The Impact of the COVID-19 Pandemic on Uptake of Routine Childhood Immunization: How a Behavioral Science Led Analysis Can Strengthen Vaccination Policy

Main Article Content

Anushka Ashok Sangiwe Moyo Saransh Sharma Laura Myers


In addition to the direct health and economic impacts of the COVID-19 pandemic, routine immunization of children for vaccine-preventable diseases has also suffered. Quantitative studies have shown evidence of backsliding in routine immunization, i.e., children failing to receive their vaccinations on schedule. Pandemic restrictions were the cause for some of this behavior, and there are signs that subsequent campaigns and supply-side initiatives have influenced trends toward routine immunization catch-up. However, limited qualitative research indicates that the pandemic may have disrupted parents/caregivers’ decision-making processes around routine immunization, and their attitudes toward vaccination, in ways that could have long-term effects on rates of immunization. Further behavioral research can help elucidate this and provide guidance to policymakers to boost immunization uptake.

This policy article explores the decision dynamics leading to missed routine immunization doses during the pandemic, through an analysis of secondary literature, a summary of primary-research studies on COVID-19 vaccine hesitancy conducted during the pandemic across Côte d’Ivoire, Burkina Faso, Kenya and Pakistan, and a summary of a study on the impact of COVID-19 on routine immunization uptake in South Africa.

We found that the COVID-19 pandemic severely disrupted prior patterns of engagement with the health system, turning routine immunization from a default decision for parents/caregivers into an “active decision-making” moment. Restrictions on movement, limited routine immunization supplies and other practical impediments combined with fear of contracting COVID-19 at health facilities, misinformation, and fear of vaccine side-effects, creating an emergent behavior of missed  immunization doses during the pandemic period. We also found that hesitancy about COVID-19 vaccines may be transferred onto previously accepted vaccines, impacting routine immunization.

We identified three decision-making pathways for routine immunization uptake among South African parents/caregivers once the lockdowns were lifted: the “path of procrastination,” the “path of doubt,” and the “path of persistence.” We highlight the policy implications of these, and suggest potential interventions to increase routine immunization uptake for parents/caregivers on each path, as well as for general communications, service delivery, and pandemic readiness.

Article Details

How to Cite
ASHOK, Anushka et al. The Impact of the COVID-19 Pandemic on Uptake of Routine Childhood Immunization: How a Behavioral Science Led Analysis Can Strengthen Vaccination Policy. Medical Research Archives, [S.l.], v. 11, n. 5, may 2023. ISSN 2375-1924. Available at: <>. Date accessed: 02 oct. 2023. doi:
Research Articles


