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1、For Every Child,VaccinationT H E S TAT E O F T H E WO R L D S C H I L D R E N 2 0 2 3Published by UNICEF since 1980,The State of the Worlds Children report seeks to deepen knowledge and raise awareness of key issues affecting children,and advocates for solutions that improve childrens lives.Publishe
2、d by:UNICEF Innocenti Global Office of Research and Foresight Via degli Alfani,58 50121 Florence,Italy Tel:(+39)055 20 330 Email:florenceunicef.org For the latest data,please visit.To access the report online:www.unicef.org/state-worlds-children-2023Suggested citation:United Nations Childrens Fund,T
3、he State of the Worlds Children 2023:For every child,vaccination,UNICEF Innocenti Global Office of Research and Foresight,Florence,April 2023.ISBN:978-92-806-5442-4 United Nations Childrens Fund(UNICEF)April 2023Cover photo:In Yemen,seven-year-old Hind Ali Nasser holds her arm after being vaccinated
4、 as part of an outreach campaign.UNICEF/UN0679338/HayyanTHE STATE OF THE WORLDS CHILDREN 2023 For Every Child,VaccinationAcknowledgementsReport teamBrian Keeley,Editor in Chief;Juliano Diniz de Oliveira,Research and Policy Specialist;Tara Dooley,Editor;Moira Herbst,Editor Special Projects;Rouslan Ka
5、rimov,Data Specialist;Sahiba Turgesen,Assistant Editor/Coordinator;Kathleen Edison,Design Specialist;Dennis Gayanelo,Programme Associate;John McIlwaine,Photo Writer and Editor;and Amanda Marlin,Chief,Editorial and Flagships,UNICEF Innocenti Office of Global Research and Foresight.Technical Report Te
6、am Ephrem T.Lemango,Associate Director,Immunization;Viorica Berdaga,Deputy Chief,Immunization;Deepa Risal Pokharel,Team Leader Demand,Immunization;Ulla Griffiths,Team Leader Financing,Immunization;Niklas Danielsson,Senior Advisor,Immunization;and Jennifer Requejo,Senior Advisor,Statistics and Monito
7、ring.External Advisory Group Alusio Barros,Filimona Bisrat,Tim Crocker-Buque,Thomas B.Cueni,Tom Davis,Gaurav Garg,Githinji Gitahi,Anuradha Gupta,Randa Sami Hamadeh,Firas J.Hashim,Richard Hatchett,Sarah Hawks,Heidi Larson,Orin Levine,Violane Mitchell,Christopher Morgan,Christopher Murray,Kate OBrien,
8、Anna Ong-Lim,Walter Orenstein,Henry B.Perry,Pavani Ram,Helen Rees,Roberta Rughetti,Faisal Shuaib,Robert Steinglass,Mesfin Tessema,Naveen Thacker,Angus Thomson,Oyewale Tomori,Cesar Victora and Fredrick N.Were.Internal Advisory GroupLily Caprani,Liz Case,Lauren Francis,Christopher Gregory,Peter Hawkin
9、s,Benjamin Hickler,S.M.Moazzem Hossain,Alison Jenkins,Andrew Owain Jones,Sowmya Kadandale,Aboubacar Kampo,Priyanka Khanna,Ralph Midy,Padraic Murphy,Daniel Ngemera,Luwei Pearson and Ahmadu Yakubu.Editorial and productionSamantha Wauchope,Head of Production(Global Communication and Advocacy);Ahmed Al
10、Izzi Alnaqshbandi,Arabic Editor;Maud Combier-Perben,French Editor;Elena Munoz-Vico,Spanish Editor;Yasmine Hage and Baishalee Nayak,Fact Checkers;and Guy Manners(Green Ink),Copy Editor.Media,communications and advocacy Imad Aoun,Kurtis Cooper,Tess Ingram and Laura Kerr.Design BlossomPhotography and r
11、eportingVII Photo AgencyStatistical tablesStatistical tables prepared by the Data and Analytics team in the Division of Data,Analytics,Planning and Monitoring:Vidhya Ganesh,Director;Claudia Cappa,Senior Adviser Statistics and Monitoring;Karen Avanesyan,Jan Beise,Jorge Bica,Savvy Brar,Antonio Canavir
12、i,Samuel Chakwera,Joel Conkle,Ayca Donmez,Joao Pedro Wagner De Azevedo,Chika Hayashi,Lucia Hug,Robert Johnston,Munkhbadar Jugder,Yoshito Kawakatsu,Julia Krasevec,Yang Liu,Chibwe Lwamba,Vrinda Mehra,Suguru Mizunoya,Colleen Murray,Nicole Petrowski,Tyler A.Porth,David Sharrow,Tom Slaymaker,Liliana Carv
13、ajal Velez,Dee Wang and Danzhen You.The State of the Worlds Children is produced by UNICEF Innocenti Global Office of Research and ForesightBo Viktor Nylund,Director.Research and policy development This report draws on background papers prepared by:Tim Crocker-Buque and Sandra Mounier-Jack;ve Dub,Pi
14、ppa McDermid and Robert Bhm;Holly Seale;Alyssa Sharkey;Sarah Tougher;and Maliha Ahmad.Cesar Victora and Alusio Barros,with Bianca O.Cata-Preta,Andrea Wendt,Luisa Arroyave and Thiago M Santos,at the International Center for Equity in Health at the Federal University of Pelotas carried out a special s
15、tudy of within-country inequalities in zero-dose prevalence.PATH carried out a survey of innovations in immunization,with inputs from Deborah Atherly,Emily Carnahan,Allison Clifford,Yvette Collymore,Steven Diesburg,Collrane Frivold,Heidi Good,Miren Iturriza-Gomara,Monica Graham,Courtney Jarrahian,La
16、ura Kallen,Manjari Lal,Pat Lennon,Joe Little,Kelsey Mertes,Mercy Mvundura,Lauren Newhouse,Eileen Quinn,Maya Rivera,Joanie Robertson,Laurie Werner and Jessica White.Policy recommendations in this report draw on discussions at For every child,vaccines:UNICEF convening event on immunization,Florence,It
17、aly on 910 June 2022,facilitated by Matter Solutions and hosted by then-Director of UNICEF Innocenti,Gunilla Olsson.This report is the result of collaboration among many individuals and institutions.The report team thanks all who gave so willingly of their time,expertise and energy in particular:THE
18、 STATE OF THE WORLDS CHILDREN 2023UNICEF Country Offices and National Committees Cambodia:Foroogh Foyouzat,Representative,retired;Jaime Gill,Rathmony Hong,Hedy Ip,Raveesha Mugali and Rudina Vojvoda;Ecuador:Luz ngela Melo,Representative;Juan Enrique Quionez,Deputy Representative;Andrea Apolo,Cristina
19、 Arboleda,Magdalena Chvez and Katherine Silva;Haiti:Carine Exantus,Therloune Guerrier,Herold Joseph,Lydie Maoungou Minguiel,Rachel Opota and Ndiaga Seck;India:Luigi dAquino,Zafrin Chowdhury,Madhulika Jonathan,Purvi Malhotra and Sonia Sarkar;Indonesia:Allison Brown-Knight,Brian Clark,Sugiarto Hiu,Jim
20、my Kruglinski,Abdul Khalil Noorzad,Jana Kartika Sari,Ardila Syakriah and Ria Nurrachman(IndoXplore);Iraq:David Hipgrave,Miguel Mateos Muoz,Alaa Rahi,Anmar Rfaat and Falah Wadi;Kyrgyzstan:Christine Jaulmes,Representative;Asylgul Akimjanova,Mavliuda Dzhaparova,Tomiris Orozoeva and Galina Solodunova;Ni
21、caragua:Antero Almeida de Pina,Representative;Eduardo Gallardo,Deputy Representative;Mara Delia Espinoza,Bomar Mndez,Ana Gretchen Robleto and FACTSTORY;Nigeria:Folashade Adebayo,Ijeoma Agbo,Blessing Ejiofor,Geoffrey Njoku and Bolanle Orefejo;Pakistan:Sheeba Afghani,Shoukat Ali,Mehdi Bokhari,Mariam I
22、qbal,Tarana Jahanuddin,Hayat Khan,Mahim Maher and Arifa S.Sharmin;Somalia:Mohamed Jama Fahiye,Abdirizak Abdullahi Haga,Mohamed Hiirad,Lisa Hill,Yodit Hiruy,Abdinasir Adan Ibrahim,Monsen Owusu-Aboagye and Yakub Yahye Khalif;Uzbekistan:Umidjon Khudaykulov and Yuriya Pak;Yemen:Shawki Alabasi,Paul Conne
23、r and Malak Shaher.UNICEF Regional Offices East Asia and the Pacific:Khin Devi Aung;Europe and Central Asia:Svetlana Stefanet;Eastern and Southern Africa:Antoinette Eleonore Ba and Paul Ngwakum;Latin America and Caribbean:Maaike Arts and Leysin De Leon;Middle East and North Africa:Saba Al Abbadi;Sou
24、th Asia:Gunter Boussery and Lalita Gurung;West and Central Africa:Rokhaya Diop and Ulrike Gilbert.Division of Global Communication and AdvocacyNaysan Sabha,Director;Germain Ake,Hemawathy Balasundaram,Marissa Buckanoff,Merva Faddoul,Nicole Foster,Selma Hamouda,Jacob Hunt,William Jones,Debbie Toskovic
25、 Kavanagh,Mary Lynn Lalonde,Maria Lauret,Nicholas Ledner,Pragya Mathema,Mahak Morsawala,Harriet Riley and Alona Volinsky.Private Fund Raising and Partnerships DivisionCarla Haddad Mardini,Director;Christine Murugami.Programme GroupSanjay Wijesekera,Director;Steven Lauwerier,Director Health(ai);Natal
26、ia Winder-Rossi,Director Social Policy;Surangani Abeyesekera,Jennifer Asman,Sanjay Bhardwaj,Genevieve Boutin,Myungsoo Choo,Stanislaus Joseph DSouza,Vivian Lopez,Shahira Malm,Nikhil Mandalia,Phoebe Meyer,Miraj Pradhan,Shalini Rosario,Lauren Rumble,Nateetong Tandideeravit,Sarah Tougher and Sarah Wilba
27、nks.Public Partnerships DivisionJune Kunugi,Director;Valentina Buj,Megan Gilgan and Barbara Renamy.Supply DivisionEtleva Kadilli,Director;Jean-Pierre Amorij,Anthony Bellon,Michaela Briedova,Hans Christiansen,Kristoffer Gandrup-Marino,Soren Munk Hansen,Ian Lewis,Antonia Naydenov,Ann Ottosen and Lilia
28、 Velinova-de Boever.UNICEF Innocenti Global Office of Research and ForesightClaire Akehurst,David Anthony,Patricia Arquero Caballero,Evan Easton Calabria,Arno Johnstone,Josiah Kaplan,Laura Meucci,Daniele Regoli and Ramya Subrahmanian.Special thanks to:Cinzia Iusco Bruschi,Laurence Chandy,Paloma Escu
29、dero and Robin Nandy.From Gavi,the Vaccine Alliance:Anamaria Bejar,Seth Berkley,Olly Cann,Amanda Fazzone Tschopp and Hamzah Zekrya.From the Government of India:Talo Herang.From Lagos State and Lagos State Primary Healthcare Board:Akin Emmanuel and Ibrahim Akinwumi Mustafa.From the Ministry of Health
30、 of Uzbekistan:Shoira Khalilova,Nasiba Tairova,Dilorom Tursunova and Bakhodir Yusupaliev.From the Vaccine Confidence Project:Alex De Figueiredo,Rachel Eagan,Heidi Larson and Martin Wiegand.From the World Health Organization:Raymond Hutubessy and So Yoon Sim.FOR EVERY CHILD,VACCINATION ContentsForewo
31、rd.iKey messages.iiiIntroduction:One in five children.1Case study:Somalia.12Chapter 1.How the COVID-19 pandemic set back vaccination.15How the pandemic set back immunization.16Rising risk of measles.19HPV losses.19Understanding the pandemics impact.20Case study:Indonesia.22Making up lost ground.24Ca
32、tch-up and recovery.24Learning from the pandemic.25The urgency of routine immunization.25A sped-up,coordinated response.26Integrate health crisis response with routine immunization.27Longer-term challenges.27Case study:Cambodia.28Chapter 2.Zero-dose children matter.31Left behind:socioeconomic determ
33、inants of immunization.32Poverty.32Location.33Marginalization.35Crisis.37Case study:Nigeria.38Availability,accessibility and affordability.40Solutions.41Why it matters.42Survive and thrive.42The value of vaccination.42Making the case.43Case study:Nicaragua.44Chapter 3.Immunization and primary health
34、 care.47Structures and challenges.48Weak primary health care.48Health workforce.49Case study:Yemen.50Solutions.53Strengthen primary health care.53Integrate immunization in primary health care.53Community engagement.55Case study:Pakistan.56 THE STATE OF THE WORLDS CHILDREN 2023Support for health work
35、ers.58Next steps.59Case study:India.60Chapter 4.How can we build vaccine confidence?.63Shaken trust.65The impact of COVID-19.69Motivation and hesitancy.69The toll.71Case study:Kyrgyzstan.72Building vaccine confidence.74Community engagement,dialogue and ownership.74Social data and social listening.76
36、Pro-vaccine education and public messaging.77Applying a gender lens.78Case study:Ecuador.80Chapter 5.Funding and innovation for the future.83Funding:The current situation.84Economic instability.84Government budgets.85Financing immunizations future.86Funding.87Partnerships.87Challenges.87Solutions.88
37、Commitment.89Case study:Uzbekistan.90New vaccines and products.92Recent vaccine developments.92Vaccine product developments.94Logistics and supply chain innovations.95Digital tools.95Strengthening local manufacturing.97Case study:Haiti.98Chapter 6.For every child,vaccination:An equity agenda.101Intr
38、oduction.102For every child,vaccination:An equity agenda.1031.Vaccinate every child,everywhere.1032.Strengthen demand for and confidence in vaccination.1043.Spend more and spend better on immunization and health.1054.Build resilient systems and shockproof them for the future.106Endnotes.108Statistic
39、al tables.115FOR EVERY CHILD,VACCINATION Catherine RussellUNICEF Executive Directori THE STATE OF THE WORLDS CHILDREN 2023ForewordHuman history is full of stories of disease and pestilence.But the story of vaccines has radically altered the course of human survival and development.Almost 80 years ag
40、o,Europe struggled to recover from a catastrophic war.Millions of people crowded into wrecked buildings and dugouts conditions that were ripe for outbreaks of infectious disease.Tuberculosis(TB)was particularly infectious and virulent in communities across the continent.Children were especially vuln
