WHO/UNICEF Virtual Press Conference 13 July 2021

All right, let's get started.

Thank you all very much for joining for today's embargoed press conference and the new official data on childhood vaccination put together by WHO and UNICEF.

And I'm very glad we have two speakers representing the organisations here.

We have Doctor Kate O'Brien, Director of Immunisation, Vaccines and Biologicals at WHO, and we have up there from Limango, Who's Associate Director and Chief of Immunisation at UNICEF.

Welcome to you both.

So this briefing will present new data on childhood vaccination rates showing alarming trends in the numbers of unvaccinated children worldwide.

The briefing will also discuss the coverage for several essential vaccines with data available globally, regionally and by country.

So we're all looking forward to this all new data we may have supporting slides as we go along.

So we'll that that may come up on your screen, you hope, I hope you also have seen the, the link we sent earlier today with supporting material.

If not, we'll send the link again anyway afterwards with any further material we have.

Note again, the embargo is until 15 July at 1:00 in the morning Central European summer time, So 1:00 Geneva in the morning of the 15th of July.

With this, I'll stop and hand over to Kate O'Brien for the introductions.

[Other language spoken]

I'm Doctor Kate O'Brien and as Christian introduced me, I'm the Director of the Department of Immunizations, Vaccines and Biologicals.

As you know, every year in mid-july, usually on July 15th, WHO and UNICEF jointly produce estimates of national immunisation coverage for countries around the world.

And these estimates are reported to WHO by Member States.

And they serve as the foundation for tracking how the world is faring against devastating vaccine preventable diseases like measles, polio, diphtheria, pneumonia and others.

And today we do have sobering news.

The COVID-19 pandemic has led to major backsliding on childhood vaccination, taking us back more than a decade.

An estimated 23 million children have missed out on basic vaccines through the routine immunisation services in 2020.

That is the highest number of unprotected children since 2009.

We measure basic vaccine coverage by looking at the number of children who received 3 doses of the vaccine for diphtheria, tetanus and pertussis, which also contains other antigens, but this is known as DTP Three.

Prior to the COVID-19 pandemic, global DTP Three coverage had stalled at around 86% for a number of years.

Yet in 2020, DTP Three coverage fell to just 83%, which is unacceptably low.

Measles vaccine coverage with just the first dose of measles also fell, and it fell from 86% to 84%.

Only around 70% of children received the second dose of measles vaccine, which is well below the 95% coverage needed to prevent outbreaks of that devastating disease.

3 regions saw especially concerning declines in coverage in 2020.

The Who Southeast Asia region was significantly affected by COVID-19 disruptions to routine immunisation.

In 2020, the overall DTP 3 vaccination coverage rate in the Southeast Asia region dropped from 90 excuse me from 91% to 85%, undoing years of hard won gains in vaccination coverage.

These declines were largely driven by shortfalls in immunisation coverage in India, which was hit hard by the COVID-19 pandemic and now has the greatest number of under and unvaccinated children globally.

[Other language spoken]

The Eastern Mediterranean region experienced the most severe disruptions in immunisation services due to COVID-19 compared to other regions.

Fortunately, A robust recovery effort towards the end of 2020 helped to blunt the impact of coverage declines and recover some lost ground.

And although the region of the Americas experienced A relatively modest 2% overall decline in DTP 3 immunisation coverage in 2020, a troubling long term picture is continuing as vaccination rates in the region have fallen steadily since 2016.

This is fueled by funding shortfalls, vaccine misinformation, instability in programmes and in countries, and other factors.

Concerns are not just for outbreak prone diseases.

For example, vaccination against human papilloma virus, also known as HPV.

The vaccine protects girls against cervical cancer later in their life.

These programmes have been highly affected by school closures.

As a result, across countries that have introduced HPV vaccine, approximately 1.6 million more girls missed out on vaccination in 2020 compared to the previous year.

And globally, only 13% of girls were vaccinated against HPV, falling from 15% in 2019.

It's also worth noting that a new modelling study being published this week in The Lancet, led by researchers at the Institute for Health Metrics and Evaluation at the University of Washington, also found that coverage of childhood vaccines declined globally in 2020 compared with COVID-19 because of COVID-19 disruptions compared with 2019.

Now, while the IHME estimates are based on a different methodology than Woonick for making these estimates, and the absolute numbers are not identical, which is understandable because of different methods used, the most important takeaways from these two estimates are the same.

Both show significant disruptions to basic childhood immunisation in 2020 which put children's lives at risk.

And both show how important it is that new waves of COVID-19 and the rollout of COVID-19 vaccines don't derail routine immunisation programmes and that catch up activities are enhanced.

Vaccines are the most powerful tools we have to say our public health.

It's not acceptable that so many children are at risk for life threatening diseases.

Even if they are survived.

These can lead to long term disability and health consequences.

The world has rightly prioritised the emergency response to COVID-19, but if we fail to find a catch up and catch up those who have missed their vaccines and restore and improve the essential immunisation programme, there is a serious risk of disease outbreaks that will continue to grow.

We really can't trade one crisis for another, and we won't if we heed these warnings and recommit now to fully immunising every child on Earth.

WHOUNICEF and our partners are supporting countries and regions in their efforts to recover from the pandemic and strengthen immunisation systems, including by safely restoring immunisation services, communicating the continued importance of being vaccinated even during the pandemic, and closing vaccination coverage gaps.

In the long term, we'll partner with countries to deliver on the ambitious targets of the Global Immunisation Agenda 2030, which is referred to for short as IA 2030.