1. World Health Organization. 14.9 Million Excess Deaths Associated With The COVID-19 Pandemic In 2020 And 2021. Published May 5, 2022. Accessed March 27, 2023.
2. Verikios G. The dynamic effects of infectious disease outbreaks: the case of pandemic influenza and human coronavirus. Socioecon Plann Sci. 2020;71:100898. Published June 10, 2020. doi:10.1016/j.seps.2020.100898
3. World Health Organization. Immunization Coverage. Published July 14, 2022. Accessed March 27, 2023.
4. UNICEF. COVID-19 Pandemic Leads To Major Backsliding On Childhood Vaccinations, New WHO, UNICEF Data Shows. Published July 15, 2021. Accessed March 27, 2023.
5. Shet A, Carr K, Danovaro-Holliday MC, et al. Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories. Lancet Glob Health. 2022;10(2):e186-e194. Published December 21, 2021. doi:10.1016/S2214-109X(21)00512-X
6. Roberton T, Carter ED, Chou VB, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. Lancet Glob Health. 2020;8(7):e901-e908. Published May 12, 2020. doi:10.1016/S2214-109X(20)30229-1
7. Li X, Mukandavire C, Cucunubá ZM, et al. Estimating the health impact of vaccination against ten pathogens in 98 low-income and middle-income countries from 2000 to 2030: a modelling study [published correction appears in Lancet. 2021;397(10275):670]. Lancet. 2021;397(10272):398-408. doi:10.1016/S0140-6736(20)32657-X
8. Elston JW, Cartwright C, Ndumbi P, Wright J. The health impact of the 2014-15 Ebola outbreak. Public Health. 2017;143:60-70. doi:10.1016/j.puhe.2016.10.020
9. Abbas K, Procter SR, van Zandvoort K, et al. Routine childhood immunisation during the COVID-19 pandemic in Africa: a benefit-risk analysis of health benefits versus excess risk of SARS-CoV-2 infection. Lancet Glob Health. 2020;8:e1264-72. Published July 17, 2020. doi:10.1016/S2214-109X(20)30308-9
10. Cardoso Pinto AM, Shariq S, Ranasinghe L, et al. Reasons for reductions in routine childhood immunisation uptake during the COVID-19 pandemic in low- and middle-income countries: a systematic review. PLOS Glob Public Health. 2023;3(1):e0001415. Published January 24, 2023. doi:10.1371/journal.pgph.0001415
11. Ota MOC, Badur S, Romano-Mazzotti L, Friedland LR. Impact of COVID-19 pandemic on routine immunization. Ann Med. 2021;53(1):2286-2297. doi:10.1080/07853890.2021.2009128
12. World Health Organization. Guiding Principles for Immunization Activities during the COVID-19 Pandemic: Interim Guidance, 26 March 2020. World Health Organization; 2020. Accessed March 27, 2023.
13. World Health Organization. How WHO Is Supporting Ongoing Vaccination Efforts During The COVID-19 Pandemic. Published July 14, 2020. Accessed March 27, 2023.
14. Khatiwada AP, Maskey S, Shrestha N, et al. Impact of the first phase of COVID-19 pandemic on childhood routine immunisation services in Nepal: a qualitative study on the perspectives of service providers and users. J Pharm Policy Pract. 2021;14(1):79. Published September 29, 2021. doi:10.1186/s40545-021-00366-z
15. Saso A, Skirrow H, Kampmann B. Impact of COVID-19 on immunization services for maternal and infant vaccines: results of a survey conducted by Imprint – the Immunising Pregnant Women and Infants Network. Vaccines (Basel). 2020;8(3):556. Published September 22, 2020. doi:10.3390/vaccines8030556
16. Bimpong KA, Nuertey BD, Seidu AS, Ajinkpang S, Abdul-Mumin A. Decline in uptake of childhood vaccinations in a tertiary hospital in northern Ghana during the COVID-19 pandemic. Biomed Res Int. 2021;2021:6995096. Published December 14, 2021. doi:10.1155/2021/6995096
17. Wale Tegegne A, Kassie Gidafie A, Girma Mamo D, Tilahun Wassie S, Abita Mengie Z. Immunization status and challenges during COVID-19 and associated factors among children aged 10-23 months in South Region, Ethiopia 2020. Pediatric Health Med Ther. 2021;12:101-109. Published March 8, 2021. doi:10.2147/PHMT.S294739
18. MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036
19. World Health Organization. 10 Threats To Global Health In 2019. No publication date. Accessed March 27, 2023.
20. Betsch C, Böhm R, Chapman GB. Using behavioral insights to increase vaccination policy effectiveness. Policy Insights Behav Brain Sci. 2015;2(1):61-73. doi:10.1177/2372732215600716
21. World Health Organization. Behavioural and Social Drivers of Vaccination: Tools and Practical Guidance for Achieving High Uptake. World Health Organization; 2022. Accessed March 27, 2023.
22. Pillay Y, Pienaar S, Barron P, Zondi T. Impact of COVID-19 on routine primary healthcare services in South Africa. S Afr Med J. 2021;111(8):714-719. Published May 17, 2021. doi:10.7196/SAMJ.2021.v111i8.15786
23. Oraby T, Thampi V, Bauch CT. The influence of social norms on the dynamics of vaccinating behaviour for paediatric infectious diseases [published correction appears in Proc Biol Sci. 2016;283(1840):20161859]. Proc Biol Sci. 2014;281(1780):20133172. Published February 12, 2014. doi:10.1098/rspb.2013.3172
24. Shapiro GK, Gottfredson N, Leask J, et al. COVID-19 and missed or delayed vaccination in 26 middle- and high-income countries: an observational survey. Vaccine. 2022;40(6):945-952. doi:10.1016/j.vaccine.2021.12.041
25. Rizwan W, Duggal MN, Rana MN, Rafique M, Ghaffar J, Sadiq M. Effect of COVID-19 pandemic on vaccination of children under two years of age. Pak Pediatr J. 2021;45(2):161-168.
26. Badur S, Ota M, Öztürk S, Adegbola R, Dutta A. Vaccine confidence: the keys to restoring trust. Hum Vaccin Immunother. 2020;16(5):1007-1017. doi:10.1080/21645515.2020.1740559