One company is going to great lengths to build it up, but it will be years before it returns to the minimum level.Doses of cholera vaccine are being given to patients as fast as they are produced and the global stockpile has run completely dry, as deadly outbreaks of the disease continue to spread.This does not shock anyone in the field of emergency epidemic response because the vaccine stockpile has been precariously low for years.The surprise — the good news, which is in itself surprising since ‘cholera’ and ‘good news’ are rarely used together — is that three new vaccine makers are setting up production lines and joining the effort to replenish the stockpile.And a fourth company, the only one that currently makes the vaccine, which is given orally, has been working at a pace that experts describe as “heroic” to expand its production.Yet even with all this, the total global supply of the vaccine that will become available this year will be, at best, a quarter of what is needed.At the end of February, countries had already reported 79,300 cases and 1,100 deaths from cholera this year. Since there is no uniform system for counting cases, this is most likely a gross underestimate.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Campaigns in some countries have reduced the practice, but it remains widespread in those with high rates of population growth.More than 230 million women and girls around the world have undergone female genital cutting, according to a new analysis byUNICEF, an increase of 30 million since the organization’s last global estimate in 2016.While the data shows that in some countries a new generation of parents have chosen to forgo the practice, in other countries laws and campaigns against it have had no impact. In Burkina Faso, the share of girls aged 15 to 19 years who have undergone cutting has fallen to 39 percent from 82 percent over the past three decades. But in Somalia, where an estimated 99 percent of women have had their clitoris excised, the level of cutting has not changed.Because the countries where the practice is most prevalent are also those with the highest rates of population growth, the overall number of girls who are subject to cutting is growing each year.“The total number of women and girls is 15 percent higher than the last estimate,” said Claudia Cappa, an expert on global trends in female genital cutting with UNICEF. “The progress that has been made is too slow compared to the growth of the population of girls who are born each day in the countries that are most affected.”The United Nations has set the goal of eliminating female genital cutting by 2030, but change would need to be occurring 27 times faster than the current rate to meet that goal, she said. In Sierra Leone, Kadiatu Bangora used to perform cutting as part of traditional community rituals. But she gave up the practice and refused to allow it for her daughters.Finbarr O’Reilly for The New York TimesWe are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

An escalation of the war in Gaza could lead to the deaths of 85,000 Palestinians from injuries and disease over the next six months, in the worst of three situations that prominent epidemiologists have modeled in an effort to understand the potential future death toll of the conflict.These fatalities would be in addition to the more than 29,000 deaths in Gaza that local authorities have attributed to the conflict since it began in October. The estimate represents “excess deaths,” above what would have been expected had there been no war.In a second scenario, assuming no change in the current level of fighting or humanitarian access, there could be an additional 58,260 deaths in the enclave over the next six months, according to the researchers, from Johns Hopkins University and the London School of Hygiene and Tropical Medicine.That figure could climb to 66,720 if there were outbreaks of infectious disease such as cholera, their analysis found.Even in the best of the three possibilities that the research team described — an immediate and sustained cease-fire with no outbreak of infectious disease — another 6,500 Gazans could die over the next six months as a direct result of the war, the analysis found.The population of the Gaza Strip before the war was 2.2 million.“This is not a political message or advocacy,” said Dr. Francesco Checchi, professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

