key: cord-0723878-kwk61c8f authors: David, Chelo; Félicitée, Nguefack; Dominique, Enyama; Richie, Nansseu; Garbert, Feudjo Tefoueyet; Désiré, Mbassi Awa Hubert; Isabelle, Mekone Nkwelle; Georges, Nguefack-Tsague; Paul, Ndenbe; Olivier, Koki Ndombo Paul title: Impact and projections of the COVID-19 epidemic on attendance and routine vaccinations at a pediatric referral hospital in Cameroon date: 2021-06-09 journal: Arch Pediatr DOI: 10.1016/j.arcped.2021.05.006 sha: 20f22ad16dd84c54881583cafbc8e80fe8c4b2e9 doc_id: 723878 cord_uid: kwk61c8f Background: At the beginning of March 2020, Cameroon experienced its first cases of infection with the new coronavirus (SARS-COV-2). Very quickly, there was a drop in the rate of hospital attendance. The purpose of this study was to observe the variations in the uptake of pediatric consultations and vaccinations in a pediatric hospital. Methods: A descriptive and retrospective cross-sectional study was carried out using consultation and vaccination statistics from a pediatric hospital in the city of Yaoundé, political capital of Cameroon, from January 2016 to May 2020. Data were entered in Microsoft Excel and exported to R software (Version 3.3.3) for statistical analysis. First, time series raw data (before and after COVID-19) were plotted and the trend estimated by locally weighted scatterplot smoothing (LOWESS) methods. Then a classic seasonal decomposition was performed to distinguish between seasonal trends and irregular components using moving averages. The Webel–Ollech overall seasonality test (WO test) was also run to formally check for seasonality. The results of the study are presented as narrative tables and graphs. Results: Following the partial confinement recommended by the government of Cameroon, the number of pediatric consultations decreased by 52% in April and by 34% in May 2020 compared with rates during the same periods in 2019 (p = 0.00001). For antenatal visits, the rates dropped by 45% and 34%, respectively, in April and May 2020 compared with 2019. The demand for immunization services also declined. As a result, the demand for BCG vaccines, third-dose tracer vaccines (diphtheria, tetanus, pertussis), polio, and MMR in children as well as tetanus vaccines in childbearing women dropped significantly. Conclusion: The start of the COVID-19 pandemic was accompanied by a significant drop in consultation and vaccination activities. If no action is taken to correct this phenomenon, the ensuing months could be marked by a considerable increase in patients, sometimes suffering from vaccine-preventable diseases. The death rate could increase considerably in the pediatric population. Declared in Wuhan, China in December 2019, the coronavirus infection (COVID-19) quickly became a pandemic [1] . It is a respiratory infection caused by the new SARS-CoV-2 coronavirus, which is transmitted from human to human through respiratory droplets and contaminated surfaces [2, 3] . J o u r n a l P r e -p r o o f 3 From the start of the pandemic untiltill July 8, 2020, 11, 892 . 382 cases were diagnosed in 188 countries, including 545, 618 deaths. In Cameroon, the first case was declared on March 6, 2020 and by July 8, 2020, the country had 14,916 diagnosed cases with 359 deaths [4] . On March 17, 2020 , Cameroon implemented a government response strategy to the COVIDovid-19 pandemic with a series of measures including the closing of borders, schools, and universities as well as social distancing measures [5] . In Cameroon, the Expanded Immunization Program provides for the bacillus Calmette-Guérin (BCG) and oOral pPolio vVaccine at birth. At 6, 10, and 14 weeks of age, the diphtheriatetanus-pertussis (DTP), hHepatitis B, Haemophillus influenzae b1, oOral polio vaccine, rRotavirus vaccine, and pPneumococcal vaccines are administered plus a dose of injectable polio vaccine at 14 weeks. Vaccines against measles and rubella (MR) and, yellow fever (AA) are administered at 9 months of age. As of April 13, 2020, the World Health Organization (WHO) ,provided guidance on the importance of continuing routine immunization services as well as an alert on the risks associated with its interruption, be it temporary, during the COVIDovid-19 pandemic., , , The WHO also insisted on the need to continue these activities while respecting optimal safety conditions both for both health care providers and for beneficiaries [6] . The Centers for Disease Control and Prevention (CDC) also reported in April 2020 a decline in vaccine coverage related to the COVIDovid-19 pandemic in the state of Michigan in the United States [7] . Experiences from previous epidemics in Africa indicate that any disruption of immunization services is likely to lead to epidemics of vaccine-preventable childhood illnesses with, as a corollary, an increase in infant mortality in the months or years to come [8] . A longitudinal cohort study in rural South Africa to assess changes in access to primary health care during the confinement period in the fight against COVID-19 showed a significant drop in visits of children under the age of 5 [9] . The purpose of this study was to assess the impact of the COVID-19 pandemic on the uptake of