Photo: iLab/CSIS
This transcript is from a CSIS event hosted on April 30, 2025. Watch the full video here.
Katherine E. Bliss: Last Friday, the Centers For Disease Control and Prevention reported that in the first three and a half months of 2025 the United States had nearly 900 confirmed cases of measles, a dangerous viral infection that is vaccine preventable. That’s a big jump from 285 confirmed cases for all of 2024. And it’s getting close to the almost 1,300 reported in 2019, when the United States nearly lost its certification as having eliminated measles. Now, elimination means that even if cases are introduced, perhaps by someone traveling from overseas, they do not seed sustained outbreaks, because of sufficient rates of vaccine coverage as well as quarantine of suspected cases and contact tracing.
But the United States is not alone in seeing higher rates of measles cases in recent years. In Europe, in 2024 there were more than 127,000 cases. And globally, several fragile and conflict-affected countries are seeing very high numbers, with Yemen, Pakistan, and Ethiopia near the top of the list. Now, measles vaccines have been available since the 1960s, but they were initially most readily available in high-income countries. With support from the World Health Organization, UNICEF, and Gavi, low-income countries have been increasing coverage in recent years. But worldwide immunization coverage stalled even before the pandemic, and then dipped due to disruptions in health services. While some countries have yet to fully recover from the pandemic, people’s faith in vaccines has dipped too. And this is especially pronounced among young people aged kind of 18 to 26. And in 2019, 80 percent of respondents in a survey in this age group expressed confidence in vaccines, but that dropped to below 60 percent in 2023.
I’m Katherine Bliss, senior fellow with the CSIS Global Health Policy Center. And on today’s episode, which coincides with the conclusion of World Immunization Week, I’ll talk with Dr. Ephrem Lamango, chief of immunizations at UNICEF, and Dr. Adam Ratner, with the American Academy of Pediatrics’ Committee on Infectious Diseases about current measles outbreaks in the U.S. and overseas, why immunization rates have slowed or dropped, steps that can be taken to improve people’s trust in vaccines, and what recent cuts for domestic and global health programs, along with research and development, mean for measles outbreaks. On behalf of the CSIS Bipartisan Alliance for Global Health Security, welcome to The CommonHealth.
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J. Stephen Morrison: This is The CommonHealth podcast, a product of the CSIS Bipartisan Alliance for Global Health Security. We engage with diverse leaders on the question of how best to navigate this period of exceptional turmoil, reform, and uncertainty in U.S. leadership.
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Dr. Bliss: So it’s the final day of World Immunization Week 2025 and it’s such a pleasure to talk with two immunization experts, Dr. Ephrem Lamango, chief of immunizations at UNICEF, and Dr. Adam Ratner, of the American Academy of Pediatrics Committee on Infectious Diseases, both based in New York. Ephrem and Adam, welcome to The CommonHealth and thank you for joining me today to share your expertise on measles outbreaks, domestic and global, and what can be done to strengthen coverage of measles vaccines worldwide. Welcome. Wish I were there in New York with you. (Laughs.)
Now, Ephrem, I want to start with you. You are at UNICEF. Your work is international, covering all world regions and more than 130 countries. Can you provide some context about measles outbreaks globally? You know what we’ve seen in recent years, kind of what the trends are with respect to both outbreaks and coverage, and just say a little bit about the situations that you’re seeing right now that really concern you the most as you look at the year ahead.
Ephrem T. Lemango: Thank you very much, Katherine. Thank you for having me here. And there cannot be a better time than this, as we are celebrating the World Immunization Week, to discuss this important issue.
As a global community and partner in immunization, we are calling for global attention for these increasing number of outbreaks, particularly measles outbreaks, across several countries. UNICEF works over – in 130 countries. We have direct program implementation that serves children, most importantly the underserved children. And child health is one of our priorities, whereby immunization is one of our biggest programs in that. And we have been doing this for the past eight decades, in serving children in – you know, in every country, particularly across low- and middle-income countries.
What we are seeing is there is an increasing trend of measles outbreak across the world. And this increases in size and spread, where in 2023, which we had the last estimate, we estimated about 10 million cases were reported across the world. And recent estimates in 2024 has shown that 138 countries have reported having measles outbreaks. And this is the total number of countries that are reporting. But in order to mount response and have the right amount of strategy on the ground, we have what we call large and disruptive measles outbreaks. This is when the disruptive health services results in increasing number of cases in those countries and when the threshold reaches about 10 cases per 1 million population. And above that, we call it large and disruptive measles outbreak.