An escalation of the war in Gaza could lead to the deaths of 85,000 Palestinians from injuries and disease over the next six months, in the worst of three scenarios that prominent epidemiologists have modeled in an effort to understand the potential future death toll of the conflict.These fatalities would be in addition to the more than 29,000 deaths in Gaza that local authorities have attributed to the conflict since it began in October. The estimate represents “excess deaths,” above what would have been expected had there been no war.In a second scenario, assuming no change in the current level of fighting or humanitarian access, there could be an additional 58,260 deaths in the enclave over the next six months, according to the researchers, from Johns Hopkins University and the London School of Hygiene and Tropical Medicine.That figure could climb to 66,720 if there were outbreaks of infectious disease such as cholera, their analysis found.Even in the best of the three possibilities that the research team described — an immediate and sustained cease-fire with no outbreak of infectious disease — another 6,500 Gazans could die over the next six months as a direct result of the war, the analysis found.The population of the Gaza Strip before the war was roughly 2.2 million.“This is not a political message or advocacy,” said Dr. Francesco Checchi, professor of epidemiology and international health at the London School of Hygiene and Tropical Medicine.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

Brazil is experiencing an enormous outbreak of dengue fever, the sometimes fatal mosquito-borne disease, and public health experts say it is a harbinger of a coming surge in cases in the Americas, including Puerto Rico.Brazil’s Health Ministry warns that it expects more than 4.2 million cases this year, outstripping the 4.1 million cases the Pan-American Health Organization recorded for all 42 countries in the region last year.Brazil was due for a bad dengue year — numbers of cases of the virus typically rise and fall on a roughly four-year cycle — but experts say a number of factors, including El Niño and climate change, have significantly amplified the problem this year.“The record heat in the country and the above-average rainfall since last year, even before the summer, have increased the number of mosquito breeding sites in Brazil, even in regions that had few cases of the disease,” Brazil’s health minister, Nísia Trindade, said.Dengue case numbers have already soared in Argentina, Uruguay and Paraguay in the last few months, during the Southern Hemisphere summer, and the virus will move up through the continents with the seasons.“When we see waves in one country, we will generally see waves in other countries, that’s how interconnected we are,” said Dr. Albert Ko, an expert on dengue in Brazil and a professor of public health at Yale University.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe.

A U.N.-affiliated panel said the territory could tip into famine very soon. International laws to protect people from human-made famines offer little help.The number of people facing possible starvation in the Gaza Strip in the coming weeks is the largest share of a population at risk of famine identified anywhere since a United Nations-affiliated panel created the current global food-insecurity assessment 20 years ago.After Hamas’s surprise attack on Israel on Oct. 7, Israel responded with air and ground assaults and a sealing of the territory, which have left the 2.2 million people who live there deprived of sufficient food, water and supplies. The U.N. has concluded that without significant intervention, Gaza could reach the level of famine as soon as early February.Limited amounts of food and other aid are entering Gaza from Israel and Egypt at border points with rigorous inspections; the ongoing bombardment and ground fighting make distribution of that aid extremely difficult.Scholars of famine say it has been generations since the world has seen this degree of food deprivation in warfare.“The rigor, scale and speed of the destruction of the structures necessary for survival, and enforcement of the siege, surpasses any other case of man-made famine in the last 75 years,” said Alex de Waal, an expert on humanitarian crises and international law at Tufts University who wrote “Mass Starvation: The History and Future of Famine.”The situation in Gaza is the latest in a series of recent crises that have reversed progress against famine. Mass death from starvation declined steadily from the 1980s well into the 21st century. But over the past seven years, food crises associated with conflict (such as those in Yemen, Syria and the Tigray region of Ethiopia) and those stemming from environmental conditions and climate change (such as in Somalia) have resulted in the loss of more than a million lives.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? 