Launched earlier this year, IA 2030 is a bold new strategy to ensure that everyone, everywhere, at every age fully benefits from vaccines and IA 2030 aims to achieve 90% coverage for essential childhood vaccines.

It aims to cut in half the number of children who receive 0 vaccine doses through their routine programme and to introduce into programmes, especially in low and middle income countries, underused vaccines such as rotavirus and pneumococcal vaccine.

So today's data reinforce the urgency of meaningful commitments and actions to advance that bold global agenda.

WHO and UNICEF and our partners are supporting countries as they work to develop regional and national strategies to make real the implementation of IA 2030.

For example, WHO recently developed a strategic response plan to support countries in preventing, preparing for, and responding to measles outbreaks.

This is more critical than ever, but to be successful, everyone from world leaders to scientists to donors to individuals can and must step up, take action and commit to fully implementing IA 2030.

Committing to IA 2030 means averting an estimated 51 million future deaths through vaccinations given over the next decade and ensures that no one is left behind by immunisation efforts in any situation or at any stage of life.

So with that, I'll turn over to Ephraim from UNICEF to take us through some issues around 0 dose.

[Other language spoken]

Over to you, Ephraim.

[Other language spoken]

My name is Ephraim.

I am the Associate Director and Chief of Immunisation here in UNICEF Headquarters in New York, and I'll be following on a note on zero those children following the the comment made by my dear friend Kate.

2020 has been also a year where we have lost a significant ground on the number of children that miss on their vital first vaccines.

In all regions, rising number of children miss vital first vaccine doses and million more misled vaccines.

Mr patients in immunisation service were widespread in 2020 and accordingly as access to health services and vaccine outreach were curtailed and the number of children no receiving even their very first vaccination increased in all regions, 3.5 million more missed their first dose of diphtheria, tetanus and pertussis containing vaccine, while 3,000,000 more missed their first for measles vaccine.

The number of 0 dose children back in 2019 used to be around 13.6 million and this has increased to 17.1 million children missing on their first dose of vaccine.

Ephraim the pandemic.

Ephraim I'm hearing, I'm hearing, we have trouble hearing your voice.

If you could try speak up a little bit please.

Can you hear me now very well?

[Other language spoken]

Thank you very much.

[Other language spoken]

So in all regions, rising number of children with vital first vaccine doses in 2020, disruption and immunisation services were widespread.

Access to health services and vaccination outreach were curtailed and the number of children no receiving even their first vaccination increased.

In all regions across the world, 3.5 million more missed their first dose of titanis and pertussis vaccine, while 3,000,000 missed their first for measles vaccine.

In 2019, the number of children who did not receive their first vaccine was 13.6 million.

This has increased to 17.1 million in 2020.

Even before the pandemic disrupted global immunisation services, progress toward reaching the most vulnerable children with vaccines was stagnating and continued to be exacerbated by the pandemic, resulting in millions more children going and immunised.

His latest data show an alarming increase in the number of children who did not receive any vaccines at all, which we call them 0 dose children, putting fed of millions of young lives in the past.

Most of these children that miss their first dose of vaccine live in communities affected by conflicts and crises, live in communities that are underserved, remote rural places and they live in informal slum settings, particularly in urban poor areas.

In these communities, they do not also face challenge in immunisation, but they also experience multiple deprivations, including poor access to basic health and key social services.

South Asia reported a significant increase in the number of children who did not receive a single vaccine, a total of increase about 2.1 million children in 2020 as we compare it to 2019.

This has been followed by East Asia and the Pacific region whereby near 500,000 new children have missed their first dose and Eastern and Southern Africa region also faced a significant increase of around 400,000 fueled by funding shortfalls and vaccine misinformation and access to vaccines.

A travelling picture is also emerging in Latin America and the Caribbean regions where there has been an ongoing drop in vaccination coverage for several years and COVID has actually worsened this whereby in 2016, ninety, 1% children in this region were fully vaccinated and significant number of children more than this have been actually able to access their first dose which has significantly decreased over this year.

10 countries with the greatest increase in children not receiving the first dose of Dipteria Titanus pertussis containing vaccine.

Their first dose are #1 is India, Pakistan, Indonesia, Philippines, Mexico, Mozambique, Angola, United Republic of Tanzania, Argentina, Venezuela and Mali are the ones that are leading with significant increase in the number of 0 dose children.

As we compare the performance in 2019 with 2020, India has seen almost a doubling of the number of 0 dose children and Pakistan also seen an significant increase of about 85% increase in number of 0 dose children.

This data shows that middle income countries now account for an increasing share of unprotected children and that is heavily driven by the significant loss of performance in India, children missing out on at least some vaccine doses.

And as I stated, with India experiencing a particular large drop with DTP three coverage falling from 91% to 85% as Kate was earlier underlying.

What does this mean to the current state of childhood immunisation?

Globally, countries risk resurgence of measles and other vaccine preventable diseases due to the increase in number of children that continuously miss on the vaccine.

Even prior to the COVID-19 pandemic, global childhood vaccination risk against DTP 3 and DTP One had stalled for several years and it is well below the 95% recommendation by WHO to protect against measles, often the first dose to research when children are not reached with vaccines and insufficient to stop other vaccine preventable diseases.

These gaps have now widened with many health facilities, resources and personnel diverted to support COVID-19 response.

We are calling for urgent recovery and investment of written immunisation as countries work to recover the lost grounds due to COVID-19 related disruptions.

