The Medical Journal of Australia - Pre-print - 20 May 2021
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The Medical Journal of Australia – Pre-print – 20 May 2021 Impact of the COVID-19 pandemic on vaccination uptake in Victorian children, adolescents and older adults Brynley P Hull Research Fellow National Centre for Immunisation Research and Surveillance Centre (NCIRS) Children's Hospital Westmead Westmead, New South Wales, Australia Alexandra J Hendry Senior Research Officer - Coverage & Surveillance Children's Hospital at Westmead National Centre for Immunisation Research & Surveillance Westmead, New South Wales, Australia Aditi Dey Manager Surveillance National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases – Surveillance Westmead, New South Wales, Australia Senior Lecturer University of Sydney Discipline of Paediatrics and Child Health Camperdown, New South Wales, Australia Kerin Bryant Principal Project Officer Victoria Department of Health and Human Services Health Protection Branch Melbourne, Victoria, Australia Catherine Radkowski Manager, Immunisation Projects and Policy Victoria Department of Health and Human Services Communicable Diseases, Health Protection Branch Melbourne, Victoria, Australia Stephen Pellissier Manager, Immunisation Victoria Department of Health and Human Services Health Protection Branch Melbourne, Victoria, Australia
The Medical Journal of Australia – Pre-print – 20 May 2021 Kristine Macartney Director Children's Hospital at Westmead National Centre for Immunisation Research and Surveillance (NCIRS) Westmead, New South Wales, Australia Professor University of Sydney Department of Paediatrics and Child Health Sydney, New South Wales, Australia Frank H Beard Staff Specialist - Public Health Physician The Children's Hospital at Westmead National Centre for Immunisation Research and Surveillance Westmead, New South Wales, Australia Senior Lecturer School of Public Health University of Sydney Sydney, New South Wales, Australia Competing interests: No relevant disclosures
The Medical Journal of Australia – Pre-print – 20 May 2021 Abstract (50 words) We analysed Australian Immunisation Register data to assess COVID-19 pandemic impact on vaccination uptake in Victoria in 2020. No impact was seen in young children. HPV vaccinations were 18% lower in 2020 than 2019 for dose 2 but similar for dose 1, and zoster vaccinations in 70-year-olds were 4% lower.
The Medical Journal of Australia – Pre-print – 20 May 2021 Main text (799 words) The coronavirus disease 2019 (COVID-19) pandemic and associated measures to reduce spread of disease have impacted routine immunisation in many countries.1-3 Strict physical distancing and movement restrictions (stage 3 ‘lockdown’ measures) were implemented nationally from 23 March 2020, with many healthcare providers pivoting to a telehealth-based model. While previous analyses found no impact of the first pandemic wave on uptake of childhood vaccinations due up to July 2020, at either national or state/territory level,4 these analyses did not assess potential impacts of the more stringent measures, particularly ‘stage 4’ lockdowns in Melbourne, implemented in Victoria from early August to late October 2020, due to a second epidemic wave. Additionally, no analyses have reported on impact of the shift to remote learning on adolescent vaccination, usually delivered on school premises in Australia, or uptake in older adults. Using Australian Immunisation Register (AIR) data as of 28 February 2021, we compared vaccination uptake in Victoria in 2020 with 2019. Monthly uptake for selected vaccines due at 2, 4 and 12 months of age was assessed by Indigenous status (all/Indigenous). One-month wide birth cohorts were used with uptake assessed at one month after vaccine due, i.e. earlier than standard vaccination coverage reporting (6-12 months after due).5 Proportion of children vaccinated was calculated using number vaccinated with the relevant vaccine as numerator and number registered on AIR as denominator. Monthly counts of human papillomavirus (HPV) vaccinations (dose 1 and 2) in adolescents aged 11-14 years, and zoster vaccinations in adults aged 70 years, were calculated by Indigenous status. As we did not sample a population but analysed AIR data for the entire Victorian population within the specified age groups, we considered calculation of confidence intervals to not be required. No substantial impact of either stage 3 or 4 lockdown restrictions was seen on uptake in young children of diphtheria-tetanus-pertussis-containing vaccine (dose 1 due at 2 months of age), 13-valent pneumococcal conjugate vaccine (dose 2 due at 4 months of age), and measles-mumps-rubella vaccine (12 months of age), in either all (Box 1A) or Indigenous (Box 1B) children. HPV dose 1 vaccinations in adolescents were lower in March and April 2020 (20.0% and 79.3%, respectively), when students were learning from home, but substantially higher (96.4%-801.6%) in all subsequent months than in 2019, including August-October when students were also learning from home (Box 2A). HPV dose 2 vaccinations were lower in March and April 2020 (6.4% and 12.9%, respectively), and August-October (47.2%-61.1%), but higher in other months, notably December (352.8%). The total number of HPV