And we have seen, in 2022 we had about 37 countries reporting large and disruptive measles outbreak. In 2023, this increased to 47 countries. In 2024, it increased to 60 countries. So we started with 37 countries, and that went on to 47 countries, and then now we are in 60 countries. And you see this increasing number of cases, not only in countries that we normally see measles outbreak. For example, the African continent you still have the largest number of outbreaks, but what we are seeing this year and last year is that we are seeing similar cases in the European region, in Southeast Asia, and the Eastern Mediterranean region, in areas such in the Middle East and Northern Africa region.
So it shows you that there is a growing number of cases across countries and the number of countries that are reporting are increasing. And it is very concerning at this moment unless and otherwise we are able to do something about it. And this has been the result of the disruption caused by the pandemic and the increasing number of unvaccinated children that we see in countries. Immunization trends for the past 10 years – 10-plus years, we have seen a stagnation of coverage at around 83-84 percent with the first dose of measles vaccination, which is an important vaccine to prevent measles outbreaks and prevent and protect kids. But during the pandemic we have seen a considerable backsliding from what we had before the pandemic. And that backsliding was a result of the disruption caused by overstretched health systems, health workers had to be repurposed to respond to the COVID-19 pandemic, and there was so much disruption in delivery of vaccination services across countries.
That resulted in a dipping of immunization coverage from what we had, right then around 86 percent, to 83-82 percent across several countries. But after the pandemic we did all we can as partners to encourage countries to recover, to catch up on children that were missed, because we estimate around 86 million children may have missed their vaccination, one or two vaccine doses, in the period between 2020 and 2023. And that’s a significant number of children that are missing one vaccination.
And the third nature that we are seeing now is there is a slow recovery back to pre-pandemic levels. We had a good indication in 2023 where there has been a good spike of coverage, but that did not sustain. So we still see that many countries are in the coverage rate they had after the pandemic. So they have not recovered to pre-pandemic levels, especially countries with conflict and fragility. They face significant challenge at this moment. And they are home to many of those unvaccinated children.
Dr. Bliss: And so in July of this year, that’s when you’ll get the next round of estimates that will be published, but that will be looking retrospectively at 2024. Is that right? So we won’t –
Dr. Lemango: That’s correct. So we gather the data at the end of the year, when countries have a full idea of what has happened in their countries. And then that is reported through the existing system, that we call the electronic joint reporting formats, across the world. And then we use that to be able to estimate the coverage across countries. And that’s important because it gives us a good way of comparing how coverage is improving or decreasing between countries. And you can compare with previous years. And this is an estimate – an estimate based on reported administrative data, reported survey data. And that’s what we use.
Dr. Bliss: OK. Thank you.
So, Adam, I want to turn to you. You know, Ephrem has really, you know, laid out how UNICEF is looking, you know, across all of the countries where it works, and this, you know, trend of large and disruptive outbreaks in particular, over recent years, you know, along with the kind of stagnation or even decline of immunization coverage.
Now, you recently published a book called “Booster Shots: The Urgent Lessons of Measles and the Uncertain Future of Children’s Health.” And I see a copy there on the shelf behind you as well. So let me ask you to say, you know, a bit about what prompted you to write the book, you know, as you were working in the New York context and looking, you know, at the U.S. and what’s happening globally. And as you look at the situation here in 2025, you know, with nearly 900 confirmed cases and now three – I think, three confirmed deaths, two of which were in children – where do you see the greatest vulnerabilities to be, you know, kind of in our national context here in the U.S.?
Adam Ratner: Sure. Thank you. And thank you for having me on today.
You know, I came to my interest, obsession, with measles – the proximate event was the large measles outbreaks in New York State in 2018 and 2019. There were two large linked outbreaks, one in Brooklyn, New York and one in Rockland County, which is north of the city. And I found myself, for the first time in my career, taking care of just an enormous number of children who were quite sick from a completely preventable disease.
And that was a combination of interesting, because I’m an infectious disease expert and I had never seen this many cases of measles, and just uniquely frustrating. You know, because we have so many things that put children in danger that we cannot prevent, and we do our best to take care of children when they get sick or when they get injured, and we have a handful of things that we can prevent. And measles is one of them. And so to see children and families suffering from that was frustrating.
And I’m interested in measles, and I, you know, devoted the time to writing a book about measles, in part because of how it affects individual children. So it has both very significant short- and long-term health outcomes for kids. The natural history of measles in an unvaccinated child is that most children end up doing fine. They are sick for a week or two and then recover and have immunity to measles.