UNICEF, WHO and partners like Gavi and the Vaccine Alliance and many other partners working on immunisation are supporting efforts to strengthen immunisation systems by restoring services to in countries, by helping health workers communicate clearly with community influencers on the value and importance of vaccines and by supporting coverage and immunity cups recovery activities.

This includes identifying communities that are persistently missed and conducting catch up interventions and implementing country plans to prevent and respond to outbreaks of vaccine preventable diseases And the need to strengthen Immunisation systems will continue to become useful and we call for all partners to join their hands in doing the same.

Under the overarching guidance and leadership of the Immunisation Agenda 2030, we're aiming to forge to achieve at least 90% coverage for essential childhood vaccinations in 20-30.

But doing this would require strong engagement and partnership of several partners.

Governments will need to take a lead.

The global health community and partners must invest in urgent recovery of essential immunisation and other child health services on the backdrop of this alarming decrease in coverage of immunisation, when a significant increase in the number of 0 dose children and the likelihood of several outbreaks coming ahead of us.

We have the tools to control disease that treat in children, but we must now jointly redouble efforts to deploy them equitably and to boost confidence in them as well.

As governments respond to recover from impact of the pandemic, they must prioritise actions to strengthen health systems in the poorest countries.

This will require increasing global and national investment to continue delivering vaccinations and other critical services, particularly for most vulnerable children and most vulnerable communities who tend to face multiple deprivations.

The global health community must leverage the current political commitment that we are witnessing in COVID-19 vaccine roll out to push governments and global partners to invest more in all of the health services that people need, including child routine immunisation.

Last but not least, partners, governments, and healthcare workers must work together to build confidence in vaccines was COVID-19 and the routine immunizations that save children's life.

If we are to eradicate preventable diseases, we must not falter in our commitment to reach all children with the vaccines.

And an important note in here is as we strive to push out COVID-19 vaccines and reach those most vulnerable, we should not forget that and it shouldn't come at the expense of childhood immunisation and vaccines for children.

Thank you very much.

Thank you very much, Ephraim.

And let me ask both speakers, because I understand you have both very long and very detailed interventions, if possibly we can have these interventions from you and we could share them with the with the participants of the press briefing afterwards, if that's possible.

I assume that would help many of the colleagues only here online here with this.

Thank you very much.

Let me open the round for questions.

And as you know, just raise your hand with the raise your hand.

I can as Albert Otti from BPR already did.

So I bet the floor is yours.

Hello, thanks for taking my question and thanks for the press briefing.

I have a question, just because many children missed their vaccines last year doesn't automatically mean that they will never get them or that they won't get them this year.

So my question is what signals are you getting about countries that where where many kids have missed their vaccines that they're catching up this year or do you have, if you don't get signals yet, do you have historical?

Experience about children not getting missing their first vaccines.

The likelihood that they will never catch up or that they will never catch them.

Thank you very much, Albert, for this.

And I guess we'll start with Kate O'Brien and then Phil in as others want to come in from.

Same for you, right, Kate?

[Other language spoken]

What we've seen already in 2020 is that countries have made substantial efforts to catch up kids who we're missing vaccines during the course of 2020.

We provided you a slide in the slide deck that we we offered that shows the monthly data and you see this massive reduction in the middle of the year in April and May in many country, in many of the regions and then an increase later in the year.

What we're monitoring now in 2021 is first of all, it depends on the country.

And secondly, we, we have only a small amount of data regarding the, the catch up.

But what we, what we do are emphasising with countries and what we see countries trying to do is to retain the catch up that they've done.

However, we do know from past years and past experience that for children who are not included in the routine immunisation programme, and that's really where we're seeing kids having missed out, is that they are often lost to immunizations overall.

So this is a significant concern for us.

Thank you very much and I I assume you all see the supporting sliding on screen.

Efren, do you want to add?

[Other language spoken]

Many countries have taken recovery measures and have implemented catch up activities, particularly on the second-half of the year 2020.

In the first half of 2020, there has been a significant decrease in the, for example, the African region and the Eastern Mediterranean region as well.

And this has been due to the closure of facilities and people being scared of travelling to health facilities.

And there were significant lockdown measures that were implemented by different countries to contain the spread of the pandemic.

But later on, recovery interventions such as community mobilisation activities and supply of protective equipments to health providers and conducting repetitive outreach activities had actually enabled some regions such as the Middle East and Northern Africa region as well to really improve its coverage.

And the African region had also seen a significant improvement in coverage but happened on the second-half of the year.

One thing to emphasise is it is unlikely when children are missed on their first dose, it's unlikely that they will get their third dose or other vaccines.

But it's important to underline children.

We need to get vaccines timely based on the established schedule in countries.

But in the event of in unlikely event of pandemics such as COVID-19, we are encouraging countries to actually provide vaccines whenever these children are accessible.

Thank you very much Efre and Kate to understand you had something to add briefly.

Yeah, we've put in the chat, we did release guidance in August of 2020 on catch up activities and I think you see some of that showing up in the data later in 2020.

So in the chat is the guidance, the link to the guidance on catch up again which many countries are are acting on.

I just put it also in case others couldn't put it in.

I don't know how the rules are who can't put what it should appear.

The link should appear in the chat now.

Thank you for this both.

Next question goes to Peter Kenny from Anadolo News Agency.

Peter, please go ahead.

[Other language spoken]

I would also like to reiterate what Christian said, that it would be most helpful to get your interventions.

