Largest Global Immunization Backslide in 30 Years after COVID-19 Pandemic — What can We Do?

Realities of urban immunization outreach, from Unnao, Uttar Pradesh, India. June 2022.

By Lora Shimp

We are all aware that the COVID-19 pandemic has significantly affected global health, and immunization is often an indicator. Newly released data from WHO and UNICEF show significant immunization coverage reductions across most countries, and that the pandemic and health system constraints have resulted in the largest backslide in vaccination rates in 30 years.

The recovery and rebuilding in 2021 did not reach countries’ immunization programs, particularly catch-up vaccination for children in the 12–36 month age group who missed it during the pandemic. This decline in basic vaccine coverage has pushed the world off-track in meeting global goals, with continuing challenges in also reaching the current 0–11 month cohort with all antigens (rotavirus, pneumonia, measles, and other vaccines).

Government health programs are in recovery, with constrained staff who have heavy workloads and are burnt out. There is also a lack of funding for the day-to-day operational needs of preventive health and routine immunization (RI) programs. A disproportionate amount of funding is earmarked for disease or antigen-specific initiatives, not recurrent costs for delivering vaccines and ensuring uptake.

While funding has gone up — such as the significant increase in USAID’s immunization investments under the Biden Administration — much of the recent influx of global funds has focused on COVID-19. Those funds will need to be increasingly leveraged (along with local country resources) for immunization catch-up that includes children under 3 years of age. This does not readily align with the COVID-19 vaccination prioritization, given significant needs to reach older age groups. Additionally, ‘maternal and child health’ funds that have supported immunization over the last decades rarely cover human papillomavirus (HPV) vaccination for pre-adolescents and adolescents, which was also heavily stymied by COVID-19 interruptions. Even large bilateral organizations that provide resources across health interventions struggle to include sufficient resourcing for immunization amidst many other health-programming urgencies. Purposeful coordination among funders and programs is essential for cross-cutting needs, such as human resources for health and delivery of essential products, including vaccines, from dense urban to rural remote populations and those in fragile settings.

As Catherine Russell, UNICEF executive director, says, “This is a red alert for child health.”

Global support and the immunization paradigm need to shift to a focus on primary and preventive health care and consistent local resourcing. This includes the immediate need for 2–3-year and longer-term flexible funding for partners with well-rounded technical and programmatic immunization experience and a record of working closely with communities directly in countries, including international nongovernmental and civil society organizations that can assist with local decision-making. This has been a recommendation since 2019 and included in the Immunization Agenda 2030 (IA2030). It is even more urgent now. IA2030 is a collective action for strengthening immunization, including catch-up on missed vaccinations and rebuilding essential services and improving uptake. However, the working groups for each of IA2030’s strategic priorities lack funding to implement their activity plans.

In addition, while there have been impressive developments with e-learning and digital health, these may be unintentionally contributing to inequity, particularly for people without consistent technology access, such as simply having data minutes for a mobile phone. The emphasis on e-health also needs to be matched with competencies across the range of immunization technical expertise to facilitate holistic on-ground assistance that includes subnational country colleagues’ input and is relevant to their context. This is particularly the case when it comes to updating and implementing micro-planning and tailoring immunization programs with local monitoring solutions and resourced strategies, as in this example from Tanzania. Future support must provide the current 0–11 month cohort with all antigens while also identifying and reaching the missed 12–36-month-olds who are not completely vaccinated.

What can we do?

1) We call for high-level officials to urgently fundraise and ensure more flexible mechanisms that can help directly with country implementation for immunization programs beyond 6–12 months. Gavi, the Vaccine Alliance, is an important and valued partner, but the resources it provides do not sufficiently supplement most countries’ needs, are not designed for urgency, and are not easily implementable at facility and community levels. A variety of local country resources — and regional and global funder and partner support — are needed.

2) Countries need technically and operationally feasible, 2–3-year costed and resourced immunization and preventive health plans to intensify RI for the current birth cohort and children who missed their vaccines during the pandemic. Many countries would benefit from collaborative on-ground assistance in adapting global guidance and putting complex programmatic and data components together. This can be done through in-country multi-stakeholder coordination co-led by ministries of health (MOH) and Expanded Programs on Immunization and immunization technical experts, including WHO and UNICEF, following an approach similar to what we supported several years ago in DRC (with the then-Minister of Health H.E. Mashako), as well as learning from local leadership in places like Jharkhand State in India. As such, comparative advantages of various on-ground immunization technical partners can be included in the resource needs for RI and PIRI to reach individuals and not default to costly broad-stroke campaign approaches.

3) We can all be preventive health and immunization advocates, moving beyond short news cycles and dedicating attention to the longer-term efforts needed to build stronger health systems. JSI has been part of IA2030 development and leadership and engaged in several of its technical working groups. As importantly, we provide immunization program technical advice and linkages directly with country MOH and partners around the world to ensure equitable and complete vaccination (including two doses of measles vaccine and HPV vaccination), particularly in low-resource settings.

The need for country-tailored and co-designed immunization support continues to intensify, given the urgency to build back and build up health systems, and catch up the three recent birth cohorts with full vaccines and other services. Without clear steps to strengthen the RI platform in countries around the world, the health gains of the last 20 years will be lost. This is not the COVID-19 legacy that anyone wants.

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John Snow, Inc.

John Snow, Inc.

JSI is a public health consulting firm that works to improve the health and well-being of underserved and vulnerable people and communities throughout the world