- Globally, between 1980 and 2023, vaccine coverage doubled against diseases such as diphtheria, tetanus, whooping cough (pertussis), measles, polio, and tuberculosis.
- Additionally, there was a 75% global decline in the number of children who had never received a routine childhood vaccine (also known as zero-dose children), falling from 58.8 million in 1980 to 14.7 million in 2019 before the COVID-19 pandemic.
- But since 2010, progress has stalled or reversed in many countries, with measles vaccination declining in 100 of 204 countries between 2010 and 2019, while 21 of 36 high-income countries experienced declines in coverage for at least one vaccine dose against diphtheria, tetanus, whooping cough, measles, polio, or tuberculosis.
- The COVID-19 pandemic further exacerbated challenges to childhood vaccination coverage. In 2023, there were an estimated 15.7 million zero-dose children, who had received no doses of the diphtheria, tetanus, and pertussis vaccine in their first year of life, with more than half living in just eight countries, primarily in sub-Saharan Africa (53%) and South Asia (13%).
- The authors stress that global immunisation goals for 2030 will not be met without targeted, equitable immunisation strategies, alongside primary healthcare strengthening and efforts to tackle vaccine misinformation and hesitancy.
The world has made unprecedented progress in vaccinating children against life-threatening disease since WHO established the Expanded Programme on Immunization (EPI) in 1974. Despite the progress of the past 50 years, the last two decades have also been marked by stagnating childhood vaccination rates and wide variation in vaccine coverage. These challenges have been further exacerbated by the COVID-19 pandemic, leaving millions of children vulnerable to preventable diseases and death, according to a major new analysis from the Global Burden of Disease Study Vaccine Coverage Collaborators, published in The Lancet.
The authors say that these latest estimates should be taken as a clear warning that global immunisation targets for 2030 will not be met without 'transformational improvements in equity'. These findings come ahead of Gavi's high-level funding summit, scheduled for 25 June 2025 [1].
"Despite the monumental efforts of the past 50 years, progress has been far from universal. Large numbers of children remain under- and un-vaccinated", said senior study author Dr Jonathan Mosser from the Institute for Health Metrics and Evaluation (IHME), University of Washington, USA. "Routine childhood vaccinations are among the most powerful and cost-effective public health interventions available, but persistent global inequalities, challenges from the COVID pandemic, and the growth of vaccine misinformation and hesitancy have all contributed to faltering immunisation progress. These trends increase the risk of outbreaks of vaccine-preventable diseases, including measles, polio, and diphtheria, underscoring the critical need for targeted improvements to ensure that all children can benefit from lifesaving immunisations."
Launched to provide all children, everywhere, access to life-saving vaccines, EPI initially focused on six childhood vaccine-preventable diseases: tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. The programme later expanded to include additional vaccines both in childhood and across the life course, protecting against Haemophilus influenzae type B, Hepatitis B, rubella, pneumococcal disease, rotavirus, and human papillomavirus.
Over the past 50 years, EPI has vaccinated more than 4 billion children, preventing the deaths of an estimated 154 million children worldwide and providing a total of 10.2 billion years of full health [2]. In 2019, WHO set ambitious goals for improving vaccine coverage globally through the Immunisation Agenda 2030 (IA2030)—including halving the number of 'zero-dose' children (estimated as children aged under one who have not received any dose of the diphtheria-tetanus-pertussis vaccine). The programme also aims to achieve global coverage of 90% for each of the life-course vaccines—including the full three doses of the combined diphtheria-tetanus-pertussis vaccine, the second dose of measles-containing vaccine, the vaccine against pneumococcal disease and the human papillomavirus vaccine [3].
However, vaccine-preventable disease outbreaks persist, reflecting longstanding inequalities in vaccine coverage worldwide, and pose a growing global risk. Increasing numbers of wild-type polio cases have been reported in Pakistan and Afghanistan, and there is an ongoing polio outbreak in Papua New Guinea, where less than half of the population is immunised. In 2024, there was a nearly tenfold increase in measles infections recorded in the European Union and the European Economic Area. The ongoing measles outbreak in the USA reached over 1,000 confirmed cases in 30 states in May 2025, surpassing the total number of cases in 2024 [4].
With the global coverage targets deadline fast approaching, the new analysis provides updated and extended global, regional, and national estimates of annual routine childhood vaccination coverage from 1980 to 2023 in 204 countries and territories for 11 vaccine-dose combinations recommended by the WHO for all children globally [5]. Using up to 1,085 unique data sources, including all major multi-country and national survey data, the analysis estimates the long-term impact of the COVID-19 pandemic (2020-2023) on routine childhood immunisation. It also examines the progress needed to achieve the IA2030 targets.
Despite years of progress, wide variation in coverage persists
The success of the past 50 years is partly the result of a doubling of global coverage for the original vaccines against diphtheria-tetanus-pertussis (first dose 49% to 89%; and all three doses 40% to 81%), measles (37% to 83%), polio (42% to 80%), and tuberculosis (38% to 83%) between 1980 and 2023. Additionally, there has been a 75% drop in the number of unvaccinated zero-dose children worldwide from 58.8 million in 1980 to 14.7 million in 2019, as well as the introduction and scale-up of critical new lifesaving vaccines against pneumococcal disease, rotavirus, and a second dose of the measles vaccine.
