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.
Saving lives one dose at a time - Immunization across Europe and Central Asia
Vaccines protect children against disease and death, saving up to 3 million lives globally every year, and are one of the most cost-effective child survival interventions. In short, #VaccinesWork. The Europe and Central Asia Region continues to enjoy overall high childhood immunization coverage and is polio-free. The benefits of vaccines, however, are spread unevenly. Too many children are still missing the protection they deserve. A mother in Serbia holds her baby during her free vaccination as part of the Serbia's national immunization plan. A mother in Serbia holds her baby during her free vaccination as part of the Serbia's national immunization plan. Of particular concern is a rebounding of measles in the region, despite a record-low of new cases in 2016, causing over 33,000 cases and 79 deaths. The largest current outbreaks have been in Romania (12,368 cases and 49 deaths including 46 children), Ukraine (16,500 cases, 13 deaths including nine children) and Serbia. Although Serbia has a long and successful tradition in child-health protection, it is currently facing a measles outbreak with nearly 5,000 cases (as of 24 April 2018) which have resulted in 15 fatalities. UNICEF is working with the Ministry of Health to support its response and to improve records of immunization in the future. A little boy cries as he receives a routine vaccination at a clinic in Moldova. A little boy cries as he receives a routine vaccination at a clinic in Moldova. Due to universal vaccinations of newborns in Moldova, cases of Hepatis B have dropped from 682 in 1994 to only four in 2015. However, only 89 percent of all children are immunized against all preventable diseases and UNICEF has been working with the government to precure more vaccine doses to ensure all children have access to immunizations. A young boy puts on a brave face as he receives his second dose of the MMR vaccine in Kyiv, Ukraine. A young boy puts on a brave face as he receives his second dose of the MMR vaccine in Kyiv, Ukraine. Two-thirds of the world’s unvaccinated children live in fragile countries or countries affected by armed conflict. Between 2010 and 2016, conflict-affected eastern Ukraine had the world’s second lowest coverage rate of children fully immunized against diphtheria, pertussis, and tetanus. The country also had the third lowest coverage rate in the world for MMR vaccine in 2016. A plane with a crate of UNICEF-labelled MMR vaccines next to it. On the 26 February, 220,000 doses of the MMR vaccine arrived in Ukraine facilitated by UNICEF. UNICEF in Ukraine is helping to fast-track the delivery of MMR vaccines, assisting the Ministry of Health to respond to the recent measles outbreak in which 14,500 people have been infected – killing 13 people including nine children. Nine-month-old Sasha gets a kiss from his mother, after receiving the diphtheria, pertussis, tetanus (DTP) vaccine in Kyiv. Nine-month-old Sasha gets a kiss from his mother, after receiving the diphtheria, pertussis, tetanus (DTP) vaccine in Kyiv. Vaccine hesitancy has also become an issue in Ukraine but UNICEF is working to change attitudes and educate people on the dangers of not vaccinating their children. “Before his birth, we decided we would give our child all the necessary vaccinations,” says Sasha's father. “When my grandmother was a child, she got polio and, although she recovered from the illness, she was disabled for life. As caring parents, we want to protect Sasha from all sorts of infections.” In Turkey, a boy receives a dose of the Oral Polio Vaccine (OPV). In Turkey, a boy receives a dose of the Oral Polio Vaccine (OPV). UNICEF Turkey is supporting a vaccination program, led by the Ministry of Health. The campaign has included nine rounds of polio campaigns reaching 1.4 million refugee and migrant children and Turkish children in remote provinces between 2013-2015, and the provision of additional doses of MMR, Hepatitis B, Diphtheria, Tetanus, Pertussis, Polio and Haemophilus in 2017. A health worker vaccinates a one-year-old Syrian refugee boy at a neighbourhood health centre in Gaziantep, Turkey. A health worker vaccinates a one-year-old Syrian refugee boy at a neighbourhood health centre in Gaziantep, Turkey. UNICEF has also helped produce and disseminate information materials, in both Turkish and Arabic, to raise awareness about the importance of being immunized. A young baby receives her vaccination injection in Uzbekistan. In Uzbekistan, four-month-old Ziyoda receives a dose of the new polio vaccine - 'Inactivated Polio Vaccine’ (IPV) - which is designed to help stop polio globally. Despite Uzbekistan having an almost 99 percent coverage rate of the Polio vaccine, UNICEF continues to work with the Government to ensure that no child is left unimmunized in the future. A group of women wait for their children to be vaccinated at a village clinic in Uzbekistan. A group of women wait for their children to be vaccinated at a village clinic in Uzbekistan. Ensuring vaccination levels are high in every country across the region is essential. UNICEF is working to ensure all children are protected against the spread of vaccine-preventable childhood diseases and the best defence is a vaccine-protected population and a strong and responsive health system. The whole region benefits when ALL countries achieve and maintain high vaccine coverage at both national and subnational levels.
