The headline number from the WHO Regional Office for Africa’s new report is designed to reassure.
Nearly 20 million measles deaths have been averted in the African Region since 2000, and 500 million children have been reached through routine immunization in one generation.
Gavi’s press release amplifies that figure, and Dr. Sania Nishtar calls it evidence of the “immense life-saving power of vaccines when immunisation is prioritised as a matter of policy.”
The second number is less reassuring.
Coverage with the second dose of measles-containing vaccine in the African Region reached 55% in 2024, and coverage with the first dose has stagnated around 70% for a decade.
Measles transmission cannot be interrupted until both doses exceed roughly 95% in every community, not just on average.
The report buries this tension in careful language about progress being “uneven, and even slowing.”
What is significant in the WHO AFRO report is the recognition, on page after page, that the African Region is now off track for six of the seven Immunization Agenda 2030 impact goals, and that no vaccine in the Region has coverage above 90 percent.
Measles, which the report explicitly treats as “a tracer of immunization programme performance,” is telling us something uncomfortable about what vaccines alone can and cannot do.
What the report says, and what it does not
The report is rigorous on outputs and careful on inputs.
It documents 44 countries that have introduced the second measles dose, 622 million supplementary doses delivered, and three sub-Saharan African states, Cabo Verde, Mauritius and Seychelles, achieving measles and rubella elimination in 2025.
It also documents a resurgence of large or protracted measles outbreaks between 2022 and 2024, with reactive campaigns in Cameroon, Ethiopia, Kenya, and outbreak preparedness plans in 14 priority countries.
What the report largely leaves out is the social infrastructure on which all of this depends.
The foreword by WHO’s Regional Director for Africa, Dr. Mohamed Yakub Janabi, reminds readers that “behind the numbers in the report, are children and their parents,” and that “the real measure of progress is the wellbeing and overall health of our communities.”
But when the text turns to challenges, it lists population growth, weak health systems, climate change, humanitarian crises and political instability.
Trust appears nowhere on that list, and vaccine confidence is not measured anywhere in the report.
That omission matters because the global landscape has changed.
Globally, the World Health Organization reported in late 2025 that measles deaths fell by 88 percent between 2000 and 2024, and that more than 60 million deaths have been averted by measles vaccination since 1974.
In the same breath, WHO warned that cases are surging, with 30 million children left under-protected in 2024 alone.
Nature called the pattern a “spike” across measles, polio and tuberculosis, tied not to biology but to eroding immunization and eroding trust.
Some observers describe the United States situation bluntly as “the perfect storm: measles resurgence in an era of vaccine disinformation and the dismantling of public health.”
This is the context the AFRO report does not fully name.
A global right-wing and libertarian backlash against vaccination, amplified by the COVID-19 infodemic and increasingly coordinated with populist politics, has collapsed measles coverage in communities where it was once taken for granted, first in Europe and North America, now spreading through digital networks that respect no border.
The scientific consensus that measles-containing vaccines are safe and effective has not moved.
What has moved is the social contract around them.
Why trust is the actual story
Heidi Larson, the anthropologist who founded the Vaccine Confidence Project, has spent two decades making a point that global health institutions have been slow to absorb.
“We do not have a misinformation problem,” she writes. “We have a relationship problem.” Misinformation can be deleted, she argues, but the distrust that allows it to stick is what remains.
Her book Stuck traces vaccine rumors from 19th-century smallpox protests to 21st-century polio boycotts, and concludes that digital media has amplified risk perception without being its single cause.
Larson’s team has documented how quickly confidence can collapse when trust is broken.
After the 2017 Dengvaxia controversy in the Philippines, the share of respondents who “strongly agreed” that vaccines are important fell from 93 percent to 32 percent in three years, and strong agreement that vaccines are safe fell from 82 percent to 21 percent.
That collapse rippled into measles and polio uptake, not only dengue.
The lesson, Larson insists, is that confidence is a leading indicator, not a lagging one, and that “an extraordinary effort will be needed to sustain confidence in vaccines, given the unprecedented level of misinformation being propagated about them, even from official sources.”
Framed through Larson’s work, the WHO AFRO report reads differently.
The report’s quiet pivot from the “national” to the “sub-national” in its concluding paragraphs is not just a technical recommendation.
“Focus on building or rebuilding resilient immunization systems at sub-national level is central to containing prevalent immunisation inequities and sustaining coverage at no less than 90 percent,” the report states.
Read alongside Larson, that sentence is an acknowledgement that the remaining work may be less about cold chains or vial sizes and more about relationships between health workers and the communities they serve, built or broken one district at a time.
What frontline health workers actually said
The most direct evidence that trust, not technology, is the binding constraint comes from the health workers themselves.