Nutrition experts say the progression from hunger to severe malnutrition can be rapid, especially in children.A panel of experts affiliated with the United Nations has warned that the population of the Gaza Strip is at imminent risk of famine, with more than 90 percent of its 2.2 million people facing “acute food insecurity” and a quarter of the population experiencing “catastrophic levels of hunger.”Even before the war between Israel and Hamas, nearly 70 percent of Gazans were dependent on humanitarian assistance for food because the territory has been under Israeli and Egyptian blockade since 2007. Now, only 20 to 30 percent of what people there need is being permitted over the border into Gaza, according to the World Food Program. The lack of electricity and fuel and the impossibility of moving around safely have compounded the challenges of producing food or getting it to people. Most people are going a day or longer without eating, the expert panel said.As in a vast majority of other food crises the panel, the Famine Review Committee, has assessed in the 20 years since it was created, the situation in Gaza is not environmental but human-made. But Gaza is unusual for the speed with which people have been pushed into malnutrition.In interviews, nutrition experts and doctors described what can happen when people can’t get food.Children often fail firstChildren, pregnant and lactating women, people with medical conditions and older adults typically succumb first to acute malnutrition. How long they can survive under conditions of extreme hunger will vary.“It depends on the age of the person,” said Zita Weise Prinzo, senior nutritionist with the World Health Organization. “It depends on their health status. It depends on whether they have access to liquids, or to some sort of food, even if it doesn’t cover all the nutrient needs.”UNICEF, the humanitarian aid organization that focuses on children, is particularly concerned about infants, said Anuradha Narayan, the agency’s senior adviser on child nutrition in emergencies. Before the war, about 60 percent of Gazan infants were formula-fed. Their families now have little or no access to any food supply for them.“We know that there are many families who are probably unable to feed their children with infant formula,” she said.For families who have found formula, the challenge is getting clean water to make it; an estimated 1.6 liters of drinking water (versus the minimum of 15 liters per day recommended by the W.H.O.) are available per person in Gaza now.Palestinians displaced by Israeli bombardment waited for water at a makeshift tent camp in the Muwasi area of southern Gaza.Fatima Shbair/Associated PressProgression to severe malnutrition is fastMs. Narayan said the agency estimated that 7,000 to 8,000 children are so severely malnourished that they are at risk of death without immediate treatment, but the active conflict in Gaza was making it difficult for aid agencies to evaluate the situation.“We expect that those numbers can go up pretty dramatically in the next two to three weeks,” she said.Ms. Narayan said that in her work in other food security crises, such as in Ethiopia, it was typical to see a child fall ill and progress to severe malnutrition and wasting within days.For Gaza, she said, “It’s harder to predict but if there is nearly no food to feed young children, and illness involved, I would say it could be exactly the same. You go from being reasonably OK to being on some level of malnutrition, maybe not severely wasted, but still wasted, within a span of a few days. Particularly for the young, less than 2 years old, for sure that is likely to be the case.”The trajectory for people with some access to food would be different, said Dr. Stanley Zlotkin, a professor of nutrition at the University of Toronto and an expert on the effects of critical food shortage. An adult may be able to survive for an extended period with only intermittent access to calories or with only foods that offer limited nutrients, he said. In a situation like Gaza’s, where there is still sporadic availability of some food, most adults would be able to survive for some time, but that would not be enough for children to prevent a progression to malnutrition.What happens in the bodyA malnourished body first burns fat reserves, said Heather Stobaugh, an expert on nutrition and emergencies with the aid agency Action Against Hunger, until those are depleted. Then, “The body will resort to using muscle, and eventually vital organs will begin to break down,” she said. “In the most severe forms of malnutrition, immune systems are weakened and vital organs actually start to shrink — the heart, lungs and so on.” “When a child or an adult reaches this point,” she added, “their body is literally wasting away.”Ms. Weise Prinzo said that people in this state minimize energy expenditure. “They stop any movement not necessary for immediate survival, but also within the organs, there are changes in how the heart and liver function,” she said. “They really try to manage, but eventually one or the other of the systems starts to fail.”At this point, a starving person has a range of physical degradations, including extreme fatigue, an inability to regulate temperature and emotional impairment.“We say ‘acute malnutrition’ and acute means that it could happen in a short period of time,” Dr. Stobaugh said. “It doesn’t always have to be months of a slow degradation.”A destroyed building in Rafah, southern Gaza.Fatima Shbair/Associated PressMalnutrition and disease drive a grim cycleA malnourished person is vulnerable to disease because of a weakened immune system and because pf the conditions of conflict, where there is a lack of clean water and sanitation facilities, and people are often living in crowded shelters.A malnourished body’s defenses — epithelial cells, which make up the surface of the skin and barrier tissues in places such as the gut — break down, and white blood cells malfunction.“Then when you get sick, the body uses whatever protein and energy stores that you have, trying to fight the infection, and that cycle of infection and malnutrition is what rapidly causes the wasting to take place,” Ms. Narayan said. This process is more rapid in children, she said.Dr. Zlotkin said disease spreads rapidly in situations such as the current one in Gaza, where 90 percent of people have been displaced and are sheltering in tents or other temporary structures, and there are few adequate latrines or washing facilities. Pneumonia and gastrointestinal infections are the main causes of death for malnourished people.“You have outbreaks of illness such as extreme diarrhea in combination with no health care services, no food, no clean water,” Dr. Stobaugh said. “This sort of perfect storm of adverse environmental conditions and health conditions is going to exacerbate the speed with which a body will become malnourished and can ultimately become on the brink of death quite quickly.”