41、erable,with thousands suffering debilitating fever,weight loss,chest pain,even death.Until then,diseases like smallpox,measles and polio frequently ravaged large segments of the human population,claiming the lives of countless children in the process.But this time was different.Equipped with vials o
42、f BCG,the vaccine that helps protect against TB,teams of medical workers fanned out across Europe to save lives.By 1950,some 11.4 million children had been vaccinated against the disease through the UNICEF-supported campaign.It marked the beginning of a new era in which the lives of millions of chil
43、dren would be protected from vaccine-preventable diseases.Fast forward to 1980.The first-ever edition of The State of the Worlds Children report stated that“in the poorest countries only one child in ten will ever see a trained health worker or be immunized in its first year against diphtheria,tetan
44、us,measles,tuberculosis,pertussis or poliomyelitis the six most common preventable diseases of childhood.”This finding was deeply troubling,but there were signs of hope and progress in immunization.That same year,smallpox was finally declared eradicated,demonstrating the remarkable power of vaccines
45、 to save lives.That success helped inspire a global programme to protect more of the worlds children against other life-threatening diseases measles,diphtheria,pneumonia and more.By the end of the 1980s,about 7 in 10 of the worlds children were protected by vaccines,and that number continued to clim
46、b,albeit more slowly,in subsequent decades.UNICEF played its part,and we still do.Today,we supply vaccines that reach 45 per cent of the worlds children under 5 years of age.In 2020,the COVID-19 virus continued to spread around the world lives were lost and put on hold,schools closed,health systems
47、were pushed to their limits and beyond.But in an extraordinarily short period of time,vaccines were developed,and mass vaccination campaigns began.Again,UNICEF was there.With our partners Gavi,the Vaccine Alliance,the World Health Organization(WHO)and the Coalition for Epidemic Preparedness Innovati
48、ons(CEPI),we are part of the largest vaccine supply operation in history,providing almost two billion vaccine doses to 146 countries and territories.In addition,we have supported the development of technology that keeps vaccines cold as we move them to the most remote regions of the world,and we hav
49、e worked hard to increase trust in the safety and efficacy of vaccines.FOR EVERY CHILD,VACCINATION iiFor almost 80 years,UNICEF has worked with international partners,national governments and many others to protect children against vaccine-preventable diseases.But,in a world slowly recovering from t
50、he COVID-19 pandemic,we know that the approaches we have taken in the past may not always be suited for current or future circumstances.Despite decades of progress in childhood immunization,our collective efforts are falling short.Put simply,we are not meeting our goal to vaccinate every child.While
51、 new vaccines have been introduced that broaden protection against disease,none have managed to reach more than 9 out of 10 children.Many are not even coming close only one in eight girls has received the HPV vaccine,which protects against cervical cancer.The pandemic has only darkened this picture.
52、In the past three years,more than a decade of hard-earned gains in routine childhood immunization have been eroded.Getting back on track will be challenging.The shadow of the pandemic will hang over economies for years to come,forcing tough choices in spending and investment.Another challenge looms
53、too:Confidence in vaccines seems to be waning in many countries.While vaccine confidence is far from being the most important determinant of vaccine demand in most communities,the apparent rise in hesitancy cannot be ignored.Reaching our goal to vaccinate every child will require a real commitment b
54、y governments.Some of this change will be technical making better use of data,improving communication and outreach,and strengthening cold chains.Some will require difficult conversations about financing and challenging trade-offs,including by national governments,donors and others,on how best to fun
55、d primary health care and immunization services and how to make them more resilient to future shocks.And some will force societies and communities to examine their fundamental values.Children from marginalized communities are among the least likely to be vaccinated.Whether or not they are vaccinated
56、 is often a result of deep inequities between rich and poor,between men and women,between communities at the centre of power and communities on the margins.Achieving the change needed to vaccinate every child will not be easy.But the achievements of the past 80 years should give us hope.Time and aga
57、in,the world has made remarkable progress in immunization,often in the most difficult and challenging circumstances.Those achievements have transformed our world.They have allowed millions of children to survive and to live lives free of the lingering effects of illness.They have relieved families o
58、f the heartache and financial burden of caring for sick children.And they have added to the human capital,talent and energy of our societies.In the years to come,we can achieve even more.New vaccines are already helping in the war against malaria.There will likely be more soon,including against chro
59、nic diseases such as cancer and Alzheimers disease.Our journey has been long but,in many ways,it is only just beginning.iii THE STATE OF THE WORLDS CHILDREN 2023KEY MESSAGE 1Vaccines save livesVaccines save lives,but far too many children in the world are not being vaccinated.The COVID-19 pandemic o
60、nly added to their numbers.The children who are missing out live in the poorest,most remote and most marginalized communities.To reach them,it is vital to prioritize investment in primary health care and in the health workers mostly women who deliver services.It is essential,too,to build confidence
61、in vaccines and to make the most of a host of new ideas and technologies that can boost the power of vaccines and ensure they reach every child.Over the past decade or so,despite growing efforts to expand immunization,there has been little progress in reducing the number of zero-dose children.Reachi
62、ng every child remains a challenge.Figure 1.Zero-dose children globally,20002021Source:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.children have no protection at all against measles,a childhood killer.eligibl
63、e girls are not vaccinated against human papillomavirus(HPV),which can cause cervical cancer.children are zero-dose(unvaccinated)and under-vaccinated,leaving them vulnerable to a range of vaccine-preventable diseases.Number of zero-dose children,millions2000205202522.315.418.21 in 51 in 5
64、AroundAround7 in 8 FOR EVERY CHILD,VACCINATION ivKEY MESSAGE 2When we dont vaccinate children,we risk their lives and health as well as our societies growth and developmentVaccines help children thrive,support families and caregivers,and benefit the health of the wider communityVaccines deliver an u
65、nrivalled return on investmentBeing immunized protects children against illness.That helps prevent absences from school,which improves learning outcomes.Families are also less likely to face the emotional pain and sometimes catastrophic costs of caring for a sick child.When children are protected ag
66、ainst illness,parents and caregivers mostly mothers need to take less time off work to care for sick children.Vaccinating children supports the health of the wider community by promoting herd immunity and helping to limit the spread of antimicrobial resistance.Before the introduction of a vaccine in
67、 1963,measles killed an estimated 2.6 million people globally every year,mostly children.By 2021,that had fallen to 128,000 still too high,but a remarkable improvement.Vaccines save every year,a figure that could rise to Every dollar spent on vaccination delivers a return on investment of US$26.by 2
68、030 if the goals of the Immunization Agenda 2030(IA2030)are met.4.4 million lives US$265.8 millionv THE STATE OF THE WORLDS CHILDREN 2023KEY MESSAGE 3The COVID-19 pandemic set back childhood immunization around the world67 million children UNICEF estimates that missed out entirely or partially on ro
69、utine immunization between 2019 and 2021;of them missed out entirely.Disruptions caused by the pandemic interrupted childhood vaccination almost everywhere,setting back vaccination rates to levels not seen since 2008.What can be done?Catch-up and recovery:Children born just before or during the pand
70、emic are now moving past the age when they would normally be vaccinated.Urgent action is now needed to catch up on those who missed out on vaccination and to support the recovery of immunization services set back during the pandemic.48 millionFigure 2.The number*of children who missed vaccination ro
71、se during the COVID-19 pandemicSource:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.*Numbers are rounded.Why did the pandemic set back childhood immunization?It placed huge new demands on health systems,which t
72、hey were often ill-equipped to cope with.It exacerbated existing shortages of health workers.It placed heavy strains on front-line health workers,mostly women,who were also coping with additional care burdens at home.0502019Zero-doseVaccination statusUnder-vaccinated16.56.422.913.35.919.1
73、202118.26.825Number of children(millions)Stay-at-home recommendations and the fear of contracting the virus from health-care facilities led families to put off vaccinating children.FOR EVERY CHILD,VACCINATION viKEY MESSAGE 4But even before the pandemic,far too many children missed out on vaccination
74、.Many live in the poorest and most marginalized communitiesThe story of the children who are not being vaccinated is a story of inequity,poverty,underserved communities and unempowered womenUnderserved communities face challenges of availability,access and affordabilityUnderserved communitiesAvailab
75、ilityAre vaccines delivered to health centres or outreach campaigns and are health workers there to administer them?AccessibilityAre vaccines and services located in a place and offered at a time where and when children and families can get to them?Many zero-dose and under-vaccinated children live i
76、n challenging settings,such as remote rural communities,built-up urban settlements,and areas experiencing conflict and crises.2 in 5 of the children in the world who had not been immunized lived in conflict-affected or fragile settings(in 2018).These challenges are greatest in low-and middle-income
77、countries,where about 1 in 10 children in urban areas are zero-dose;the figure is just under 1 in 6 in rural areas.In upper-middle-income countries,there is almost no gap in between urban and rural children.AffordabilityCan families afford health service,pay for bus fares or skip a days work to get
78、to the health centre?Unempowered womenChildren of mothers with no or little education are much less likely to be vaccinatedMothers with:Proportion of zero-dose childrenNo education23.5%Primary school education13.1%At least secondary school education6.9%PovertySource:Victora,Cesar,and Alusio Barros,W
79、ithin-Country Inequalities in Zero-Dose Prevalence:Background paper for The State of the Worlds Children 2022,International Center for Equity in Health,Federal University of Pelotas,Brazil,December 2022.In the poorest households,just over 1 in 5 children are zero-dose;in the wealthiest,it is just 1
80、in 20.In some regions,the gap is even greater:In West and Central Africa,almost 1 in 2 children in the poorest households are zero-dose,compared with around 1 in 16 in the wealthiest.vii THE STATE OF THE WORLDS CHILDREN 2023KEY MESSAGE 5To vaccinate every child,it is vital to strengthen primary heal
81、th care and provide its mostly female front-line workers with the resources and support they need Many children miss out on vaccination because they live in places where there is no or limited primary health care a health-care approach that includes health promotion,disease prevention and treatment.