But in a small, but significant, percentage they can go on to develop pneumonia, which can lead to hospitalization, chronic lung disease. About one in a thousand children in high-income countries who get measles will die from it. About one in a thousand children in high-income countries who get measles will develop encephalitis, which is swelling of the brain, which can lead to deafness or blindness or seizure disorders, other – you know, significant, life-altering diagnoses. And so it’s an important disease from that point of view.
And from a public health lens, I think that measles is two things. I describe it in the book as a bully. And what I mean by that is it is something that picks disproportionately on populations that are crowded, that are malnourished, that are underserved. And when you look in those sorts of populations, you see much higher death rates and much higher rates of severe disease, like encephalitis. And it’s a – you know, it is a disparities-enhancing disease.
The second thing is, precisely because it’s both eminently contagious – like, it is the most contagious disease that we know of. It moves through populations at unbelievable speed, you know, faster than COVID, or flu, or polio, or Ebola, or anything else you can think of. So precisely because it is both that contagious and totally preventable at this point, it is a bellwether for not – it’s about much more than just measles. So measles tells us, yes, there’s a breakdown in – you know, in public health trust and that kids aren’t getting their measles vaccine.
But it tells us also – it gives us a look into the future. And I’m concerned in the U.S., but also in other places that are experiencing measles outbreaks now, that – we have to pay attention to measles, of course – but that other not only vaccine-preventable diseases, so – and I’m worried about those. Like I worry in the U.S. about the rise of pertussis, which is whooping cough. We’re seeing that already. We just had two deaths in Louisiana in infants from pertussis, which is also vaccine-preventable. You know, I’m worried about diphtheria returning. But also, just the general breakdown of trust in public health, and in governmental systems, and what that means for keeping kids healthy from a wide – you know, a wide variety of contexts, not just infectious diseases.
Dr. Bliss:
So you’ve talked about the breakdown of trust, not just in vaccines but kind of in science and maybe health care, writ large. And so, you know, I want to – I want to ask each of you to say a bit about kind of what we’re seeing in terms of trends with vaccine confidence. You know, certainly, you know, Ephrem, you pointed out that, you know, even before the pandemic, just kind of – the global numbers had stalled. And, you know, we hadn’t seen that kind of rapid progression that had been seen earlier in the 21st century.
But what – I want to ask each of you to say a bit about what you’re seeing in terms of the circulation of messaging and information, or misinformation, about vaccines, and measles in particular. And to ask you to say a bit about, you know, who are the best messengers to talk about vaccines, you know, with patients. Like, Adam, for example, in the U.S., I mean, you hear that, you know, parents will say, well, measles is not really a big issue anymore. We don’t see it. And, you know, parents haven’t really experienced it. Maybe their parents did, but that was – it seems like it was ancient history. Ephrem, maybe, you know, in some of the countries where, if there have been 10 million cases, people are more familiar with the effects of measles, short term and long term.
So, Adam, let me start with you. I mean, if you could just say, you know what you’ve seen in terms of the circulation of vaccine information and misinformation. And, Ephrem, would like to hear from you also.
Dr. Ratner: Right. I think that there are both short- and long-term trends that are important here. And it’s important to realize that even in the unique couple of months that we’ve been inhabiting recently, with an explosion of anti-vaccine information, I think even before that there was erosion of trust and, consequently, erosion of vaccination rates. And if you look at kindergarten entry, two-dose measles, mumps, rubella, rates – which is kind of a bellwether rate that we use to assess vaccine confidence – they had been around 95 percent prior to the COVID pandemic. That’s right around where we need them to be. It’s not as high as we would like them to be. But they eroded during the COVID pandemic, for a variety of reasons. And we’re now in a situation where that rate is under 93 percent and falling.
And that’s a nationwide rate. And I want to detour for one second and talk about geographic heterogeneity, because it’s important. So if you – if you look at our national rate, we’re close to 95 percent, but we’re not there. If you look at state rates, some states do much better than others. But when you start to really drill down at county-level rates, and at even ZIP Code, neighborhood level rates, you can see substantial heterogeneity. That’s what happened in New York City in 2018 and 2019. The overall vaccination rate in the city for kindergartners with MMR was 98 percent. I wouldn’t have given that rate a second look in terms of thinking about New York as being vulnerable in that time. But the rates in Williamsburg and Borough Park, which were the specific areas that were the epicenters of the outbreak, it was about 70 percent.
