Childhood Vaccination Worldwide in 2023: Stalled Below Pre-Pandemic Levels

In 1974 the World Health Organization (WHO) launched the Expanded Programme on Immunization, to protect every child in the first year of life against diphtheria, tetanus, pertussis, polio, measles and tuberculosis. Now called the Essential Programme on Immunization, it covers many more vaccines through childhood and adolescence. In 2020 the World Health Assembly endorsed the Immunization Agenda 2030, a 2021–2030 strategy whose goals include fairer coverage, halving the number of "zero-dose" children and introducing more new vaccines.

The COVID-19 pandemic set that back: disrupted health services drove global coverage down and increased the number of zero-dose children by nearly 40%. This CDC report tracks WHO and UNICEF coverage estimates for all 194 WHO member countries from 2010 to 2023.

Key measures

• Zero-dose children never received a first dose of diphtheria-tetanus-pertussis-containing vaccine (DTPcv1) — a sign of poor access to immunization and other health care.
• Incompletely vaccinated children got DTPcv1 but not the third dose (DTPcv3). DTPcv3 coverage by 12 months is the long-standing yardstick of program performance.
• Dropout from DTPcv1 to DTPcv3, or from DTPcv1 to the first measles dose (MCV1), shows children who reached services but didn't keep coming.

Global coverage

Coverage plateaued in 2022–2023 below 2019 levels. Only the Americas had improved on 2019 by 2023 (DTPcv1 91%, up from 89%; DTPcv3 86%, up from 84%).

• Low-income countries fell furthest: DTPcv3 dropped from 75% in 2019 to 68% in 2023, while every other income group returned to within 1 point of 2019. Their DTPcv1-to-DTPcv3 dropout rose from 9% to 13%, and their DTPcv1-to-MCV1 dropout reached 18%.
• Globally, DTPcv1-to-DTPcv3 dropout rose from 5% (2019) to 6% (2021 and 2023), and DTPcv1-to-MCV1 dropout from 5% to 7%.

Children left out

• Zero-dose children: 15.8 million in 2010, 12.8 million in 2019, 14.5 million in 2023. Ten countries held 59% of them: Nigeria (2,134,000), India (1,592,000), Ethiopia (917,000), the Democratic Republic of the Congo (839,000), Sudan (701,000), Indonesia (662,000), Yemen (580,000), Afghanistan (467,000), Angola (411,000) and Pakistan (396,000).
• Unprotected against measles: up 15%, from 19.3 million in 2019 to 22.2 million in 2023.

Zero-dose and measles-unvaccinated children and dropout rates, by World Bank income group and fragile, conflict-affected and vulnerable settings, 2019–2023. CDC figure.

Fragile and conflict-affected countries

The UN Office for the Coordination of Humanitarian Affairs classed 31 WHO member countries as having fragile, conflict-affected and vulnerable (FCV) settings in 2023 — humanitarian crises, protracted emergencies and armed conflict.

• DTPcv1 fell from 81% to 78% and DTPcv3 from 75% to 70% between 2019 and 2023; MCV1 fell from 70% to 67%.
• Zero-dose children rose 25%, from 6.4 million in 2019 to 8.0 million in 2021, then stayed there. Children unprotected against measles rose 17%, from 10.4 million to 12.2 million.
• By 2023, 55% of children who missed MCV1 lived in FCV countries, which also held a large share of zero-dose children.
• Dropout was far higher than elsewhere: 11% from DTPcv1 to DTPcv3 and 15% to MCV1, against 4% for each in the 163 other countries.

Zero-dose and measles-unvaccinated children and dropout rates, by WHO region, 2019–2023. CDC figure.

New vaccines kept advancing

• Second measles dose: 42 countries added MCV2 in 2010–2019, lifting global coverage from 41% to 71%; most were in the African Region, where coverage rose from 4% to 33%, and 10 more African countries added it in 2020–2023, reaching 49%.
• Other vaccines fell during 2019–2021 — BCG (89% to 85%), hepatitis B third dose (86% to 81%), third polio dose (83% to 81%) and others — but first-dose inactivated polio vaccine (IPV1) was back at 83% by 2023.
• In 2019–2023, nine countries introduced the hepatitis B birth dose, 17 rotavirus vaccine, and 58 oral-polio-using countries a second IPV dose (42% global coverage by 2023).
• HPV vaccine was introduced in 73 countries in 2010–2019 and 30 more in 2020–2023. First-dose coverage among girls rose from 17% in 2019 to 27% in 2023, and full coverage from 13% to 20%.

What's needed

Countries whose coverage fell have not recovered and face more vaccine-preventable disease. The authors called for regular intensification of routine immunization and catch-up vaccination — core to the Big Catch-Up, which aims to reach children who missed vaccines in 2019–2022, restore coverage to at least 2019 levels, and strengthen primary health care — with plans tailored to each country, especially in FCV settings. New vaccine introductions strengthen programs and support Immunization Agenda 2030. Low-income countries, the African Region and FCV settings need action most urgently.

Limitations: the pandemic disrupted surveys, so some estimates rely less on survey data; administrative data can be inaccurate; surveys are subject to selection and recall bias; population estimates may be off; estimates carry no measure of uncertainty; and late doses, including catch-up doses, are not counted.

Sources

• Jones CE, Danovaro-Holliday MC, Mwinnyaa G, et al. "Routine Vaccination Coverage — Worldwide, 2023." Morbidity and Mortality Weekly Report 73(43), Centers for Disease Control and Prevention.
• The report gives two different shares of the world's zero-dose children living in FCV countries (about one half in its abstract, a higher figure in its results); this page gives neither.