82、Vaccine campaigns play a powerful role in reaching many of these children,and they will continue to do so.But campaigns are,by definition,short-lived,and they have inherent limitations because they do not necessarily offer continuous and predictable services.Integrating childhood immunization into s
83、trengthened primary health is essential to sustainably reach the goal of vaccinating every child.Support health workersAs health workers and community health workers,women are at the front line of delivering vaccinations,but they face low pay,informal employment,lack of career opportunities and thre
84、ats to their security.Far too few are in leadership positions.Responses need to include:Offering full-time jobs with good and regular pay and decent working conditions Providing career development and training opportunities,including in the integrated management of childhood illness Recognizing and
85、regularizing the role of community health workers.Integrate servicesAs a well-established point of contact with families,vaccination services can be an entry-point for providing additional essential health services.Equally,strong primary health-care systems can contribute to vaccination efforts,prov
86、iding platforms to reach those left behind.Engage with communitiesVaccination interventions designed,delivered and evaluated by members of the communities they serve can increase equity and efficacy.Prioritize financing immunizationEven in a time of tight budgets,the high returns on investment from
87、immunization underscore the benefits of prioritizing funding.FOR EVERY CHILD,VACCINATION viiiKEY MESSAGE 6Parents and communities need to believe in the value of vaccination;there are worrying signs that confidence in vaccines is slipping in some countriesEngage with communities and promote dialogue
88、Engagement can also stem the influence of rumour and misinformation and bolster widespread support for immunization.Dialogue can help foster trust,opening the door for people to share their feelings and concerns about vaccination.Support health-care providers to make an impactHealth-care providers a
89、re a trusted voice on vaccines.Motivating and equipping immunization providers and the community health workers supporting them to have impactful conversations about vaccination is essential.Carry out social listeningSocial listening investing in understanding peoples attitudes to vaccines in real t
90、ime is vital.Approaches can include carrying out regular surveys and monitoring debates and discussions on social media.Empower women and girlsUnderstanding how gender impacts vaccine uptake can help with the design of more effective programmes,as well as education and information campaigns.To bolst
91、er vaccine confidence,strong efforts are needed to:Data collected before and during the COVID-19 pandemic indicate declines in the perception of the importance of vaccines for children in many(but not all)countries for which data are available(see Figure 3).Confidence levels appear to have declined
92、more in younger than in older age groups.Vaccine confidence is notoriously volatile,and any trends are time and location specific.But any signs of broader loss of confidence need to be taken seriously.Trends in vaccine confidenceix THE STATE OF THE WORLDS CHILDREN 2023Figure 3.Confidence that vaccin
93、es are important for children dropped after the start of the pandemicPercentage of population that currently(most recent year)perceive vaccines as important for children and percentage point change before and after the start of the pandemic.Source:UNICEF analysis based on data from The Vaccine Confi
94、dence Project,London School of Hygiene&Tropical Medicine,2022.ChinaIndiaMexicoSwedenViet NamArgentinaNigerIrelandPortugalItalyPeruLuxembourgAustraliaSpainGermanyCanadaFinlandDenmarkMaliRomaniaTrkiyeBrazilPolandAustriaIndonesiaCyprusFranceGreeceCzechia Democratic Republic of the CongoUnited States of
95、 AmericaMongoliaBelgiumNigeriaEstoniaMalaysiaLithuaniaSyrian Arab RepublicSloveniaMaltaBulgariaRussian FederationNetherlands(the Kingdom of)HungaryPakistanPhilippinesSlovakiaLatviaCroatiaSouth AfricaJapanSenegalGhanaPapua New GuineaRepublic of Korea504030201001095%98%93%88%97%91%90%86%92%85%88%86%86
96、%89%81%82%89%87%88%84%85%89%80%75%78%82%75%81%76%81%79%79%72%79%72%67%69%77%69%70%63%54%70%74%64%71%61%59%60%62%54%63%60%46%48%FOR EVERY CHILD,VACCINATION xKEY MESSAGE 7Overcoming fiscal constraints in low-and middle-income countries is essential to remove significant obstacles to providing vaccinat
97、ion services Overall,governments are the largest contributors to immunization,but donors provide other essential funds.The amount governments allocate is not always the same as what is actually spent.Problems can include revenue projections falling short,shifting of funds to meet other needs,delays
98、in procurement,and coordination issues.Further strengthening of health and finance systems is essential to ensure funds are spent efficiently.The COVID-19 pandemic helped change the landscape for vaccine development The speed with which vaccines were developed and produced during the pandemic offers
99、 important lessons for faster vaccine development and approval.Several new vaccines are emerging and one has already been approved to protect children against malaria,which kills nearly half a million children each year.Innovations in producing a new pneumococcal conjugate vaccine(PCV),which helps p
100、rotect children from pneumonia,look set to cut the cost of the vaccine and improve supplies.Innovations in vaccine supply chains will help improve access to vaccines in remote areas Small temperature-sensitive indicators on vaccine vials allow health workers to monitor vaccines for heat exposure.Dro
101、nes are being successfully used to deliver health commodities in some African countries.Digital technologies are helping to improve the quality and timeliness of data Electronic immunization registries can ensure the right child receives the right vaccination at the right time.Mapping systems using
102、big data from vaccinators phones can help ensure communities in need are being identified.Sending text-message reminders to parents can help raise vaccination rates.Vaccinating every child means investing in new approaches to strengthen financing and make the most of scientific and technological inn
103、ovations2 THE STATE OF THE WORLDS CHILDREN 20232 THE STATE OF THE WORLDS CHILDREN 2023In Nigeria,Victoria Aina became worried about her granddaughter Toluwalase when she no longer ate her favourite foods.A neighbour spotted Toluwalase in the street and recognized that the little girl had measles.Tre
104、atment followed,and Toluwalase recovered.UNICEF/U.S.CDC/UN0671473/Nelson Apochi Owoicho 1INTRODUCTIONOne in five childrenOn a mat in a tenement in Lagos,a little girl is sleeping.Her forehead and arms are covered with fading scars.A few months earlier,the girl fell ill with a high fever and develope
105、d a skin rash.Her grandmother,Victoria Aina,who cares for her,was concerned.2 THE STATE OF THE WORLDS CHILDREN 2023“I became worried when she stopped eating her favourite meals,”she said.“Toluwalase loves bread and beverage.I was alarmed when she shunned them.”Someone in the neighbourhood spotted To
106、luwalase in the street and diagnosed her illness:measles.Treatment followed,and the girl recovered.Toluwalase was lucky.Many other children are not.Measles is a killer.Often dismissed as just one of those things that children get a rash and a fever that clears in a few days measles claims around 351
107、 lives every day,mostly children.1 Children who catch the highly contagious disease are at risk of pneumonia and of longer-term consequences such as brain damage,deafness and blindness.2Since the introduction of a vaccine in 1963,infections and deaths from measles have been preventable.That vaccine
108、has helped to transform childhood.Before its introduction,measles claimed around 2.6 million lives every year and was the leading cause of childhood blindness in low-income countries.3 Over the past two decades,immunization against measles is estimated to have saved more than 31 million lives.4 But
109、far too many children are still not getting the protection they need against measles and a raft of other serious diseases.For the little girls grandmother,the lesson is simple:“Children should be vaccinated.”The children left behindToluwalase is not alone.In remote rural villages,in city slums,in co
110、nflict and fragile settings,and in many other places around the world,far too many children are not getting the vaccines they need to protect them against serious disease.In 2021,just over 25 million children were estimated to be either unvaccinated zero-dose or under-vaccinated(see Box 1).5 Like To
111、luwalase,many of these children come from the poorest families and communities.Their lives are often marked by multiple deprivations,with limited access to basic services,such as clean water,education and crucially primary health care(see Chapter 2).Just as it did with so many other aspects of life,
112、the COVID-19 pandemic severely disrupted childhood immunization.Between 2019 and 2021,UNICEF estimates that 67 million children missed out entirely or partially on routine immunization;48 million of them missed out entirely.6 In percentage terms,the share of vaccinated children fell 5 percentage poi
113、nts to 81 per cent.In other words,around one in five children worldwide were not fully protected against vaccine-preventable diseases.7 Worryingly,the backsliding during the pandemic came at the end of a decade when,in broad terms,growth in childhood immunization had stagnated(see Figure 1).For the
114、sake of children like Toluwalase,and children everywhere,we must do better.Box 1 Understanding zero-doseZero-dose and under-vaccinated have become key concepts in explaining immunization coverage,in aligning global efforts to improve vaccine coverage,and for monitoring success.What do they mean?Zero
115、-dose refers to children who have not received any vaccinations.Most live in communities that experience multiple deprivations(see Chapter 2).Under-vaccinated refers to children who have received some,but not all,of their recommended schedule of vaccinations.To calculate the numbers of zero-dose and
116、 under-vaccinated children,a proxy measure is used.Children who have not received the first dose of the diphtheria,tetanus and pertussis(DTP1)vaccine are described as zero-dose.Children who have received DPT1 but not the third dose(DTP3)are described as under-vaccinated.Children typically receive th
117、ese vaccines in the first year of life.In general terms,therefore,where data for zero-dose and under-vaccinated children are presented in percentage terms,these numbers represent percentages of surviving infants(rather than the entire child population).FOR EVERY CHILD,VACCINATION 3Figure 1.Backslidi
118、ng in vaccination coverage during the pandemic came at the end of a decade that saw little growthPercentages of under-vaccinated children,19802021Figure 2.Children in parts of Africa and South Asia are at higher risk of not being vaccinated Zero-dose and under-vaccinated children by UNICEF programme
119、 regions,2021FOR EVERY CHILD,VACCINATION 30Zero-dose children(millions)Under-vaccinated children(millions)West and Central AfricaEastern and Southern AfricaSouth AsiaEast Asia and the PacificLatin America and CaribbeanMiddle East and North AfricaEurope and Central Asia6.854.63.92.41.40.312345687Sour
120、ce:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.Source:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.0199520
121、00200520%10%20%30%40%50%60%70%80%90%100%DTP3 coverage Initial growthSlower growthPlateau81%81%76%86%4 THE STATE OF THE WORLDS CHILDREN 2023In countries around the world,governments,donors and partners are working with communities on solutions:They are reaching out to immunize the most mar
122、ginalized children and provide essential primary health care services.3 HAITIMona Yvrose Jean Claude,a nurse at Sacr Coeur Health Centre for more than 10years.“To improve immunization in our health centre,it would be helpful to renew our multi-skilled community health workers and have the possibilit
123、y of creating assembly stations and carry out mobile clinics.”1 NICARAGUAReynilda Cramer,part of a team of community nurses from the Miskito community who visit children in their homes.Children are given routine vaccines according to their schedule,their height and weight.Furthermore,heights are tak