At Teach to Reach, hundreds of practitioners have contributed structured experiences of measles outbreaks and prevention across more than a dozen countries.
Their accounts read like field notes from a long negotiation over credibility.
Consider Dr. Khalid Hussain Memon, a public health specialist in Sindh, Pakistan, describing a single street of seven “refusal houses” in Golimar.
After a measles case in the neighborhood led to severe post-measles pneumonia in an unvaccinated child, Memon’s team stayed in contact with the family through the child’s recovery.
“I and my team remained in touch with parents of the child,” he recounted. “After recovery of the child, we contacted the mother of the child and made her realize that all her sufferings were due to non-vaccination of her child against measles. She later became our social mobilizer and visited all refusal houses for measles vaccine, along with vaccination teams, and told them her story.”
A similar point comes from Madagascar, where a UNICEF social and behavior change consultant, Souleymane Kagambega, put it almost lyrically. “There were no more eloquent people than the victims of measles within the communities. There was no better lesson for caregivers than the suffering these children around us were experiencing.”
Neither of these statements fits comfortably in an outbreak report.
Neither would appear in a coverage table.
Both describe the mechanism by which population immunity is actually rebuilt after it has been lost.
The same theme surfaces in Cameroon, where a laboratory scientist described being surprised not by the outbreak itself but by the silence that preceded it.
“What surprised us was the fact that that the health facility had had cases previously and did not report them.”
Reporting, like vaccination, is a behavior that depends on trust.
It collapses first at the edges of systems, and it recovers last.
Community-based surveillance, which the Teach to Reach contributors discuss repeatedly, is the operational form of this insight.
Community health workers, volunteers, and in one Nigerian account, “local medicine vendors” around a hospital, are trained to recognize fever and rash and to alert formal services.
When Dr. Mulungula Walasa describes a campaign in the Kalambayi Health Zone of the Democratic Republic of the Congo, his emphasis is relational, not technical.
“This approach allowed the local community to take ownership of the campaign and thus made it possible to vaccinate a large number of children.”
Some formalists may dismiss such field stories as feel-good anecdotes.
We posit that they are significant, credible evidence of the social contract around vaccination being renegotiated in real time, in precisely the districts where the WHO AFRO report concedes coverage is lowest.
The two peer learning gaps
The Lancet correspondence on peer learning in immunisation programmes, published in late 2024, frames the problem at the national level.
Immunization leaders operate in dynamic sociopolitical contexts where evidence is incomplete and decisions cannot wait for the next randomized trial.
Peer learning across national programmes, the authors argue, is the only credible way to align strategy with implementation reality.
We need to extend that argument to the local leaders who are the interface with communities.
“Implementation challenges are situated, and solved, at the local levels,” we wrote in 2025, and peer learning that stops at national EPI managers misses precisely the layer where trust is built and measles is stopped.
Our account of Gavi-supported, TGLF-facilitated work in Côte d’Ivoire and Nigeria documents thousands of sub-national practitioners contributing detailed experiences and analyzing each other’s strategies at scale.
The Côte d’Ivoire case study, where Mathieu N’Guessan’s team raised second-dose measles coverage in Bouaké North-East from under 30 percent to 96 percent in a year, is a story of re-establishing relationships with community health workers, religious leaders, and caregivers who had never met MCV2 before.
This is where the AFRO report, the Lancet, and Larson’s trust research converge.
National peer learning tells ministries what other ministries are doing.
Sub-national peer learning tells districts what other districts have tried, including with refusal houses in Golimar, riverine communities in Bakassi, or koranic schools in Dawakin Tofa.
Only the second can repair the relationship problem that underpins trust, because relationships are always local.
What this means for leaders and donors
The immediate implication for WHO, Gavi, and ministries of health is that measles coverage targets cannot be hit with supply-side instruments alone.
Campaign counts and dose deliveries are necessary, and the AFRO report documents them in detail.
They are not sufficient.
Vaccine confidence, in both Larson’s and Teach to Reach’s evidence, behaves more like a financial market than a pipeline, and it is volatile under political pressure.
For donors, the implication is uncomfortable.
The hardest-to-reach children, whom the AFRO report names as the largest remaining gap, live in communities where trust in health services is thinnest, where rumors travel fastest, and where returns on investment are measured in years, not quarters.
Financing structures that reward short-term campaign coverage are poorly matched to this work.
Financing that supports sustained peer learning networks at district level, and listens systematically to what frontline workers actually experience, is better matched but institutionally harder to justify.
For immunization leaders specifically, three practical consequences follow.
- First, treat measles outbreaks as relationship diagnostics, not only programmatic failures, and conduct after-action reviews that ask what trust had frayed before the outbreak began.