It will really be.

Helpful to us writing reporters, I would just like to ask about this vaccine hesitancy.

I know you've said that it's been on the go say since 2016.

So it's not something new with COVID, but did it accelerate with COVID?

And what are you doing research on why there is vaccine hesitancy?

Because during the sort of pandemic in some countries, it almost seems to become an ideological matter.

Thank you much, Peter.

I'm looking into my virtual room here.

Maybe this time we'll start with Kate again.

[Other language spoken]

Let's do the opposite way.

Ephraim, go ahead 1st and then we'll come back.

[Other language spoken]

In, in, in, in immunisation, particularly childhood immunisation in those areas that are least served where we have significant number of 0 dose children.

Even though vaccine hesitance, particularly vaccine under information and a bit of misinformation is a cause, the main challenge that we couldn't treat children is due to supply related issues.

Supply meant the availability of nearby facilities to vaccinate children and the opening hours of this facility is not necessarily being convenient for those people who live in remote rural areas and even issues related to registering children that are born in urban poor areas in slum areas.

So the the main challenge are particularly supply related or availability of service related challenge.

But it's still vaccine misinformation that's associated with vaccine hesitance is also growing, particularly in middle income countries.

And significant effort has already been put in place to really encourage countries to design innovative interventions to reach communities and to use community structures to mobilise influencers for families to understand the value and importance of vaccination for children.

And additionally, WH and UNICEF and that also work together in really creating networks to really differ and find ways of preventing info demics or misinformation pandemic with an intention of strengthening systems at country level and particularly using human centred designs and social listening as an innovative intervention to really understand why communities do not necessarily prefer this vaccine or that vaccine.

But at the end, bottom line is that major reason why children are not being vaccinated, it's not due to vaccine hesitancy, but it's rather access related factors, particularly in low and middle income countries.

Over to you, kids.

Just a couple of things to add to that.

As you know, WHO in 2019 highlighted vaccine hesitancy as a critical global health issue.

And I think we we should just comment on what happened, not that we're out of it yet, but what has been happening during the COVID pandemic unrelated to COVID vaccine, but related to childhood immunizations.

The first is that there there was absolutely behaviours on the part of families who were concerned about both for themselves and about providers exposure by going to places where vaccinations would be given.

So there was hesitancy on that side of, you know, should they seek vaccine services even if the services were there because of concerns about COVID exposure.

The second was really what from emphasised is service disruptions.

And once a service is disrupted, it's really much more difficult for families to then have an understanding about the resumption of services, confidence that the services will be there at the time and place when they're expected to be there.

And then the third is around consequences, whether they were real or whether they were perceived by people, consequences about violating, you know, travel related COVID rules.

And so concerns on the part of families about whether or not any transportation issues were, you know, there would be some some consequences if they were violating those rules.

And, and in all countries seeking essential health services was certainly supported and allowed.

But again, communication around when and how and where the services were going to be was, was certainly an issue for a vaccine hesitancy.

And as we head further into 2021, of course, this pandemic is not not over in most countries.

And so these are continue to be real issues.

And we're really concerned that we have clarity around communication and resumption of the services.

So there is confidence on the part of families about seeking services, that they will be there, that healthcare providers are protected, that they're not putting healthcare providers at risk by, you know, servicing immunisation programme.

So those are some of the vaccine hesitancy issues that were sort of layered on top of the baseline vaccine hesitancy issues.

Thank you very much, Ephraim and Kate.

Next question goes to Gabriela Sotomayor from Proceso Abuela.

[Other language spoken]

Thank you, Christian.

Thank you, Proceso.

Yes, thank you for giving me the floor.

[Other language spoken]

First, just a clarification, it's a very basic question, but what does it mean exactly with 0 those children vaccines, 0 dose, What does that mean then if it's newborn children or all the children?

[Other language spoken]

And then what is happening in Mexico because you, you mentioned that in that 0 dose children 2020 list Mexico, it's part of it, the 4th, the 4th place I think and then also with measles, but not not only in, in the pandemic year, but also in 2019.

So what is happening there?

Because in Mexico there is no anti vax.

Everybody puts the arm to be vaccinated in Mexico, I mean.

So what is happening there?

Are you worried about this?

What is happening in in Mexico that used to be very good with vaccination?

Maybe I can start on the 0 dose and then we'll speak a little bit about Mexico and perhaps we can just prepare to put the slide up on the, on the, the circles with the coverage and the, and the numbers.

The.

So just to clarify what we mean by zero dose children.

This is a terminology that we use in immunisation services.

It refers to children who don't get even 1 dose of vaccine through the routine immunisation programme.

[Other language spoken]

They've received 0 doses of vaccine through the routine immunisation programme.

They may be getting vaccines through special campaigns, polio campaigns or measles campaigns, but because campaigns function in a way where you're not required to show that vaccination card in order to get your dose.

In other words, a campaign is attempting to immunise anybody who is in the age group that is targeted for the campaign.

The campaigns don't necessarily then link a child who has previously not received any doses to the routine programme.

So that that's what we mean by a zero dose child.

They receive 0 doses of vaccine through the routine programme.

The way that we analyse that is we look at children who have not received their first dose of ADTP containing vaccine.

So that's DTP one recognising that DTP is a vaccine that requires 3 doses in the infant programme.

So this is the slide that shows the number of 0 dose children by region, showing 2019 and 2020 in the big bubbles on the right hand side and the multiple circles on the left hand side.

