Immunization is a proven and cost-effective public health  intervention, saving the lives of millions of children and protecting millions more from illness and disability.  Immunization is also a wise financial investment - with every $1 invested in immunization returning an estimated $16 in health-care savings and increased economic productivity.  Most countries in Europe and Central Asia have immunization coverage of 95 percent or more for three doses of diphtheria, tetanus and pertussis (DTP), often seen as the measure of national performance on immunization. However, while most national averages for DTP vaccination may be adequate, the regional average is hovering at around 92 percent, a slight decrease from the previous year, which is not high enough to ensure immunity for everyone. Over 70 percent of the region’s unvaccinated infants are from middle income countries, with Ukraine presenting the lowest coverage rate and the greatest challenge. National averages also mask disparities, with Roma children  and those from other ethnic and vulnerable groups, including refugee and migrant children, all lagging behind. Measles outbreaks are a growing problem. Last year there were over 10,000 cases of measles in the region. Despite increased coverage of the first dose of the measles vaccine among children (up from 63 percent in 2000 to 93 percent in 2016) more work is urgently needed, as children are not fully protected against measles unless they receive two doses. Currently, second dose coverage is at 88 percent, which does not provide adequate protection.            In total, over 500,000 children in the region are still not protected against measles - a life-threatening, but easily preventable disease.   There are also concerns about ‘vaccine hesitancy’ – a growing mistrust of immunization among some parents, fuelled by myths and misinformation. Such hesitancy may stem from negative media stories linking a child’s death to immunization without the full facts. It may be influenced by the region’s anti-vaccine movements, which spread anti-immunization messages. Meanwhile, measures to counter vaccine hesitancy and build parental trust in immunization are hampered by a lack of discussion with parents about its importance and the minimal risks.  A baby girl receives her vaccination at a clinic in Serbia. A baby girl receives her vaccination at a clinic in Serbia. Donor support for immunization is falling in some countries that still require such support. Elsewhere, the concern is to ensure financial sustainability for immunization programmes once countries ‘graduate’ from the support provided by Gavi (The Vaccine Alliance). Ongoing reforms in some countries are affecting both the structure and financing of immunization programmes. Some countries, challenged by competing priorities at home and inaccessibly priced vaccines on the global market, experienced several vaccine shortages in 2015–2016, sometimes causing critical disruptions of services. These issues are particularly acute in middle-income countries, many of which self-procure vaccines and continue to face significant challenges in achieving financial sustainability of their immunization programmes. Some countries also lack adequate monitoring of vaccine coverage, which is critical to understand and address any gaps.   As a result of such challenges, the region faces outbreaks of vaccine-preventable disease, such as a polio outbreak in 2015 and an ongoing measles outbreak in Ukraine  – a country where conflict and economic recession have depleted stocks of vaccines and vaccine hesitancy is reducing immunization coverage. There is also an ongoing large measles outbreak in Romania, with over 10,000 cases of the diseases and 38 deaths. During the last five years, measles outbreaks have been registered in Georgia (2013), Kazakhstan (2014), Kyrgyzstan (2015), and Tajikistan (2017). Outbreaks in one country can spread rapidly to others, signalling the interdependence and vulnerability of all countries, whatever their stage of economic development.  
