Almost three years ago, the world watched in terror as COVID-19 spread like wildfire globally. What was an outbreak in China soon became a global pandemic. It was almost the real-life scene of the erupting Mount Sibo in the Jurassic Park movie. Life really does imitate art.
A novel virus that forced the world to come together for a solution. Economies tanked, jobs lost, businesses closed, and the global health systems took a hit like never before. And the fastest vaccine development to ever happen in the history of humankind happened.
While the focus on the effects of COVID-19 is based on mortality and morbidity, measures taken to contain the outbreak had a broader impact on other health systems, including vaccine distribution.
The COVID-19 pandemic led to the backsliding of routine vaccinations globally, including routine childhood vaccinations. The disruption was significant, fuelled by the diversion of resources and personnel to support the COVID-19 response, funding shortfalls, and vaccine misinformation, especially in low and middle-income countries.
WHO and UNICEF estimate that 23 million children missed out on basic vaccines through routine immunisation services in 2020, with 17 million not receiving a single vaccine.
A ray of sunshine
Tanzania reported its first confirmed case of COVID-19 on March 16, 2020, and the first one million COVID-19 vaccine doses – donated by the U. S. government and delivered by COVAX arrived in Tanzania on July 24, 2021.
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On July 28, 2021, President Samia Suluhu Hassan launched the COVID-19 vaccination campaign by receiving her first Johnson and Johnson vaccine shot.
“I’m a mother of four children, grandmother to many, wife and, most importantly, the President and Commander-in-Chief of the Tanzanian armed forces,” Samia said immediately after taking the shot.
“You can imagine how many people depend on me from that chain,” the Head of State added. “In that context, I cannot put my life at risk if the vaccines are not safe.”
Almost a week after the President’s public vaccine launch, as I finished a night shift in the neonate ward as an intern doctor at Temeke Regional Referral Hospital, I also received my shot of the Johnson and Johnson vaccine. It was a ray of hope to go back to normal.
As the government, in collaboration with implementing partners, rolled out COVID-19 vaccines, the uptake of routine vaccination began to increase as lockdowns were lifted worldwide and the world opened up again.
Recovering from the storm
The COVID-19 pandemic did not leave us unscathed. According to the Tanzania Demographic Health Survey and Malaria Indicator Survey 2022 (TDHS-MIS) conducted after COVID-19, 53 per cent of children aged 12-23 months are fully vaccinated against all primary antigens.
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Basic vaccination coverage has decreased from 75 per cent between 2015 and 2016. The trends in childhood vaccination in Tanzania have been steady since 1991, with a slight increase, but the significant, never-seen-before drop has only been seen between 2015/16 and 2022.
“The decline in children fully vaccinated against all basic antigens relative to the 2015–16 TDHS-MIS appears due to a large drop off in the coverage of Oral Polio Vaccine (OPV3), from 83 per cent in 2015–16 to 59 per cent in 2022”, states the TDHS 2022 report.
With such a drop in Polio vaccination and several Polio outbreaks in neighbouring countries, it is no surprise that in May 2023, Tanzania confirmed a case of Polio in the Rukwa region, 25 years after the last confirmed case of Polio in Tanzania and eight years after being certified Polio-free.
Since then, in collaboration with WHO Tanzania and UNICEF Tanzania, the Ministry of Health has conducted several mass immunisation campaigns against Polio to scale up Polio vaccination in many regions.
Human Papillomavirus (HPV) vaccination was not left behind by the disruption caused by the COVID-19 pandemic. With the primary target of HPV vaccines being nine to 14-year-old girls, their catchment area is usually in schools.
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As schools and health facilities closed during the pandemic, HPV vaccinations, including mass campaigns, were delayed. Since 2019, HPV vaccination coverage dropped by an alarming 15 to 25 per cent, meaning that 3.5 million girls missed out on HPV vaccination.
HPV infection remains to be the cause of over 90 per cent of cervical cancer cases. Tanzania introduced HPV vaccines in April 2018 to integrate them into its routine immunisation program.
President Samia, then Vice President, led the launch of the HPV vaccine, which is given in two doses to girls nine to 14 years old.
The Ministry of Health, in collaboration with implementing partners, including Girl Effect, is scaling up HPV vaccination to close the gap.