And that’s an enormous difference. They’re small areas, so in the context of a large city they didn’t move the needle in terms of the overall rate. But that’s all that you need to seed really large outbreaks. And that’s what we see in Texas also. The statewide rate for Texas in the last data that we have is about 94 percent. The rate in Gaines county is between 70 and 80 percent. So I think that that heterogeneity is really, really important.
Dr. Bliss: So, Ephrem, do you see the same, you know, kinds of – I mean, there’s patchiness and pockets of unvaccinated and under-vaccinated children. And you’ve talked about that. But do you see challenges associated with the circulation of misinformation about vaccines? And, if so, like, who are the messengers who are most able to kind of build that confidence within communities?
Dr. Lemango: Let me start by restating some of the things that Adam raised, from a global point of view, which are, I think, very important. Before we had measles vaccination, every child that has caught measles will either have complication or will likely die because of limited services provided in health facilities. And access to service was quite limited. So there used to be annually 2.6 million children that used to die from measles globally. That is a huge number. And that’s not acceptable. And what the measles vaccine did is it reduced this significantly, to as low as, in 2013 – in in 2023, now we see about 100,000 or plus – 10,000-plus cases across countries. From that 2.6 million we had six, you know, decades ago. And that’s a significant reduction.
But still, 100,000 is not acceptable because this is a disease that can be prevented. And all it takes is to get 95 percent of children vaccinated with two dose of vaccination. And that is easy to do because it’s, one, for poorer countries, countries that are not able to afford, still a cheap vaccine. And for countries that are challenged, you can provide these vaccines through campaigns, even if you don’t have strong systems on the ground. So the ability to deliver these vaccines is actually – if you compare it with the other more complex vaccines – it is much easier. And if you see the overall impact of immunization over the past 50 years, it is one of the most important public health tools that has been able to save about 154 million lives over the past five decades.
And perhaps next to water, clean water, this must have been the most consequential public health story that we have at hand. And this is six lives saved every minute for the past 50 years. That’s very significant. And measles accounts for about 90 million of this – out of this 154 million. So we can see the lifesaving impact of measles vaccination. Before measles vaccine, parents never had any chance. In the time where they see – they start seeing fever and rush on their children, they start to panic because there isn’t any other solution. And now that we have this vaccine, it is important that we are able to give it to everyone. And addressing the needs of communities is much, much important at this moment.
One of them is the vaccine confidence. And the way we see it in UNICEF is vaccine confidence is a spectrum. A spectrum, in a way that you find a parent that is questioning the impact of the vaccine, the potential side effects and what should I expect – which are generic, important questions that you will ask as a parent. And the other side of the spectrum is obviously people who speak against the vaccine. But most of the problem across low- and middle-income countries that we see is most of the parents are vaccine questioning, and all they need is explanation about what they can expect after the vaccination. And some parents are hesitant because there are religious leaders, faith leaders, or community gatekeepers that tells them it’s not good to be vaccinated. And it will require you to engage these community gatekeepers for them to understand the impacts of such kinds of decisions.
And the key, most trusted messengers that we know, based on our experience, is there is no replacement to health workers. Health workers the most trusted source of information for communities. And they are able to provide the right amount of information, based on the questions that parents have. And usually, most parents, they get the first vaccine and they don’t take the second vaccine when the health worker do not necessarily advise them on the potential side effects that they can expect. If a mother sees her child having fever, a bit of headache after the vaccine, if the health worker did not advise her then she would say, oh, this is not good vaccine. So it is those kinds of very simple, it doesn’t take much long to advise a parent about the potential side effects that they can expect. And these are very short-lived, a day or two, and then the child is protected. And it’s a process of our body that is mounting immunity that’s bringing this fever and so on. So that’s important.
Another one is in low-income countries where there are no health workers as close to – as close as to the communities, you will find a value of community health workers who go door to door, knocking at each house, and informing communities and parents about the importance of vaccination, the importance of, you know, health services for children, and the importance of bringing children whenever they are sick. So we find those to be important messengers. But in several other countries, we see religious leaders playing a big role. They encourage communities. We have seen it during the COVID days and we have also seen it for our effort in eradicating polio, where faith leaders have been really useful in disseminating such messages to build trust and confidence on vaccines.
And survivors of some diseases have also been quite useful, because these are people who have experienced the diseases and the impacts on themselves. And it’s easier for people to really see and trust these people who have been affected. We have done this, for example, for polio survivors, our biggest advocates for polio eradication in vaccination. And we have so many measles survivors. Some of them are, you know, blind, some are deaf as a result of the consequence – you know, the complications. And have been quite an important advocate in this work.
