The World Health Organization and UNICEF have sounded the alarm on the largest sustained decline in global childhood vaccinations in approximately 30 years, with 25 million infants missing out on lifesaving routine vaccines. 

The percentage of children who received three doses of vaccine against diphtheria, tetanus and pertussis (DTP3) – a marker for immunization coverage within and across countries – continues to decline, falling 5 percentage points between 2019 and 2021 to 81%. 

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 2019, highlighting that there are a growing number of children at risk from devastating but preventable diseases. 

“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, in a joint WHO and UNICEF news release. 

The decline has been attributed to many factors, including an increased number of children living in conflict and fragile settings where immunization access may be difficult; increased misinformation; and COVID-19 related issues such as service and supply chain disruptions. 

Russel acknowledged the disruptions caused by COVID-19, but stated that this “was 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.”

Majority of children who missed DTP doses from low- and middle-income countries 

18 million of the 25 million children did not receive a single dose of DTP during the year, the vast majority from low- and middle-income countries. India, Nigeria, Indonesia, Ethiopia, and the Philippines recorded the highest numbers of unvaccinated children. 

Myanmar and Mozambique are among countries that recorded the largest relative increases in the number of children who did not receive a single vaccine between 2019 and 2021. 

Overall, vaccine coverage has dropped in every region, with the East Asia and Pacific region recording the steepest reversal in DTP3 coverage, falling 9% in just two years. 

While many thought that 2021 would be a year of recovery in which strained immunization programmes would rebuild and those children missed in 2020 immunizations would be caught up, instead, DTP3 coverage was set back to its lowest levels since 2008. 

This has pushed the world off-track to meet global goals, including the immunization indicator for the Sustainable Development Goals. 

HPV vaccine coverage progress lost in 2021 

In addition to declining DTP vaccinations, over a quarter of the global coverage of HPV vaccines that was achieved in 2019 has been lost. 

3.5 million children had missed the first dose of the HPV vaccine, which protects girls against cervical cancer, in 2021. 

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.

Uganda and Pakistan resisted coverage declines 

However, some countries were able to hold off declines in vaccination coverage. Uganda maintained high levels of routine immunization programs whilst rolling out a targeted COVID-19 vaccination programme to protect priority populations, including health workers.

Pakistan also returned to pre-pandemic levels of coverage thanks to high levels of 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,” the joint WHO and UNICEF press release reads. 

Avoidable outbreaks of measles and polio result from inadequate coverage 

In the past twelve months, avoidable outbreaks of measles and polio have occurred as a result of inadequate coverage levels, underscoring the vital role of immunization to keep children, adolescents, adults, and societies healthy. 

First dose measles coverage had dropped to 81% in 2021, also the lowest since 2008, which meant 24.7 million children missed their first measles dose in 2021, 5.3 million more than 2019. 6.7 million children had also missed a third dose of the polio vaccine in 2021. 

The drop in measles coverage had led to declaration of a measles outbreak in the southern African country of Malawi in March. In response, WHO had launched a mass vaccination campaign in order to reach 23 million children across five countries – Malawi, Mozambique, Tanzania, and Zambia, and Zimbabwe.

“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”.

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 global partners to achieve set goals on preventing diseases through immunization and vaccines for everyone. 

Gavi had also launched a $100 million initiative to identify and reach zero-dose children – those without a single routine shot, earlier in June 2022. 

“It’s heart-breaking to see more children losing out on protection from preventable diseases for a second year in a row,” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance.

“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,”

Image Credits: Twitter: @WHOAFRO, WHO PAHO, UNICEF Pakistan, WHO/John Kisimir.