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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

GENEVA/NEW YORK,15 July 2022 – The largest sustained decline in childhood vaccinations in approximately 30 years has been recorded in official data published today by WHO and UNICEF. The percentage of children who received three doses of the vaccine against diphtheria, tetanus and pertussis (DTP3) – a marker for immunization coverage within and across countries – fell 5 percentage points between 2019 and 2021 to 81 per cent. As a result, 25 million children missed out on one or more doses of DTP through routine immunization services in 2021 alone. This is 2 million more than those who missed out in 2020 and 6 million more than in 2019, highlighting the growing number of children at risk from devastating but preventable diseases. The decline was due to many factors including an increased number of children living in conflict and fragile settings where immunization access is often challenging, increased misinformation and COVID-19 related issues such as service and supply chain disruptions, resource diversion to response efforts, and containment measures that limited immunization service access and availability. “This is a red alert for child health. We are witnessing the largest sustained drop in childhood immunization in a generation. The consequences will be measured in lives,” said Catherine Russell, UNICEF Executive Director. “While a pandemic hangover was expected last year as a result of COVID-19 disruptions and lockdowns, what we are seeing now is a continued decline. COVID-19 is not an excuse. We need immunization catch-ups for the missing millions or we will inevitably witness more outbreaks, more sick children and greater pressure on already strained health systems.” 18 million of the 25 million children did not receive a single dose of DTP during the year, the vast majority of whom live in low- and middle-income countries, with India, Nigeria, Indonesia, Ethiopia and the Philippines recording the highest numbers. Among countries [1] with the largest relative increases in the number of children who did not receive a single vaccine between 2019 and 2021 are Myanmar and Mozambique. Globally, over a quarter of the coverage of HPV vaccines that was achieved in 2019 has been lost. This has grave consequences for the health of women and girls, as global coverage of the first dose of human papillomavirus (HPV) vaccine is only 15%, despite the first vaccines being licensed over 15 years ago. It was hoped that 2021 would be a year of recovery during which strained immunization programmes would rebuild and the cohort of children missed in 2020 would be caught-up. Instead, DTP3 coverage was set back to its lowest level since 2008 which, along with declines in coverage for other basic vaccines, pushed the world off-track to meet global goals, including the immunization indicator for the Sustainable Development Goals. This historic backsliding in rates of immunization is happening against a backdrop of rapidly rising rates of severe acute malnutrition. A malnourished child already has weakened immunity and missed vaccinations can mean common childhood illnesses quickly become lethal to them. The convergence of a hunger crisis with a growing immunization gap threatens to create the conditions for a child survival crisis. Vaccine coverage dropped in every region, with the East Asia and Pacific region recording the steepest reversal in DTP3 coverage, falling nine percentage points in just two years. “Planning and tackling COVID-19 should also go hand-in-hand with vaccinating for killer diseases like measles, pneumonia and diarrhea,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “It’s not a question of either/or, it’s possible to do both”. Some countries notably held off declines. Uganda maintained high levels of coverage in routine immunization programmes, whilst rolling out a targeted COVID-19 vaccination programme to protect priority populations, including health workers. Similarly, Pakistan returned to pre-pandemic levels of coverage thanks to high-level government commitment and significant catch-up immunization efforts. To achieve this in the midst of a pandemic, when healthcare systems and health workers were under significant strain, should be applauded. Monumental efforts will be required to reach universal levels of coverage and to prevent outbreaks. Inadequate coverage levels have already resulted in avoidable outbreaks of measles and polio in the past 12 months, underscoring the vital role of immunization in keeping children, adolescents, adults, and societies healthy. First dose measles coverage dropped to 81 per cent in 2021, also the lowest level since 2008. This meant 24.7 million children missed their first measles dose in 2021, 5.3 million more than in 2019. A further 14.7 million did not receive their needed second dose. Similarly, compared to 2019, 6.7 million more children missed the third dose of polio vaccine and 3.5 million missed the first dose of the HPV vaccine - which protects girls against cervical cancer later in life. The sharp two-year decline follows almost a decade of stalled progress, underscoring the need to not only address pandemic-related disruptions but also systemic immunization challenges to ensure every child and adolescent is reached. WHO and UNICEF are working with Gavi, the Vaccine Alliance and other partners to deliver the global Immunization Agenda 2030 (IA2030), a strategy for all countries and relevant global partners to achieve set goals on preventing diseases through immunization and delivering vaccines to everyone, everywhere, at every age. “It’s heart-breaking to see more children losing out on protection from preventable diseases for a second year in a row. The priority of the Alliance must be to help countries to maintain, restore and strengthen routine immunization alongside executing ambitious COVID-19 vaccination plans, not just through vaccines but also tailored structural support for the health systems that will administer them,” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance. The IA2030 partners call on governments and relevant actors to: Intensify efforts for catch-up vaccination to address backsliding on routine immunization, and expand outreach services in underserved areas to reach missed children and implement campaigns to prevent outbreaks; Implement evidence-based, people-centred, and tailored strategies to build trust in vaccines and immunization, counter misinformation and increase vaccine uptake particularly among vulnerable communities; Ensure current pandemic preparedness and response and the global health architecture strengthening efforts lead to investment in primary health care (PHC) services, with explicit support to strengthen and sustain essential immunization; Ensure political commitment from national governments and increase domestic resource allocation to strengthen and sustain immunization within PHC; Prioritize health information and disease surveillance systems strengthening to provide the data and monitoring needed for programmes to have maximum impact; and Leverage and increase investment in research to develop and improve new and existing vaccines and immunization services that can achieve community needs and deliver on IA2030 goals. ##### Notes for editors: About the data Based on country-reported data, the official WHO and UNICEF estimates of national immunization coverage (WUENIC) provide the world’s largest and most comprehensive data-set on immunization trends for vaccinations against 13 diseases given through regular health systems - normally at clinics, community centres, outreach services, or health worker visits. For 2021, data were provided from 177 countries. About Immunization Agenda 2030 The Immunization Agenda 2030 (IA2030) is an ambitious global strategy to maximize the lifesaving impact of vaccines -one of the most successful and cost-effective public health interventions of all time. IA2030 aims to reduce by half the number of children who still miss out on essential vaccines, achieve 500 introductions of new or under-used vaccines in low- and middle-income countries, and achieve 90 per cent coverage for key life-saving vaccines. Achieving these goals would avert over 50 million deaths and help build healthcare systems that can withstand the impact of pandemics and deliver rapid vaccination response. The strategy was endorsed by all countries through the 73 rd World Health Assembly and is a commitment of IA2030 partners comprised of UN agencies, global health initiatives (such as Gavi, the Vaccine Alliance, the Global Polio Eradication Initiative , the Measles & Rubella Initiative ), non-governmental organizations, civil society organizations, faith-based organizations and academia. For more information on IA2030 partners, please visit the partners commitment page . [1] Of countries with at least 10,000 zero-dose children in 2021 A child reacts as she is given an injection of vaccination by a healthcare worker in Ukraine. UNICEF/UN0201066/Krepkih A child reacts as she is given an injection of vaccination by a healthcare worker in Ukraine.

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