124、en,deworming and vitamins are administered if appropriate.If anyone else in the family has health problems,we also take care of that other person.”2 ECUADORMaria Catucuago,part of a corps of indigenous volunteers who keep watch over the health and well-being of children under the age of 5.“I feel pa
125、ssionate about helping others.For many years,I have been involved in community activities that promote the well-being and health of families.”213FOR EVERY CHILD,VACCINATION 56 KYRGYZSTANMirlan Dezhyusubekov,an imam who works with the Kaiyrma village community health committee.“From a religious point
126、 of view,we cannot judge parents decisions to vaccinate or not to vaccinate their children.But I tell families that I was vaccinated,as well as my children,and we have all been well.”10 SOMALIAMaimuna Hussein,a nurse and head of the Jilab Health Centre,part of the Jilab camp for internal displaced p
127、ersons.“Antenatal care is very,very important.It is the entry-point when the mothers get a private consultation.That is why you need to give them more time.”7 CAMBODIAPyun Kunthea,a government health worker who immunizes children in a remote community.“Just 20 years ago,preventable diseases were sti
128、ll common.Things got better,but it was still difficult to reach villages like this,which were distant from health centres.Also,people lacked confidence in vaccines because they werent always given information in their own language.Thats changed.”8 INDONESIAIrwan Hakim,a community clinic nurse who wo
129、rks on routine immunization outreach in a remote island community.“Fathers are the decision makers of the household here.Im lucky Im from a neighbouring island and I can speak local dialect so its easier to communicate with them.”5 UZBEKISTANUmida Djuraeva,a nurse who administers the HPV vaccine at
130、the Central Multidisciplinary Policlinic of Kibray.“Nowadays,people come voluntarily.They have realized the vaccine is safe and tolerated well.”4 YEMENGhada Ali Obaid,midwife and vaccinator,who has witnessed needless suffering when children are not vaccinated.“The essence of our work is saving peopl
131、es lives and reducing the suffering of women and children.Personally,this is the most significant indicator of success in my work and life.”Most often,the goals are realized by health workers,especially women.9 INDIADematso Khamblai,a health worker who is part of the Alternative Delivery System,whic
132、h brings vaccines to remote areas by foot.“It becomes dangerous during the monsoon season as rains make the trek slippery.There are also frequent landslides during the monsoon season,which make the trek tough.”56978104We can do betterImmunization is one of humanitys most remarkable success stories.I
133、t has saved countless lives.Many more lives will be saved if the ambitious but realizable goals of the Immunization Agenda 2030(IA2030)are achieved.This global strategy for increasing vaccination coverage aims for a world where“everyone,everywhere,at every age,fully benefits from vaccines for good h
134、ealth and well-being”(see Box 2).8 By helping to protect against some of humanitys greatest scourges,immunization allows children everywhere to live lives free of many forms of disability.Immunization has led to the eradication of smallpox,a disfiguring and often fatal disease that in the twentieth
135、century alone claimed an estimated 300 million lives.9 There has been remarkable progress,too,on the long road to eradicating polio:Today,most of us live in countries that are free of a disease that once robbed so many people of the ability to walk.10The power of immunization was demonstrated again
136、in the COVID-19 pandemic.The disease claimed 14.9 million lives directly and indirectly in 2020 and 2021,according to the World Health Organization(WHO),and disrupted many more lives around the world,especially childrens.11 The development of vaccines against COVID-19,many using innovative technolog
137、ies(see Chapter 5),has essentially allowed life to return to normal in much of the world.While it has taken far too long to get those vaccines to people living in the poorest countries,the global impact is still astounding:Already,at least two thirds of the worlds population has been immunized again
138、st COVID-19.12 Those vaccines have prevented an estimated 20 million deaths globally.13The achievements of mass immunization and the development of the COVID-19 vaccines are all the more remarkable considering how quickly they happened.Following the identification of the COVID-19 virus in December 2
139、019,it took only a year for the first vaccine against COVID-19 to be authorized.14 Within another year,it is estimated that more than half of the global population had received at least one dose of a COVID-19 vaccine.15 These examples demonstrate that public demand,scientific innovations and perhaps
140、 above all political will can drive rapid change.We must do more,and we must do better,nowThat change is needed,and it is needed now.The backsliding in immunization during the pandemic should sound an alarm bell.As the 67 million children who missed out on vaccines over the past three years pass the
141、 age when they would routinely be immunized,it will require a dedicated effort to ensure that they catch up with their vaccinations(see Chapter 1).Box 2 Immunization Agenda 2030The Immunization Agenda 2030(IA2030)is the international communitys vision and strategy to ensure that immunization leaves
142、no one behind over the next decade.This ambitious global strategy aims to halve the number of children who miss out on essential vaccines and to achieve 90 per cent coverage for key life-saving vaccines.Overall,if the agenda is met,it will save an estimated 50 million lives in this decade.16 The str
143、ategy also targets a major increase in the introduction of new vaccines in individual countries.Between 2010 and 2017,some 116 low-and middle-income countries introduced at least one new vaccine.17 Worryingly,however,none of the newer vaccine introductions,such as the second dose of measles vaccine
144、and the vaccine against rotavirus(a virus that can cause diarrhoea and vomiting in children and lead to death),have achieved global coverage above 90 per cent.18 The pandemic set progress back still further,with marked slowdowns in vaccine introductions in 2020(other than COVID-19 vaccines),followed
145、 by only a slight pick-up in 2021.19 The IA2030 sets a target of 500 introductions of new or under-used vaccines.20 Strengthening the role of health systems in immunization is a key pillar of IA2030.The global strategy also emphasizes the role of immunization as a key part of people-centred primary
146、health care services.And it places countries at the centre of the strategy,emphasizing the core role of national governments in ensuring citizens are immunized.21 6 THE STATE OF THE WORLDS CHILDREN 2023FOR EVERY CHILD,VACCINATION 7The backsliding is worrying not just in itself,but also for what it r
147、epresents.It highlighted the reality that the story of zero-dose and under-immunized children is overwhelmingly a story of inequities.In Angola,Nigeria and Papua New Guinea,a child from the wealthiest group in society is at least five times more likely to be vaccinated than one from the poorest grou
148、p(see Chapter 2).The children who are not vaccinated are also often the children of mothers who have not been able to go to school and who are given little say in family and spending decisions.The pandemic also exposed and exacerbated persistent weaknesses in health systems and primary health care,w
149、hich are key to ensuring children are vaccinated.Key resources were diverted to respond to the pandemic,which,along with many other factors(see Chapter 1),contributed to the backslide in routine immunization.But even before the pandemic,far too many primary health care systems suffered from a lack o
150、f skilled health workers,limited access to essential supplies and equipment,weak capacity for collecting and using data and conducting disease surveillance,and shortages of key medicines and vaccines at the local level.These systems also faced barriers to using available resources efficiently and ef
151、fectively.The pandemic highlighted the difficulties facing women working in health-care and immunization programmes.Although they form the bulk of the health workforce,they have long been underrepresented in leadership roles,denied opportunities for training and professional advancement,and have fac
152、ed the risk Figure 3.Top 20 countries with the largest numbers of zero-dose childrenZero-dose children by number and percentage of the countrys child population,2021Source:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,Ju
153、ly 2022.010%20%30%50%40%60%Democratic PeoplesRepublic of KoreaMyanmarSomaliaThe PhilippinesAngolaMadagascarMozambiqueNigeriaEthiopiaChadIndonesiaBrazilAfghanistanCameroonDemocratic Republicof the CongoUnited Republicof TanzaniaMexicoViet NamIndiaPakistanPercentage of zero-dose childrenNumber of zero
154、-dose chilren0.5 million1 million1.5 million2 million2.5 millionof violence and gender-based violence in doing their jobs.The pandemic only exacerbated these challenges.Many women health workers faced the additional burden of balancing an increased workload with extra family responsibilities,such as
155、 looking after children locked out from school.If primary health care is to become more resilient,the needs and potential of women health workers must be better recognized.They need more opportunities for full-time rather than short-term and ad hoc employment and for training and professional develo
156、pment.They also need to be better represented in leadership roles,so that decisions at the top of health systems better reflect the realities faced by the people who account for the vast majority of health workers on the ground.The pandemic also brought fresh attention to vaccine hesitancy.A multifa
157、ceted challenge,vaccine hesitancy or the state of being undecided or uncertain about vaccination is only one of many barriers to families seeking out vaccines for children.22 But it is a challenge that new data presented in this report show needs greater attention.The data,from the Vaccine Confidenc
158、e Project,show that confidence in the importance of vaccines for children was lower after the emergence of the pandemic than before in most countries for which data are available(see Chapter 4).The declines were generally greater among younger people than older people.Even before the pandemic,vaccin
159、e hesitancy was identified as one of the top ten threats to global health.23 The influence of a number of factors,including growing access to misleading information on social media,declining trust in authority in some parts of the world,and political polarization,24 suggest this threat may only be g
160、rowing.The consequences of failureFailure to protect children against disease has serious consequences.Put bluntly,children die,and many more suffer lifelong disabilities.Unfortunately,the world continues to see far too many outbreaks of vaccine-preventable diseases.In 2022,for example,the number of
161、 measles outbreaks was double the total in the previous year(see Chapter 1).25 Meanwhile,the discovery of poliovirus in Israel,the United Kingdom of Great Britain and Northern Ireland,and the United States of America in 2022 was a reminder that even remarkable progress against a disease like polio c
162、an be put at risk if we fail to vaccinate every child.In other words,no one is safe until everyone is safe.26 The consequences of failing to vaccinate children may become more severe in years to come.Climate change risks exposing new communities to infectious diseases such as malaria,dengue and chol
163、era,and may alter seasonal disease patterns.Increasing risk of overlapping climate crises,including droughts,heatwaves and floods,will put further strain on childrens access to essential services,including clean water and primary health care.27 Also of long-term concern is the rise of drug-resistant
164、 infections(see Chapter 2).28 Failure to immunize children undermines their right to what the Convention on the Rights of the Child describes as“the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health.”29 8 THE STATE OF T
165、HE WORLDS CHILDREN 2023FOR EVERY CHILD,VACCINATION 9And it sets back still further the prospects of attaining the Sustainable Development Goals(SDGs).Immunization is key to achieving SDG 3,which aims to“ensure healthy lives and promote well-being for all at all ages.”But it is also linked to 13 of t
166、he other SDGs.For example,by supporting childrens cognitive development and education attainment,it can drive progress on SDG 4 delivering quality education.30 In that sense,immunization is at the heart of our collective commitment to achieve a better and more sustainable future for us all.A time fo