Researchers in developing countries are trying to find treatments for conditions that affect the poorest people. But the system is stacked against their therapies.Three years ago, Jesús Tilano went to a hospital in a thickly forested valley in Colombia with large open lesions on his nose, right arm and left hand. He was diagnosed with leishmaniasis, a parasitic disease that is spread in the bite of a female sand fly and which plagues poor people who work in fields or forests across developing countries.He was prescribed a drug that required three injections a day for 20 days, each one agonizingly painful. Mr. Tilano, 85, had to make repeated expensive bus trips to town to get them. Then his kidneys started to fail, which is a common side effect of the drug, as are heart failure and liver damage.“The cure was worse than what I had before,” Mr. Tilano said.Leishmaniasis is a terrible disease, with terrible treatments that have hardly changed in a century. The drug Mr. Tilano took was first given 70 years ago. All the treatments are some combination of painful, toxic, expensive, or challenging to administer, requiring an inpatient hospital stay or daily visits for a month.Among the so-called “neglected tropical diseases,” many experts believe leishmaniasis is in a class of its own in terms of the lack of progress, in the 120 years since it was first identified, to help the two million people who contract it each year.Now, finally, that is starting to change: When Mr. Tilano’s grandson Andrés Tilano, 14, contracted leishmaniasis last year, he was treated in a clinic in Medellín, with an experimental therapy that cured his infection in days.The treatment he received is one of several being developed by the Program for the Study and Control of Tropical Diseases, known as PECET, a small research institute based at the University of Antioquia in Medellín. In its effort to hunt for new treatments for leishmaniasis, the program has partnered with the Drugs for Neglected Diseases Initiative, or DNDi, a nonprofit research and development organization based in Geneva.All of the experimental treatments the researchers are evaluating are far less toxic, onerous or expensive than what exists now. But a big hurdle still stands in the way of getting them to the millions of people who need them.Mr. Tilano’s son Luís, a logger who has become something of a local expert on the disease, receiving a locally developed cream to treat leishmaniasis from Dr. Quintero.Federico Rios for The New York TimesNone of the new treatments have been tested in a large-scale trial, or approved by Colombia’s drug regulator, or adopted into the national treatment guidelines. When a drug is made by a pharmaceutical company, the firm will shepherd it through the expensive and time-consuming regulatory process.But there is no money to be made on a drug for a condition that overwhelmingly affects the poor, and academic or public health institutes rarely have the resources to push a drug through to the end of the process, said Marcela Vieira, a Brazilian intellectual property lawyer with an expertise in drug development and access.The global drug development system has long favored private sector firms that can bankroll experiments and diseases that afflict people with money to pay for treatments. Increasingly, new research on diseases such as leishmaniasis is coming from public sector and academic institutions in middle-income countries, particularly Brazil, South Africa, India, Cuba and China, Ms. Vieira said. The Covid-19 pandemic, during which low- and middle-income countries were shunted to the back of the line for vaccines and therapeutics, helped spur new investment into building drug development and production capacity.“We need to do it, because no one will do it for us,” said Dr. Juliana Quintero, an expert in leishmaniasis and researcher at PECET.The program’s research labs sit six floors up in a bulky brick building at the University of Antioquia in Medellín. On the ground floor, Dr. Quintero sees patients who arrive on buses from rural towns. She knows that few can afford to stay in the city for a month of injections; she wants a treatment she can send home with them, ideally one they can take by mouth. Because funds for drug development for leishmaniasis are so scarce, she hopes for something that will work for every one of the 22 parasites in the family that cause variations of the disease in tropical countries around the world.The leishmaniasis researchers have taken inspiration from Indigenous people in the region: One drug they are testing, a gel applied to lesions, is derived from a plant Indigenous people use to fight the parasite. The experimental treatment that cured Andrés Tilano is called thermotherapy, and it resembles the traditional Indigenous cure of burning the lesions. In her clinic, Dr. Quintero used a hand-held device that emitted heat at 50 degrees Celsius, or 122 degrees Fahrenheit, over top of the lesion, killing the parasite deep inside.Dr. Iván Darío Vélez-Bernal, who recently retired as the director of the Program for the Study and Control of Tropical Diseases, at the University of Antioquia in Medellín, Colombia.Federico Rios for The New York TimesToday Dr. Quintero prescribes two treatments her institute has developed and supplies them to patients under a so-called compassionate use model, since they have not yet