Girl Effect, which uses media and technology to empower girls, has launched the Mwanzo Mwema, or Beautiful Beginning, campaign, which focuses on increasing the uptake of HPV and routine vaccines in regions with low HPV vaccine uptake, including Katavi, Mtwara, Shinyanga, and Lindi.
The road ahead
One notable outcome of the COVID-19 pandemic is the increase in vaccine hesitancy and a decrease in vaccine confidence due to vaccine misinformation and disinformation that spread widely through social media and mass media during the pandemic.
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Vaccine hesitancy is not a new concept in Tanzania, even in childhood vaccinations and more so for HPV vaccines. The UNICEF report published in April 2023 indicates a decline in confidence in childhood vaccines of up to 44 per cent in some countries during the COVID-19 pandemic.
In most countries, people under 35 and women were more likely to report less confidence about vaccines for children after the start of the pandemic.
This is very concerning as these two groups are the current parents, and worse enough, women play a vital role in ensuring childhood vaccination success. There is a need to regroup and improve vaccine education to the public to change this dangerous situation that threatens public health.
In the context of Tanzania, our initial response towards the COVID-19 pandemic and later vaccines did not help other vaccines, especially with the pseudoscience misinformation that was peddled with little resistance.
Vaccine confidence is volatile, and there is always a spillover from mistrust of one vaccine to others. The increased access to misleading information, declining trust in medical expertise and political polarisation play a significant role in vaccine hesitancy.
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While scientists considered this a breakthrough achievement, little did they know that the pushback would be even more significant.
A lesson to take here is that scientists should do more to educate the public. When there is an information gap regarding science-related issues, the public is likely to fill it with whatever is available.
Health financing
Another challenge facing vaccination programs is health financing as Tanzania moved from a low-income country to a lower-middle-income country.
Gavi-the Vaccine Alliance support depends on economic growth, whereby low-income countries contribute 0.2 USD per dose of supported vaccines, while middle-income countries contribute by price fraction that increases gradually by 15 per cent annually.
Tanzania has consistently met its co-financing obligations to Gavi of paying US$0.2 for each dose of vaccine.
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With the Gavi transition policy, Tanzania, as a lower-middle-income country, will start contributing a price fraction of about eight per cent for each of the five co-financed vaccines in 2023, hence the need for Domestic Resource Mobilization to fill the funding gap.
Despite the increase in public healthcare funding, the allocated budget for healthcare services is not fully provided, hence the gaps in the cost of care and dependency on development partners.
New initiatives to scale up sustainable domestic resource mobilisation are needed to reach Universal Health Coverage and reduce dependency on development partners in crucial parts of healthcare, including childhood vaccinations.
Universal Health Insurance can also help to close the gap, although health financing through health insurance remains low in Tanzania.
Hope for a better tomorrow
Tanzania has seen its fair share of emerging and re-emerging infectious diseases in the past decade. These outbreaks threaten the existing health systems and programmes, including routine immunisation and mass immunisation campaigns.
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In her biography, The Tanzanian Woman of Many Firsts, Prof Esther Mwaikambo, the first female doctor in Tanzania and renowned Pediatrician for over 50 years, highlights the journey of Tanzania’s vaccination programs.
“In the 1970s, the rate of diseases that are now immunisable was high, but we didn’t have vaccines,” Prof Mwaikambo writes. “As a result, Polio and Tuberculosis often tore through communities, leaving devastation. Through the course of my career, I witnessed the changes vaccination brought about.”
“In 1971, when I began working, no children were being immunised at all until the big drive of 1974-76 after the introduction of the expanded programme of immunisation (EPI) when parents brought their kids in very willingly to be vaccinated,” the highly celebrated professional writes.
As the dust settles and Tanzania works to catch up with vaccinations, this is a reminder of preparedness for the possibility of future emerging infectious diseases.
This year’s theme for World Immunization Week, The Big Catch Up, reminds all stakeholders of the responsibility of vaccinating communities for healthy communities.
Kuduishe Kisowile is a medical doctor and public health commentator based in Dar es Salaam, Tanzania. She is available through kuduzekudu@gmail.com or on X as @Kudu_ze_Kudu. These are the writer’s own opinions and do not necessarily reflect the viewpoint of The Chanzo. Want to publish in this space? Contact our editors at editor@thechanzo.com for further inquiries.
