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NEW YORK, 20 April 2023 – The public perception of the importance of vaccines for children declined during the COVID-19 pandemic in 52 out of 55 countries studied, UNICEF warned today in a new report on immunization. The State of the World’s Children 2023: For Every Child, Vaccination reveals the perception of the importance of vaccines for children declined by more than a third in the Republic of Korea, Papua New Guinea, Ghana, Senegal and Japan after the start of the pandemic. In the new data, collected by The Vaccine Confidence Project and published today by UNICEF, China, India and Mexico were the only countries studied where the data indicates the perception of the importance of vaccines held firm or even improved. In most countries, people under 35 and women were more likely to report less confidence about vaccines for children after the start of the pandemic.* Vaccine confidence is volatile and time specific. Additional data collection and further analysis will be required to determine if the findings are indicative of a longer-term trend. Despite the falls, overall support for vaccines remains relatively strong. In almost half the 55 countries studied more than 80 per cent of respondents perceived vaccines as important for children. However, the report warns the confluence of several factors suggest the threat of vaccine hesitancy may be growing. These factors include uncertainty about the response to the pandemic, growing access to misleading information, declining trust in expertise, and political polarisation. “At the height of the pandemic, scientists rapidly developed vaccines that saved countless lives. But despite this historic achievement, fear and disinformation about all types of vaccines circulated as widely as the virus itself,” said Catherine Russell, UNICEF Executive Director. “This data is a worrying warning signal. We cannot allow confidence in routine immunizations to become another victim of the pandemic. Otherwise, the next wave of deaths could be of more children with measles, diphtheria or other preventable diseases.” “This data is a worrying warning signal. We cannot allow confidence in routine immunizations to become another victim of the pandemic. Otherwise, the next wave of deaths could be of more children with measles, diphtheria or other preventable diseases.” Alarmingly, the decline in confidence comes amid the largest sustained backslide in childhood immunisation in 30 years , fuelled by the COVID-19 pandemic. The pandemic interrupted childhood vaccination almost everywhere, especially due to intense demands on health systems, the diversion of immunization resources to COVID-19 vaccination, health worker shortages and stay-at-home measures. Today’s report warns a total of 67 million children missed out on vaccinations between 2019 and 2021, with vaccination coverage levels decreasing in 112 countries. Children born just before or during the pandemic are now moving past the age when they would normally be vaccinated, underscoring the need for urgent action to catch up on those who were missed and prevent deadly disease outbreaks. In 2022, for example, the number of measles cases was more than double the total in the previous year. The number of children paralysed by polio was up 16 per cent year-on-year in 2022. When comparing the 2019 to 2021 period with the previous three-year period, there was an eight-fold increase in the number of children paralysed by polio, highlighting the need to ensure vaccination efforts are sustained. The pandemic also exacerbated existing inequities. For far too many children, especially in the most marginalised communities, vaccination is still not available, accessible or affordable. Even before the pandemic, progress on vaccination had stalled for almost a decade as the world struggled to reach the most marginalised children. Of the 67 million children who missed out on routine vaccination between 2019 and 2021, 48 million didn’t receive a single routine vaccine, also known as “zero-dose”. As of the end of 2021, India and Nigeria (both countries with very large birth cohorts) had the largest numbers of zero-dose children but increases in the numbers of zero-dose children were especially notable in Myanmar and the Philippines. The children who are missing out live in the poorest, most remote and marginalized communities, at times impacted by conflict. New data produced for the report by the International Center for Equity in Health found that in the poorest households, 1 in 5 children are zero-dose while in the wealthiest, it is just 1 in 20. It found unvaccinated children often live in hard-to-reach communities such as rural areas or urban slums. They often have mothers who have not been able to go to school and who are given little say in family decisions. These challenges are greatest in low- and middle-income countries, where about 1 in 10 children in urban areas are zero dose and 1 in 6 in rural areas. In upper-middle-income countries, there is almost no gap between urban and rural children. To vaccinate every child, it is vital to strengthen primary health care and provide its mostly female front-line workers with the resources and support they need. The report finds women are at the front line of delivering vaccinations, but they face low pay, informal employment, lack of formal training and career opportunities and threats to their security. “We know all too well that diseases do not respect borders. Routine immunizations and strong health systems are our best shot at preventing future pandemics, unnecessary deaths and suffering." To address this child survival crisis, UNICEF is calling on governments to double-down on their commitment to increase financing for immunization and to work with stakeholders to unlock available resources, including leftover COVID-19 funds, to urgently implement and accelerate catch-up vaccination efforts to protect children and prevent disease outbreaks. The report is urging governments to: Urgently identify and reach all children, especially those who missed vaccinations during the COVID-19 pandemic Strengthen demand for vaccines, including by building confidence Prioritise funding to immunization services and primary health care Build resilient health systems through investment in female health workers, innovation and local manufacturing “Immunizations have saved millions of lives and protected communities from deadly disease outbreaks,” said Catherine Russell. “We know all too well that diseases do not respect borders. Routine immunizations and strong health systems are our best shot at preventing future pandemics, unnecessary deaths and suffering. With resources still available from the COVID-19 vaccination drive, now is the time to redirect those funds to strengthen immunization services and invest in sustainable systems for every child.” A baby is inoculated against rotavirus in a clinic in Hopital Immaculée Conception, the largest hospital in Les Cayes, Departement du Sud, Haiti. UNICEF/U.S. CDC/UN0695667/Roger LeMoyne