been approved or registered by the Colombian government.Mr. Tilano and his grandson had cutaneous leishmaniasis, which is the least severe form of the disease. It can progress to mucosal leishmaniasis, when the parasite infects tissue such as that inside of the nose, or to what’s called visceral leishmaniasis, when the parasite migrates to the spleen, liver or bone marrow. Untreated, the visceral form of the disease is fatal in more than 95 percent of cases; it kills an estimated 6,000 people each year, most of them in Africa and Asia. The number of deaths has dropped significantly in the past few years mainly because of progress in finding and treating leishmaniasis in India, where it is known as kala-azar.Because the existing treatments are so onerous and hard to get, Dr. Quintero said, few patients complete the course. That creates a newly drug-resistant parasite, which another sand fly can transmit to its family or others in their community. When Dr. Quintero went to visit Mr. Tilano at home not long ago, she met his daughter and granddaughter, who had the large circular scars of lesions that had finally healed.Mr. Tilano’s son Luís, a logger who has become something of a local expert on the disease, asked Dr. Quintero to accompany him down to the bank of the Cauca River to see a neighbor who he thought might also have leishmaniasis. After navigating a field of curious cattle and a steep river bank, she crawled through the twisted vines of a fig tree and met a group of older women panning for gold at the water’s edge. The neighbor, María de las Mercedes González, 55, had large lesions on her face, and Dr. Quintero used the flashlight of her cellphone to try to determine whether the parasite had already moved into the cartilage in her nose.María de las Mercedes González, a gold miner on the Cauca River, had her lesions inspected by Dr. Quintero.Federico Rios for The New York Times“Imagine such a tiny animal that in one bite can cause such a problem: It’s a very irritating little creature,” Ms. González said after Dr. Quintero explained the risk she faced without treatment, and broke the news she would have to spend 10,000 pesos (about $2.50, more than she typically earns in a day of mining) to make the daily trip to the city for treatment. The drugs, at least, would be free through Colombia’s public health system.DNDi, the nonprofit organization, has screened more than 2.5 million compounds — a standard first step in drug development — to come up with five chemical structures that seemed, in early lab tests, like they might work against the parasite that causes leishmaniasis. But of those five, only one or two will progress to larger clinical trials, said Jadel Kratz, who runs the organization’s drug discovery work in Latin America.Early discovery and preclinical studies cost $10 million to $20 million, he said, while getting through the first small clinical trials for safety and some sign of efficacy could be another $6 million. The last phase, a large trial in patients to test whether the drug works, costs at a minimum $20 million — far more than the public and academic research teams can fund.“It’s a huge risk for local research if only multinational corporations can do this work,” said Dr. Iván Darío Vélez-Bernal, who recently retired as director of PECET, the research institute.But DNDi’s focus on leishmaniasis, and the work of researchers in a network that includes India, Colombia and Brazil, is starting to pay off. Today there are five drugs in Phase 1 trials, and another in Phase 2, which is unprecedented in the history of the disease.It is not clear when or how the drugs will get to the next phase of the process. Drugs that come out of public sector institutions tend to languish without a champion, said Ms. Vieira, who is a researcher with the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva.Mr. Tilano and his grandson, Andrés, who developed lesions last year but was treated in a clinic in Medellín with an experimental heat therapy that cured his infection in days.Federico Rios for The New York TimesDrugs that originate from public health organizations in Brazil or India are often different in key ways from ones developed by a pharmaceutical company in an industrialized country, Dr. Kratz said: The scientists creating them think about access from the start, knowing that whatever they design will have to be delivered by a low-resource health system.In Colombia and neighboring Brazil, leishmaniasis mainly affects farmers, loggers and miners — people whose work brings them into regular contact with the sand fly. But climate change is causing the fly’s habitat to spread quickly, and Dr. Quintero finds herself more frequently treating cases from semi-urban areas. During Colombia’s long civil war, much of which was fought in jungles, the parasite also sickened soldiers, who accounted for up to half of the cases nationally. So the army was keen to find treatment, and helped test some of the experimental drugs.The Colombian government is missing an opportunity now by not funding the Phase 3 trial for PECET’s experimental therapies, Ms. Vieira said.“The trials are expensive but it’s much less than what they will pay for a treatment if it is developed by a for-profit company, or all the things that they already have to pay for, for people who are sick and don’t have access to the treatment,” she said.

