vaccine while 91,644 children received their first dose of measle vaccinations. In the same year, Grand Bassa, Montserrado and Nimba alone issued 71,412 yellow fever vaccines.
In 2020 however, during COVID-19, 80,852 children received Penta3 while measles first dose accounted for 78,699. Grand Bassa, Montserrado and Nimba alone administered 49,410 yellow fever vaccine.
12,640 fewer Penta3 vaccines were given between 2019 and 2020. And, almost 13,000 fewer measles vaccines were given across the four counties.
In 2021, 84,662 children received Penta3 while 75,836 children received vaccines for measles. Yellow fever records in Grand Bassa, Montserrado and Nimba accounted for 65,631.
After COVID-19, in 2022, Penta3 recorded 101,509 and Measles first dose recorded 102,434 in the four counties while 83,724 children received yellow fever vaccine in Grand Bassa, Montserrado and Nimba alone.
This means Penta3 vaccine dropped by 12,640 in 2020 and 8,830 in 2021 as compared to 2019.
Fortunately, in 2022, Penta3 vaccine significantly increased by 16,847 as compare to 2021 during COVID and 8,017 as compare to 2019 before COVID.
Measles first dose in 2020 dropped by 12,945 and 15,808 in 2021 as compared to 2019. In 2022, measles first dose recorded huge increase of 26,598 as compared to 2021 and 10,790 as compare to 2019.
These data clearly illustrate that routine immunization program experienced a decline during COVID-19 pandemic.
According to a UNICEF Liberia Country Office Annual Report 2021, “Routine immunization coverage in Liberia declined, with only 8 out of 15 counties vaccinating at least 82% of children aged 0–11 months with three doses of Penta vaccine, and high numbers of zero-dose children.”
This was attributed to emergencies and the focus on introducing the new nOPV, COVID-19 and typhoid vaccines. Despite this, 123,190 children 0-12 months were fully vaccinated, a 31% increase from 2021 to 2022.
New data published by UNICEF in their State of the World’s Children, indicates declining confidence in childhood vaccines of up to 44% in some countries during the COVID-19 pandemic.
The Report highlights up to 67 million children missed out on one or more vaccinations over three years due to service disruption caused by strained health systems and diversion of scarce resources, conflict and fragility, and decreased confidence. According to the Report, 48 million out of the 67 million children who missed out on routine vaccination between 2019 and 2022, did not receive a single routine vaccine.
The report states that public perception of the importance of vaccines for children declined during the COVID-19 pandemic in 52 out of 55 countries studied.
The United Nations organ wants governments live up to their commitment to increase financing for immunization to unlock available resources, including leftover COVID-19 funds, to urgently implement and accelerate catch-up vaccination efforts to protect children and prevent disease outbreaks.
The sudden increase of the utilization of health facilities in the four counties in 2022 is as a result of the huge reduction in COVID-19 prevalence, increased community outreach and media campaign.
Ruth Yinih, said, “The Ministry of Health and partners are carrying out awareness across the country. We are being educated about the importance of vaccines and COVID-19. They are encouraging us to carry our children for vaccination at all times. So, pregnant women and their babies are now going to the hospital – no fear again brother.”
Mothers with young babies at health facilities in Monrovia and Ganta cities in Montserrado and Nimba Counties confirmed the vigorous campaign being carried out by health authorities in the country.
For Elizabeth Sarplah, a young mother from Duport Road Community, said, “Although there was curfew and movement had to be restricted, a lot of women braved the storm to ensure their children get vaccinated. It is true that others were afraid and stayed away, but if you don’t take your children to the hospital for vaccines, we know that you will be harming them.”
Adolphus Clarke of Liberia’s EPI program, stated, “Post COVID-19, as measured by our 2022 recovery efforts, from January to December, measles first dose is at 96% and Penta3 third dose is at 95% – meaning we have a re-bounded in 2022.”
Fortunately, 2022 witnessed a significant increase of 13% for Penta3 and 18% for measles first dose as compare to the height of COVID-19. Similarly, 2022 saw 8% increase for Penta3 and 11% for measles first dose as compare to 2019.
Clarke continued, “It took a lot of effort in terms of community engagements throughout 2021 to sensitize people. We told them that it is incumbent upon them to bring their children to the health facilities for vaccination for a healthy life. In 2022, we began to see a positive effect, people begin to trust the system and regain confidence in vaccines.”
In terms of support to EPI, July 29, 2013, Liberia signed a Partnership Framework Agreement (PFA) with GAVI, Vaccine Alliance binding the government to GAVI with respect to financing immunization operations.
Under the PFA, GAVI provides 80% of the total cost and government will co-finance the remaining 20%. The government is also providing support through different layers. USAID, WHO, UNICEF, US CDC and Africa CDC among others are providing support as well. The country is currently finalizing a five-year strategic plan called the National Immunization Strategy. It runs from 2023 to 2027.
This program will see the procurement of vaccines, vehicles and motorbikes for 725 health facilities providing immunization services, supply of other accessories and human resource costs, among others.
Despite this, a 2022 report on EPI program performance states that the Liberian government is contributing about 10% to the program, citing limited engagement with Ministry of Finance and the National Legislature for the Program. It adds that 98% of National EPI Staff is paid by partners.
The document also points to knowledge gap particularly for new vaccines, noting that private health facility vaccinators are not as comprehensively trained as those in the public health facilities, adding “there is high staff turnover in private facilities.”
The UNICEF State of the Children Report 2021, further states “Despite the falls, overall support for vaccines remains relatively strong. In almost half the 55 countries studied more than 80% of respondents perceived vaccines as important for children.”
Moreover, as part of the vaccine integration program, Liberia is expected to introduce malaria vaccine into its routine immunization program in 2024. Although discussions are being concluded, the country’s Health Minister, Dr. Wilhelmina Jallah, recently boasted of significant reduction in malaria prevalence among children in Liberia. COVID vaccine is also expected to be integrated into the routine immunization program.
This reporting was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in Africa.