consultation and immunization services in a level-3 referral paediatric hospital in Yaoundé, Cameroon. This It was a descriptive and retrospective cross-sectional study. This study was carried out at the Mother and Child Center of the Chantal Biya Foundation (MCC / CBF). It is a mother and child hospital with a 260262-bed capacity. The hospital has 65 doctors, 300 302 paramedics, and approximatelyaround 100 101 support staff. Half of the staff is made up of civil servants paid by the state, while the other half comprises providers recruited by the hospital and paid from the funds generated by the costs of services All services have remained fully functional since the start of the pandemic in Cameroon. The study was conducted from June 1 to 30, 2020 and covered the period from January 1, 2016, to May 31, 2020. The study included all the children and women received at the MCC / CBF during the study period for consultations and vaccinations. Data werewas collected from the hospital's computerized database as well as statistical records from various departments of the MCC / CBF. All the children and women received in outpatient consultations as well as at the vaccination units were included. Concerning vaccination services for children, the vaccines included from the Expanded Program on Immunization (EPI) included were: BCG, third3rd dosecontact of Diphtheria -Tetanus -Pertussis (DTP3), and measles. In women, data relating to the first1st, second2nd, and fifth5th dosecontact for tTetanus vVaccines (VAT) were analyzed. Prior to initiating this study, ethical clearance was obtained from the ethics committee of the included in the study. All data collected was were kept confidential; only investigators had access to anonymous patient data. Data was were entered into Microsoft Excel and exported to R software (Version 3.3.3) for statistical analyses. Firstly, time series raw data (before and after COVID-19) werewas plotted and the trend was estimated by lLocally wWeighted sScatterplot sSmoothing (LOWESS) methods. Then a classical seasonal decomposition was performed to distinguish between seasonal, trend, and irregular components using moving averages. This allowed to graphically visualizeing whether the time series displayed seasonal variation. The Webel--Ollech overall seasonality test (WO -test) was also performed tofor formally check forconfirming or not seasonality. This was followed byAfter testing for stationarity using the aAugmented Dickey--Fuller tTest; when seasonality was present, a seasonal aAutoregressive and mMoving aAverage (ARIMA) mModel (Box--Jenkins models) was used for modeling, otherwise a simple ARIMA model was used. Models were identified using the sample autocorrelation function (ACF) and partial autocorrelation function PACF and parameters were estimated. The model adequacy was assessed with the diagnostic plots of standardized residuals, the ACF of the residuals, a boxplot of the standardized residuals, and the p-values associated with the Qstatistic. When the model passed the diagnostics, it was used for forecasting and determining a 12-month ahead 95% prediction intervals for forecasts from June 2020 to May 2021. Predictions (Figure 6) show that women's consultations by women could reach very low levels, as low as less than 200 patients for some months in the year 2021. Immunization activities have experienced a decreasing trend with non-seasonal activities (Pvalue QS-test p=0.12 and P-value kwman -test p=0.09), and appear to be nonstationary However, there was a resurgence during the month of May 2020 (Figure 7) . Following the same identification methods as described previously, the ARIMA The tetanus toxoid (TT) vaccination of women of childbearing age followed the same pattern as the paediatric vaccinations whatever the dose considered (TT1, 2, 3, 4, and 5). We notice observed a pronounced decline in the demand for vaccinations in April and Our goal was to assess the effect of the pandemic on hospital attendance, including consultations and vaccinations in a pediatric hospital. The month of April 2020 saw a considerable drop in consultations compared to with other months of the year and especially when compared withto the same months of the previous four4 years. The decrease was even more evidentnoticeable because, over the years, the months of April and May proved to be the months with the greatest influx at MCC/CBF [10, 11] . The rainy season in the cCenter region where the hospital is located begins in April and is usually accompanied by an increased prevalence of malariathe major ailment treated atin the hospital [10, 12] . Until mid-March, hospital use was inon its normal course. The drop in consultations coincides with the Cameroon Cameroonian government's containment measures decided on March 17, 2020, in the face of this disease for which no consensual treatment was yet known [5] . These measures, which were signs of concern, from the public authorities, were perceived by the population with anxiety. The atmosphere of fear created by the disease may have discouraged parents from takinggoing out with their children to the hospitala place that was considered, by many, to be a high-risk area for infection. This phenomenon of fear of the hospital is in fact notneither limited to our hospital ornor to our country [13, 14] . Consequently, the population might have resorted to alternatives for the care of sick childrechildren [15] . The recourse to care within our population is indeed manifoldnumerous and varied, ranging from simple self-medication to the solicitation of alternative medicine [16] . It should be noted that a large fraction of the population works in the informal sector [17] . This economic sector was negatively impacted by the containment measures (18) [18] . MoreoverMeanwhile, in Cameroon, patients pay out of pocket for their medical care [19] [20] [21] . Insufficient finances to pay for consultations and workups as well as to purchase the necessary medications may have also prevented parents from coming to the hospital with their children. The relaxation of partial confinement with the resumption of activities at the end of April coincided with a slight increase in hospital attendance in May. This could also explain the increase in activities in the maternal care unit, where there had been a significant drop in consultations during the confinement period. Paediatric preventive care activities were not spared, in any way, spared. The demand for vaccination services declined significantly from the start of the COVIDovid-19 pandemic. All vaccines were affected. We noted, nonetheless, that this decrease was less important for the first vaccines (BCG and pPolio 0) than for the other vaccines of the expanded program of immunization. The negative impact of the pandemic on vaccination has already been reported (7, 22, 23) [7, 22, 23] . There are fears of a resurgence of vaccine-preventable diseases in the coming months. Vaccines for pregnant women have followed the same trend, putting future babies at an increased risk of neonatal tetanus. Projections of hospital attendance into the coming months increase our concern since most hospital staff are paid from the revenue generated by paid services. At this rate, the hospital would not be able to pay its staff and this could have a negative impact on hospital performance (24) [24] . There was also clearly an impact on hospitalizations and mortality duringat that period; details can be found in the publication by Chelo et al. ([25) ]. A major public awareness campaign using all available means of communication is therefore important. This will reassure the populations of their safety in hospitals. In addition, it will remind them of the importance of vaccination in the prevention of certain childhood diseases. It The campaign should rely not only on health care providers, but also on opinion leaders, religious authorities, and even popular artists. This campaign could be accompanied by attractive measures such as reducing consultation fees and additional examinations for a specific certain period. The retrospective nature of this study limits its scope, because we could not collect all the necessary information from patients. Oour database did not allow us to analyze patient subgroups (emergencies, outpatient consultations) as we would have liked. We also limited ourselves to a period of 2.5 two and a half months after the start of the pandemic. FurthermoreAlso, since the epidemic had been declared less than 3 months earlierago;, this Page 13 of 27 J o u r n a l P r e -p r o o f 13 duration was not long enough to measure the size of the change in various outcomes as it is common practice in interrupted time series analysis [26] . In addition, our study focused on a single hospital, which makes it difficult to generalize our findings to all health facilities in the country. Such a study should be undertaken in several hospitals of different levels and over a long period after the start of the COVID-19 pandemic. This study illustrates the negative impact of the COVID-19 pandemic on the uptake of preventive and curative care services in a referral pediatric hospital in Cameroon, in this case consultations and vaccination. There is a risk of an upsurge in vaccine-preventable diseases in the coming months, especially since predictions point to a drastic drop in the demand for vaccination services between June 2020 and May 2021. To anticipate these poor forecasts , it is important that strong actions be taken to restore the relationship of trust between clients (populations) and health services. This is an emergency, because apart from the quality care offered to the populations, the survival of the hospital depends in part on the income from the payment for care to ensure its functioning. The authors declare no conflicts of interest regarding the publication of this paper.: None Novel Coronavirus Disease (Covid-19) In Children Severe Acute Respiratory Syndrome Coronavirus 2 (Sars-Cov-2) And Coronavirus Disease-2019 (Covid-19): The Epidemic And The Challenges Et et Alal. The Species Severe Acute Respiratory Syndrome-Related Coronavirus : Classifying 2019-Ncov And Naming It Sars-Cov-2 Covid-19 Pandemic In Cameroon Government Response Strategy To The Coronavirus Pandemic (Covid-19) World Health Organization. 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