The Medical Journal of Australia – Pre-print – 20 May 2021 vaccinations was 0.2% lower for dose 1 (but 38.6% higher for Indigenous adolescents) and 17.6% lower for dose 2 (10.3% higher for Indigenous) in 2020 than 2019. Zoster vaccine doses recorded for adults aged 70 years were substantially lower in May, August and September 2020 (45.2%, 42,2% and 23.4%, respectively), but higher in March (33.6%; likely due to earlier rollout of the influenza vaccination program), November (46.5%) and December (67.4%), than in in 2019 (Box 2B). The total number of zoster vaccinations recorded for adults aged 70 years was 3.8% lower (21.5% for Indigenous) in 2020 than 2019. Study limitations include that substantial underreporting of zoster vaccination in older adults to the AIR has previously been identified,6 so if reporting completeness was greater in 2020 than 2019 we may have underestimated the impact on uptake. As we assessed vaccination uptake for young children earlier than usual, it will be important to monitor any impacts in populations where timeliness of vaccination is a known issue e.g. Indigenous children. In summary, we found no evidence of impact of the pandemic and associated measures on vaccination uptake in Victoria in young children, despite the longest and most restrictive pandemic response measures in Australia. This continued strong uptake in Victoria, and Australia more broadly,4 is likely due to consistent messaging by health authorities that immunisation is an essential health service, efforts by vaccination providers to provide COVID-19 safe services, continued engagement of parents/carers, and lower disease rates than many other countries. However, there were substantial impacts on HPV dose 1 vaccination in adolescents in the first epidemic wave, with flow-on effect to dose 2 vaccinations later in 2020, given the minimum 6-month interval between doses. Pleasingly, no similar impact of the second epidemic wave was seen, likely due to the Victorian health department’s engagement with local councils to facilitate alternative program delivery arrangements, and with general practitioners to promote catch-up vaccination, and mainstream and social media messaging and additional resources for providers and parents.7 We also found some impact on zoster vaccination uptake in older adults, particularly Indigenous, which may reflect greater propensity to delay routine vaccination due to concerns about COVID-19 infection risks. Overall our findings demonstrate resilience of the Victorian immunisation delivery system in the face of unprecedented social and healthcare disruption.
The Medical Journal of Australia – Pre-print – 20 May 2021
Box 1: Vaccination uptake at 2-, 4- and 12-month age milestones for selected vaccine
doses8, assessed 1 month after vaccines due for successive 1-month-wide birth
cohorts; all children (A) and Indigenous children (B), Victoria, 2019-2020*
A (all children)
B (Indigenous children)
100
90.2
90 85.7 91.2
82.8 89.2
80 83.5
80.4
76.6
70 74.6
Uptake (%)
End 66.1
65.2 Stage 3
60 lockdo
wn-
26/5-
End Stage 60.1
4/3
Start 9/6† lockdow n
50 Stage 3
Start
- 12-
DTP-containing vaccine - dose 1 lockdow n
- 23/3 Metro &
26/10‡
Mitchell
40 13vPCV- dose 2 Shire
Stage 3
lockdown
MMR vaccine - dose 1 - 8/7
30
Start
Metro
20 Stage 4 &
Regional
Stage 3
lockdow n
10 -2/8
0
Jan
Jan
Dec
Dec
Nov
Nov
Jun
Feb
Feb
Apr
Jul
Aug
Oct
Oct
Apr
Jun
Jul
Aug
Mar
Mar
May
Sep
May
Sep
2019 2020
Month vaccines dueThe Medical Journal of Australia – Pre-print – 20 May 2021 * Vaccination uptake in this figure represents timely uptake of selected doses and does not equate to vaccination coverage as usually assessed (at 6-12 months after dose due capturing catch-up vaccinations well beyond the first month as assessed here) † Partial return to school on 26 May; full return on 9 June 2020. ‡ Stage 3 ended in regional areas on 12 October 2020; and metropolitan areas on 26 October 2020. DTP = diphtheria-tetanus-pertussis 13vPCV = 13-valent pneumococcal conjugate vaccine MMR = measles-mumps-rubella
The Medical Journal of Australia – Pre-print – 20 May 2021
Box 2: Monthly dose counts recorded on the AIR8 for HPV vaccinations (dose 1 and 2)
in adolescents aged 11-14 years (A) and zoster vaccinations in adults aged 70 years
(B), Victoria, 2019-2020
A (HPV)
B (zoster)
3500
Number of zoster vaccine doses recorded on AIR
End Stage
3 lockdown
Start Stage 3 - 26/5-9/6*
lockdow n -
2932 23/3 Start Metro Start Metro
3000 & Mitchell Stage 4 &
End Stage
Shire Regional 4/3
Stage 3 Stage 3
lockdow n - lockdow n - lockdow n -
8/7 2/8 12-26/10†
2500
2000 1876 1927
1570 1606
1494
1500 1293 1336 1379
1175 1175
1088
985
1000
755
679
500
0
Dec
Jan
Jan
Dec
Aug
Nov
Apr
Jul
Apr
Aug
Nov
Oct
Feb
Oct
Jun
Feb
Jun
Jul
Mar
May
May
Sep
Mar
Sep
2019 2020
Month of vaccinationThe Medical Journal of Australia – Pre-print – 20 May 2021
* Partial return to school on 26 May; full return on 9 June 2020.
