Vaccination is a crucial and most cost-effective method for controlling life-threatening infectious diseases. More than 120 vaccines have shown the effectiveness of preventing and disappearing of many infectious diseases. Most countries in the world have developed a national policy for immunization based on the World Health Organization (WHO) recommendation. Globally, vaccine-preventable diseases (VPDs) are still the cause of two million pediatric deaths every year due to skipping or delaying vaccination.
Vaccination delay increases the time between the depletion of the mother’s antibodies and vaccines’ protection, leading to the outbreak of VPDs. Many factors could lead to vaccination delay, including not being a first child, not having insurance, and living in peripheral zones. Not only this but also outbreaks of infectious disease were found to be a strong factor that could have a negative impact on adherence to vaccination schedule among children.
Recently, the world is facing the outbreak of COVID-19 that affects health care and lead to restricting all daily activities. COVID-19 is a very contiguous and higher pandemic risk than other coronavirus types. In January 2020, the WHO officially announced the COVID-19 outbreak as a public health crisis of universal concern. According to Wang et al. and Adhikari et al. the only way to be protected from COVID-19 is through prevention of spreading and decreasing transmission in the community.
Worldwide, Governments take different precautions at different times to restrict the spread of infection by limiting the movement of people, lockdown forced on all society, hospital visits have been limited to emergency care and urgent procedures to minimize crowding and close contact as much as possible.
As a result of this huge awareness, the quick spread of COVID-19, and strict precautions around the world, the outbreak is inducing a considerable degree of fear, anxiety, depression, and other psychological issues among the population in general and increasing to some extent among certain groups. Such a negative impact could affect the families decision to adherence to their children’s vaccination schedule. Therefore, this study aims to investigate the factors that are associated with delayed vaccination in children during COVID-19 pandemic.
The cross-sectional study was conducted during May 2020 including all the 13 regions of the Kingdom of Saudi Arabia. It was conducted using a self-administered online questionnaire that was distributed through social media. This study (RC20/264/R) was approved by the Institutional Review Board in King Abdullah International Medical Research Center. According to the Saudi Arabia General Statistical Authority, there were 34,218,169 adults in 2019. Based on Raosoft, a sample size online calculator with an acceptable error margin of error 5% and 95% confidence level, a sample size of at least 385 was required.
Participants who were addressed in this study were caregivers or parents who take care of a child from birth to 4 years old and reside in Saudi Arabia at the time of quarantine. The total number of respondents was 2,352. The data were collected through a structured questionnaire.
The questionnaire was modified to fit the purpose of research and was reviewed by a specialized physician. It consisted of two parts: the first part is showing the purpose of the research. The second part consisted of three sections: the first section included socioeconomic variables including: nationality, age, sex, relation to the child, marital status, region, residence, level of education, occupation, health insurance, and financial income. The second section included child information that contains age, number of other siblings and if she/he had any infections, asthma, or any neurological diseases. The last section included immunization history which focused on where vaccination is taken, duration of the vaccination process, whether the child had delayed or missed immunization before pandemic or not, reasons Delayed child vaccine during coronavirus disease-2019 Pandemic 20 of not continuing immunization during the pandemic which included six prespecified reasons, if a participant has his/her own car for transportation, the awareness of the importance of vaccination, and if a participant knows how to take an appointment during the pandemic.
Participants are considered late in vaccinating their children when they plan to not to continue vaccination during the pandemic in the next upcoming months, while participants who will to continue vaccination have positive attitude towards vaccination during pandemic. The analysis was performed using the statistical package of social science version 25 (IBM corporation, Armonk, NY). The categorical data are presented as numbers and percentages.
Of 2,352 contacted participants, 2,325 agreed to participate and filled up the questionnaire. Eight hundred twenty of participants were included in the criteria. Majority of the participants were Saudis (n = 766, 93.4%). Most of participants were aged 21-25 years (n = 230, 28.0%). Female participants accounted for more than 70% of the surveyed cohort (n = 607, 74%). Most of study participants were mothers (n = 456, 55.6%). The vast majority of the participants were married at 75.6% and resided in urban area at 84.1%. More than one quarter of the studied sample was from Eastern region at 21.5%, followed by Riyadh, Najran, Makkah region, Tabuk, and Hail. Majority of participants had bachelor’s degree (n = 517, 63%). Moreover, most of the participants were employed (n = 502, 61.2%).
A total of 56.8% did not have health insurance (n = 466), but most of the participants’ monthly financial income was between 10,000 and 25, 000 SR (n = 365, 44.5%). Half of the sample size have children between age 6 and 11 months (n = 364, 44.4%) and have 2-4 children (n = 384, 46.8%). Seven hundred sixty nine of children do not have skin rash and hay fever. Majority of children were healthy with no chronic diseases (n = 795, 97%), and minority suffers from neurological diseases such as cerebral palsy or genetic disorders such as Down syndrome (n = 25, 3.0%). More than 90% of the participants had vaccination cards (n = 738). Participants showed a commitment to vaccination before COVID-19 pandemic in around 59.3% of the study sample.
Appointments for vaccination by the current study participants were taken mostly in primary healthcare centers (PHC) (n = 607, 74%), with a travel distance to hospital or Primary health care centers (PMC) of less than 20 minutes in more than half of the study sample (n = 548, 66.8%) with private car as the most common mode for transportation in 93.2% of participants (n = 764). A total of 75.6% of parents participated in this study had a positive attitude towards completing their children vaccination even during the COVID-19 pandemic.
Participants elected not to adhere to the vaccination schedule in 24.4%. The main reasons for not giving the vaccine was the fear of getting the child and caregiver exposed to infection by COVID-19 virus if they visit the health care facilities and planning to postpone vaccination till the pandemic ends (Figure 1). Figure 2 shows participants who continued and did not continue the vaccination during COVID-19 pandemic. According to age, participants who have children from age 2 to 3 months old have higher number in refusing to continue vaccination than 4-5 months, 6-11 months and the least are (n = 388). Despite that, 72% of participants were aware of the online appointment system provided by Ministry of Health (MOH) for vaccination. Overall, 94.3% of participants had strong knowledge about the importance of the vaccination.
The current study was conducted in a very critical and short period, but the finding was obvious that 24.4% of participants are not planning to continue vaccination during the pandemic. This might increase the number of preventable diseases in the new generation. Notably, more educated parents are strongly associated with continuing immunization even in such a pandemic period. The awareness about importance of immunization will improve the childhood vaccination coverage. Therefore, launching awareness programs targeting this topic will have a great impact. MOH once did a home vaccination service for influenza to cover largest number as possible. Therefore, we recommend doing home vaccination service for children by MOH for covering the basic immunization in all regions of Saudi Arabia. This will reduce the hospital load and decrease the possibility of virus transmission. Moreover, although awareness of immunization was established before pandemic, it should be more during these days through social media and other means.