- Second, invest in infrastructure for peer learning at district and facility level, so that innovations like Memon’s mother-advocate or N’Guessan’s MCV2 turnaround are not locked inside single case studies.
- Third, take seriously what Heidi Larson has been saying for fifteen years: listen before you correct, because the rumor is almost always a symptom of a prior breach.
The question the report does not ask
The WHO AFRO report closes with an appeal for continued investment and strong political commitment.
That appeal is correct, and overdue.
It is also incomplete.
The measles resurgence of the 2020s is not a failure of vaccines, which work as well as they ever have, nor primarily a failure of supply, which is better than at any point in history.
It is a failure of trust, accumulating slowly in some places and collapsing suddenly in others, and it is being actively cultivated by political movements that see public health as an adversary rather than a commons.
The question the report does not ask, and that the global immunization community can no longer avoid, is this one.
If measles is the tracer of programme performance, what is the tracer of trust, and who is accountable for measuring it before the next outbreak arrives?
A peer learning course to strengthen health worker preparedness, response, and recovery from measles outbreaks
The Geneva Learning Foundation offers a free peer learning course built entirely on the measles experiences shared at Teach to Reach. In about six hours of self-paced learning, health workers study what actually worked in other districts across early case detection, community engagement, vaccine supply management, second-dose coverage, and outbreak preparedness. Participants reflect on their own context and exchange feedback with colleagues facing similar challenges. The course is available in English and French, and it is open to anyone working in immunization or primary health care.
References
- Adamu, A.A., Ndwandwe, D., Jalo, R.I., Ndoutabe, M., and Wiysonge, C.S. (2024). Peer learning in immunisation programmes. The Lancet 404, 334–335. https://doi.org/10.1016/S0140-6736(24)01340-0
- Eagan, R.L., Larson, H.J., and de Figueiredo, A. (2023). Recent trends in vaccine coverage and confidence: A cause for concern. Human Vaccines and Immunotherapeutics 19, 2237374. https://doi.org/10.1080/21645515.2023.2237374
- Gavi, the Vaccine Alliance (2026). Nearly 20 million lives saved in Africa through measles vaccinations. Press release, Brazzaville and Geneva, 15 April 2026.
- Larson, H.J., and Bersoff, D.M. (2025). Science’s big problem is a loss of influence, not a loss of trust. Nature 640, 314–317. https://doi.org/10.1038/d41586-025-01068-1
- Moore, K., Muzzulini, B., Roldán, T., Bedford, J., and Larson, H. (2022). Overcoming barriers to vaccine acceptance in the community: Key learning from the experiences of 734 frontline health workers (1.0). The Geneva Learning Foundation and Anthrologica. https://doi.org/10.5281/zenodo.6965355
- Moore, K., Muzzulini, B., Roldán, T., Bedford, J., and Larson, H. (2022). Surmonter les obstacles à l’acceptation des vaccins dans la communauté: Principaux enseignements tirés de l’expérience de 734 professionnels de la santé en première ligne. https://doi.org/10.5281/zenodo.6965365
- Reda Sadki (2025). Peer learning in immunization programmes. Reda Sadki: Learning to make a difference. https://doi.org/10.59350/wkr1w-y7x78
- The Geneva Learning Foundation (2024). Making connections at Teach to Reach: Connect 9 (1.0). Geneva: The Geneva Learning Foundation. https://doi.org/10.5281/zenodo.11190111
- La Fondation Apprendre Genève (2024). IA2030 Rapport “Écouter pour Apprendre” n° 9. Tisser des liens à Teach to Reach 9 (13 octobre 2024) (1.0). Genève: La Fondation Apprendre Genève. https://doi.org/10.5281/zenodo.14440467
- N’Guessan, M., Mbuh, C., Jones, I., and Sadki, R. (2023). Mathieu N’guessan. Transforming second-dose measles vaccine coverage in Côte d’Ivoire (IA2030 Case Study 30) ([object Object]) https://doi.org/10.5281/ZENODO.10039276.
- World Health Organization (2025). Measles deaths down 88 percent since 2000, but cases surge. WHO news release, 28 November 2025. https://www.who.int/news/item/28-11-2025-measles-deaths-down-88–since-2000–but-cases-surge
- World Health Organization Regional Office for Africa (2026). Towards Immunization Agenda 2030 targets: two decades of immunization efforts in the WHO African Region. Brazzaville: WHO Regional Office for Africa. ISBN 978-92-9031-589-6. https://iris.who.int/handle/10665/385093
- World Health Organization Regional Office for Africa (2026). Nearly 20 million lives saved in Africa through measles vaccinations. News release, 14 April 2026. https://www.afro.who.int/news/nearly-20-million-lives-saved-africa-through-measles-vaccinations