And of course, finally, policymakers and politicians are also useful because vaccine confidence – one aspect of it is people do not necessarily mistrust just the vaccine. They mistrust the systems that provide the vaccine. They mistrust the people who pay for the vaccine, people who procure the vaccine, and the facilities that deliver. So it’s vaccine confidence and vaccine hesitance is not an isolated phenomenon. It’s part of a broader lack of trust to the systems around. So it is important that we work on those systems to build confidence. And one of the good ways to do this is provide quality health services, ensure health workers to spend a good amount of time advising parents on the importance of vaccination, and then use that opportunity to make sure you address questions that parents may have.
Dr. Bliss: So, Ephrem and Adam, I mean, you both talked about the importance of really the need to spend time with parents and explain the value of vaccines and the importance. And, Ephrem, you’ve also talked about the role that health workers, community health workers, and, you know, just the overall aspect of a strong health system can play in building confidence, not just in vaccines but in the entire institution. Of course, you know, at this moment we’re seeing here in the United States cuts to funding for states and localities for health services. Not just for health workers, but also for data collection, for analysis, and for some of the other elements that might go into that overall health system.
And, of course, internationally, at least, you know, the United States has announced its intent to withdraw from the World Health Organization. There may be a termination of funding for Gavi, the Vaccine Alliance. And so, you know, there may be decreases in terms of funding associated with some of the global immunization programs as well. At least from this government. So could you say a bit about the impact, you know, the likely impact of these cuts? You know, whether or not they’re specific to immunizations, but kind of more generally to health systems, how this is likely to shape the kind of future of measles outbreaks and the potential for strengthening immunization coverage? Adam, let me start with you.
Dr. Ratner: Sure. I think we’re in a uniquely dangerous situation right now, for the reasons that you described. And that’s based on several things. So the first thing is that when we have measles outbreaks, or really any local public health crisis in the United States, we rely strongly on state and local health departments. So the CDC is wonderful. It is incredibly valuable for providing expertise and help when asked. But really, the front line of our public health efforts rests in state and local health departments. And many of those are under incredible strain right now in terms of both staffing and just availability of resources in general. Many of those get a significant percentage of their operating budget from federal funds, not just state funds. And so even though many of the cuts that have been announced have been at the federal level, to CDC or to other things like that, there are also reductions in – and even clawing back of funds that have been given to state and local health departments.
And so that sets us up for, you know, bad things in a number of ways. So, first of all, as Ephrem was alluding to internationally, there’s the potential for us to be flying blind. In that, if we don’t have good surveillance, if we don’t have robust testing for infectious diseases, or, you know, wastewater monitoring, or all of the other things that we do to understand how infectious diseases move through populations, we put ourselves in a bad position of ending up responding to outbreaks only when they are larger, only when it’s blaringly obvious that that is what’s going on. And, again, just to go to outside of infectious diseases for a second, if you look at something like the lead crisis in Milwaukee, where they requested help from CDC, and CDC was unable to give it, that is – you know, that’s something that puts children in acute danger as a result of the funding cuts that we’re seeing now. And so that’s one piece of it.
And then the other reason that I think that this is a uniquely dangerous time is that as we look at the trends – and I’m talking specifically about measles now but, again, it’s about much more than just measles – there was a modeling study that came out of Nathan Lo’s group at Stanford just in the last week looking at what would happen at various levels of childhood immunization in terms of the return of measles endemicity to the United States – meaning loss of our elimination status. And what the group showed was that it is likely, even if we just maintain the levels that we have, that endemicity will return in the next 20 years, perhaps much sooner than that. And I think that that was an important and sobering analysis, because I think for many of us, we don’t have the illusion that we’re going to be able to even maintain the levels that we have now.
And also, it doesn’t – it doesn’t take into account some of the more hyperlocal outbreaks that happen, and what’s going on beyond our borders. Where, as Ephrem was describing, you know, we have increases in measles outbreaks globally, including linked outbreaks to U.S. outbreaks in both Canada and Mexico. So I think those things together put us in a precarious state.
Dr. Bliss: Ephrem, looking at the international situation, the announced cuts by the United States, or the planned withdrawal from the World Health Organization, cuts to international organization funding, and the reported termination – although we’re not – maybe not – hasn’t fully been announced – the relationship with Gavi, what do you anticipate being the impact of these cuts in the short and longer term?