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.
Frontline social workers provide vital support to improve health
Yura has been a social worker for many years. “When I started working in social services, I was mainly interested in family therapy,” she says . “In time, I found out that supporting communities to become resilient and self-reliant is an extremely rewarding experience.” A year ago, she joined the Council of Refugee Women in Bulgaria (CRWB) – a civil society organization created in 2003 to support the integration of refugees and migrants. “Guiding through people from refugee and migrant backgrounds on health-related procedures in their host country is a way to empower them to find solutions to health issues,” explains Yura. And this is particularly vital for those fleeing from armed conflicts and humanitarian crises. As they search for safety and better life opportunities, both adults and children go through many traumatic experiences as a result of often prolonged stays in refugee camps, limited access to health care, and the dangers they face as they travel through volatile areas. By the time they finally reach a safe destination, they are often in very bad physical and psychological shape. “In Bulgaria, refugee children arrive with their parents or – in some cases – unaccompanied. Psychological problems, infectious diseases, medically unobserved pregnancies and, in particular, a lack of immunization, are common problems that have a negative impact on their health and wellbeing.” Radostina Belcheva, Project Coordinator and Deputy-Chair of CRWB The CRWB partners with UNICEF Bulgaria to provide general health checks and referrals, as well as life-saving vaccines in line with children’s immunization schedules, and equips parents with information on health risks, entitlements and how to access medical services. “As part of the ‘Strengthening Refugee and Migrant Children’s Health Status in Southern and South-Eastern Europe’ (RM Child-Health) project co-funded by the European Union’s Health Programme, we work with our partners to ensure that children can follow immunization plans and that their vaccination status is updated in their immunization documents. These are crucial steps in ensuring good health . ” Diana Yovcheva, Programme Officer with UNICEF Bulgaria Working directly with refugees, Yura consults families that want to access health services. “Some cases are easier than others”, she says, recalling a consultation with Ahmed*, a 45-year-old father of six children, who fled Syria in 2020 and received humanitarian status in Bulgaria. A chef by profession, Ahmed settled quite well in the host country, found a job in a restaurant and, after some time, managed to reunite with his wife, his four sons and two daughters. “Ahmed was referred to the CRWB by friends and he came in for a consultation on the immunization process with his youngest baby girl, Yasmina, only one year old” explains Yura. During their meeting, the social worker provided information about the health system in Bulgaria, the role of a general practitioner, and how people with refugee status can access medical services including vaccinations for their children. Although Ahmed’s baby girl had been vaccinated before her arrival in Bulgaria and had an immunization passport, the father urgently needed to update her vaccination status to synchronize her vaccinations with the recommendations of the national immunization calendar. “I contacted the Regional Health Inspectorate and helped Ahmed to provide the necessary documents and find a translator, as the documents were in Turkish”, says Yura. Subsequently, she helped Ahmed schedule an appointment with a medical doctor and Yasmina received her next vaccine. Parents often lack the necessary vaccination documents. According to Yura, “Sometimes children have not had any vaccinations, or they have been vaccinated in their country of origin, but their immunization cards have been lost or destroyed.” Such cases require additional consultations, research and coordination, as well as testing for antibodies and immune responses when it is not clear whether