† Stage 3 ended in regional areas on 12 October 2020; and metropolitan areas on 26 October 2020.
HPV = human papillomavirus
LINE GRAPHS
Box 2: Monthly dose counts recorded on the AIR8 for HPV vaccinations (dose 1 and 2)
in adolescents aged 11-14 years (A) and zoster vaccinations in adults aged 70 years
(B, Victoria, 2019-2020
A (HPV)
40000
37803 Dose 1
Start Stage End Stage
Dose 2
Number of HPV vaccine doses recorded on AIR
3 lockdow n 3 lockdow n
35000 - 23/3 - 26/5-9/6*
31573 Start Start
30257 Metro & Metro
End
30000 Mitchell
Shire
Stage 4
&
Stage 4/3
Stage 3 Regional lockdow n
lockdown - Stage 3 - 12-
8/7 lockdown 26/10†
25000 -2/8
20000
17490
15000
12269
10000 9512 9124
5000 6212
3318
0
Jan
Jan
Dec
Dec
Nov
Nov
Feb
Jun
Feb
Jun
Oct
Apr
Jul
Aug
Apr
Jul
Oct
Aug
Mar
May
Sep
Mar
May
Sep
2019 2020
Month of vaccinationThe Medical Journal of Australia – Pre-print – 20 May 2021
B (zoster)
3500
Number of zoster vaccine doses recorded on AIR
End
Stage 3
Start Stage lockdow n
3 lockdow n - 26/5-
2932 - 23/3 9/6* Start Start
3000 Metro & Metro
Mitchell Stage 4 &
End Stage
4/3
Shire Regional
Stage 3 lockdow n
Stage 3 - 12-
lockdow n lockdow n
- 8/7 26/10†
2500 -2/8
1927
2000
1494
1500
1000
900 679
824
500
0
Jan
Jan
Dec
Dec
Nov
Feb
Apr
Feb
Apr
Nov
Jun
Jul
Oct
Aug
Jun
Jul
Oct
Aug
Mar
Sep
Mar
Sep
May
May 2019 2020
Month of vaccination
* Partial return to school on 26 May; full return on 9 June 2020.
† Stage 3 ended in regional areas on 12 October 2020; and metropolitan areas on 26 October 2020.
HPV = human papillomavirusThe Medical Journal of Australia – Pre-print – 20 May 2021 References 1. World Health Organization. WHO and UNICEF warn of a decline in vaccinations during COVID-19. 2020. Available from: https://www.who.int/news/item/15-07-2020-who-and-unicef- warn-of-a-decline-in-vaccinations-during-covid-191 December 2020. 2. Santoli JM, Lindley MC, De Silva MB, et al. Effects of the COVID-19 Pandemic on Routine Pediatric Vaccine Ordering and Administration — United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:591-3. 3. Public Health England. Impact of COVID-19 on childhood vaccination counts to week 43, and vaccine coverage to September 2020in England: interim analyses. London: Public Health England; 2020. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file /933545/hpr2120_chldhd-vc_wk43.pdf Accessed 2020 24 November 2020. 4. National Centre for Immunisation Research and Surveillance. COVID-19: Impact on routine childhood vaccination uptake in Australia. 2020. Available from: https://www.ncirs.org.au/sites/default/files/2020-11/COVID- 19_Impact_Analysis_Final%20Report.pdf1 December 2020. 5. Hull B, Hendry A, Dey A, et al. Immunisation Coverage Annual Report 2019. Commun Dis Intell. 2021 Mar 31;45. 6. Hull B, Hendry A, Dey A, et al. Exploratory analysis of the first 2 years of adult vaccination data recorded on AIR. Sydney: National Centre for Immunisation Research and Surveillance; 2019. Available from: http://ncirs.org.au/sites/default/files/2019- 12/Analysis%20of%20adult%20vaccination%20data%20on%20AIR_Nov%202019.pdf Accessed 2020 3 December 2020. 7. Victorian Government Department of Health and Human Services. Secondary school immunisation program 2020 during COVID: Advice for parents and guardians – 3 August 2020. 2020. Available from: https://www2.health.vic.gov.au/about/publications/factsheets/sec-school- immunisation-2020-covid-fs-parents3 December 2020. 8. Australian Government - Services Australia. Australian Immunisation Register. Canberra: Australian Government - Services Australia; 2020. Available from: https://www.servicesaustralia.gov.au/individuals/services/medicare/australian-immunisation- register Accessed 2021 18/05/2021.
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