Each one of those is a country and it's shown by region.

And so this shows the increase in the number of children by region who are receiving no doses through the routine immunisation programme.

Maybe if we could go to the slide that also shows the top ten countries of on and under immunised children comparing 2019 and 2020 and we'll see what happened in Mexico there.

Thanks for scrolling through the slide to find that that specific slide.

The situation in Mexico is complex.

There's no one reason why there has been a reduction in the number of children who are receiving vaccines.

There have been some stock outs in for some of the vaccines in some years and other factors are affecting the offering of vaccines, the availability of vaccines.

I would like to highlight though that Mexico is currently conducting A measles and rubella catch up campaign to try to recover some of the the vast majority of kids who have missed out on those important vaccines.

And you can see on this slide where Mexico sits.

So on the right hand side it's India, Pakistan, Indonesia, Philippines and then Mexico with the number of children who are 0 dose children according to country.

I don't know if there's anybody else on the line from a technical perspective who'd like to make any comments about Mexico.

Efren, anything to to add now I see again so and then meet me.

Yes, I just wanted to underline that what we did is we looked at the 10 countries that are driving the significant that are responsible for the significant number of 0 dose children combined together And in this top ten countries.

Mexico is one of the countries that has seen a significant increase in number of children who did not receive their first shot of vaccine that contains if teriatitis and pertussis vaccine.

And the number which used to be in 2019 was near 350,000.

I'm rounding the numbers and this has increased in by 2020 to 450,000.

So it's around 100,000 new children being 0 those children in Mexico.

But if you compare it with countries such as, for example, Brazil, which have had been a significant improvement from 2019, that has been largely attributed to improved availability of vaccines.

So even though we do not have specific data on Mexico, it is important to keep in mind people might be willing to be vaccinated, infants may have the opportunity to be vaccinated, but availability of vaccines and convenience of service facilities.

And as we have seen last year where there has been significant restriction in opening of facilities and people fear for people fear of contracting the COVID-19 and also deterred significant number of people from actually accessing facilities.

So this could definitely be attributed to that.

And one important lesson is what we have seen in Brazil at a very important point to really compare where there has been an improvement in actual coverage and decrease in the zero to Australian data improvement in vaccine availability.

Yeah, thank you very much, Efraim and Kate.

And again with some links in the in the chat one hand went down.

[Other language spoken]

Or the gentleman from UNICEF?

Whether you have any.

Initial data yet this.

Year about outbreaks of childhood diseases that are at, you know, higher rates than one would have had in 2000.

And 19 due to under vaccination or lack of vaccination, particularly in those two, in those ten countries that you mentioned.

[Other language spoken]

Seeing any data about, you know, greater greater numbers of.

Children affected by.

Outbreaks for some of these vaccine preventable diseases please.

Yeah, let's start with air from this time.

[Other language spoken]

So in 2021 of the impacts of the COVID-19 pandemic and associated disruptions of services was not only interruption of essential immunisation service for children, but also postponing of several planned supplemental immunisation activities.

These are campaigns that we normally use to vaccinate children on missiles, vaccine or polio and other outbreak focused interventions.

So more than 60 countries have had actually postponed even though it had improved later in the year.

I've had postponed these campaigns and new vaccine introductions as well have also really been slowed down.

And I think Jan is going to display one of the graphs, yes.

So 66 countries with at least one vaccine preventable disease campaign postponed and this is the latest data we have.

And this is more likely to lead to outbreaks and occurrence of some diseases that have been well controlled.

I'm not exactly sure on the data with regard to current reports on the out on the rate of outbreaks in each country.

I would defer it to the technical colleagues if they have the updated data.

[Other language spoken]

So you want to come in or anyone from the colleagues adding with data.

Yeah, a couple of things just to add to Efrem's comments.

So Stephanie, specifically on measles, we are seeing an outbreak in Pakistan with measles in some of the some of the provinces already.

I think the measles story is incredibly important and I want to make a couple of comments on that.

The first is we are seeing already and we will expect that it may continue to occur that either sub parts of countries or countries as a whole are loosening the public health and social measures on COVID.

We've lived through 2020 where there were, you know, quite strong public health and social measures and many of the diseases that are vaccine preventable diseases are transmissible from person to person, not all of them, but most of them are.

So as we go from 2020, where we did see actually a period of social engagements that were interventions in themselves for reducing transmission of these vaccine preventable diseases, in 2021, we have potentially a perfect storm about to happen.

And we don't want to get to that perfect storm to be ringing the alarm bell.

We're ringing it now because if countries are continuing to loosen their public health and social measures in spite of what we're saying about COVID, that we're not past the we're not past the worst yet and vaccines are continuing to roll out for COVID.

So now is not the time to release public health and social measures, but if that's happening and as it's happening, we are going to see more and more transmission of the pathogens that are otherwise vaccine preventable pathogens for measles.

In addition to that, as you know, we had a terrible year in 2019, we had huge outbreaks in 2019 and so there is a group of children who experienced those outbreaks and are immune from natural disease.

But now coming in behind them is an accumulating number of children who have missed out on vaccination and they will continue to accumulate.

If we don't see a restoration of the immunisation programmes and efforts to go ahead and immunise those kids who missed their immunisation in 2020, the catch up campaigns, they will continue to accumulate.

So these two things of an accumulation of children who are not immune because they haven't received vaccine and more and more transmission because of early release to early release of public health and social measures is the sort of perfect storm that we're ringing the alarm bell about right now.

