Reply to Anderson and Caniza

To the Editor—We thank Anderson and Caniza for their letter and interest in our article on the impact of Haemophilus influenzae type b and 13-valent pneumococcal conjugate vaccines on child pneumonia hospitalizations and deaths in Botswana [1]. They highlight the continued high pneumonia mortality among children of mothers with human immunodeficiency virus (HIV) in our study despite introduction of these vaccines. The authors also express concern about the effect of the coronavirus disease 2019 (COVID-19) pandemic on immunization and other child health programs, noting that disruptions of these services may be particularly detrimental to the health of children of mothers with HIV. As pediatricians working to improve the health of children in Botswana and other low- and middle-income countries (LMICs), we share these concerns and agree that concerted action is necessary to prevent a reversal of the recent health gains experienced in these countries.

Both children with HIV and HIV-exposed, uninfected (HEU) children have higher infectious morbidity and mortality than the children of mothers without HIV (unexposed) [2]. In particular, prior studies suggest that much of this excess mortality results from pneumonia [3–6]. Although a number of factors contribute to their high infection risk, children with HIV and HEU children acquire lower levels of maternal antibodies to several common childhood pathogens, including H. influenzae type B and Streptococcus pneumonia [7, 8]. However, children with HIV and HEU children generate robust antibody responses to these pathogens following routine vaccination, illustrating the importance of prioritizing these vulnerable groups for vaccination services in Botswana and other settings with high HIV prevalence.

The COVID-19 pandemic has a substantial impact on the World Health Organization (WHO), the United Nations Children’s Fund, and the Global Alliance for Vaccines and Immunizations estimate that routine immunization services could be disrupted for more than 80 million children aged <1 year during the pandemic [9]. In many LMICs, chronic underfunding of child health programs has been exacerbated as staff and resources have been reallocated to COVID-19 preparedness and response efforts [9–11]. Closures of country borders have interrupted vaccine supply chains, and personal protective equipment shortages have hindered the ability to offer routine vaccination services [11]. In Botswana, public clinics instituted additional safety precautions and provided vaccines and other essential child health services while stay-at-home orders were in effect. Unfortunately, despite these efforts, coverage for several childhood vaccines has fallen below the WHO’s 90% goal during the COVID-19 pandemic (personal communication was oral and performed on 9/18/2020 by Dr. Arscott-Mills, Ndibo Monyatsi, Child Health Division, Botswana Ministry of Health).

Approaches to mitigate the impact of the COVID-19 pandemic on preventive services for children must consider local severe acute respiratory syndrome coronavirus 2 transmission, health system capacity, and the substantial benefits of these programs to child health [9]. Moreover, these efforts will be influenced by local priorities and resources and must be flexible in the setting of frequently evolving COVID-19 precautions and restrictions [10]. In Botswana, several efforts to improve vaccine coverage are currently planned, including programs that target children of mothers with HIV and linkage of child health screenings to household vector spraying in malaria-endemic districts. We applaud the efforts in Cambodia, Syria, and Burkina Faso highlighted by Anderson and Caniza and encourage continued discourse regarding strategies to maintain childhood vaccine coverage rates during the COVID-19 pandemic.

Notes

Acknowledgments. We thank Ndibo Monyatsi from the Child Health Division of the Botswana Ministry of Health for her comments on the provision of immunization services in Botswana during the coronavirus disease 2019 pandemic.

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.