167、r political willMuch will have to happen if we are to protect every child against vaccine-preventable disease.The needs are complex,even daunting.They will become even more so if vaccines are to reach children in those places that are often overlooked the remote village miles from the nearest road,t
168、he urban slum where newly arrived families live in anonymity,the warzone where families do not know where they will be sleeping tomorrow night.But overriding them all is one single necessity:political will.Nothing will happen unless we garner the political will globally,nationally and locally to pro
169、tect children against vaccine-preventable diseases.That will should be grounded in optimism.The emergence of mass immunization in the 1980s and the development of COVID-19 vaccines show we can make progress,and we can make progress quickly.Encouragingly,and despite the setbacks it caused to childhoo
170、d immunization,the pandemic may also have helped lay the groundwork in some countries for faster progress.For example,investment in cold chains to distribute COVID-19 vaccines,the emergence of innovative approaches to vaccine development and delivery,and the use of advanced data collection technique
171、s to keep track of vaccine doses and vaccinations all have the potential to support childhood immunization in the years to come.Political will should also be grounded in the realization that immunizing children makes economic sense.At an average cost of about US$58 per child in low-and middle-income
172、 countries,the standard course of vaccines can contribute enormously to protecting against disease and lifelong disability.31 But it does much more than that.For example,it can help to protect families livelihoods:Families,especially the poorest,can face catastrophic costs if parents have to take ti
173、me off work to care for a sick child or pay for health care.Longer term,protecting children against disease can result in huge savings in spending on health care,and can support societies and economies in developing human capital and productivity.32 Despite shrinking national budgets in some countri
174、es,immunization must remain a priority because it is a proven strategy for reducing future health-care costs and it supports economic growth.33 Continued and sustainable investment in immunization as part of health budgets is essential.But governments and donors need to work together to improve the
175、efficiency and effectiveness of planning,budgeting and service delivery.34 Now is a time for determination.Now is a time for political will.Now is the time to protect the health of every child.Despite shrinking national budgets in some countries,immunization must remain a priority because it is a pr
176、oven strategy for reducing future health-care costs and it supports economic growth10 THE STATE OF THE WORLDS CHILDREN 2023About this reportThe State of the Worlds Children 2023 examines what needs to happen to ensure that every child,everywhere is protected against vaccine-preventable diseases.In t
177、he wake of the COVID-19 pandemic,which set back progress in childhood immunization globally,it focuses on the role of poverty,marginalization and gender in determining whether or not children are vaccinated.Drawing on lessons learned during the pandemic and from UNICEFs decades-long expertise and ex
178、perience in vaccinating children,it examines the ways in which primary health care can be strengthened to better support immunization services.It looks,too,at concerns around trust in vaccines.And examines a range of innovations in vaccine development and delivery and in financing.Chapter 1 looks at
179、 how and why the COVID-19 pandemic set back childhood immunization.It examines what needs to happen to make up the ground that was lost during the pandemic and explores some of the lessons the pandemic offers for making routine immunization more resilient.Chapter 2 examines which children are missin
180、g out on immunization and why it matters.It presents new data and analysis that help to explain the role that a range of social,cultural,economic and gender-related factors play in shaping immunization outcomes.Chapter 3 explores the vital links between immunization and primary health care.A key foc
181、us of IA2030 is the need to make immunization services sustainable and resilient by integrating them into strong and well-resourced primary health care systems that put the needs of communities at their heart.Lindalva de Freitas,a community health agent in the Amazon region of Brazil,waves goodbye t
182、o a family after a visit to check childrens health and confirm vaccination.UNICEF/UN0822150/HillerChapter 4 looks at the role of vaccine confidence in shaping families decisions to vaccinate children.It explores a range of approaches,including community engagement,social listening and empowering wom
183、en and girls,that can help counter some worrying signs of declines in confidence.Chapter 5 examines innovative approaches in vaccine development and delivery,as well as promising new approaches to improve funding for immunization services.And Chapter 6 proposes an action agenda for equity in immuniz
184、ation.It offers four key recommendations for global,national and local stakeholders to help ensure life-saving vaccines reach every child.1.Vaccinate every child,everywhere by,first,catching up on children who were not vaccinated during the pandemic and helping disrupted services to recover fully.Lo
185、nger term,an even more determined effort is needed to tackle the bottlenecks in health and other systems that have persistently prevented children in marginalized and underserved communities from being vaccinated.2.Strengthen demand for and confidence in vaccination by engaging with communities,to e
186、nsure their evolving needs help to shape programmes,and by focusing on interventions that target the role of women.Health workers,especially women working on the front lines of primary health care,can be helped to play an even stronger role in advocating for and building confidence in vaccination,wh
187、ile strengthened accountability in health-system governance can help ensure communities needs are better met.These efforts will ultimately boost trust in health systems.3.Spend more and spend better in immunization and health.In times of fiscal pressure,the high return on investment means that immun
188、ization needs to remain a priority for governments.However,investment in immunization needs to be coupled with more effective and efficient planning,budgeting and service delivery.Developing innovative financing mechanisms is also important.In addition,donors need to increase their support,harmonize
189、 it with country contexts,and centre it on strengthening primary health care.4.Build resilient systems and shockproof them for the future by expanding the health workforce,especially community health workers,and by offering them training,support and predictable payments.Focus especially on supportin
190、g,motivating and retaining the many women working in health systems,and offer clear paths for career development.Adopt innovations in vaccines,supply chains,delivery,data collection and disease surveillance to reach every child,which will help build the foundations to meet the challenges of disease
191、outbreaks and future pandemics.FOR EVERY CHILD,VACCINATION 1112 THE STATE OF THE WORLDS CHILDREN 2023SOMALIAMeasles:Health centre outreach provides personal link to vaccinationWhen all else fails,Maryam Mohamud and her team at Gargaar Health Centre turn to the experts on the importance of immunizati
192、on:mothers who have lived through the tragedy of measles.“We conduct awareness campaigns,and we explain to the moms about the importance of the measles vaccine,”Mohamud said.In 2022 in Somalia,two of Nasro Dires children died of measles.She plans to make sure that her one-month-old son,Marwan Abdi,i
193、s fully vaccinated.UNICEF/UN0758481/Ekpu VII PhotoFOR EVERY CHILD,VACCINATION 13Then,Mohamud and her team allow a mother whose child died from measles to explain the importance.“Thats when they accept the vaccine,”she said.It is a difficult lesson,one laced with loss and tragedy.In Somalia,the effec
194、ts of drought and food insecurity have left children at great risk of disease including measles.Indeed,from January to October 2022,Somalia had more than 15,000 suspected cases of measles 79per cent in children under age 5.Nasro Dire knows the sorrow of measles.Dire,23,lives in the Jawle camp for in
195、ternally displaced persons,a labyrinth of metal shacks on the northern outskirts of Garowe,in central Somalia.At the beginning of 2022,two of Dires children Aanas,age 2,and Masude,age 1 fell ill.First they had fever,then a rash.She took them to Jawle Medical Centre,near the camp where she lives.But
196、Aanas and Masude died a month apart.“As a parent I felt very bad,”Dire said.“But I still believe God has taken them.”Under the guidance of Luul Agani,a midwife and vaccine volunteer in the Jawle community,Dire made sure her surviving children ages 3,4 and 6 were fully vaccinated.And she will do the
197、same for her one-month-old boy,Marwan.Dire also helps Agani convince other mothers to do the same.“The experience I went through with the death of my children made me want to vaccinate others,”Dire said.In general,most parents in the Jawle camp want their children immunized,said Mohud Hassan,the man
198、ager of Jawle Medical Centre.But getting these children vaccinated takes work.It means reaching out to some of the worlds most vulnerable communities internally displaced persons,host communities and families who live in the dusty dirt-road settlements of metal on the outskirts of Garowe.UNICEF prov
199、ides support in Somalia by procuring vaccines,supporting the cold chain and conducting social mobilization campaigns for routine and supplementary immunization activities.Jawle Medical Centre,like many health centres that serve marginalized communities in the Garowe area,mobilizes workers who reach
200、out by text messages,phone or in person to make sure children have access to vaccination.At Jilab Health Centre,for example,health workers set up fixed temporary outreach three times a week in parts of the community where mothers and children do not make use of the central facility.“Outreach is very
201、 important to reach the child who cannot come to the health centre and the mother who cannot come,”said Kowther Abdikadir,a 24-year-old clinical health worker and social worker at Jilab Health Centre.“It is important as well for the health workers.It is very important to check exactly what is going
202、on at home.”Fixed temporary outreach efforts are also part of the services Mohamud and her staff offer from Gargaar Health Centre.But one-on-one interaction,a critical part of the centres newborn delivery programme,also plays a critical role in establishing an ongoing relationship with newborns and
203、mothers.Mohamud and staff members make sure they have contact information for the mothers of newborns delivered at the health centre and the mothers who come to the health centre for services.Most mothers have mobile phones,Mohamud said.But when they do not,health workers take a neighbours number or
204、 the number of the local store owner.This personalized outreach paid off for multiple mothers who recently came to Gargaar Health Centre for vaccinations.Amina Said,a mother of four children,walked for an hour to have Kafio vaccinated she was responding to a message she received from the health cent
205、re.“Thats why I always vaccinate my children,”Said said.“I dont write and I dont read but they give me calls on the phone.”14 THE STATE OF THE WORLDS CHILDREN 202314 THE STATE OF THE WORLDS CHILDREN 2023In Viet Nam,12-year-old Dong Duc Huy heads to the monitoring room after receiving a COVID-19 vacc
206、ination.UNICEF/UN0625901/Hoang 15CHAPTER 1How the COVID-19 pandemic set back vaccinationThe world is facing a red alert for childrens health:Vaccination coverage dropped sharply during the COVID-19 pandemic,leaving millions more children unprotected against some of childhoods most serious diseases.C
207、atch-up and recovery are urgently needed to vaccinate the children missed and to avoid further backsliding.But encouragingly,the pandemic also provided some useful lessons on how to do immunization better.16 THE STATE OF THE WORLDS CHILDREN 2023The COVID-19 pandemic has been a disaster for childhood
208、 immunization.It set immunization back to levels last seen in 2008.In just two years,the world lost more than a decades progress in ensuring every child is adequately immunized.This backsliding reflected some issues specific to the pandemic,particularly the impact of lockdowns and service disruption
