Childhood Vaccination Worldwide in 2022: A Partial, Uneven Recovery

Key points

• The COVID-19 pandemic pushed childhood vaccination to its lowest level in more than a decade. In 2022 it began to recover — but not everywhere, and not all the way.
• First-dose DTP coverage (diphtheria-tetanus-pertussis–containing vaccine, DTPcv1) rose from 86% in 2021 to 89% in 2022 — still under 90% in 2019.
• Third-dose DTP (DTPcv3) rose from 81% to 84% — under 86% in 2019.
• 14.3 million "zero-dose" children got no DTP vaccine at all in 2022: 21% fewer than the 18.1 million in 2021, but 11% more than the 12.9 million in 2019.
• 84% of zero-dose children live in low- and lower-middle–income countries. Recovery there has been slowest.

Why it matters

In 2020 the World Health Assembly endorsed the Immunization Agenda 2030, a global strategy for 2021–2030 in which everyone, everywhere, at every age benefits fully from vaccines. Its central target: halve the number of zero-dose children by 2030, and bring DTPcv3 coverage to 90%.

The pandemic hit just as the plan began. From 2019 to 2021, the number of zero-dose children rose 40%, and fewer vaccinations were given in 2021 than in 2020.

How the estimates are made

The World Health Organization (WHO) and UNICEF estimate coverage in each of the 194 WHO countries from national reports and surveys, and roll them up by WHO region, by World Bank income group, and worldwide.

• Zero-dose children are those who have never been reached by vaccination services — no first DTP dose by 12 months of age.
• Incompletely vaccinated children started the DTP series but did not get the third dose.
• A dropout rate is the share of children who got the first DTP dose but not a later vaccine.

DTP vaccines

• DTP coverage improved in every WHO region except Africa, where it stalled at 80% (first dose) and 72% (third) — below 2019's 83% and 77%.
• The European Region stayed at 97% or more for the first dose and 94% or more for the third.
• South-East Asia recovered most: first-dose coverage went from 86% to 93%, third-dose from 82% to 91%.
• 73 countries (38%) saw third-dose coverage drop at least 5% between 2019 and 2021. Only 15 of them (21%) were back to their 2019 level or higher in 2022.

Where the unvaccinated children are

• Only the African Region had more zero-dose children in 2022 than in 2021: up 2.6%, from 7.6 million to 7.8 million — over half the world's total.
• Incompletely vaccinated children barely changed — 6.3 million in 2021, 6.2 million in 2022 — but were still above 5.5 million in 2019.
• 71% of zero-dose children lived in countries eligible for support from Gavi, the Vaccine Alliance.

Zero-dose and incompletely vaccinated children (bars) and first- and third-dose DTP coverage (lines), by WHO region, 2019, 2021 and 2022. CDC.

Measles and other vaccines

• Measles, first dose (MCV1): 81% in 2021, 83% in 2022 — still under 86% in 2019. Every region was below 2019 except the Eastern Mediterranean, back at 83%.
• 115 countries (59%) had lower first-dose measles coverage in 2022 than in 2019.
• Measles, second dose (MCV2): up from 71% in 2019 to 74%, mainly because 11 countries, mostly in Africa, added it to their schedules.

Still below 2019 in 2022, though up from 2021:

Higher than 2019, thanks to newer introductions: HPV first dose (19% → 21%), HPV last dose (14% → 15%), pneumococcal conjugate, third dose (51% → 60%) and rotavirus, last dose (40% → 51%).

Hepatitis B at birth (about 45%) and Hib third dose (about 76%) have hardly changed in a decade.

Children who start but don't finish

• First to third DTP dose, 2022: 12% dropout in low-income countries, against 5% in lower-middle–income and 3% in upper-middle– and high-income countries.
• First DTP dose to first measles dose: up worldwide from 5% (6.3 million children) in 2019 to 7% (7.6 million) in 2022 — and 17% in low-income countries.

What the authors conclude

• Recovery is uneven. Lower-middle–income countries, home to nearly half the world's zero-dose children, improved; low-income countries saw little change in zero-dose numbers and higher dropout.
• Fast-growing birth cohorts are part of it: some countries vaccinated as many children in 2022 as in 2019, but had many more babies to reach.
• Missed children are ageing out. Once past the usual age for a vaccine, children may get few chances to catch up unless countries adopt catch-up schedules for older children. Such immunity gaps raise the risk of outbreaks — falling measles vaccination helped drive more measles outbreaks in 2022.
• Returning to 2019 is not enough. Cutting outbreaks of diseases such as diphtheria, measles, polio and yellow fever needs coverage above prepandemic levels, with strategies aimed at the urban poor and at remote, rural and conflict-affected communities.
• Build resilience. WHO and UNICEF urge countries to strengthen their health workforce, vaccine supply chains, and community demand and confidence, backed by sustainable funding and data used to find unvaccinated children.

Limitations

• 12 countries (2.2% of the world's births) had not reported 2022 data by July 23, 2023, so their 2021 estimates were carried forward.
• Data quality problems may skew administrative estimates.
• Surveys can suffer from selection and recall bias.
• The estimates carry no statistical uncertainty.
• Pandemic disruptions meant fewer surveys informed the 2022 estimates.
• Population figures used to count zero-dose and incompletely vaccinated children may be inaccurate.

Sources

Based on Gurpreet Kaur, M. Carolina Danovaro-Holliday et al., "Routine Vaccination Coverage — Worldwide, 2022," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, by authors from CDC, the World Health Organization and UNICEF; published by CDC. The report's summary box gives first-dose measles coverage as rising to 84%; its results section and table give 83%, which is used here.