The number of malaria cases rose again in 2022, propelled by flooding and warmer weather in areas once free of the illness.There were an estimated 249 million cases of malaria around the globe last year, the World Health Organization said on Thursday, significantly more than before the Covid-19 pandemic and an increase of five million over 2021. Malaria remains a top killer of children.Those new cases were concentrated in just five countries: Pakistan, Nigeria, Uganda, Ethiopia and Papua-New Guinea. Climate change was a direct contributor in three of them, said Dr. Daniel Ngamije, who directs the W.H.O. malaria program.In July 2022, massive flooding left more than a third of Pakistan underwater and displaced 33 million people. An explosion of mosquitoes soon followed. The country reported 3.1 million confirmed cases of malaria that year, compared with 275,000 the year before, with a fivefold increase in the rate of transmission.“With the very heavy monsoons we expected these consequences, but not up to this magnitude,” said Dr. Muhammad Mukhtar, director of Pakistan’s national malaria control program.While floodwaters have receded in some areas, vast tracts of standing water remain, and the malaria parasite is now well-established and circulating in communities that had little prior immunity, Dr. Mukhtar said.More than seven million bed nets were given out to displaced people, but people who are living in small tents or in big crowded halls have nowhere to hang them, Dr. Mukhtar said. The country is relying on insecticide spraying to try to control mosquitoes and mass administration of anti-malarial drugs.Pakistan has confirmed 2.3 million malaria cases so far this year and expects the total to be even higher than the total from 2022.“It will take another one to two years for the situation to become normal if, God forbid, there is not another natural disaster,” Dr. Mukhtar said.In Pakistan, as in other places where weather emergencies drove malaria’s spread, new mosquito habitat was only part of the problem. The floods damaged 2,200 health facilities, leaving millions of people without access to treatment in affected districts.The number of deaths from malaria worldwide stayed largely stable between 2021 and 2022, but at an estimated 608,000 it was still significantly higher than the total of 576,000 in 2019, before the Covid pandemic.Deaths had fallen steadily from 2000 to 2015, because of a wide push to make better diagnostics and treatments, as well as insecticide-treated bed nets, widely available across malarial areas in sub-Saharan Africa. But growing resistance to those drugs and insecticides, plus stagnating funding and changes in mosquito behavior, have combined to stall that progress. Covid has further disrupted both health services and supply chains.The changing climate was also at least partly responsible for a rise in malaria in Ethiopia (with 1.3 million more cases than it had the year before) and Uganda (with 600,000 more), Dr. Ngamije of the W.H.O. said. Highland areas that had long been too cool and dry to support the breeding of malaria-transmitting mosquitoes have started to report cases in those two countries.In Ethiopia, large civil conflicts that displaced millions of people also made them newly vulnerable to malaria. Conflict drove the spread of malaria in other areas, as well: Cases increased more than sevenfold in Myanmar, for example.And Ethiopia is among African countries where an invasive mosquito species, Anopheles stephensi, which thrives in urban areas once largely free of malaria, is now spreading the disease.In Uganda, there are also worrying signs that the malaria parasite is growing resistant to the main medication used to treat the disease.Nigeria, the country with the highest burden of malaria, also saw extreme flooding in 2022. The country managed to keep the rate of new infections stable, but its rapid rate of population growth meant there were an additional 1.3 million cases.Climate change is also driving malaria cases where people are displaced by drought, heat waves and storms, leaving them in substandard housing, Dr. Ngamije said. Weather disasters disrupt the supply chains of malaria tests, treatments and insecticides. Food insecurity, rising in sub-Saharan Africa because of floods and droughts, means more children are malnourished, and thus more susceptible to severe malaria. Repeated malaria infections keep children out of school, and wipe out the savings of the lowest-income families in affected countries.The malaria report did contain some good