The largest sustained decline in childhood vaccinations in approximately 30 years has been recorded in official data published last week by WHO and UNICEF globally.

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 five percentage points between 2019 and 2021 to 81 percent, the two agencies said in a joint press release on Tuesday after the release of the data on July 15.

As a result, 25 million children missed out on one or more doses of DTP through routine immunization services in 2021 alone.

This is two million more than those who missed out in 2020 and six 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, more 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,” said Catherine Russell, UNICEF executive director.

“We are witnessing the largest sustained drop in childhood immunization in a generation.

“The consequences will be measured in lives.

“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.”

Eighteen 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 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 human papillomavirus (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 the HPV vaccine is only 15 percent, 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 programs 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.”

In Vietnam, more than 251,000 children missed out on one or more doses of DTP through routine immunization services in 2021– an almost fourfold increase compared with 63,001 in 2019.

At present, 52 out of 63 provinces in Vietnam have failed to meet the required target of reaching 90 percent of children below one year old receiving all recommended routine vaccines.

To address backsliding in routine immunization, Vietnam has been planning and implementing catch-up immunization in low-coverage areas.

For instance, the country has conducted supplementary immunization activities (SIAs) on MR and bOPV for children aged one to five.

Thus, 144,448 children received one MR dose and 141,866 were prescribed additional doses of bOPV this year.

“The government of Vietnam is making efforts to get the routine immunization for children back on track,” said Rana Flowers, UNICEF representative to Vietnam.

“We look forward to seeing Vietnam return to the strong child and adolescent immunization system it built before the pandemic – the system that stood up strongly to safely and effectively deliver COVID-19 vaccines to the people.

“Parents need to be assured that catching up with the recommended vaccines for their youngest is essential – if preventable deaths are to be avoided.”

Monumental efforts will be required to reach universal levels of coverage and to prevent outbreaks worldwide.

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 percent in 2021, also the lowest level since 2008 globally.

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 did not get 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,” 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.”  

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