#VaccinesWork to protect children in Ukraine, amid measles outbreak
As a mother of two young children, Natalia was once told by her doctor that vaccinations were unnecessary. Now – with a measles outbreak gripping Ukraine –Natalia is glad she chose to ignore the doctor’s advice and instead vaccinate her children. This recent national outbreak has affected 16,500 people and killed 13, including nine children. According to a UNICEF poll taken in 2016, 16 percent of parents in Ukraine have refused vaccinations for their children.  Natalia with her two children in a park in Kyiv. Natalia, with her two young children in a park in Kyiv. “Many parents I know still refuse to vaccinate their children,” says Natalia, whose children received the MMR vaccine against measles, mumps and rubella. “They say the vaccines are bad, that they have adverse effects. My children are fine and I think their health is more important.” Ukraine’s Ministry of Health has been leading the outbreak response since 2017 with support from UNICEF and other partners. While less than half of all children in the country were vaccinated against measles as part of routine immunization in 2016 (via the MMR vaccine), the number more than doubled in 2017 to over 90 percent, according to the Ministry. Valentyna Ginzburg, a doctor who heads Kyiv’s state healthcare department, says she and her team have been working to combat the measles outbreak since first being alerted to a rise in infections following the New Year and Orthodox Christmas celebrations in 2018. “We received information on the incidence rates of measles in Kyiv,” Dr. Ginzburg says. “We knew we needed to take rapid action to prevent a situation similar to other regions, such as Odesa, where there had already been fatalities amongst both adults and children from the illness.” Measles is one of the most contagious diseases around and we understood that if we were not proactive and did not control it, it would have not been long before we had the same situation as in other regions. Dr. Ginzburg Dr. Ginzburg explains how she and her colleagues had to act quickly to stop the spread of the disease in Kyiv. UNICEF/2018/Krepkih Dr. Ginzburg explains how she and her colleagues had to act quickly to stop the spread of the disease in Kyiv. In the four days that followed, 11,000 children were vaccinated in Kyiv. Around 48,000 children were immunized from January to March, a tally that would normally take 12 months to reach. Following national recommendations on outbreak response, authorities in Kyiv launched a ‘situation room’ to collect the latest information and coordinate response actions. Being vaccinated was also made a pre-condition for children attending schools and preschools to help stop the spread. The city administration also encouraged medical specialists to visit schools and raise awareness of vaccination among both teachers and parents.  Maryna Stefanenko, a pediatrician at a clinic on the left bank of Kyiv, gives more details. “We had a lot of people coming in, even those who normally go to private clinics,” she says. Dr Stefanenko’s clinic usually administers around 80 vaccines per day, but during the outbreak they were immunizing around 1,200 people each day.   On the other side of the city, in Obolon district, another clinic rushed to meet demand. A pediatrician there, Dr Natalia Yatsenko, explained that as part of her job, she must sign the paperwork for parents who refuse to vaccinate their children. She says she spends a lot of time explaining the benefits of vaccination, as well as the risks for children who do not receive their shot. Before the measles outbreak, she managed to talk some 10 per cent of objectors into changing their mind. However, during the outbreak, she did not even have to persuade them – many parents who were once against vaccinations were very keen to bring their children to the clinic. A young boy receives several vaccines at a time at Dr Natalia Yatsenko clinic in Kyiv. A young boy receives several vaccines at a time at Dr Natalia Yatsenko clinic in Kyiv. Another factor in the response? The effects of armed conflict in eastern Ukraine. “We had some internally displaced people from the eastern regions who came to our clinic,” says Yatsenko. “They told us that their children’s vaccination records had been falsified, and now they wanted to vaccinate them for real. So we vaccinated them.” “We also vaccinated some parents,” adds Stefanenko. “The parents bought the vaccines for themselves from the pharmacy then brought them to us and we administered the shots.” Dr. Ginzburg also advocated with the Kyiv authorities to address one of the biggest issues the country is struggling with - access to vaccines for adults and health workers. “All health workers had to be checked and those who required vaccination had to be immunized,” she says. “Then we were sure that, no matter what, the doctors wouldn’t be incapacitated.” The city administration also made sure the municipal pharmacy chain had measles vaccines available for adults. Artem, six, receives his second dose of the MMR (mumps, measles, rubella) vaccine in Kyiv. Artem, six, receives his second dose of the MMR (mumps, measles, rubella) vaccine in Kyiv. Although vaccines for children were available in 2017, increased demand had depleted stocks in some regions. To help replenish stocks, a new expedited supply of MMR vaccines was delivered by UNICEF at the request of the Ministry of Health at the end of February 2018, and another 800,000 doses are due this month, to ensure sufficient vaccines for both routine immunization of children and those who may have missed their immunizations in previous years. Significant progress has been made in reaching more children with vaccines, yet still an estimated 1.5 million children die globally from vaccine preventable diseases every year and an estimated half a million children in the region are still not immunized. Millions of lives can be saved by extending basic health services like routine immunization to the most vulnerable and disadvantaged, and UNICEF is on the ground immunizing millions of children each year . Vaccines protect children against disease and death, saving up to three million lives every year. In short, #VaccinesWork. 