news. Azerbaijan, Belize and Tajikistan were all certified as malaria-free by the W.H.O. in 2022.More than two million children in Ghana, Kenya and Malawi had received at least one dose of a new malaria vaccine by the end of 2022. Vaccination coverage will be broadened to 12 more countries next year. There has been a 13 percent drop in child deaths over four years in the areas where the first malaria vaccine has been administered.Dr. Ngamije said he had hoped that the 2022 malaria data would show global cases falling rather than rising. But the W.H.O.’s approval of a second malaria vaccine that will rapidly increase supply, plus the growing availability of bed nets treated with multiple kinds of chemicals to counter the effect of insecticide resistance, make him optimistic that there will be significant progress next year.“If it turns out to be a normal year,” he said.

About 60 million “zero-dose children” have not received any vaccines and have aged out of routine immunization programs. Protecting them will require a costly vaccination blitz.Large outbreaks of diseases that primarily kill children are spreading around the world, a grim legacy of disruptions to health systems during the Covid-19 pandemic that have left more than 60 million children without a single dose of standard childhood vaccines.By midway through this year, 47 countries were reporting serious measles outbreaks, compared with 16 countries in June 2020. Nigeria is currently facing the largest diphtheria outbreak in its history, with more than 17,000 suspected cases and nearly 600 deaths so far. Twelve countries, from Afghanistan to Zimbabwe, are reporting circulating polio virus. Many of the children who missed their shots have now aged out of routine immunization programs. So-called “zero-dose children” account for nearly half of all child deaths from vaccine-preventable illnesses, according to Gavi, the organization that helps fund vaccination in low- and middle-income countries.An additional 85 million children are under-immunized as a result of the pandemic — that is, they received only part of the standard course of several shots required to be fully protected from a particular disease.The cost of the failure to reach those children is fast becoming clear. Deaths from measles rose 43 percent (to 136,200) in 2022, compared with the previous year, according to a new report from the World Health Organization and the Centers for Disease Control and Prevention. The figures for 2023 indicate that the total could be twice as high again.“The decline in vaccination coverage during the Covid-19 pandemic led us directly to this situation of rising diseases and child deaths,” said Ephrem Lemango, associate director of immunization for UNICEF, which supports delivery of vaccines to almost half the world’s children every year. “With each new outbreak, the toll on vulnerable communities rises. We need to move fast now and make the investment needed to catch up the children that were missed during the pandemic”Mothers and babies waiting for shots in Accra, Ghana.Natalija Gormalova for The New York TimesOne of the biggest challenges is that the children who missed their first shots between 2020 and 2022 are now older than the age group typically seen routinely at primary health care centers and in normal vaccination programs. Reaching and protecting them from diseases that can easily turn fatal in countries with the most fragile health systems will require an extra push and new investment.“If you were born within a certain period of time, you were missed, full stop, and you’re not going to get caught just by restoring normal services,” said Lily Caprani, UNICEF’s chief of global advocacy.UNICEF is asking Gavi for $350 million to purchase vaccines to try to reach those children. Gavi’s governing board will consider the request next month.Unicef is urging countries to implement a catch-up vaccination blitz, an exceptional, one-time program to reach all the children between the ages of 1 and 4 who were missed.Many developing countries have some experience of carrying out catch-up campaigns for measles, targeting children between 1 and 5, or even 1 and 15, in response to outbreaks. But now those countries also need to deliver the other vaccines and train personnel — typically community health workers who are only accustomed to vaccinating babies — and to procure and distribute the actual vaccines.Dr. Lemango said that despite the urgency of the situation, it had been a struggle to get plans for such campaigns in place and that he hoped most could come together in 2024.