We have to act now in order to protect those children.

Otherwise we're going to be in this kind of press conference in the coming months now talking about the outbreaks that we knew were going to happen if we didn't act.

So we do see some starting to happen and we're really really sort of expressing our **** concern on these very outbreak prone diseases.

Thank you very much both.

And the next hand on my list here is Kristof Fuk from AFP.

Kristof, please go ahead.

[Other language spoken]

Is this question is really naive, but I was just wondering to what extent you could use the everything that is being put into place to vaccinate against COVID in different countries, to use that infrastructure, to use those people who are in those places to catch up with children immunisation?

Or is it something that is so different that it cannot be used for both?

[Other language spoken]

Logistics FM, you want to start again?

Yes, thanks Chris.

This is a very important question.

Even there is this growing narrative on how investments are COVID-19 and COVID-19 vaccine rollout can be used to support routine immunisation.

Yes, this investments can actually be used to strengthen essentially immunisation services as long as they are invested in strengthening capability of the health workforce, as long as they are invested on the strengthening the cold chain capacity and the storage capacity of essential immunisation and as long as they are invested in strengthening generally the health system itself.

Given that the COVID-19 vaccine roll out is being done separately in in a vertical form of implementation, given that it requires a significant drive to reach out to adults who require these vaccines, we have a risk that we need to be really aware and it requires A deliberate effort.

The risk is that investments will be made on immunisation that fully focuses on adults.

Given that COVID-19 vaccine is given to **** risk adults followed by those those people with comorbidities.

It is likely that it will also divert significant resources from the routine immunisation services that usually would have been used to vaccinate children to delivering vaccines to adults and this service that disruptions and diversion of resources from routine immunisation for children could further exacerbate what we are talking about now.

The disruptions caused by the containment measures to prevent the spread of COVID-19 may also further be precipitated if we continue to divert the resources necessary.

Who can do the childhood immunisation?

This is particularly important in using the human resource given childhood immunisation is given.

With a very limited human resource available in primary healthcare facilities, health centres and community outreach facilities.

As more number of adults come to get vaccinated by COVID-19 vaccines, it is likely that this very limited human resource will be overstretched.

That is why earlier stated if we make this deliberate investment of the COVID-19 investment to actually strengthen this human resource capacity, it will lead to supporting immunisation activities.

But we cannot take it for granted and the usual modality given the need for speed and ability to actually reach the unreached and **** risk population risk COVID-19 vaccine, we risk the likelihood of actually delivering this vertically, investing everything on COVID-19 and COVID-19 vaccine and not necessarily investing on routine immunisation.

So it is essential for all programme implementers and donors and supporters and particularly governments to ensure health system focused investments, primary healthcare strengthening investments are made using the COVID-19 vaccine investments so that it could have a spillover and lasting impact on essential immunisation.

Thank you very much handing to Kate.

[Other language spoken]

Let me just add 2 points to what Doctor Lamongo has described.

I think your question is, is a really good question in the sense that it seems kind of obvious that one can imagine in settings where there's been a significant backsliding in immunisation for kids that you could just use the programme that is trying to deliver COVID vaccines and say, well, let's deliver everything.

[Other language spoken]

That's not what we're seeing.

It's a really complicated thing to go offer at the same place where you're providing COVID vaccines.

And I'll just give you, you know, for anybody who's, you know, been themselves vaccinated as an adult for COVID vaccine, I would venture to guess that absolutely none of those programmes, those were designed and stood up as COVID vaccine programmes.

They're not Co offering vaccines for kids, even though there's backsliding even in in **** income countries, really complicated programmatic thing to start to provide settings where you're both offering adult COVID vaccine and you're offering infant vaccination programmes.

It's not when and where and how kids get vaccines.

And for the most part, the second is so Doctor Mungo really emphasised that it's really the system investments that are being strengthened.

And that's how COVID vaccine can help the, the, the, the full immunisation programme is on those system investments, cold chain investments, data system investments, safety monitoring investments that they of course serve the infant and childhood and adolescent immunisation programme along with an adult immunisation programme.

And then the Third Point I just want to make is we're absolutely seeing that other vaccines are not being introduced in the way that they had otherwise been planned.

So we've pointed out both in our analysis and in our comments here is that new vaccine introductions for in countries where life saving vaccines have not yet been introduced have really fallen off in 2020 because the programme just couldn't do everything that it had planned.

So here you see the pace of new and underused vaccine introductions has just, you know, really fallen off, especially in low income countries shown in the red bars.

We basically had none of them in low income countries.

And you see also in lower middle income countries, the orange bars as well as upper middle income countries in light blue and and less of a problem in **** income countries.

So we really the COVID vaccine effort and COVID pandemic has has the opportunity to strengthen the system.

[Other language spoken]

We aren't seeing sort of Co administration or Co offering of the infant and childhood and adolescent vaccines at the same time and place where the adult Co vaccine programmes, vaccine programmes are being stood up.

[Other language spoken]

Thank you very much.

And I think we have two follow-ups, Stephanie.

First Stephanie Neiberheim, Reuters, you were unmuted, now you muted again.

[Other language spoken]

Let's try Peter Kenny first if that works better.

And then we come back to Stephanie.

[Other language spoken]

So basically there seem to be 3 factors in this vaccine backsliding.

It's one is the financial, 2 is the hesitancy and three is the COVID programmes.

And I'm just wondering, is there any one particular area with children are more endangered in terms of disease like say measles or something like that because of the situation?

