Two years of the COVID-19 pandemic led to a cumulative 5% decline in basic vaccine coverage and disrupted routine immunizations globally from 2020 – 2021, reports a new analysis of the state of routine immunizations across 57 lower-income countries.

The analysis, by Gavi, the Vaccine Alliance, indicates that signs of recovery are beginning to emerge in some countries, such as Pakistan, although in other countries such as the Democratic Republic of Congo, the setbacks persist.  

“Even though more than half of countries have increased or maintained their campaigns, we can still see that we are not getting ourselves out of the woods when it comes to the pandemic,” declared Thabani Maphosa, Gavi Managing Director of Country Programmes, at a press briefing just before the report’s release.

The analysis used data from the recently published WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) to examine the state of immunization in 57 lower-income countries supported by Gavi for bulk procurement and rollout of basic vaccines, mostly to children. 

Basic vaccine coverage in lower-income countries dropped by one percentage to 77% in 2021, after a four-percentage point fall in 2020, the first year of the pandemic, the report found. Basic vaccine coverage is defined as receiving three doses of a diphtheria, tetanus, pertussis shot (DTP3). 

The number of zero-dose children – those who have not received a single routine vaccine shot – rose for the second year running to 12.5 million. 

“Hiding behind these figures is a human tragedy on an enormous scale” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance.  “Millions of children have missed out on life saving vaccines, leaving them vulnerable to some of the world’s deadliest diseases.”

‘Country specific impacts’ leading to decline found in larger countries

The overall decline since 2019 has been primarily driven by larger countries, including the DRC and India. DRC, after a strong growth trajectory in previous years, fell from vaccinating 73% of children in 2019 to 65% in 2021. India dropped from a high coverage level of 91% to 81%.

The Democratic People’s Republic of Korea (North Korea), Myanmar, and Mozambique also saw further declines in coverage in 2021, in addition to those of 2020. 

“This analysis represents a very sobering assessment of the impact the pandemic continues to have on essential routine immunization,” said Anuradha Gupta, Deputy CEO of Gavi.

Many of these declines in coverage can be attributed to what Gavi called ‘country specific impacts’, including natural disasters that struck Mozambique and attacks on health care workers amid conflict in DRC.  

“While health systems have certainly been placed under great stress [due to the pandemic], other factors, for example, health worker strikes, political crises, or internal conflict are all having major country specific impact,” said Berkley, in a press briefing on Thursday. 

Earlier this month the World Health Organization and UNICEF had also reported that 18 million of the 25 million unvaccinated children who did not receive a single DTP3 dose in 2021 were located in low- and middle-income countries such as India, Nigeria, Indonesia, the Philippines, and others. 

Signs of recovery: one-third of countries increased coverage

On the brighter side, however, one-third, or 19 of the 57 countries included in the analysis, increased vaccine coverage in 2021. Two-thirds of African countries brought coverage back up to pre-pandemic levels or close to that marker. 

Chad and Niger both increased coverage across the pandemic period from 2019 – 2021, reducing the number of zero dose children by 16% and 20% respectively. Pakistan saw strong recovery in 2021, reducing the number of zero-dose children by over 400,000, bringing numbers back to pre-pandemic levels. 

Interestingly, however, other fragile and conflict-affected countries saw a lower decline in vaccine coverage than other countries, with Gavi maintaining coverage at 67% over the course of 2021. 

Heroic efforts to administer both routine immunization shots and COVID vaccines 

Notably, including COVID-19 vaccinations, lower-income countries administered more vaccines in 2021 than any year in history. 

“Gavi-supported countries not only administered routine vaccines to 65 million children, but they did so alongside frankly heroic efforts to administer more than 2 billion COVID-19 vaccines,” Berkley said.  He asserted, however, that it was not the additional burden of COVID vaccinations, per se, that kept routine coverage rates lower in some countries but rather a “more complex” array of factors, related to civil and political strife, in particular.

Gavi will now be working with lower-income countries towards further recovery – focusing on restoring coverage to pre-pandemic levels, with a laser focus on zero dose children.

The Vaccine Alliance had launched a new $100 million initiative, the Zero-Dose Immunization Programme (ZIP) last month in partnership with the International Rescue Committee (IRC) and World Vision (WV) to reach unvaccinated children specifically in the Horn of Africa and Sahel regions. 

Gavi will also be dedicating a further $2 billion towards strengthening health systems and immunization delivery, with half of that dedicated to reaching zero dose children and missed communities. 

The challenges are evermore greater due to population increases, Maphosa said, which mean that there are 1.2 million more children annually that need to be vaccinated.

“We have our challenges, but I’m confident that we can build routine immunization back even stronger especially on the backbone of what we have been able to achieve in our pandemic response,” said Maphosa. 

Image Credits: Gavi, Gavi, UNICEF/Pakistan , Gavi/2021/Asad Zaidi.