209、.But it also cast a powerful spotlight on longer-term issues,including the weakness of far too many primary health care systems,which has long undermined efforts to vaccinate every child.Catching up on the children who missed out entirely or partly on vaccination during the pandemic will be a major
210、challenge,and it will require substantial investment to design and implement appropriate catch-up interventions.In the face of difficult economic headwinds,there is also a need to support health and immunization services to prevent continued backsliding.The pandemic also provided important lessons f
211、or the future of immunization,including highlighting the role of the health workforce as a key component of resilient primary health care systems.It also led to the development of new approaches to vaccine development,production and delivery,which have the potential to greatly reduce the time it tak
212、es to develop vaccines in the future and to speed up responses to future health emergencies.How the pandemic set back immunizationThe numbers are stark.Between 2019 and 2021,the number of zero-dose children rose from 13 million to 18 million globally,an increase of more than a third.There was a shar
213、p increase,too,in the number of under-vaccinated children,which rose by 6 million to 25 million.The increases in the numbers of zero-dose children were especially notable in India,Indonesia,Myanmar and the Philippines.In terms of coverage,the percentage of children fully vaccinated against diphtheri
214、a,tetanus and pertussis a key measure of vaccine coverage fell from 86 per cent to 81 per cent.There was a similar fall in measles vaccine coverage.The COVID-19 pandemic has been a disaster for childhood immunization.It set immunization back to levels last seen in 2008.In just two years,the world lo
215、st more than a decades progress in ensuring every child is adequately immunized.FOR EVERY CHILD,VACCINES 16Rom Tola,a nurse in the Battambang Province of Cambodia,carries a cold box of COVID-19 vaccines delivered as part of the COVAX dose-sharing effort.The Government of Cambodia had a widespread ef
216、fort to vaccinate the country.UNICEF/UN0587970/But Figure 1.2.Vast regional differences exist for the 67 million children who missed out on vaccination Zero-dose and under-vaccinated children from 2019 to 2021 by UNICEF programme region in millions19.5 million13.9 million12 million8.3 million6.8 mil
217、lion3.8 million0.9 millionWest andCentral AfricaSouth AsiaEastern andSouthern AfricaEast Asia andthe PacificLatin America andthe CaribbeanMiddle East andNorth AfricaEurope andCentral Asia136.53.410.52.79.31.56.92.24.61.52.30.60.3Source:World Health Organization and United Nations Childrens Fund,Esti
218、mates of National Immunization Coverage(WUENIC),2021 revision,July 2022.Note:Numbers may not add up to 67 million because of rounding.FOR EVERY CHILD,VACCINATION 17Figure 1.1.East Asia and the Pacific region experienced particularly large declines in vaccine coverageDTP3 vaccination coverage by UNIC
219、EF programme region,20192021Source:World Health Organization and United Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.Middle East and North Africa:2ppSouth Asia:5pp2000%95%90%85%80%75%70%65%West and Central Africa:2pp94%88%96%92%90%79%6
220、9%85%83%75%74%67%East Asia and the Pacific:9ppEurope and Central Asia:2ppEastern and Souther Africa:5ppLatin America and the Caribbean:4pp18 THE STATE OF THE WORLDS CHILDREN 2023Figure 1.4.The pandemic set back already-low rates of HPV vaccine coveragePercentage of girls who received the first dose
221、of the HPV vaccine(HPV1)by UNICEF programme region,2019202118 THE STATE OF THE WORLDS CHILDREN 2023Source:World Health Organization estimates of human papillomavirus(HPV)immunization coverage,20102021,15 July 2022.20192021100%80%60%40%20%0%4%58%49%14%67%40%0%1%4%3%2%East Asia and PacificEastern and
222、Southern AfricaEurope and Central AsiaLatin America and the CaribbeanMiddle East and North AfricaSouth AsiaWest and Central AfricaFigure 1.3.The COVID-19 pandemic brought a drop in vaccination coveragePercentages of children globally who received DTP1,DTP3 and measles vaccinesChildren who received D
223、TP1 vaccine(percentage)Children who received DTP3 vaccine(percentage)Percentage of children who received DTP1,DTP3 and measles vaccines90%86%86%87%83%83%86%81%81%2000%90%80%70%60%50%40%30%20%10%0%Children who received measles vaccine(percentage)Source:World Health Organization and United
224、Nations Childrens Fund,Estimates of National Immunization Coverage(WUENIC),2021 revision,July 2022.FOR EVERY CHILD,VACCINATION 19Rising risk of measlesThese figures,for zero-dose and under-vaccinated children,are based on vaccination against diphtheria,tetanus and pertussis,or DTP(see Introduction).
225、But vaccinations against other diseases also dropped sharply during the pandemic.Two years of decline during the pandemic saw a 5-percentage point fall in the number of children receiving their first measles shot.Because measles is so contagious,around 95 per cent of a community needs to be immunize
226、d in order to reach herd immunity.1 As a result,any decline in coverage is worrying and raises the risk of significant outbreaks of the disease.The number of measles cases doubled in 2022 compared with the previous year,2 and UNICEF and the World Health Organization(WHO)warned of a“perfect storm”of
227、conditions for outbreaks of the disease.3 There have also been concerns about the risk of outbreaks of other vaccine-preventable diseases.4 This deteriorating situation reflects not just disruptions to immunization during the pandemic,but also disruptions caused by conflict,fragility and extreme wea
228、ther events in countries including Afghanistan,Ethiopia,Myanmar,Somalia and Ukraine.As a result,many families have been forced to leave their homes,leaving children with limited access to clean water and sanitation,and exposing them to overcrowding,all of which raise the risk of outbreaks of vaccine
229、-preventable disease.There are also worrying signs on childrens nutrition.Poor diets can make children more vulnerable to infections.Since 2016,some countries have seen a rise of at least 40 per cent in wasting,a life-threatening condition characterized by a child being too thin for their height.5 T
230、he number of people globally affected by hunger has risen by about 150 million since the pandemic began,while there have also been increases in the numbers facing food insecurity.6 HPV lossesThe pandemic had a particularly severe impact on the effort to vaccinate children against human papillomaviru
231、s(HPV).Over the course of the pandemic,the world lost more than a quarter of global coverage of HPV vaccination.That large fall reflected in part the closure of schools,where many children receive their vaccinations.7 The HPV vaccine helps protect against a number of cancers,notably cervical cancer,
232、which is estimated to be the fourth-biggest cause of cancer deaths among women worldwide.8 Almost three out of five cervical cancer cases occur in countries that have yet to introduce HPV vaccination.9 Currently,only around 12 per cent of eligible girls are fully vaccinated against HPV.10 20 THE STA
233、TE OF THE WORLDS CHILDREN 2023Understanding the pandemics impactWhy did the pandemic set back immunization?A number of factors led to the decline,including strains on overstretched health systems and health workers,and especially on overworked women health workers,as well as confusing communication
234、to parents.Overstretched health systemsPerhaps the most significant factor was the impact of the pandemic on primary health care and health systems.As previous crises have shown,countries with already weak health systems are especially vulnerable to the impacts of conflict,major disease outbreaks an
235、d natural disasters.11 The COVID-19 pandemic was no exception.A young girl receives one of the first doses of human papillomavirus(HPV)vaccine in Mauritania.Globally,about 7 in 8 eligible girls are not vaccinated against the virus.UNICEF/UN0434343/PougetFOR EVERY CHILD,VACCINATION 21The pandemic for
236、ced many health systems to divert scarce resources away from providing routine care,including immunization.12 For example,at the end of 2021,nearly half of 72 countries in a WHO survey said that routine vaccination programmes were being disrupted by the need to respond to the pandemic.13In addition,
237、the pandemic badly interrupted vaccination campaigns,which,unlike routine immunization,are usually targeted efforts to vaccinate large numbers of people in relatively short periods of time.In May 2020,for example,57 per cent of campaigns in 57 countries had to be cancelled or postponed,representing
238、the loss of 796 million vaccine doses.Although the situation began to improve in mid-2020,disruptions continued:At the end of 2021,stalled campaigns in African countries still meant the loss of 382 million doses.14There was also a serious impact on the health workforce.Even before the pandemic,many
239、countries were short of skilled health workers,particularly in disadvantaged areas.The pandemic exacerbated this problem and added to the challenges facing health workers,especially women in the health workforce(see Chapter 3).Many could not access essential equipment,including personal protective e
240、quipment.They also faced the risk of infection,social discrimination and attacks.As well as being expected to handle a huge increase in their workload,most also had their own responsibilities to care for friends and family,including children locked out from school.Burn-out became a critical issue.Th
241、e pandemic also affected countries capacities to gather health information and data and carry out surveillance of disease outbreaks.For example,following the alarming detection of a case of wild poliovirus in February 2022,Malawi struggled to determine how polio had arrived and how long it had sprea
242、d undetected.15 Even by mid-2022,disease surveillance across many countries had not returned to pre-pandemic levels.Vaccine supply chains also came under strain,for a time at least,amid global restrictions on international travel and limits on movement within borders.16 It is estimated that early on
243、 in the pandemic,in April 2020,global vaccine sales fell by about a third.17 The global picture varied but,overall,these supply constraints seem to have been relatively short-lived.Family fearsA final factor is the impact the pandemic had on families abilities and willingness to get their children v
244、accinated.Even where health-care facilities remained open,travel restrictions or tight family budgets may have led families to put off getting children vaccinated.Stay-at-home recommendations may have led some parents to see routine vaccination as non-essential care,which underlines the need for car
245、eful,nuanced communication with families during major disease outbreaks.18 Significantly,parents may also have been wary of visiting clinics for fear of contracting COVID-19.1922 THE STATE OF THE WORLDS CHILDREN 2023INDONESIAIn the Wake of COVID-19:Catching up on childhood immunizationThe sun had ju
246、st risen on a Sunday morning in August as Irwan Hakim,a community clinic nurse,strode through the streets of Kerayaan,a remote village in Kalimantan,the Indonesian part of Borneo.With a megaphone pressed to his mouth,Irwan broadcast his message:Immunize your children today.Zulaiha was trained by her
247、 mother,who was trained by her grandmother,to be a traditional healer and birth attendant.Health officials also call on her to inform families about the importance of immunization.UNICEF/UN0692943/ClarkFOR EVERY CHILD,VACCINATION 23By 8:30 a.m.,381 children aged 512 years and their parents had heede
248、d his call and gathered at the Rusung Raya Public Primary School for vaccines against potentially deadly diseases,such as measles and rubella.“The turnout is usually not this high,”Irwan said,surveying the front yard of the school where the children and their families assembled.“This morning is an e
249、xception.”The major reason for this success is efforts by Irwan and a network of nurses,midwives and traditional birth attendants who work closely with the community to build trust,dispel myths and encourage parents to immunize their children.Irwan and his network were activated as part of the Natio
250、nal Child Immunization Month(BIAN).With support from partners including UNICEF,BIAN campaigns had been launched throughout Indonesia.The goal:to reverse a backslide in routine childhood vaccinations linked to the COVID-19 pandemic.COVID-19 took a significant toll on routine immunization services for
