Tens of millions of children around the world have been denied life-saving vaccines against measles in both rich and poor countries due to Covid-19 disruptions, with fears of further outbreaks this year. Since March, routine childhood immunisation services have been disrupted on a scale unseen since the 1970s, according to the World Health Organization (WHO). Data collected by Unicef, the Gavi Alliance, WHO and Sabin Vaccine Institute found in May that immunisation programmes had been substantially hindered in at least 68 countries, leaving 80 million children under the age of one unprotected from diseases including measles, tetanus, polio and yellow fever. Although progress on immunisation coverage was stalling even before the pandemic hit, limited access to health centres, a lack of personal protection equipment (PPE) for healthcare workers, and fear of contracting Covid-19 have all contributed to major disruptions in the delivery and uptake of vaccination programmes. At least 30 measles vaccination campaigns were or remain at risk of being cancelled, according to Unicef’s chief of immunisation Dr Robin Nandy. “We were seeing an increase in the spread of measles globally over the past two years, even before the pandemic hit, so obviously now with Covid and the associated disruptions, we are more concerned,” said Nandy. “These outbreaks are not limited to low-income countries or countries with weak systems in Africa or south Asia. They extend to a number of middle-income countries in the Americas, such as Brazil, Venezuela and Mexico, where in 2019 we saw worrying trends, including up to a 20 percentage point decrease in measles vaccination coverage in some places.” Globally, November 2019 saw the greatest number of measles cases reported since 2006, according to Unicef. In Cambodia, which received its measles elimination status in 2015, the first confirmed case of Covid-19 in January coincided with 84 confirmed cases of measles. By early May, when 341 cases had been recorded, outreach teams were forced to go door to door, and in some cases, boat to boat, in order to maintain routine immunisation services. By the end of that month, the number of reported cases began to fall. Measles vaccination campaigns have been rolled out in a number of other countries, including the Central African Republic (CAR), the Democratic Republic of the Congo (DRC), Ethiopia, Nepal and South Sudan, said Nandy. In CAR, which declared a nationwide measles epidemic in January, more than 26,000 cases have been reported over the past seven months, said Médecins sans Frontières’ CAR and DRC operations coordinator Emmanuel Lampaert. “The Ministry of Health is planning a vaccination campaign for August but the main challenge so far has been the lack of PPE,” said Lampaert. “MSF has managed to vaccinate 332,228 children since February, but there are still over 1.9 million children who need to be vaccinated against measles, by some estimates. Today, overall case notification is decreasing, with about 350 new cases for the last two weeks, down from 2,000 cases per week in mid-March. But we know that we are facing an underreporting of cases and deaths as there are important delays in the transmission of surveillance data.” In DRC, where a measles epidemic has been raging since June 2019, all 26 provinces remain affected, and nearly 1,000 children have died of measles this year, said Lampaert. “The toll of this epidemic is just devastating, with 7,000 children killed since early 2019 and 380,000 people infected. In the capital city, Kinshasa, we noticed a major drop in consultation as many people feared they would be infected with Covid by going to health facilities deemed under-equipped with protective equipment, or feared being isolated and stigmatised for a long time due to the delays in obtaining test results,” said Lampaert. “This situation affected the care of sick people and the monitoring of their treatment, especially for conditions such as diabetes, tuberculosis, malaria and HIV/Aids. In other parts of the country, some people do not consider Covid-19 as real, they don’t believe in it or see it as a foreigners’ sickness.” The pandemic has forced countries to make local innovations as they resume their vaccination programmes, all while accounting for transportation shutdowns, lack of PPE and social distancing, said Unicef’s Nandy. “In Brazil, they tried things like drive-through vaccines so people wouldn’t have to get out of their cars. In Tanzania, they were doing vaccinations under different trees to account for physical distancing,” he said. “It’s a question of countries learning from one another, from both good and bad innovations, because it’s not like we have prototypes of guidance that we can roll out. “We are building the ship as we sail.”