However, this long-term progress masks recent challenges and substantial disparities. Between 2010 and 2019, coverage gains slowed and, in some areas of the world, reversed. For example, 21 of 36 high-income countries experienced declines in coverage for at least one of the original EPI-recommended vaccine-doses (excluding the tuberculosis vaccine, which is no longer included in routine immunisation schedules in some countries)—including a 12% decline in first dose measles vaccination in Argentina, and 8% and 6% declines in third dose diphtheria-tetanus-pertussis vaccination in Finland and Austria, respectively.
Additionally, the proportion of children receiving the measles vaccine declined in 100 of 204 countries, with the largest decrease observed in Latin America and the Caribbean, where coverage fell from around 90% in 2010 to 87% in 2019, resulting in almost one million fewer children being vaccinated against measles in 2019.
Enduring effects of the COVID-19 pandemic
The COVID-19 pandemic exacerbated these challenges with global coverage rates of the original EPI-recommended vaccines declining sharply beginning in 2020—resulting in an estimated 15.6 million children missing the full three doses of the diphtheria-tetanus-pertussis vaccine or a measles vaccine between 2020 and 2023, as well as 15.9 million children not receiving any polio vaccine, and 9.18 million missing out on the tuberculosis vaccine.
Sub-Saharan Africa experienced the greatest COVID-19 pandemic-related disruptions to coverage, with an estimated 6.96 million fewer children vaccinated against rotavirus between 2020 and 2023, 5.31 million missing out on immunisation against pneumococcal disease, and 4.94 million missing out on immunisation against polio.
The COVID-19 pandemic also reversed previous gains in reducing the number of unvaccinated zero-dose children globally, which peaked at 18.6 million before falling to 15.7 million by 2023. The study estimates that disruptions to immunisation services during the COVID pandemic resulted in around 12.8 million additional unvaccinated zero-dose children globally during the four pandemic years (2020-2023).
Wide discrepancies remain, with markedly lower coverage and higher rates of under and un-vaccinated children in low- and middle-income countries. In 2023, more than half of the world's 15.7 million unvaccinated children were living in just eight countries, primarily in sub-Saharan Africa (53%) and South Asia (13%)—Nigeria (2.48 million), India (1.44 million), the Democratic Republic of Congo (DRC, 882,000), Ethiopia (782,000), Somalia (710,000), Sudan (627,000), Indonesia (538,000), and Brazil (452,000).
"The challenge now is how to improve vaccine delivery and uptake in areas of low coverage," said lead author Dr. Emily Haeuser. "The diversity of challenges and barriers to immunisation vary widely between countries and within communities, with rising numbers of displaced people and growing disparities due to armed conflict, political volatility, economic uncertainty, climate crises, and vaccine misinformation and hesitancy, underscoring the need for new, tailored solutions."
Achieving global immunisation targets
The analysis indicates that accelerated progress will be necessary to achieve the 2030 target of halving the number of zero-dose children compared to 2019 levels, with only 18 of 204 countries and territories estimated to have already met this target as of 2023 [6]. Two-thirds (65%) of the zero-dose children that need to be reached by vaccination between 2023 and 2030 live in sub-Saharan Africa (4.28 million) and South Asia (1.33 million).
Coverage of 90% or greater for each of the life-course vaccines (full three doses of the diphtheria-tetanus-pertussis vaccine, the second dose of measles-containing vaccine, and the vaccine against pneumococcal disease) is a central target set by IA2030.
However, the analysis predicts that only the diphtheria-tetanus-pertussis vaccine is likely to achieve the target of 90% global coverage by 2030, and only under an optimistic scenario. The wide variation seen in both the diphtheria-tetanus-pertussis and measles vaccines' coverage in 2023 is expected to persist through 2030, with coverage rates in sub-Saharan Africa remaining substantially lower than in other regions even under an optimistic scenario at 82% and 69% respectively.
Moreover, population pressures will add a double burden to already overstretched healthcare systems that are ill-equipped to handle the substantial growth in vaccine target populations. In Nigeria, Ethiopia, and the DRC, where 27% of all unvaccinated zero-dose children lived in 2023, birth cohorts are expected to expand by 16%, 11%, and 6% respectively by 2030.
To increase vaccine acceptance and uptake, the authors call for more concerted efforts to tackle vaccine misinformation and hesitancy. As Dr. Haeuser explained, "Successful vaccination programmes are built on understanding and responding to people's beliefs, concerns, and expectations. Vaccination services must prioritise trust-building, engage community leaders, and tailor interventions with more culturally appropriate local strategies to improve vaccine confidence and uptake."
The authors note some important limitations, including variability in coverage of available data sources. Through modelling, this study aims to add further detail and likely forecasts of future trends, but challenges such as collecting survey data in conflict zones, accounting for catch up vaccinations, parental recall of childhood vaccines or methodological variability in data collection mean there is uncertainty in the estimates, as reflected in the data ranges provided in the paper. They also point out that the reliance on coverage with the first dose of the diphtheria-tetanus-pertussis vaccine as a measure of whether children are vaccinated or not (so called 'zero-dose' children) —although standard practice—could overestimate the number of children who did not receive any vaccination, as in some cases they may have received other vaccinations. Finally, they say that national estimates can mask local pockets of low coverage, underscoring the need for a better understanding of local patterns of vaccine coverage.
Writing in a linked Comment, Professor Hai Fang, China Center for Health Development Studies, Peking University, China (who was not involved with the study) said: "In light of the potential decline in international aid from high-income countries, there is an even greater need to strengthen routine childhood vaccination coverage at all levels. Sustained investment and targeted strategies will be essential to maintain progress, close immunization gaps, and ensure equitable access to life-saving vaccines."