Dr. Lemango:
Katherine, this is very important because it has exacerbated the critical challenge that immunization and health programs have been already having. And this exacerbation could be catastrophic because it is impacting the entire health system. So this announced and planned funding cuts from different donors, including the U.S. government, it is important to understand this by understanding what sorts of health systems components that these funds used to support.
Primarily, if you look at from overall health system support point of view, these funds used to pay for health workers, used to pay for strengthening of supply chain that keeps vaccines safe and potent, and that’s able to be delivered to the last mile. These funds used to pay for the data and the health information system that gathers how many children are vaccinated and how many cases of outbreaks that we are seeing in those countries. Unfortunately, when this goes away, the delivery of vaccination service, even in health facilities – because the health workers are not there – the delivery of vaccination in outreach sites, which is closer to communities done by community health workers and outreach nurses and midwives, all these will be disrupted. And that’s what we are seeing now.
WHO did a pulse survey to understand the level of impact in countries. And from survey of 108 countries, about 50 of them – five-zero – are reporting moderate to severe disruption of their vaccination program, of their surveillance or their ability to pick these diseases, and the delivery of vaccination services closer to community. And this is part of a broader disruption of health services. In many of these countries, this is equivalent to the level of disruption we had during the COVID days. So before we recovered from the impacts of COVID we are having another shock that is equivalent to COVID, from health service point of view. So that will likely – definitely impact the access to services by communities, and will decrease immunization coverage and reach, and that further push this increasing number of outbreaks.
The second line, and the most immediate, is these fundings used to cover – used to fund the surveillance system, a system that is able to pick when cases come out. And when there is a case, you do clinical investigation to categorize this as probable case or not, and then you do laboratory test to confirm it. Those systems, we do not have them anymore. That used to be supported through these findings. That means we are really moving blind. And we do not – these are the systems also that are able to pick when outbreaks in Mpox, or Ebola, or other diseases of global health security concern happen. So basically, we do not have the mechanism to be able to pick when this disease happen at this moment. So that’s an important impact, and an immediate one that requires quite an attention.
The third and associated with this is the ones that you mentioned about the funding that is needed to make sure alliances like Gavi are able to continue to do what they have been doing so far. Gavi is a very phenomenal alliance that has been able to vaccinate over a billion children in the past 25 years across the world. And this would have not been possible had it not been for the support by the donors and the private sector as well. And what Gavi does is it’s able to pool the global demand for vaccines and able to negotiate good prices for these countries. And then it relies on countries paying a share of the vaccine price and paying for the rest of the vaccine price by Gavi and avail the vaccines to countries. And it also supports their health system so that they will be able to deliver these vaccines.
So any reduction to this important platform, important alliance, would exacerbate the current challenge, and would likely impact the reach of vaccination going forward, Gavi is now preparing for its Gavi 6.0 strategy, which is the strategy from 2026 till 2030. And it aims to reach 500 million children, with the potential to save about 9 million lives. That is a huge number of lives that can be saved. And cutting any funding from Gavi would likely exacerbate this challenge that we are seeing at this moment. And entities like UNICEF, who heavily relies on voluntary contribution by donors, are also feeling this significant challenge. We estimate in the range of 20 to 30 percent funding reduction. And this will affect our direct activity, especially in countries affected by conflict, fragility, and who have humanitarian challenge, who are heavily dependent on these funds.
UNICEF buys the vaccine for Gavi, but also buys the vaccines that are not covered by Gavi for governments in countries. And we do not have that capability at this moment because of these funding cuts. So we are calling on the global community to be able to really understand that saving the lives of children is a humanly thing to do. It is the right thing to do. And it keeps the world safe, because any infectious diseases in a part of the world is a threat to the rest of the world, even if it doesn’t feel like it’s a threat. So it’s an important part. And we’re very concerned, concerned by countries facing this challenge, and the limited capacity they have any health systems, will further be impacted, and they’re not able to deliver services.
And we are also seeing communities themselves – the biggest impact of whenever you have service interruption is communities will go to that health facility and they are told, oh, there is no service. They will not come back, even if you restart the service. And it really affects the confidence that communities have on the health service delivery. So it is a far-reaching impact that we can expect. And of course, the biggest concern is for our global health security. You may be in a situation where an Ebola outbreak is happening somewhere and you have no idea it’s happening, until it reaches to the rest of the world. So it’s an important undertaking at this moment that we rethink our decisions and donors are able to step up to be able to meet this demand. Thank you.