Europe and Central Asia has surpassed global progress on child mortality, more than halving the deaths of children under five and infants since 1990. And as progress for the poorest households has accelerated, the health gap between the richest and poorest has narrowed.  However, persistent inequities reflect a continued failure to invest effectively in child-centred health systems for all. In South-East Europe, for example, child mortality among the Roma population is two to three times higher than national averages.    Problems missed at an early age can be more difficult and expensive to address later in life. Such inequities are compounded by a failure to spot problems during pregnancy and during the first 1,000 days of life, when children’s bodies and brains build the foundations for their life-long development. Problems missed at an early age can be far more difficult and expensive to address later in life.  Across the region, more than half of the children who die before their fifth birthday die in their first month of life.These deaths are often the result of conditions that are readily preventable or treatable at low cost through, for example, access to good obstetric, ante-natal and post-natal care, routine immunization and exclusive breastfeeding . The main killers of children under the age of five in the region are also preventable: pneumonia and injuries.  Emergencies have an intense impact on child health and nutrition. The impact of emergencies on children's health and nutrition can be extreme. Children on the move, such as those caught in Europe’s refugee and migrant crisis , for example, often lack adequate clothing, food, shelter or warmth. Access to health services, including immunization, has often been inadequate on their journey. The region’s existing HIV prevalence, coupled with lack of safe water and sanitation, as well as ongoing challenges related to early child development and protection all heighten the vulnerability of children during emergencies.  The region is also experiencing vaccine ‘hesitancy’ – the reluctance of some parents to immunize their children, or parental delays in immunization . This hesitancy, often fuelled by misinformation, puts children at risk of contracting, and even dying from, infectious diseases, including polio and measles.
Empowering refugee and migrant children to claim their right to health: Improving health literacy
“I have always had to behave ‘like a girl’ and I am not used to being asked for my opinion, but you ask me to say what I think during these workshops.”   A 13-year-old girl from Syria describes the impact of empowerment workshops in Serbia  Boy is drawing a picture. UNICEF-supported activities for children on the island of Lesvos, Greece The ‘RM Child-Health’ initiative has supported work across five European countries to improve health literacy among refugee and migrant children over the past year. As a result, they and their families have learned about key health issues, about the health services available to them, and how to demand health services as their right. Through its support for health literacy – the ability to find, understand and use information to take care of your own health – the initiative has helped to dismantle some key barriers to health services for refugee and migrant children and their families in Bosnia and Herzegovina, Bulgaria, Greece, Italy and Serbia. This 27-month, €4.3 million co-funded initiative, which was launched in January 2020 by the European Union Directorate-General for Health and Food Safety, works alongside young refugees and migrants to ensure that they have accurate health information in their own languages – information that reaches them via the channels they use and the people they trust. Importantly, the initiative makes them more aware of their right to health care in these European countries – welcome news for those who have fled from countries where good quality health care is either unaffordable or unavailable. With support from the initiative, UNICEF and its partners first worked with young refugees and migrants to identify gaps in the information available to them and in their own knowledge. This informed the health literacy packages that have been rolled out in all five countries over the past year, spanning a wide range of topics from immunization and nutrition to sexual and reproductive health (SRH) and gender-based violence (GBV). The packages themselves have been backed by detailed plans to ensure that their messages reach their audiences and gain real traction. Great care has been taken to ensure that information materials are culturally appropriate, gender sensitive and child-friendly, and that they are suitable for the ages and backgrounds of their audiences. Cultural mediators and interpreters have helped to overcome language and cultural barriers, while materials have been made available in, for example, Arabic, Farsi and Pashto. Activities have often been led by trusted professionals, such as nurses, physicians and psychologists who are already familiar with the needs of refugee and migrant children and their families. Materials have been shared through channels and locations that are well-used by refugees and migrants, including asylum offices, temporary reception centres, health centres, Mother and Baby Corners (MBCs), workshops and discussion sessions, during outreach activities and via social media. As a result, health literacy is now embedded into existing activities with refugee and migrant children and parents across all five countries, and is based firmly on their views and needs.
Refugee and migrant children in Europe
People have always migrated to flee from trouble or to find better opportunities. Today, more people are on the move than ever, trying to escape from climate change, poverty and conflict, and aided as never before by digital technologies. Children make up one-third of the world’s population, but almost half of the world’s refugees: nearly 50 million children have migrated or been displaced across borders.   We work to prevent the causes that uproot children from their homes While working to safeguard refugee and migrant children in Europe, UNICEF is also working on the ground in their countries of origin to ease the impact of the poverty, lack of education, conflict and insecurity that fuel global refugee and migrant movements. In every country, from Morocco to Afghanistan, and from Nigeria to Iraq, we strive to ensure all children are safe, healthy, educated and protected.  This work accelerates and expands when countries descend into crisis. In Syria, for example, UNICEF has been working to ease the impact of the country’s conflict on children since it began in 2011. We are committed to delivering essential services for Syrian families and to prevent Syria's children from becoming a ‘ lost generation ’. We support life-saving areas of health , nutrition , immunization , water and sanitation, as well as education and child protection . We also work in neighbouring countries to support Syrian refugee families and the host communities in which they have settled.