1. Myth? Breastfeeding is easy. Babies are born with the reflex to look for their mother’s breast. However, many mothers need practical support with positioning their baby for breastfeeding and making sure their baby is correctly attached to the breast. Breastfeeding takes time and practice for both mothers and babies. Breastfeeding is also time intensive, so mothers need space and support at home and work. 2. Myth? It’s usual for breastfeeding to hurt – sore nipples are inevitable. Many mothers experience discomfort in the first few days after birth when they are learning to breastfeed. But with the right support with positioning their baby for breastfeeding and making sure their baby is correctly attached to the breast, sore nipples can be avoided. If a mother faces breastfeeding challenges like sore nipples, support from a lactation consultant or other skilled professional can help them overcome the issue. 3. Myth? You should wash your nipples before breastfeeding. Washing your nipples before breastfeeding isn’t necessary. When babies are born, they are already very familiar with their own mother’s smells and sounds. The nipples produce a substance that the baby smells and has ‘good bacteria’ that helps to build babies’ own healthy immune system for life. Мать кормит грудью своего ребенка в Центре семейной медицины № 1 города Ош, Кыргизстан. Did you know? Breastfeeding protects your baby from ear infections, diarrhoea, pneumonia and other childhood diseases. 4. Myth? You should separate a newborn and mother to let the mother rest. Doctors, nurses and midwives often encourage the practice of ‘skin-to-skin’ – also known as kangaroo mother care – immediately after birth. Bringing your baby in direct contact, so their skin is against yours, is a very important practice that helps them to find and attach to the breast. If you can practice this within one hour after birth and then frequently after, it helps to establish breastfeeding. If the mother cannot do this, then the partner or another family member can step in. 5. Myth? You should only eat plain food while breastfeeding. Like everybody else, breastfeeding mothers need to eat a balanced diet. In general, there is no need to change food habits. Babies are exposed to their mothers’ food preferences from the time they are in the womb. If a mother perceives that her baby reacts to a specific food she eats, it is best to consult a specialist. 6. Myth? Exercise will affect the taste of your milk. Exercise is healthy, also for breastfeeding mothers. There is no evidence that it affects the taste of your milk. 7. Myth? You won’t be able to breastfeed unless you do it straight away. It is easier to get breastfeeding started if you begin in the first hour after birth because a baby’s reflexes are very strong at that time. They are ready to learn to feed at the breast. If you do not latch your baby on right after birth, do it as soon as possible in your situation. If you need help putting your baby to the breast, ask for support from a qualified lactation consultant or other skilled professional. Frequent skin-to-skin contact and putting your baby to the breast will help to get breastfeeding going. Did you know? Breastfeeding protects the mother from diabetes, breast and ovarian cancers, heart disease and postpartum depression. Мать кормит своего ребенка грудью, а отец и старший сын поддерживают их 8. Myth? You can never use formula if you want to breastfeed. Mothers may decide they need to use formula on some occasions, while continuing to breastfeed. It is important to seek unbiased information on formula and other products that replace breastmilk. To keep breastmilk production going, continue offering the breast to your baby as often as possible. It can be useful for mothers to consult a lactation specialist or skilled professional to help with a plan that works best for them to continue breastfeeding. 9. Myth? Many mothers can’t produce enough milk. Almost all mothers produce the right amount of milk for their babies. Breastmilk production is determined by how well the baby is latched on to the breast, the frequency of breastfeeding and how well the baby is removing milk with each feeding. Breastfeeding isn’t a ‘one woman’ job and mothers need support. Support like ongoing breastfeeding guidance from health care providers, help at home, and staying healthy by eating and drinking well. 10. Myth? You shouldn't breastfeed if you’re sick. Depending on the kind of illness, mothers can usually continue breastfeeding when they’re sick. You need to make sure you get the right treatment, and to rest, eat and drink well. In many cases, the antibodies your body makes to treat your disease or illness will pass on to your baby, building his or her own defences. 11. Myth? You can’t take any medication if you’re breastfeeding. It’s important to inform your doctor that you are breastfeeding and to read the instructions with any medications you buy over the counter. It might be necessary to take medications at a specific time or in a specific dosage, or to take an alternative formulation. You should also tell the baby’s doctor about any medications that you’re taking. 25 июня 2015 г. мать кормит грудью своего ребенка на собрании группы поддержки грудного вскармливания в Центре здоровья в Беловаре, Хорватия. Did you know? The ‘first milk’ – or colostrum – is rich in antibodies and gives newborns an immunity boost while their own immune systems are still developing. 12. Myth? Babies who have been breastfed are clingy. All babies are different. Some are clingy and some are not, no matter how they are fed. Breastfeeding provides not only the best nutrition for infants, but is also important for their developing brain. Breastfed babies are held a lot and because of this, breastfeeding has been shown to enhance bonding with their mother. 13. Myth? It’s hard to wean a baby if you breastfeed for more than a year. There’s no evidence that it is more difficult to stop breastfeeding after one year, but there is evidence that breastfeeding up to two years is beneficial for both mothers and children. All mothers and babies are different and need to determine together how long they want to breastfeed. 14. Myth? If you go back to work, you’ll have to wean your baby. Many mothers continue breastfeeding after going back to work. First, check the policies in your country and your own workplace. If you have the right to time and a place to breastfeed during working hours, you may be able to go home and breastfeed, ask a family member or friend to bring your baby to you, or to express your milk and take it home. If you don’t have the option to breastfeed during working hours, look for moments during the day to express your milk and then feed your baby directly when you are at home. If you decide to give your baby a breastmilk substitute for some feeds, it still very good to continue breastfeeding whenever you are with your baby. This article was developed in collaboration with Dr. Michele Griswold PhD, MPH, RN, IBCLC. Dr Griswold is a lactation consultant, registered nurse, breastfeeding researcher and advocate. She represents the International Lactation Consultant Association to the WHO/UNICEF Global Breastfeeding Collective , which calls on governments and society as a whole to provide mothers the support they need to breastfeed.

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