“Coming out of the pandemic, there was this hangover — no one wanted to do campaigns,” he said. “Everyone wants to return to normalcy and do regular strengthening of immunization. But we already had unfinished business.”In some countries, such as Brazil, Mexico and Indonesia, health systems have recovered from severe Covid disruption and have regained or even surpassed the levels of vaccination coverage they had reached before the pandemic. But others — mostly countries where vaccination rates were already considerably lower than the targets set by UNICEF — have not caught up to their previously lower levels.The countries with the most zero-dose children include Nigeria, Ethiopia, India, the Democratic Republic of Congo and Pakistan. Many with the lowest levels of coverage are facing compounding challenges, such as the civil conflicts in Syria, Ethiopia and Yemen the growing population of climate refugees in Chad, and both of those problems in Sudan.Priscilla Obiri, a community health nurse in charge of vaccinations at the Teshie clinic in Accra.Natalija Gormalova for The New York TimesGhana’s experience is representative of the challenges of many lower-income countries. Parents couldn’t take their children for routine shots when communities were locked down to protect against Covid, and when those restrictions were lifted, many parents still stayed away because of fear of infection, said Priscilla Obiri, a community health nurse in charge of vaccinations in low-income fishing communities on the edge of the capital, Accra.Of the children Ms. Obiri sees these days at a typical pop-up vaccination clinic, where she sets up a table and a few chairs in the shade at a crossroads, as many as a third will have incomplete vaccinations, or sometimes none at all, she said. She agrees on a plan with their mothers to make up the gap.But some parents don’t, or can’t, bring their children to a clinic. “We must go out to the community and hunt for them,” she said.As Ms. Obiri and her colleagues attempt to regain that lost ground, they face another challenge: disinformation campaigns and hesitation about Covid vaccines have spilled over and eroded some of the traditional eagerness that parents had to get their children routine immunizations, according to the Vaccine Confidence Project, a long-running research initiative at the London School of Hygiene and Tropical Medicine.“In 55 countries, there was a precipitous drop between 2015 and 2022 in the number of people who said that routine immunization is important for children,” said the project’s director, Heidi Larson, whose team collected what she described as “robust global polling data” in more than 100 nationally representative surveys.Even as people around the world were seeking information about vaccines, there was a surge in mis- and disinformation, she said, and people with low trust in officials and official guidance were particularly vulnerable to believing alternative sources of information.In 2015, 95 percent of Ghanaian parents said they believed vaccines were safe. That figure plunged to 67 percent of parents in 2022. It had climbed back to 83 percent by October of this year.Ms. Sebi carried immunizations in a refrigerated box on her way to set up the Teshie mobile clinic.Natalija Gormalova for The New York TimesDr. Kwame Amponsah-Achiano, who oversees the childhood immunization program in Ghana, said he did not believe that confidence had fallen during the Covid pandemic. Demand remains high and has outstripped the program’s ability to supply in some areas, he said.Ms. Caprani said UNICEF had found that both problems were occurring in parallel.“You can have demand outstripping not just physical supply, but also outstripping access — convenient, affordable, reachable access — and simultaneously see some declining confidence,” she said. “It’s not necessarily the same people.”Last year, 22 million children missed the routine measles vaccination given in their first year of life — 2.7 million more than in 2019 — while an additional 13.3 million did not receive their second doses. To reach herd immunity, and prevent outbreaks, 95 percent of children must have both doses. Measles acts as an early warning system for gaps in immunization, because it is highly transmissible.“There are communities where an outbreak of measles is a bad thing, and there are communities where it’s a death sentence, because of the combination of other risk factors such as poor malnutrition, poor access to health care, poor access to clean water,” Ms. Caprani said.