Global, regional, and national trends in routine childhood vaccination coverage from 1980 to 2023 with forecasts to 2030:A systematic analysis for the Global Burden of Disease Study 2023

Abstract

BackgroundSince its inception in 1974, the Essential Programme on Immunization (EPI) has achieved remarkablesuccess, averting the deaths of an estimated 154 million children worldwide through routine childhood vaccination.However, more recent decades have seen persistent coverage inequities and stagnating progress, which have beenfurther amplified by the COVID-19 pandemic. In 2019, WHO set ambitious goals for improving vaccine coverageglobally through the Immunization Agenda 2030 (IA2030). Now halfway through the decade, understanding past andrecent coverage trends can help inform and reorient strategies for approaching these aims in the next 5 years.Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2023, this study provides updatedglobal, regional, and national estimates of routine childhood vaccine coverage from 1980 to 2023 for 204 countriesand territories for 11 vaccine-dose combinations recommended by WHO for all children globally. Employing advancedmodelling techniques, this analysis accounts for data biases and heterogeneity and integrates new methodologies tomodel vaccine scale-up and COVID-19 pandemic-related disruptions. To contextualise historic coverage trends andgains still needed to achieve the IA2030 coverage targets, we supplement these results with several secondary analyses:(1) we assess the effect of the COVID-19 pandemic on vaccine coverage; (2) we forecast coverage of select life-coursevaccines up to 2030; and (3) we analyse progress needed to reduce the number of zero-dose children by half between2023 and 2030.Findings Overall, global coverage for the original EPI vaccines against diphtheria, tetanus, and pertussis (first dose [DTP1]and third dose [DTP3]), measles (MCV1), polio (Pol3), and tuberculosis (BCG) nearly doubled from 1980 to 2023. However,this long-term trend masks recent challenges. Coverage gains slowed between 2010 and 2019 in many countries andterritories, including declines in 21 of 36 high-income countries and territories for at least one of these vaccine doses(excluding BCG, which has been removed from routine immunisation schedules in some countries and territories). TheCOVID-19 pandemic exacerbated these challenges, with global rates for these vaccines declining sharply since 2020, andstill not returning to pre-COVID-19 pandemic levels as of 2023. Coverage for newer vaccines developed and introduced inmore recent years, such as immunisations against pneumococcal disease (PCV3) and rotavirus (complete series; RotaC)and a second dose of the measles vaccine (MCV2), saw continued increases globally during the COVID-19 pandemic due toongoing introductions and scale-ups, but at slower rates than expected in the absence of the pandemic. Forecasts to 2030for DTP3, PCV3, and MCV2 suggest that only DTP3 would reach the IA2030 target of 90% global coverage, and only underan optimistic scenario. The number of zero-dose children, proxied as children younger than 1 year who do not receiveDTP1, decreased by 74·9% (95% uncertainty interval 72·1–77·3) globally between 1980 and 2019, with most of thosedeclines reached during the 1980s and the 2000s. After 2019, counts of zero-dose children rose to a COVID 19-era peak of18·6 million (17·6–20·0) in 2021. Most zero-dose children remain concentrated in conflict-affected regions and those withvarious constraints on resources available to put towards vaccination services, particularly sub-Saharan Africa. As of 2023,more than 50% of the 15·7 million (14·6–17·0) global zero-dose children resided in just eight countries (Nigeria, India,Democratic Republic of the Congo, Ethiopia, Somalia, Sudan, Indonesia, and Brazil), emphasising persistent inequities.Interpretation Our estimates of current vaccine coverage and forecasts to 2030 suggest that achieving IA2030 targets,such as halving zero-dose children compared with 2019 levels and reaching 90% global coverage for life-coursevaccines DTP3, PCV3, and MCV2, will require accelerated progress. Substantial increases in coverage are necessaryin many countries and territories, with those in sub-Saharan Africa and south Asia facing the greatest challenges.Recent declines will need to be reversed to restore previous coverage levels in Latin America and the Caribbean,especially for DTP1, DTP3, and Pol3. These findings underscore the crucial need for targeted, equitable immunisationstrategies. Strengthening primary health-care systems, addressing vaccine misinformation and hesitancy, andadapting to local contexts are essential to advancing coverage. COVID-19 pandemic recovery efforts, such as WHO’sBig Catch-Up, as well as efforts to bolster routine services must prioritise reaching marginalised populations andtarget subnational geographies to regain lost ground and achieve global immunisation goals