251、 children throughout Indonesia.Full vaccination coverage dropped from 93.7 per cent in 2019 to 84.5 per cent in 2021,according to the Ministry of Health.In part,the drop was caused by disrupted supply chains,regulations that limited vaccination activities and a lack of available health workers.Natio
252、nwide,parents and caregivers were reluctant to bring children to health-care facilities for fear of infection,according to a 2020 survey by the Indonesia Ministry of Health and UNICEF.In Kerayaan,an area that already had a small health workforce,the virus sidelined many health workers.Vaccines were
253、also not delivered and locations that provide vaccinations were closed.Vaccination has been particularly low in Kerayaan,where only 10 out of 45 newborns were vaccinated as of April 2022.Its remote location is a major barrier.“It takes about 13 hours by motorized vehicles,ferry and wooden boat to re
254、ach Kerayaan from the provincial capital,”said Dr.Suprapti Tri Astuti,head of Kotabaru District Health Office,which oversees immunization services in Kerayaan.“So the pandemic exacerbated this situation.”In addition to the geographic difficulties,scepticism about vaccines is also common.To address t
255、hese concerns,the health network turns to traditional healers such as Zulaiha.Zulaiha was trained by her mother,who was trained by her grandmother.She attends women who are in labour and provides guidance to people who come to her for traditional healing,including incantation and application of herb
256、s.But she also knows the power of immunization.As part of the BIAN campaign,Zulaiha continued her work going house to house to encourage parents and caregivers to take their children to the health centre for vaccinations.“I do house visits to get children to be vaccinated,”Zulaiha said.“I explain to
257、 their parents,get them to go to posyandu health post.I told them to not be afraid.Side effects like fever are normal.”Thanks to Irwan,Zulaiha and the wider network of which they are a part,nearly 90 per cent of newborns in Kerayaan were vaccinated during BIAN.UNICEF has supported health workers thr
258、ough workshops,monitoring and coordinating with village officials to identify unvaccinated children and encourage families to bring their children for immunization.“Increasing understanding and awareness of the importance of immunization for children is critical for families and needs to be continuo
259、usly instilled in the whole community,”Irwan said.“It is our dream that all children on Kerayaan Island can have the right to live a healthy life free from illness,disability and death from diseases that can be prevented through immunization.”24 THE STATE OF THE WORLDS CHILDREN 2023Making up lost gr
260、oundIn total,UNICEF estimates that some 67 million children missed out entirely or partially on routine immunization from 2019 to 2021.The challenge of reaching these children will be substantial.While some will eventually be vaccinated through catch-up campaigns,most will not receive full vaccinati
261、on,and some will receive none.And as they pass the age when children are typically vaccinated,it will become ever harder to reach them through conventional campaigns and routine immunization programmes.Encouragingly,however,there were some early signs of recovery in childhood immunization services i
262、n a number of countries in 2022.Catch-up and recoveryAs this report states,investments in areas such as primary health care,vaccine development and delivery,and innovations are required to reach the global immunization goals.In the short term,there is also an urgent need to reach the children who mi
263、ssed out on vaccination because of the pandemic and other factors including conflict with intensified catch-up initiatives.These initiatives will need to identify and locate zero-dose and under-vaccinated children and missed communities.This will allow the development of specific plans and strategie
264、s to ensure catch-up initiatives reach the communities and children with the greatest needs.A key component of this work is engaging with communities to help identify barriers to children being vaccinated and to develop approaches that meet the needs of their families.But catch-up alone will not be
265、enough.In countries where the pace of recovery in immunization services is slow,and where there is a risk of continued backsliding,there is a need to ensure services are fully restored to at least pre-pandemic levels as quickly as possible.Key priorities will include tailoring strategies to specific
266、 settings that have been identified as priority areas for reaching zero-dose children.In urban settings,this will involve ensuring immunization services respond to families needs and recovering human resources lost due to the need to respond to the pandemic.There will also be a need in many urban se
267、ttings to address the social exclusion of displaced and refugee populations.In remote rural areas,a focus will be needed on outreach activities to communities and on better integrating services.And in fragile and conflict-affected settings,restoring health workforces and infrastructure is a key prio
268、rity,as is negotiating access to communities and bundling immunization with delivery of humanitarian and other essential services.Success in both these catch-up and recovery approaches is essential to sustainably make up ground lost during the pandemic and to lay the foundations for the longer-term
269、goals set out in the Immunization Agenda 2030.Catch-up alone will not be enough.In countries where the pace of recovery in immunization services is slow,and where there is a risk of continued backsliding,there is a need to ensure services are fully restored to at least pre-pandemic levels as quickly
270、 as possible.Learning from the pandemicCalamitous as it has been,the COVID-19 pandemic has brought changes in the vaccine landscape that the global community must capitalize on to boost childhood immunization.The experience of the pandemic revealed that,with political will and leadership,vast resour
271、ces can be mobilized,and new vaccines can be developed rapidly and introduced around the world.These included the worldwide COVID-19 Vaccines Global Access(COVAX)initiative,which aimed at equitable access,and which has shipped just under 1.9 billion vaccine doses around the world.20 The establishmen
272、t of the COVID-19 Vaccine Delivery Partnership(CoVDP)to coordinate,harmonize and streamline support for vaccine delivery is another testimony to the political will and institutional agility needed in times of crisis(see Box 3).With millions of childrens lives at stake,we need the same urgency around
273、 routine child immunization.The urgency of routine immunizationWhile an emergency in itself,the pandemic underscored another one:the pressing need to maximize uninterrupted,high-quality health care for children as a fundamental human right.Routine immunization is a central component of such life-sav
274、ing care.Ensuring that it continues amid emergencies will require improved governance and enhanced financing,both at global level to ensure better pandemic preparedness and responses,and at national level to enable a strong health system with access to quality health care and surge capacity to accom
275、modate heightened need during crises.To adequately fund health systems,low-income countries would need to dramatically increase their health spending beyond what they have ever done in the past,according to the World Bank.21 Not doing so would compromise their ability to strengthen and maintain publ
276、ic-health preparedness and response capabilities and may force countries into difficult zero-sum choices regarding which health services deserve investments.Unfortunately,many countries are facing these choices amid worsening fiscal constraints.While some countries may be able to increase the share
277、of spending on health,it may not always be possible to achieve adequate levels of health financing from governments domestic resource investments alone.22 A key pandemic lesson is that failures in one countrys health system contribute to suffering beyond that countrys borders.Collaborative efforts,i
278、ncluding increases in development assistance for health and debt relief for countries facing debt distress,can bolster countries abilities to immunize every child.These efforts thus represent a public good that can improve health outcomes globally.Box 3 Partnerships to tackle COVIDThe COVID-19 pande
279、mic brought to light the urgent need for governments and partners to work together to accelerate vaccination to protect children and families.Key among these partnerships was COVID-19 Vaccines Global Access(COVAX),a global initiative to ensure equitable access to COVID-19 vaccines.COVAX is directed
280、by the Coalition for Epidemic Preparedness Innovations(CEPI),Gavi,the Vaccine Alliance and the World Health Organization(WHO),with UNICEF as the delivery partner.In 2020,COVAX initiated a COVAX Country Readiness and Delivery workstream,which provided global guidance and technical support for introdu
281、cing COVID-19 vaccination initiatives.Building on this work,UNICEF,Gavi,WHO and other partners founded the COVID-19 Vaccine Delivery Partnership(CoVDP)in January 2022.CoVDPs goal is to provide support to 92 low-and middle-income countries.FOR EVERY CHILD,VACCINATION 25 The particular focus is on 34
282、countries with COVID-19 vaccination coverage at or below 10 per cent.Since CoVDP was founded,coverage in the 34 countries increased from 3 per cent to 25 per cent in January 2023.As of January 2023,the number of countries at or below 10 per cent coverage had decreased from 34 to 7,with 13 of the ori
283、ginal 34 reaching over 20 per cent coverage.In addition,six countries recorded coverage above 40 per cent.CoVDP has contributed to this progress by combining high-level advocacy and technical country missions to 27 countries.It also facilitated the urgent release of US$145 million in funding for vac
284、cine delivery,provided specialized technical assistance,and coordinated cooperation among the partners.As the pandemic made clear,health systems are only as strong as their health workforces.WHO has released guidance on health workforce policy to support and protect health workers so that they can m
285、aintain essential health care at all times.23 Infection prevention and control,proper and timely remuneration,and mental health support are all essential supports for health workers.24A number of countries stepped up in the face of health worker burn-out and other difficulties during the pandemic.Fo
286、r example,Peru established procedures for mental health care and self-care of health-care providers,along with psychosocial support teams in facilities.A sped-up,coordinated responseThe COVID-19 response accelerated norms and practices around vaccine development and approval.Advancements such as mes
287、senger RNA(mRNA),a breakthrough vaccine platform with wide applicability that had been in development on the margins for decades,suddenly had proof-of-concept with vaccinations around the globe.Approval processes by many governments for COVID vaccines were also sped up,laying the groundwork for more
288、 rapid approval of forthcoming vaccines against infectious diseases such as influenza(flu)and respiratory syncytial virus(RSV).Governments and non-governmental organizations(NGOs)also stepped in to remove risks from the research and development(R&D)process,incentivizing pharmaceutical companies to c
289、ompete to develop vaccines.The global community can capitalize on these developments to hasten discoveries of new vaccines to protect children against diseases such as malaria,HIV and tuberculosis.COVID-19 vaccines procured by the COVAX Facility arrive at the airport in Kigali.COVAX aimed to foster
290、equitable access to immunization against COVID-19 UNICEF/UN0579046/KanobanaFOR EVERY CHILD,VACCINATION 27FOR EVERY CHILD,VACCINES 27The benefits of digital technologies also became more evident during the pandemic.Many low-and middle-income countries have made significant investments in digital heal
291、th systems and were able to expand these to provide substantial support to the COVID-19 response and beyond for critical activities including planning the distribution of diagnostics,treatments and vaccines,and monitoring coverage.The pandemic also spurred innovations such as greater use of qualitat