Dr. Bliss: So you’ve painted a picture really of, you know, it takes quite a long time and a lot of effort to build trust and really encourage people to come to health systems, and really, you know, kind of learn about, you know, the options and what’s available to them through vaccines and other kinds of services. But that can all be taken away very quickly, you know, with, you know, the disappearance of services, or some other – some other policy intervention.
So I want to – you know, we’re coming towards the end of our time here. And, of course, we’re looking – Ephrem, you’ve mentioned the Gavi replenishment, which is coming up in June. Of course, we’ve got the World Health Assembly before that, the gathering in New York in September, more on noncommunicable diseases. And, of course, there’s some overlap with the broader issues around health services and the health system. You know, I want to ask each of you, just kind of as you look ahead towards the end of the year – you both talked about flying blind, so I sort of hate to say looking ahead. (Laughs.)
But as you anticipate what may develop over the next eight to nine months, towards the end of the year, what milestones will you be looking for to kind of give you a sense of whether we’re heading towards – you know, maybe the corner has – you know, we’ve turned a corner and things are going to be going in a better direction as far as measles and the broader immunization coverage is concerned. Or, you know, what will really kind of tell you, by the end of the year, you know, we’ve headed toward this – like Adam, as you said, this period of endemicity where, you know, the U.S., like, loses its elimination status, or, you know, in the global case, like, we’re really looking at even more than 10 million cases, and a real regression, you know, back to even before pandemic era. So, Adam, let me start with you, and then we’ll turn to Ephrem.
Dr. Ratner: You know, in terms of milestones, I think in the short term most of us are really watching the West Texas outbreak. It’s the largest one right now. It has spilled over into multiple other states. I am hopeful that we will be able to get that under control, but I’m concerned. I mean, when we had an outbreak of similar size here prior to the COVID pandemic it took an incredible, focused effort by our local public health department, who worked, you know, unbelievably hard on that problem over many months. And I’m hopeful that Texas and the other states that are involved will be able to put the effort, and have the resources and the people power, to put the effort into that, to get this under control.
You know, at the more macro level, I’m concerned. I mean, we are still in a situation where children’s health and vaccination, and things – tools like school mandates – have become wrapped up in politics and identity in a way that they were not in the past. And that puts us in a situation where I think that subgroups of families are much more vaccine hesitant than they were prior to the pandemic, prior to the recent elections. And what’s it going to take to reverse that? I mean, I’m worried that what it’s going to take is children getting sick, is what we’re seeing in West Texas. And I’m concerned that we may not be able to turn that piece of things around until, you know, parents see with their own eyes that – you know, that the things that vaccines protect against are real and that they are dangerous.
Vaccines and public health in general, you know, classically, are victims of their own success. In that when they work beautifully, when we do everything right, what happens is children don’t get sick. And you can’t see children not getting sick. You don’t know which child would have gotten measles, would have gotten diphtheria. But it’s – you know, I fear that what it’s going to take is a price that we don’t want to have to pay, but that we may end up paying in either case.
Dr. Bliss: So you’re watching West Texas, and, you know, what’s really happening in the surrounding communities and surrounding states. But also, you know, really looking ahead at the politicization of vaccines. And, you know, the sad reality that people may need to really see for themselves the effects in order to kind of see a change in some of those views.
Ephrem, as you look ahead over, you know, the next several months of kind of big global meetings and convenings on these issues, and then, of course, what’s developing in the countries themselves, what are the kind of particular, I guess, milestones you’re looking at? And what are you most hopeful about as you look towards the end of 2025?
Dr. Lemango: We are keeping an eye on important developments happening in different regions. And this is with regard to these increasing number of outbreaks and children affected. And it is important that we quickly are able to mount a response, which is an outbreak response, in these countries. We have seen in Europe under several populations, like the Roma population, being impacted by a measles outbreak. And it required very just well-designed, well-thought-out program to understand their needs and be able to respond. In the African continent, we have seen increasing number of countries in the Sahel and the Horn of Africa being impacted by measles outbreaks. And this as a result of, you know, weak health services that requires better investment to be able to respond to this outbreak, but also prevent them in the future.
And if you come to the Latin American region, you’ll see the region of the Amazonia – Amazonian population that has limited access to services and low coverage and immunization – being the center of these outbreaks. And, of course, underserved communities in urban areas as well. Most people assume urban areas have good amount of vaccination coverage, but we see so many communities underserved because the way health services are designed doesn’t necessarily meet the needs of urban population that are urban dwellers, that goes out in the morning and come back in the evening. And unless and otherwise you open health services during weekends or after work hours, it’s very hard to reach those kinds of populations and parents.
