A sharp decline in childhood immunization threatens the lives of millions of children

Millions of children around the world, most of them in the poorest countries, have had some or all of their childhood shots over the past two years due to a combination of conflict, climate emergencies, misinformation campaigns, pandemic lockdowns and Covid immunization efforts that have diverted resources missed , according to a new analysis from Unicef, the United Nations agency that vaccinates half of the world’s children.

The report said it was the biggest relapse in routine vaccination in 30 years. Combined with rapidly increasing rates of malnutrition, it has created conditions that could threaten the lives of millions of young children.

“This is a child health emergency – we need to think about the immediate impact, the number of children who will die as a result,” said Lily Caprani, Unicef’s head of advocacy. “It’s not in a few years; it’s pretty soon.”

The percentage of children worldwide who had received three doses of the diphtheria, tetanus and whooping cough vaccine known as DTP3 — which Unicef ​​uses as a benchmark for immunization coverage — fell five points to 81 percent between 2019 and 2021. Measles immunization rates also fell to 81 percent, and polio coverage also fell significantly. Herd immunity requires 94 percent vaccination coverage to break the chain of transmission of a disease.

This equates to 25 million children who have not received basic intervention to protect them from deadly diseases.

The number of children Unicef ​​designates as zero-dose children – those who have not received a single dose of the most basic vaccines – rose sharply during the pandemic to 18 million from 13 million in 2019. This group includes half of all children who died before age 5.

The agency had hoped that child immunization coverage would bounce back in 2021 after a sharp drop in 2020 caused by lockdowns, school closures and other Covid response measures, said Dr. Niklas Danielsson, Unicef’s senior immunization specialist in Nairobi.

But instead the problem got worse. DTP3 and measles coverage is at its lowest since 2008, the report says.

dr Danielsson said vaccination coverage in 2021 was the same as in 2008. “But since then, birth cohorts have increased, meaning the number of children who don’t complete or even start vaccinations is the highest per year in the last 30 years,” he said.

He and many others in the child immunization field had expected a rebound over the past year as health systems learned to adapt to the demands of the pandemic. Instead, misinformation campaigns about Covid vaccination and a broader distrust of governments over public health measures have spilled over to discourage routine vaccinations, he said.

At the same time, health systems in the poorest countries scrambled to provide limited Covid vaccinations, redirecting critical access to freezers and health workers to give gunshots.

The world made sustained strides in childhood immunization coverage in the 1990s and into the first decade of this century. Rates then began to decline as the remaining children were the hardest to reach, such as those in active war zones or in nomadic communities. But before the pandemic, there had been a redoubled commitment to try to reach the remaining pockets of zero-dose children, with support from organizations like the Bill and Melinda Gates Foundation and Gavi, the global vaccine alliance. Covid has taken away a lot of that attention and investment.

In the last two years, India, Nigeria, Indonesia, Ethiopia and the Philippines recorded the most children who had not received a vaccine.

Brazil was also on the list of the 10 most affected countries, a tough shift for a country once known for its high vaccination coverage. About 26 percent of Brazilian infants had not received any vaccinations in 2021, compared to 13 percent in 2018.

“30 years of work was lost overnight,” said Dr. Carla Domingues, epidemiologist and former coordinator of Brazil’s national immunization program.

Vaccination has become a politicized issue in Brazil during the Covid pandemic, she said. The federal government, led by President Jair Bolsonaro, downplayed the importance of the coronavirus despite Brazil having one of the highest death rates in the world, saying it would not have its own 11-year-old vaccinated against the virus.

“For the first time, the federal government did not recommend a vaccine and created a whole environment of doubt that had never existed in Brazil, where vaccination was fully accepted,” said Dr. Domingues.

At the same time, anti-vaccination groups that haven’t had much influence in Brazil, she said, have swept in during the pandemic and started spreading misinformation in Portuguese on social media.

And all of this happened, said Dr. Domingues, at a time when Brazilians were a generation away from the serious diseases they were supposed to vaccinate their children against, led them to question the necessity.

“Parents don’t know the effects of measles or polio, so they start picking and choosing vaccines,” she said. Data showing that the uptake of the pneumonia vaccine is higher than that of polio makes this clear. “Parents choose against polio. They say, ‘It’s been 30 years without polio, so I have to do this?’”

And yet they have a clear sign of the risk, she said: A handful of measles cases were found in São Paulo earlier this year, six years after Brazil reported eradicating the disease. “Measles is circulating now – it gives us a concrete example of what could happen with diphtheria, meningitis and so many other diseases,” she said.

In the Philippines, 43 percent of infants were unvaccinated last year. There the problem lies partly in the strict Covid public health measures, including lockdowns. “If you can’t take your kids outside outside of certain hours of the day, if they can’t go to school, if the cost of living goes up, going to a health center to get your child vaccinated falls from your priorities,” said Dr. Danielsson.

However, the situation in the Philippines is also complicated by the continued distrust of vaccinations following a widespread rollout of a dengue vaccine in 2016, which was later found to have caused more severe cases of the disease in some who received it.

Unicef’s Ms Caprani said it would take an extraordinary amount of resources and commitment to bring vaccine levels back to where they were originally.

“It will not be enough to just carry on as usual and restore normal, routine vaccination,” she said. “We’re going to need really concerted investment and catch-up campaigns because there is a growing cohort of millions of children who are totally unvaccinated and living in countries that have high levels of malnutrition and other stresses.”

In Zimbabwe, for example, there is currently a measles outbreak that is killing one in 10 children hospitalized with the disease. (The typical mortality rate is one in 100 in low-income countries and less than one in 1,000 in high-income countries.)

dr Fabien Diomande, a polio eradication expert at the Task Force for Global Health who has spent years working on polio campaigns in West and Central Africa, said reversing the decline in childhood immunization will require new agility, innovation and resources would.

“It’s like we’re in a new world — these emergencies aren’t going away,” he said. “We will still have Covid. We will still have climate crises. We must learn to work in the context of multiple public health emergencies.”

dr Domingues in Brazil said the Covid vaccination effort could offer some lessons on how to catch up. Brazil achieved high immunization coverage by providing pop-up vaccination posts and providing immunizations at night and on weekends.

Ms Caprani said that while there is an encouraging renewed interest in global health collaboration because of Covid, investments in new surveillance and other novelty risked distracting from the simple intervention needed to tackle the child immunization crisis: the deployment of thousands by health workers in the community.

“We’re not going to solve this with billboard campaigns or social media posts,” she said. “You need exposure to reliable, well-trained, decently-paid health workers who are out there day in and day-out building trust — the kind of trust that means you listen to them about vaccines. And there just isn’t enough of that.”

Jason Gutierrez contributed reporting from Manila.

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