292、ive data;remote data collection technologies;and improved communication,collaboration and data-sharing across international agencies.25Integrate health crisis response with routine immunizationThe pandemic underscored the importance of integrating crisis-related responses and routine immunization.To
293、o often,supplementary immunization activities(SIAs)have redirected people,money,supplies and time from under-resourced primary health care services,which hurts routine immunization outreach and the primary service.For example,and as already noted,in many countries COVID-19 immunization campaigns wer
294、e undertaken at the expense of routine vaccination programmes.During outbreaks,epidemics or pandemics,governments need to ensure that routine immunization is not interrupted.Ideally,governments can deliver routine immunization along with crisis-related vaccination and health services.In addition,rou
295、tine immunization services should also be ready to adopt new vaccines that evolve because of crisis.Integration strategies yielded results in campaigns in both Ghana and Nigeria(see Box 4).Building on the success of its National Immunization Days for polio,Child Health Promotion Weeks and outbreak r
296、esponses,Ghana has offered national COVID-19 vaccination combined with routine immunization during the pandemic.In November 2021,vaccination outreach teams carried yellow fever and COVID-19 vaccines and administered both to eligible people.This effort,which had a strong focus on risk communication a
297、nd community engagement,stopped the yellow fever outbreak.Longer-term challengesEven if rapid progress is made to catch up on ground lost during the pandemic,the longer-term challenge of reaching every child with vaccines will not be solved overnight.As the next chapter shows,zero-dose and under-vac
298、cinated children live in some of the worlds most challenging settings.Identifying them and understanding the barriers they and their families face on the journey to vaccination is essential if every child is to benefit from protection against vaccine-preventable diseases.Box 4 Nigerias family approa
299、chDuring the pandemic,Nigeria launched what is known as a whole family approach,combining COVID-19 vaccination with health services such as childhood vaccination,malnutrition,family planning,antenatal and delivery services,and screening for non-communicable diseases.With this integrated model,Lagos
300、State reported it was able to mitigate a third wave of COVID-19,prevent polio and cholera outbreaks while still curbing communicable and non-communicable diseases.The pandemic underscored the importance of integrating crisis-related responses and routine immunization.28 THE STATE OF THE WORLDS CHILD
301、REN 2023CAMBODIAProgress from the Pandemic:COVID-19 inspires innovation in immunization for childrenOn a sweltering day in June 2022,three generations of women in the same family arrived outside a small rural grocery store where a team of vaccinators had temporarily set up a one-stop shop for protec
302、tion against disease.Pum Sony,20,holds her 6-month-old daughter,Les Satha.Sony said improvements in vaccination systems in Cambodia mean that she and her daughter will not miss out.UNICEF/UN0673061/RaabFOR EVERY CHILD,VACCINATION 29Beneath a shady tree,Satha,the baby,was immunized against measles an
303、d rubella.Her mother,Pum Sony,and grandmother,Krak Nhuong,received booster shots to protect them from COVID-19.For mother and grandmother,the store-front vaccination service was a sign of progress for Mondulkiri,a remote region in the north-east of Cambodia,home to the Bunong indigenous community.“T
304、heres more information on all vaccines,and theyre delivered right here in our community,”Sony said.“Before,we had to travel on 15 kilometres of dirt roads to get vaccinated at a health centre.”The progress that has benefited Nhuong,Sony and Satha resulted from investments that the Royal Government o
305、f Cambodia has made in the countrys health system over the course of decades.“Immunization improved even before the pandemic,”said Pyun Kunthea,the government health worker who vaccinated the family.“Just 20 years ago,preventable diseases were still common.Things got better,but it was still difficul
306、t to reach villages like this,which were distant from health centres.”However,the Governments response to COVID-19 has inspired innovations in communication,technology and social behaviour change that are being applied to the national childhood vaccination programme.At the start of the pandemic,the
307、Cambodian Government,with the support of partners including UNICEF and the World Health Organization,launched an intensive communications and social behaviour change campaign aimed at reaching the entire adult population with COVID-19 vaccinations.Health officials adapted tools from successful polio
308、 and measles campaigns to design and conduct rapid community assessments.These adapted tools provided up-to-date information on where people were not vaccinated and why.Consequently,health workers could provide targeted outreach services and communication campaigns in local languages to communities
309、where coverage was low.The tools were used in eight provinces with low immunization rates.In addition,the Government of Cambodia launched the countrys first digital immunization registration system,KhmerVacc.The mobile application,which has 15.8 million registered users,allows people to sign up for
310、vaccination and sends reminders for follow up.For children,Cambodia generally has high routine vaccination coverage rates,with only about 6 per cent considered zero-dose children.However,in communities with large populations of ethnic minorities in remote areas,such as Mondulkiri,far too many childr
311、en miss out.In 2022,the Government of Cambodia committed to building on the success of KhmerVacc and began incorporating its features into a new,improved platform.Families will be able to register for the service and record routine vaccinations including those that protect children against measles,p
312、olio and tuberculosis.This new Electronic Immunization Record,designed by the Ministry of Health with UNICEF support,will help health officials and families keep track of childrens immunization status and send appointment alerts to caregivers via SMS.The improvements to these systems were also focus
313、ed on reaching zero-dose children and enhancing primary health care.Next year,these innovations will be rolled out,as the Cambodian Government introduces the new human papillomavirus(HPV)vaccine that protects against cervical cancer.For Sony,the improvements in routine immunization services mean tha
314、t her daughter will benefit from a full range of immunizations that are supported by better registration,targeted communications and expanded integrated outreach services.“Previously,children from poor families who couldnt afford to travel to health centres missed out on vaccinations,”Sony said.“Im
315、so happy my children wont miss out and will be properly protected.”30 THE STATE OF THE WORLDS CHILDREN 202330 THE STATE OF THE WORLDS CHILDREN 2023Waiting for a turn to get vaccinated as part of a national campaign at an informal settlement for displaced families on the Hama Highway in the Syrian Ar
316、ab Republic.UNICEF/UN0654274 31CHAPTER 2Zero-dose children matterThe trusted methods that were so successful for so many children failed to immunize many of the worlds most vulnerable.For these children,social and economic barriers including poverty,location,marginalization and crisis have prevented
317、 vaccines from being available,accessible and affordable.The cost of not reaching these children can be calculated in lives lost and fragile health for children,families,communities and economies.32 THE STATE OF THE WORLDS CHILDREN 2023For the most part,the children left behind live in complex conte
318、xts and face multiple deprivations.They live in the remotest of rural areas,urban slums,peripheral urban settlements,crisis-affected areas,and migrant and refugee communities.They are confronted daily by socioeconomic barriers to immunization:poverty,gender and ethnic marginalization,migration and c
319、risis.Left behind:socioeconomic determinants of immunizationAn analysis for The State of the Worlds Children 2023 puts numbers to the link between zero-dose and under-vaccinated children and socioeconomic determinants associated with immunization.1 The numbers make the connection between inequity an
320、d children who miss out on vaccination.PovertyPoverty sits at the centre of a complex interplay of deprivations that determine whether a child is immunized against vaccine-preventable diseases or not.In the analysis for The State of the Worlds Children 2023 report,data showed that children from the
321、very poorest households households with income in the bottom 10 per cent of the population were less likely to be immunized than children in the wealthiest 10 per cent(see Figure 2.1).For example,in the poorest households,22.6 per cent of children were zero-dose children.In contrast,in the wealthies
322、t group,just 4.9 per cent were zero-dose children.The data also indicated that the gaps between the wealthiest and poorest were widest in low-income countries(see Figure 2.1)and narrowest in upper-middle-income countries.West and Central Africa presented the largest gap between rich and poor:48.6 pe
323、r cent of children from the poorest households were zero-dose children compared with 6.3 per cent of children in the wealthiest(see Figure 2.2).The narrowest gaps occurred in Latin America and the Caribbean,where 11.3 per cent of children in the poorest households were zero-dose children compared wi
324、th 5 per cent in the wealthiest.Interestingly,in Eastern Europe and Central Asia,the situation was reversed:4.5 per cent of children in the poorest households were zero-dose children compared with 8.1 per cent in the wealthiest.The analysis also showed great disparities within countries:Among the te
325、n countries with the highest gaps in vaccination coverage between rich and poor,seven were in sub-Saharan Africa.Poverty sits at the centre of a complex interplay of deprivations that determine whether a child is immunized against vaccine-preventable diseases or not.FOR EVERY CHILD,VACCINATION 33Loc
326、ationIn addition to poverty,location plays a significant role in whether a child is immunized(see Figure 2.2).In the 74 low-and middle-income countries analysed for UNICEF,9.4 per cent of children in urban areas were zero-dose children and 15.1 per cent of children in rural areas were zero-dose chil
327、dren.As with poverty,the greatest gap in immunization by location was in West and Central Africa,where the prevalence of zero-dose children was 16.2 per cent in urban areas and 34.6 per cent in rural areas.In general,the gaps between rural and urban were widest in low-income countries and negligible
328、 in upper-middle-income countries.FOR EVERY CHILD,VACCINATION 33Figure 2.1.Vast inequities exist for children in poor communities and countriesIn 74 low-and middle-income countries,percentage of zero-dose children,percentage in highest and lowest wealth decile,percentage in urban and rural locations
329、 organized by World Bank income classificationTotal populationRichestPoorestUrbanRuralPercentage of zero-dose children0%5%10%15%20%25%30%35%0%5%10%15%20%25%30%35%0%5%10%15%20%25%30%35%Lower-middle-incomecountriesUpper-middle-incomecountriesLow-incomecountries30.1%18%7.3%21.4%10.9%22.1%12.1%4.2%14.3%
330、9.1%10.5%7.3%3.9%7.6%6.8%Wealthiest andpoorest decilesUrban and ruralOverall percentage ofzero-dose childrenSource:Victora,Cesar,and Alusio Barros,Within-country Inequalities in Zero-dose Prevalence:Background paper for The State of the Worlds Children 2023,International Center for Equity in Health
331、at the Federal University of Pelotas,Brazil,December 2022.Source:Victora,Cesar,and Alusio Barros,Within-country Inequalities in Zero-dose Prevalence:Background paper for The State of the Worlds Children 2023,International Center for Equity in Health at the Federal University of Pelotas,Brazil,Decemb
332、er 2022.Figure 2.3b.Some countries have great inequities between children in urban and rural areasTen countries with the largest gap in zero-dose children between urban and rural locationsZero-dose prevalence%CountryPoorestWealthiestAngola50.618.5Nigeria45.018.8Central African Republic52.528.3Guinea
333、44.721.4Papua New Guinea38.717.8Ethiopia29.710.0Democratic Republic of the Congo41.822.6Cameroon22.59.1Mali20.67.9Afghanistan29.918.0Figure 2.3a.In 10 countries,children in poor households are less likely to be vaccinated than children in wealthy householdsTen countries with the largest gap in zero-dose children between the poorest and wealthiest deciles of householdsZero-dose prevalence%CountryPo