ABSTRACT
IntroductionGovernments around the world suspended immunization outreach to control COVID-19 spread. Many have since resumed services with an emphasis on catch-up vaccinations to reach children with missed vaccinations. This paper evaluated immunization disruptions during Indias March-May 2020 lockdown and the extent to which subsequent catch-up efforts reversed them in Rajasthan, India. MethodsIn this retrospective observational study, we conducted phone surveys to collect immunization details for 2,144 children that turned one year old between January and October 2020. We used logistic regressions to compare differences in immunization timeliness and completed first-year immunization status among children that were due immunizations just before (unexposed), during (heavily exposed), and after (post-exposure) the lockdown. ResultsRelative to unexposed children, heavily exposed children were significantly less likely to be immunized at or before 9 months (OR 0.550; 95%CI 0.367-0.824; p=0.004), but more likely to be immunized at 10-12 months (OR 1.761; 95%CI 1.196-2.591; p=0.004). They were also less likely to have completed their key first-year immunizations (OR 0.624; 95%CI 0.478-0.816; p=0.001) by the time of survey. In contrast, post-exposure children showed no difference in timeliness or completed first-year immunizations relative to unexposed children, and their immunization coverage was 6.9pp above heavily exposed children despite their younger age. Declines in immunization coverage were larger among children in households that were poorer, less educated, lower caste, and residing in COVID red zones, although subgroup comparisons were not statistically significant. ConclusionDisruptions to immunization services resulted in children missing immunization during the lockdown, but catch-up efforts after it was eased ensured many children were reached at later ages. Nevertheless, catch-up was incomplete and children due their immunizations during the lockdown remained less likely to be fully immunized 4-5 months after it lifted, even as younger cohorts due immunizations in June or later returned to pre-lockdown schedules.
ABSTRACT
Indias COVID-19 lockdown, one of the most severe in the world, is widely believed to have disrupted critical non-COVID health services. However, linking these disruptions to effects on health outcomes has been difficult due to the lack of reliable, up-to-date health outcomes data. We identified all dialysis patients under a statewide health insurance program in Rajasthan, India, and conducted surveys to examine the effects of the lockdown on care access, morbidity, and mortality. 63% of patients experienced a disruption to their care. Transport barriers, hospital service disruptions, and difficulty obtaining medicines were the most common causes. We compared monthly mortality in the four months after the lockdown with pre-lockdown mortality trends, as well as with mortality trends for a similar cohort in the previous year. Mortality in May 2020, after a month of exposure to the lockdown, was 1.70 percentage points or 64% (p=0.01) higher than in March 2020 and total excess mortality between April and July was estimated to be 22%. Morbidity, hospitalization, and mortality between May and July were strongly positively associated with lockdown-related disruptions to care, providing further evidence that the uptick in mortality was driven by the lockdown. Females, socioeconomically disadvantaged groups, and patients living far from the health system faced worse outcomes. The results highlight the unintended consequences of the lockdown on critical, life-saving non-COVID health services that must be taken into account in the implementation of future policy efforts to control the spread of pandemics.
ABSTRACT
ObjectiveTo model how known COVID-19 comorbidities will affect mortality rates and the age distribution of mortality in a large lower middle income country (India), as compared with a high income country (England), and to identify which health conditions drive any differences. DesignModelling study. SettingEngland and India. Participants1,375,548 respondents aged 18 to 99 to the District Level Household Survey-4 and Annual Health Survey in India. Additional information on health condition prevalence on individuals aged 18 to 99 was obtained from the Health Survey for England and the Global Burden of Diseases, Risk Factors, and Injuries Studies (GBD). Main outcome measuresThe primary outcome was the proportional increase in age-specific mortality in each country due to the prevalence of each COVID-19 mortality risk factor (diabetes, hypertension, obesity, chronic heart disease, respiratory illness, kidney disease, liver disease, and cancer, among others). The combined change in overall mortality and the share of deaths under 60 from the combination of risk factors was estimated in each country. ResultsRelative to England, Indians have higher rates of diabetes (10.6% vs. 8.5%), chronic respiratory disease (4.8% vs. 2.5%), and kidney disease (9.7% vs. 5.6%), and lower rates of obesity (4.4% vs. 27.9%), chronic heart disease (4.4% vs. 5.9%), and cancer (0.3% vs. 2.8%). Population COVID-19 mortality in India relative to England is most increased by diabetes (+5.4%) and chronic respiratory disease (+2.3%), and most reduced by obesity (-9.7%), cancer (-3.2%), and chronic heart disease (-1.9%). Overall, comorbidities lower mortality in India relative to England by 9.7%. Accounting for demographics and population health explains a third of the difference in share of deaths under age 60 between the two countries. ConclusionsKnown COVID-19 health risk factors are not expected to have a large effect on aggregate mortality or its age distribution in India relative to England. The high share of COVID-19 deaths from people under 60 in low- and middle-income countries (LMICs) remains unexplained. Understanding mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is essential for understanding differential mortality. SUMMARY BOXO_ST_ABSWhat is already known on this topicC_ST_ABSCOVID-19 infections in low- and middle-income countries (LMICs) are rising rapidly, with the burden of mortality concentrated at much younger ages than in rich countries. A range of pre-existing health conditions can increase the severity of COVID-19 infections. It is feared that poor population health may worsen the severity of the pandemic in LMICs. What this study addsThe COVID-19 comorbidities that have been studied to date may have only a very small effect on aggregate mortality in India relative to England and do not shift the mortality burden toward lower ages at all. Indias younger demographics can explain only a third of the substantial difference in the share of deaths under age 60 between India and England. However, mortality risk associated with health conditions prevalent in LMICs, such as malnutrition and HIV/AIDS, is unknown and research on this topic is urgently needed.