the child has been vaccinated. “By empowering parents to familiarize themselves with the immunization plans and procedures we help them become proactive in following up on their children’s health." Yura, Social worker To address the COVID-19 restrictions and keep active communication with refugees and migrants, the CRWB and UNICEF developed leaflets in Bulgarian, Arabic and Farsi with details about the health system in Bulgaria and the importance of vaccinations, and regularly provide health-related information via social media. “The role of communication in immunization is essential. Our frontline staff interact on a daily basis with beneficiaries, but we have also used other means [such as a Facebook group dedicated to health-related topics] to keep the information flow going, particularly during the COVID-19 pandemic . ” Radostina Belcheva, Project Coordinator and Deputy-Chair of CRWB Logo - Strengthening Refugee and Migrant Children’s Health Status in Southern and South Eastern Europe This story is part of the Project Strengthening Refugee and Migrant Children’s Health Status in Southern and South Eastern Europe, co-funded by the Health Programme of the European Union (the ‘RM Child-Health’ initiative). The content of this story represents the views of the author only and is her sole responsibility; it cannot be considered to reflect the views of the European Commission and/or the European Health and Digital Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains .
Improving health literacy among refugee and migrant children
UNICEF has worked with partners and with young refugees and migrants on the ground to identify information gaps – work that has, in turn, guided the development of health literacy packages across all five countries on a range of crucial health issues, from immunization and nutrition to sexual and reproductive health (SRH) and gender-based violence (GBV). The assessment has shaped the development of detailed plans on how to ensure that health messages reach their audience and have an impact. The health literacy packages have also drawn on existing materials, including Facts for Life , My Safety and Resilience Girls Pocket Guide and an adapted version of the UNFPA curriculum: ‘Boys on the Move’. Refugees and migrants face a chronic lack of health information in their own languages, and a lack of information that reaches them through the channels or people they trust health navigation Some common priorities have been identified by refugees and migrants across all five countries, including access to immunization and other primary health care services, breastfeeding and young child feeding, and the prevention of GBV. They have also flagged up the pressing need for more mental health and psychological services. Other issues have emerged as priorities in specific countries, including cyberbullying and online safety in Italy, and substance abuse among young people In Serbia – the focus of a new in-depth UNICEF study. Not surprisingly, the COVID-19 pandemic is a new and urgent priority for refugee and migrant communities – and one that has heightened the health risks they already face by curtailing their movements and their access to health services. A consultation with refugee and migrant adolescents and young people living in Italy has revealed major gaps in their knowledge about sexual and reproductive health, drawing on an online survey, a U-Report poll and a series of focus group discussions. It has highlighted some common misunderstandings, such as the myth that masturbation causes infertility, and continued perceptions around the importance of a woman’s virginity at marriage, as well as knowledge gaps around menstruation, pregnancy and sexually transmitted infections. The consultation also found, however, that the young participants want to know far more about this crucial area of health. As one young man from Guinea noted during a focus group discussion: “often young people do not want to know if they have an infection, also because they are not aware that these can be treated. It is so critical to raise awareness on STIs tests and treatment options.”