So we are keeping an eye on how we are able to respond to measles outbreaks in these communities, but also able to restrengthen immunization services that are tailored to these kinds of communities. But most importantly, countries directly affected by conflict, places like Sudan where there is an active war, areas like, you know, eastern DRC, that service has been disrupted due to an active conflict, and countries that are also recovering from previous conflicts, that requires strengthening systems. A lot of investment is needed in those countries. So we’ll keep an eye on these countries and communities. And UNICEF will be able to continue to support these countries and communities.
We are also very hopeful that by the end of the year – we are currently implementing a program called The Big Catch-Up. It is an effort to be able to catch children that were missed during the pandemic, even though now they are older than the usual vaccination age, to really vaccinate them with measles, diphtheria, tetanus, and pertussis vaccines, to be able to prevent the occurrence of these diseases. And this is not a small number of children. And most of these children are in difficult-to-reach areas, in remote areas.
So we have put together, between UNICEF, WHO, and Gavi, and several other partners, what we call The Big Catch-Up Program. And the intention is to reach these children that are missed during the pandemic. And we hope that this will be able to fill the immunity gap that is prevailing now, or at least contribute to that, on top of the preventive campaigns that we do, particularly for measles. And hopefully the number of measles outbreaks will decrease starting from next year, depending on how successful we are amid these current funding cuts that will likely also affect The Big Catch-Up.
Finally, it’s, I think, important for us to be also hopeful, understanding the power of vaccines. Vaccines hold the biggest hope in preventing and continuing to prevent very easy, preventable diseases, like measles, diphtheria, pertussis, but also hold the hope that several diseases that are not vaccine-preventable at this moment could continue to become – could end up becoming a disease that we can prevent through vaccines. And how technology, general-purpose technology, the likes of artificial intelligence, would really likely support the process of discovering vaccines, developing vaccines, in identifying the right proteins to be able to respond to not only infectious diseases but also even autoimmune and noncommunicable diseases using therapeutic vaccines in the future.
And that future is not really a far future. It’s quite close to us. So there is much potential for vaccines. In the past few years we implemented a vaccination using HPV vaccine to prevent cervical cancer. And we did that and reached over 50 million adolescent girls in the African continent and Southeast Asia. And that has been quite phenomenal, because you just give one dose and that adolescent girl is protected from potential future cervical cancer. That was a phenomenal, you know, value of vaccine. We hope to get a TB vaccine over the next few years. And that will likely become also another tool to prevent such a catastrophic disease affecting almost half of the world.
So the value and potential of vaccines is so high that we will have to keep on investing on vaccines and vaccination so that we realize the potential. Our estimates show that currently we save about 4.2 million lives every year with all vaccines – not only measles, but all vaccines. And this could go as high as 5.8 million lives saved in the next five to, you know, six years, if we are able to reach the global targets that we have sets within the immunization agenda 2030. Which is reaching at least 90 percent covered with all the vaccines. So it is potentially possible, as long as we are able to put in the investment required, and as long as we are able to engage governments. And governments have been now quite forthcoming these days when they see the impact of this funding. They are doing their best with whatever money and resources they have, they are trying to step up. And hopefully this will continue.
Dr. Bliss: So I guess in the – in the light of world immunization week, it’s humanly possible as well, right? That’s the slogan for this year. And, you know, really focusing on what we can all do together. Dr. Adam Ratner with the American Academy of Pediatrics and Dr. Ephrem Lemango with UNICEF, I want to thank you for joining me today to talk about, you know, really how measles outbreaks are a reflection of the health of the health system, the access of people to services, and really kind of emblematic of health security in particular regions.
You’ve really emphasized the importance of ensuring access to services for the most vulnerable and the need to really pay attention not just to kind of the overarching coverage statistics or, you know, what we see, kind of at the state or the country level, but understanding where those pockets of unvaccinated or under-vaccinated children are – whether because of conflict, or lack of access to services, or challenges, you know, around kind of understanding the importance of vaccines. We talked a bit about the impacts of cuts to funding, both domestically and internationally. And, Ephrem, you’ve also talked about the potential for new technologies, the role of artificial intelligence and new platforms for vaccines, and, you know, studies that are ongoing for, you know, the potential for new vaccines as well.
So I really want to thank you both, on this very last day of World Immunization Week, for taking the time to speak with me. And I want to thank our audience for joining us as well. Thank you very much.
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