[Other language spoken]

So let's start this effort again.

Yeah, I tried to mention earlier the current state of 0 dose children that has been heavily driven by the restrictions of measures taken to prevent COVID-19 pandemic are the main reasons that are actually increased the number of children that missed on vaccination in addition to financial challenge and vaccine hesitance which which for the for the actual blip of increase.

Currently, we have the one we have this year.

It is more attributed to the restrictions and due to the COVID-19 related restrictions we have seen.

I mean, those restrictions ranged from a very simple restriction of closing hours and opening hours of facilities up to a complete lockdown where mobility of communities, cities and countries have been quite limited.

And in those times where in the earlier days of the pandemic, significant health facilities were closed because they weren't sure on how they can provide immunisation services safely.

And many communities have actually prevented themselves from going to the facility, one for lack of transportation services and others for fear of really contracting the disease.

And given that access to protective equipments have not been done much, so many families actually chose to remain at home rather than going to facilities.

And facilities were closed because health workers also were diverted to support COVID-19 pandemic related response related activities.

So the significant decrease in access to vaccines is heavily attributed to the disruptions caused by COVID-19 pandemic.

But the other important issues such as immunisation financing whereby particularly low and middle income countries, which they significantly face given that most of their systems are supported by critical partners and donors, whereby for example, Gabby comes significantly in here.

Particularly access to new vaccine introductions have significantly improved in countries that are supported by Gabby.

And in addition to new vaccines, also response to pandemics, I mean, I mean, response to epidemics and outbreaks have actually also improved into the support by Gavi in this context.

And the other issues related to vaccine hesitancy and misinformation are more explained by the lack of the required information, particularly at community level, which require us to really look into a way of doing business in a much more innovative way in encouraging social listening and implementing community mobilisation activities to encourage more people to access vaccines.

[Other language spoken]

I want to probably highlight a couple of things.

The first is that certainly for diseases that are highly susceptible to outbreaks, So we'll certainly point to measles as you know, this incredibly infectious disease.

And I think, you know, you know, the kinds of metrics on that for every, every person who's a measles case who is in an environment where people are not immune, they will go on to infect and cause somewhere between a dozen and 18 additional cases.

So it's one of these diseases that is highly transmissible.

And unless you're immune, the likelihood given your exposure is that you're going to become a case.

So it those can become really explosive outbreaks really quickly.

Related to that is that we've also seen a weakening of the surveillance for outbreak prone diseases and a weakening of the surveillance for a number of different reasons.

One is the transportation of specimens.

The second is that a lot of personnel have been deployed to COVID surveillance.

So we don't have the strength of vaccine preventable disease surveillance that we did even in in before the the pandemic.

The other point I'd like to make is this point on financial fragility.

So with the with the public health and social measures and all of the interventions that were needed have been needed for COVID, we are seeing absolutely, you know, countries that are backsliding in terms of government income as a result of economic backsliding and government resources based on taxation.

That means that health programmes have fewer resources and, and so you can see the scale on effect of that.

So I think the, the areas of particular concern here are related to the most infectious pathogens.

And we, I really want to highlight polio here as well.

We haven't spoken yet about polio in this press conference, but the number of circulating vaccine preventable disease related polio outbreaks has increased and is really the the battle to get on top of that.

Every CVDPV for polio is a harbinger of under immunisation in that community.

That's why circulating vaccine derived polio cases are circulating.

It's because there isn't immunity in the population.

So, so those would be sort of the two that I think that we would highlight, measles, CVDPVS and then of course we've got yellow fever is the other one of significant concern.

So those would be the primary ones, again pointing back to the financial issues for countries in their immunisation programmes, access to immunisation programmes and the catch up campaigns to get back to those kids who missed out entirely.

[Other language spoken]

So thank you both.

And maybe for a last follow up, Stephanie Nibihai.

[Other language spoken]

I think Kate referred to, you know, more measles incidents in Pakistan.

Is there any other?

[Other language spoken]

And or region that you might point to early evidence.

Of.

You know, higher than usual.

Disease incidents are spread maybe in those ten countries that you cited earlier, which include countries in Africa and Latin America.

[Other language spoken]

Stephanie, I think we're, I'm not sure if we can show it, but we can show the map of the, well certainly CVDPVS.

So you know the, the polio circulating vaccine, Dr polio issues that that is really primary and that is very dominant as you know in Africa.

So that's something that really, really needs to quickly sort of get a handle on.

The second is I'm not sure again if we can just show you the slide which shows the large and and sort of disruptive measles outbreaks that are happening in a in a number of different countries around the world.

And I'm just trying to, sorry, I'm just looking at the data right now as I'm speaking and I'm not 100% sure that these are how contemporary these are.

So I'm going to ask for my technical colleagues on the line again if we can show the slide, not sure we can.

And just speak a little bit about the measles outbreaks around the world that we're seeing in the incidence rates.

So either Marta or Carolina or Jan, and if we can show the side of the large and disruptive measles outbreaks?

I understand the trying, not sure we're getting it there and.

Then just as we're trying to do that also the the other one that I haven't mentioned is diphtheria and you'll remember in 2019 with the the issues in Venezuela on vaccination coverage again diphtheria outbreaks occurring.

So that would be the other one, polio, yellow fever, measles and then diphtheria that we would we would probably mention here.

So I'm not sure we can show the slide, but Stephanie, we can get back to you with with the slide.

So what we will do, what we can do and what we will do also with the interventions that FM and K different giving.

I put the contour link again into the into the chat and it's also the same link we sent around earlier today.

Under that link you will, you should then also be able to find those interventions in the wild where we can post them there.

And just to follow up on that, we can we can follow up with that with that information in that slide.

I think it's just if you actually look at it in a long term perspective, you probably just are in the early cycle of that uptake.

And as I think as Kate mentioned, surveyance is of course already kind of Hanford by kind of the restrictions of the pandemic as well, just like everything else.

But I think also more importantly is that you kind of measles comes in these kind of long multi year cycles.

And actually we're quite early in that, in that uptake.

I think we do see outbreaks in in the usual countries that actually have countries that have outbreaks quite often such as DRC, Pakistan, Nigeria, we can actually prepare that slide and and send that along.

It's not handy now.

All right, then maybe we can go with the last follow up with Gabriella and that's would be the last question for today.

Gabriella, over to you as to unmute Gabriella Sotomayor, please.

[Other language spoken]

Thank you very much.

[Other language spoken]

To say that I think in Mexico there was an outbreak.

Of measles.

So, yeah, I just wanted to ask that.

But yes, yeah, there was a according to to my information, there was a, an outbreak in Mexico.

[Other language spoken]

I just wanted to say that.

[Other language spoken]

I think one important message in here is as long as there is accumulation of unvaccinated children, the likelihood of diseases in our, you know, those outbreaks happening is quite ****, particularly killer diseases such as measles.

And those even those diseases that we thought we have completely eliminated in control, such as diphtheria that had happened in a few countries in Latin America.

And those diseases such as yellow fever, which are which happens usually on a significant adult population that we have seen even in the earlier part of the pandemic in a few African countries.

This, this all happens due to accumulation of children and specific target groups that remain unvaccinated.

And the solution for this is 1 is to really strengthen essential immunisation service so that more children can be accessed.

And in those areas that are hard to reach and can't be accessed, there is a need to design our health service programme to actually be focused on these missed communities and to reach those which remain unreached.

Second is in areas where there is increasing level of unprotected children and and unprotected adolescents, it is important that we conduct catch up interventions by doubling our efforts and at the same time conducting campaign based approaches or persistently intermittent regular campaigns to reach those specific children.

And finally, is outbreak preparedness and outbreak response requires a very strong surveillance system as Kate was earlier highlighting.

And given that considerable human resource and additional resource actually been diverted to do COVID-19 surveillance and COVID-19 prevention and the response, it is important that we invest heavily in really strengthening essential immunisation surveillance activities so that there will be there won't be significant outbreaks that are happening but remain unreported.

It is likely that many countries will report measles outbreaks after some time it happened and these numbers are later we will realise that they are actually significant and measles being one of the actual killer diseases that actually affect children.

Even in the IA 20-30 agenda, we have clearly indicated following up on the coverage of measles and measles outbreak and our capability to improve the state of measles outbreaks would definitely be an essential modality to measure the strengths of immunisation systems.

But as we mentioned measles, the polio is also maybe it's a great issue given that even though we are on the ever lowest.

Where we have only reported two wild polio viruses from Afghanistan and Pakistan over the last over these year.

The growing number of circulating vaccine arriving polio viruses would definitely require attention in all countries that are **** importance.

Thank you and over the case.

[Other language spoken]

Just to wrap up on the Mexico situation, so I mentioned it before that there's a measles rubella campaign going on right now to address the on and under immunised kids in Mexico.

Last year there reported about 200 measles cases and there's no specific quantifiable sort of if you have this number of cases or this rate of measles, that's an outbreak and anything underneath that is not an outbreak.

Outbreaks happen quite locally and then when they get big they can involve.

[Other language spoken]

So as was also written in the chat, there are a number of countries in Latin America that are having relatively still relatively small measles outbreaks.

And the effort, as as Doctor Lamongo said, what we're really emphasising and what countries really need to do is early detection of measles cases and transmission within a geographic area and a rapid response to constrain that outbreak to make it as small as possible.

And so having, you know, either a nationwide or statewide or province wide set of campaigns in countries that know that they're accumulating a lot of kids who have not received measles vaccine is 1 method to assure that the amount of immunity increases.

And so any outbreak that happens can be detected early.

There can be a rapid response and it won't spread to other parts of the country.

So this it's not really an, there's an outbreak, there isn't an outbreak.

Very often outbreaks are localised within a country.

What we really get worried about is when those outbreaks start to spread within a country, they start to spread across borders.

And here is just our the map that we were trying to show you previously of the large and and disruptive measles outbreaks.

Not to say that there aren't outbreaks in other countries, but these are these are the the, the pretty big ones and the ones that are quite as, as we say in this figure are quite disruptive.

[Other language spoken]

Thank you very much also for this last add on the map with this.

We've went well over time because it was very intense, very good briefing.

And I want to thank Doctor from Limongo, the Associate Director and Chief of Immunisation of UNICEF.

[Other language spoken]

And of course, Kate O'Brien, Doctor, Kate O'Brien, the Director for immunisation, Vaccines and Biological.

Thank you very much.

Again, this briefing is under embargo until the contents of the slides until the 15th July, 1:00 AM Geneva time.

Any follow-ups, please come to us and we'll direct either to Doctor Limongo or Doctor O'Brien or see whether we have anything else under the contour link.

As mentioned, we'll try to add the interventions of both of our speakers with this.

Thank you all very much and have a great day.