Breastfeeding: the best gift a mother can give her child
Breastmilk saves lives, protects babies and mothers against deadly diseases, and leads to better IQ and educational outcomes, yet rates of breastfeeding in Europe and Central Asia are low, with only 23 percent of the wealthiest families and 31 percent of the poorest breastfeeding up to the recommended age of two. Empowering and enabling women to breastfeed needs to be at the heart of countries’ efforts to keep every child alive and to build healthy, smart and productive societies. “Breastfeeding is the best gift a mother, rich or poor, can give her child, as well as herself,” said Shahida Azfar, UNICEF’s Deputy Executive Director. “We must give the world’s mothers the support they need to breastfeed.” A mother breasfeeds her baby at a maternity centre in Tashkent region, Uzbekistan. A mother breasfeeds her baby at a maternity centre in Tashkent region, Uzbekistan. The early initiation of breastfeeding – putting newborns to the breast within the first hour of life – safeguards infants from dying during the most vulnerable time in their lives. Immediate skin-to skin contact and starting breastfeeding early keeps a baby warm, builds his or her immune system, promotes bonding, boosts a mother’s milk supply and increases the chances that she will be able to continue exclusive breastfeeding. A mother learns to breastfeed her baby at a maternity hospital in Fergana, Uzbekistan. A mother learns to breastfeed her baby at a maternity hospital in Fergana, Uzbekistan. Breastmilk is safe as it is the right temperature, requires no preparation, and is available even in environments with poor sanitation and unsafe drinking water. It’s also more than just food for babies – breastmilk is a potent medicine for disease prevention that is tailored to the needs of each child. The ‘first milk’ – or colostrum – is rich in antibodies to protect babies from disease and death. A patronage nurse teachers a mother how to breastfeed in Kyzylorda city, Kazakhstan. A patronage nurse teachers a mother how to breastfeed in Kyzylorda city, Kazakhstan. In Kazakhstan, UNICEF has been working with patronage nurses to support mothers to breastfeed their children. The project has been running for several years and includes two visits during pregnancy and nine visits until the child reaches the age of three. As a result, there was a 14 percent increase in the number of children who were exclusively breastfed in the pilot region. A patronage nurse visits a family in Kyzylorda city, Kazakhstan. A patronage nurse visits a family in Kyzylorda city, Kazakhstan. There are several reasons why a mother may not be able to breastfeed, or does not wish to do so. Reasons include low awareness of the importance of breastfeeding and long-term impacts, as well as not knowing how to breastfeed properly which can subsequently cause the mother a lot of pain. Patronage nurses work with mothers to try to overcome these obstacles. A mother breastfeeds her baby, while the father and the older son support them. Mother Jovana breastfeeds her son Aleksa (two-months-old) while older son Ognjen (18-months-old) and husband Nikola support her at a clinic in Serbia. Breastfeeding is not a one-woman job. Women who choose to breastfeed need support from their governments, health systems, workplaces, communities and families to make it work. UNICEF urges governments, the private sector and civil society to create more enabling environments for breastfeeding mothers including arming mothers with the knowledge to make informed decisions, and providing them with the support they need from their families, communities, workplaces and healthcare systems to make exclusive breastfeeding for the first six months happen. Smiling parents watch as their baby breastfeeds at a maternity unit in Armenia. Smiling parents watch as their baby breastfeeds at a maternity unit in Armenia. In Armenia, UNICEF, together with the ministry of health and local health authorities, have created a sustainable parental education system at maternity and primary health-care facilities across the country to encourage breastfeeding and provide support to parents. In a UNICEF-supported space for refugee and migrant families, two mothers breastfeed their babies. In a UNICEF-supported space for refugee and migrant families in Serbia, two mothers breastfeed their babies. During the refugee and migrant crisis in Europe, UNICEF stepped in to provide support for children and mothers. Support included providing private spaces for breastfeeding mothers, nutritional guidance and breastfeeding support. UNICEF supports action to improve infant and young child nutrition across Europe and Central Asia, aiming to ensure that every child has the best possible nutritional start in life. Through its global campaign, Every Child ALIVE , which demands solutions on behalf of the world’s newborns, UNICEF urges governments, the private sector and civil society to: Increase funding and awareness to raise breastfeeding rates from birth through the age of two. Put in place strong legal measures to regulate the marketing of infant formula and other breastmilk substitutes as well as bottles and teats. Enact paid family leave and put in place workplace breastfeeding policies, including paid breastfeeding breaks. Implement the ten steps to successful breastfeeding in maternity facilities, and provide breastmilk for sick newborns. Ensure that mothers receive skilled breastfeeding counselling at health facilities and in the first week after delivery. Strengthen links between health facilities and communities, so that mothers are ensured of continued support for breastfeeding. Improve monitoring systems to track improvements in breastfeeding policies, programmes and practices.
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.