Vaccines for COVID-19 are critical tools for helping to bring the pandemic under control when combined with effective testing, treatment and existing prevention measures. Vaccinating the world against this disease is the largest vaccine procurement and supply operation in history – and UNICEF is leading this effort on behalf of the Global COVAX Facility.
More than 3.8 billion COVID-19 vaccine doses have been administered to-date. This historic global rollout is unprecedented in terms of speed, scale and demographics reached. Yet despite progress, inequities between lower and higher-income countries are continuing to cost lives and are prolonging the pandemic.
Only 16 per cent of people in low-income countries have received a single vaccine dose – compared to 80 per cent in high-income countries. In certain lower-income countries, many of the most at-risk people in society – healthcare workers, the elderly and those with underlying health conditions – are going unprotected while young, healthy adults receive booster doses in wealthier countries. The world must act urgently to close this equity gap.
Global coverage of the third dose of diphtheria-tetanus-pertussis (DTP3) fell from 86 per cent in 2019 to 81 per cent in 2021 – its lowest level since 2008. The latest WHO/UNICEF estimates of national immunization coverage (WUENIC) also show that 112 countries experienced stagnant or declining DTP3 coverage since 2019 with 62 of those countries declining by at least 5 percentage points. As a result, 25 million children were un or under-vaccinated in 2021 where more than 60 per cent live in just 10 countries (India, Nigeria, Indonesia, Ethiopia, Philippines, Democratic Republic of the Congo, Brazil, Pakistan, Angola, and Myanmar) and 18 million did not receive any vaccines (zero-dose children), an increase of 5 million from 2019.
Many factors contributed to the observed decline, including an increased number of children living in conflict and fragile settings, increased misinformation, and COVID-19 related issues such as service and supply chain disruptions, resource diversion to response efforts, and containment measures that limited immunization service access and availability.
All UNICEF regions reported a decline in DTP3 coverage in 2021 with the sharpest decline of 9 percentage points from 92 per cent (2019) to 83 per cent(2021) occurring in the East Asia and Pacific Region followed by 5 percentage point declines in both South Asia and Eastern and Southern Africa. The substantial decline in coverage in the East Asia and Pacific region to levels not seen in nearly 20 years, resulting in nearly 2 million more un- or under-vaccinated children in 2021, was largely driven by coverage declines in Indonesia, Myanmar, Philippines, and Viet Nam.
The latest WUENIC estimates present a concerning picture for Latin America and the Caribbean where DTP3 coverage has been on a persistent downtrend from 93 per cent in 2012 to 79 per cent in 2019 to 75 per cent in 2021. The COVID-19 pandemic has stressed already fragile health care and immunization delivery systems throughout countries in the region, many of which have experienced persistent funding shortfalls, increases in vaccine misinformation, and economic and political instability.
COVID-19 has reduced access to life-saving vaccines to combat diseases such as measles and polio
Immunization is one of the most cost-effective public health interventions, averting an estimated 2 to 3 million deaths every year.
Yet even before the coronavirus pandemic, more than 13 million children did not receive any dose of DTP (zero-dose children) – a number that has increased by 5 million to an estimated 18 million zero-dose children in 2021.
Inadequate immunization coverage levels have already resulted in avoidable outbreaks of measles and polio in the past 12 months, underscoring the vital role of immunization in keeping children, adolescents, adults, and societies healthy. Moreover, with DTP3 coverage at its lowest level since 2008, along with declines in coverage for other basic vaccines, the world is off-track to meet global goals and at risk of more deadly disease outbreaks.
The percentage of children receiving the diphtheria, tetanus, and pertussis vaccine (DTP) is often used as an indicator of how well countries are doing in providing routine immunization services. In 2021, global coverage rates for the third dose of the diphtheria, tetanus and pertussis vaccine (DTP3) declined to 81 per cent, down from 86 per cent in 2019, but still up from 72 per cent in 2000 and 20 percent in 1980.
95 countries sustained at least 90 per cent coverage of DTP3 vaccine over the last three years
Multiple factors, including conflict, under-investment in national immunization programmes, vaccine stock-outs, and disease outbreaks, including COVID-19, contribute to the disruption of health systems and prevent sustainable delivery of vaccination services. Approximately 44 per cent (11 million) of the un- and under-vaccinated infants live in fragile or humanitarian settings, including countries affected by conflict. These children are the most vulnerable to disease outbreaks.
Coverage challenges persist in fragile states and those affected by conflict
In 2021, 9 countries had 50 per cent or lower coverage of DTP3, an increase from 6 countries in 2019 and many of which are fragile states or affected by emergencies: Central African Republic, Myanmar, Papua New Guinea, Somalia, South Sudan, and Syrian Arab Republic. Globally in 2021, half of children unvaccinated for DTP3 lived in just 6 countries: Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, and Pakistan. Note that developing countries with large populations of children contribute significantly to the number of unvaccinated children despite achieving relatively high rates of immunization coverage. India, for example, has achieved 85 per cent coverage of DTP3, yet because it has a cohort of nearly 23 million surviving infants in 2021, this coverage level still means that 3.3 million children were un or under-vaccinated. Efforts to raise global immunization levels will require a strong focus on the countries where the highest numbers of unvaccinated children live – while also ensuring that smaller countries with a subset of hard-to- reach children are not neglected.
Rotavirus coverage continues to expand significantly from 2012, particularly in low income countries
Through UNICEF’s joint efforts with partners and countries, vaccines have become safer and more accessible than ever before. The cost of fully immunizing children in low-income countries is just US $18 per child, down from US $24.5 in 2013. Countries continued vaccine introductions despite facing multi-faceted challenges during the pandemic. Records indicate that as of 2021, 152 countries fully introduced pneumococcal conjugate vaccine to protect children against pneumonia and 116 countries fully introduced rotavirus vaccine to protect children against diarrhoea into their immunization programmes . Human papillomavirus (HPV) is the most common viral infection of the reproductive tract and can cause cervical cancer in women. By 2021, the HPV vaccine had been fully introduced in 114 countries, yet only 12 per cent of girls are fully protected against HPV.
No child should die from a preventable cause, and all children should be able to reach their full potential in health and well-being. The cost of a vaccine, often less than US $1, is much lower than the cost of treating a sick child or fighting a disease outbreak. Each US $1 invested in childhood vaccination produces a return on investment of US $44 in low- and middle-income countries. More details on the cost and financing of vaccination can be found here.
 World Bank Fragile and Conflict-affected Situations (FCS), FY 2022: