The Other Pandemic: The Promise of TB Vaccines

What disease has infected millions of people, killing an estimated 1.5 million people a year, without drawing a fraction of the attention of the COVID-19 pandemic? The answer is tuberculosis (TB). New, more effective vaccines are needed to reduce the morbidity and mortality of TB, fight the rising threat of AMR, and address inequities in disease burden and economic impact.

What disease has infected millions of people, killing an estimated 1.5 million people a year, without drawing a fraction of the attention of the COVID-19 pandemic? The answer is tuberculosis.

Tuberculosis (TB) is a leading cause of infectious disease deaths worldwide—a person dies from TB every 20 seconds 1. According to the World Health Organization (WHO), TB is currently “the second leading infectious killer after COVID-19.”2.  TB has the heaviest impact on the world’s most poor and vulnerable populations, worsening existing inequalities: More than 95% of tuberculosis cases occur in low- and middle-income countries (LMICs), with an estimated two-thirds of total cases occurring in just eight high-burden countries3.  In 2021, there were an estimated 10.6 million active TB cases, including 1.2 million cases of TB among children3. Those who survive the disease often experience economic hardship and long-term health impacts4,5.

The Bacille Calmette-Guérin (BCG) vaccine is the only vaccine currently available to protect against TB. BCG has been in use for a century and provides critical protection to 100 million newborns globally each year6. While the BCG vaccine provides good protection for young children, the vaccine’s efficacy wanes throughout the lifespan, providing negligible protection to those over 5 years old6. TB mainly affects adults, leaving millions vulnerable to the devastating effects of this vaccine-preventable disease7. To end the TB epidemic, it is critical to develop vaccines that are effective against TB in all age groups.

The Non-Specific Benefits of the BCG Vaccine: Protection Beyond TB

Despite its inability to protect adults from TB, BCG is a life-saving vaccine for infants and children under five. Beyond protecting against TB in early childhood, evidence suggests the BCG vaccine may also protect infants against other infections, ultimately reducing all-cause mortality8–10 in some contexts. Studies have found that BCG is one of the few vaccines providing additional immunity beyond the target pathogen, called non-specific specific effects or heterologous effects.

  • In a series of studies of low birthweight newborns in Guinea-Bissau, administering the BCG vaccine at birth was associated with a 38% reduction in all-cause mortality within the four weeks after birth11.
  • A 2023 meta-analysis examined 16 studies conducted among children and adults in both low- and high-income settings12. BCG vaccination was associated with a 44% lower risk of non-TB respiratory infections, a 33% reduction in infection-related mortality, and a 38% reduction in sepsis-related mortality.

Researchers don’t fully understand how BCG offers this broad protection, but one possible explanation is trained immunity — when immunization against one infectious agent can influence a person’s immune response to subsequent infection(s) by an unrelated infectious agent13. Another theory is that BCG immunization can influence an infant’s body response to subsequent routine immunizations8. It’s also possible that these benefits are affected by the timing of vaccination, as research suggests that the BCG vaccine should be given within the first month of life14. More research is needed to fully understand the mechanisms behind these non-specific effects and to determine the optimal timing and dosing for maximum health benefits.

TB and Antimicrobial Resistance: A Growing Health Security Crisis

TB is a major contributor to the global burden of antimicrobial resistance (AMR), or the ability of disease-causing microorganisms (such as bacteria and viruses) to become resistant to drugs and treatment15. Killing 700,000 people each year, AMR is considered a major global public health threat and by 2050 is projected to cause more deaths than cancer16. The rise of multidrug-resistant TB (MDR-TB) is an emerging threat to global health security, with the majority of cases going undetected17.

  • Drug-resistant TB accounts for approximately 1 in 3 deaths attributable to AMR18.
  • In 2021, there were an estimated 450,000 cases of MDR-TB globally, an increase of approximately 3% since 20203. These accounted for 3.6% of new cases of TB and nearly 1 in 5 of those previously treated.
  • Drug-resistant TB accounts for approximately 1 in 3 deaths attributable to AMR18.
  • MDR-TB can require up to two years of treatment, including eight months of daily injections, and an estimated 14,000 pills over the course of the treatment18.
  • The length and complexity of treating MDR-TB substantially increases health care costs. For example, it costs nearly 25 times more to treat MDR-TB than drug-susceptible TB in South Africa, contributing to a disproportionate portion of the country’s TB budget19.

The fight against AMR and MDR-TB will require a multi-pronged approach, and it will not be easy. TB vaccines can help by reducing the incidence and transmission of TB, which would in turn reduce the need for antimicrobial treatment and help to slow the emergence of AMR. Because vaccines prevent infections in the first place, they play an indispensable role in combatting the global crisis of drug resistance20.

An Economic Case for TB Vaccines

Research indicates that like other immunizations, BCG vaccination is generally cost-effective, particularly in high-incidence settings21. However, these cost savings are not passed downstream to the families affected by TB; treatment for the disease can take months and can lead to catastrophic health costs for families. This is one reason why preventing TB is an important consideration for equity: TB is most likely to impact those who will have the greatest challenges covering the costs of treatment, transportation to a health center, and lost wages. Low-income populations are generally at a higher risk of developing TB, possibly because they have higher exposures to risk factors such as living and working in crowded and poorly ventilated spaces and less access to health care 22. As a result, they are more likely to be saddled with the catastrophic treatment costs of TB.

  • According to a review of national patient cost surveys from 23 countries, the percentage of households affected by TB experiencing catastrophic costs ranged from 13–92%, with a pooled average of 47%23. This means that globally, nearly one in two families affected by TB will spend more than 20% of their household income on treatment, a catastrophic expense for many families.
  • Research in Ghana demonstrates that TB costs can push households below the poverty line, particularly for those already living in the middle or lower half of the income distribution24.
  • The financial impact of TB continues after treatment. Among families participating in a study in South Africa, 35% of previously employed mothers stopped working to care for children who had permanent disabilities from surviving tuberculosis meningitis 25. Nineteen percent of families reported financial loss as a result of caring for children who were disabled by the disease.

The WHO End TB Strategy outlines eliminating the number of TB-affected families facing catastrophic costs as one of its goals, and there is clearly work to be done to meet this ambitious goal26.

“The development and roll-out of new TB vaccines could yield health and economic benefits on a similar scale to some of the most influential health interventions in poorer countries in recent years.”27

Developing new TB vaccines that protect adolescents and adults will require a significant investment, but health economists project that these vaccines will save money in the long run, thanks to averted treatment costs and the boost to the economy associated with a healthy workforce. These vaccines are also expected to advance health equity, as the benefits of new TB vaccines are expected to provide the greatest benefits for those who currently bear the highest disease burden.

  • A 2023 modelling study estimates that a TB vaccine for adolescents and adults would be cost-effective in 70% of settings and could save up to US$474 billion by 205028. In this scenario, every US$1 invested in TB vaccines would provide US$7 in returns.
  • A second modelling study29 shows that more than half of TB cases averted by a new vaccine would be among the two poorest income quartiles. These two income quartiles would also account for 46% of averted treatment costs, as well as 66% of cases of catastrophic costs.

Looking Ahead: The Future of TB Vaccines

New, more effective vaccines are needed to reduce the morbidity and mortality of TB, fight the rising threat of AMR, and address inequities in disease burden and economic impact. The BCG vaccine does not adequately protect older children, adolescents, and adults against TB, and continuing to neglect these populations will only exacerbate this growing crisis.

There are at least 16 new TB vaccines currently in development, but significant funding is needed to push these new vaccines through the research pipeline. It is estimated that it will take US$790 million per year to advance TB vaccines, though the average annual investment for the past several years has been just US$115 million30. These vaccines must be prioritized to reduce the burden of this devastating disease and end the TB pandemic.


1. Global Pandemic. TB Alliance. Accessed March 16, 2023.

2. Tuberculosis (TB). Accessed March 16, 2023.

3. Tuberculosis. Accessed March 16, 2023.

4. Meghji J, Gregorius S, Madan J, et al. The long term effect of pulmonary tuberculosis on income and employment in a low income, urban setting. Thorax. 2021;76(4):387-395. doi:10.1136/thoraxjnl-2020-215338

5. Shruthi Ravimohan, Hardy Kornfeld,  Drew Weissman, Gregory P. Bisson. Tuberculosis and lung damage: from epidemiology to pathophysiology | European Respiratory Society. Accessed March 16, 2023.

6.  Martinez L, Cords O, Liu Q, et al. Infant BCG vaccination and risk of pulmonary and extrapulmonary tuberculosis throughout the life course: a systematic review and individual participant data meta-analysis. Lancet Glob Health. 2022;10(9):e1307-e1316. doi:10.1016/S2214-109X(22)00283-2

7.  2.1 TB incidence. Accessed March 16, 2023.

8. Ritz N, Mui M, Balloch A, Curtis N. Non-specific effect of Bacille Calmette-Guérin vaccine on the immune response to routine immunisations. Vaccine. 2013;31(30):3098-3103. doi:10.1016/j.vaccine.2013.03.059

9.  Moorlag SJCFM, Arts RJW, van Crevel R, Netea MG. Non-specific effects of BCG vaccine on viral infections. Clin Microbiol Infect. 2019;25(12):1473-1478. doi:10.1016/j.cmi.2019.04.020

10. Biering-Sørensen S, Jensen KJ, Monterio I, Ravn H, Aaby P, Benn CS. Rapid Protective Effects of Early BCG on Neonatal Mortality Among Low Birth Weight Boys: Observations From Randomized Trials. J Infect Dis. 2018;217(5):759-766. doi:10.1093/infdis/jix612

11.  Biering-Sørensen S, Aaby P, Lund N, et al. Early BCG-Denmark and Neonatal Mortality Among Infants Weighing <2500 g: A Randomized Controlled Trial. Clin Infect Dis. 2017;65(7):1183-1190. doi:10.1093/cid/cix525

12. Trunk G, Davidović M, Bohlius J. Non-Specific Effects of Bacillus Calmette-Guérin: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Vaccines. 2023;11(1):121. doi:10.3390/vaccines11010121

13. Covián C, Fernández-Fierro A, Retamal-Díaz A, et al. BCG-Induced Cross-Protection and Development of Trained Immunity: Implication for Vaccine Design. Front Immunol. 2019;10. Accessed March 16, 2023.

14. Berendsen MLT, Smits J, Netea MG, Ven A van der. Non-specific Effects of Vaccines and Stunting: Timing May Be Essential. eBioMedicine. 2016;8:341-348. doi:10.1016/j.ebiom.2016.05.010

15. Antimicrobial resistance. Accessed March 16, 2023.

16. Tagliabue A, Rappuoli R. Changing Priorities in Vaccinology: Antibiotic Resistance Moving to the Top. Front Immunol. 2018;9. Accessed March 16, 2023.

17. Kenyon T. Tuberculosis Is A Threat To Global Health Security. Health Aff (Millwood). 2018;37(9):1536-1536. doi:10.1377/hlthaff.2018.0894

18. Antimicrobial Resistance. TB Alliance. Published November 17, 2016. Accessed March 16, 2023.

19. Pooran A, Pieterson E, Davids M, Theron G, Dheda K. What is the Cost of Diagnosis and Management of Drug Resistant Tuberculosis in South Africa? PLoS ONE. 2013;8(1):e54587. doi:10.1371/journal.pone.0054587

20. 160525_Final paper_with cover.pdf. Accessed March 16, 2023.

21.  Machlaurin A, Pol S van der, Setiawan D, van der Werf TS, Postma MJ. Health economic evaluation of current vaccination strategies and new vaccines against tuberculosis: a systematic review. Expert Rev Vaccines. 2019;18(9):897-911. doi:10.1080/14760584.2019.1651650

22.  Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: the role of risk factors and social determinants. Soc Sci Med 1982. 2009;68(12):2240-2246. doi:10.1016/j.socscimed.2009.03.041

23.  6.2 National cost surveys. Accessed March 16, 2023.

24.  Pedrazzoli D, Siroka A, Boccia D, et al. How affordable is TB care? Findings from a nationwide TB patient cost survey in Ghana. Trop Med Int Health TM IH. 2018;23(8):870-878. doi:10.1111/tmi.13085

25.  Krauss-Mars AH, Lachman PI. Social factors associated with tuberculous meningitis. A study of children and their families in the western Cape. South Afr Med J Suid-Afr Tydskr Vir Geneeskd. 1992;81(1):16-19.

26. The End TB Strategy. Accessed March 16, 2023.

27.  New TB vaccines could produce substantial health and economic benefits in coming decades | Gavi, the Vaccine Alliance. Accessed March 16, 2023.

28.  The cost and cost-effectiveness of novel tuberculosis vaccines in low- and middle-income countries: A modeling study | PLOS Medicine. Accessed March 16, 2023.

29. Portnoy A, Clark RA, Weerasuriya CK, et al. The potential impact of novel tuberculosis vaccines on health equity and financial protection in low- and middle-income countries. Published online October 29, 2022:2022.10.29.22281678. doi:10.1101/2022.10.29.22281678

30.  An investment case for new tuberculosis vaccines. Accessed March 16, 2023.

Breaking the Barriers: How Gender Equity Advances Immunization

The COVID-19 pandemic has highlighted and exacerbated existing global gender inequities that impact the accessibility of immunizations to women and children worldwide, influencing their access to health services, education, and economic opportunities. Gender-related inequities contribute to barriers to immunization for people of all genders. Although girls and boys in most settings are equally likely to be vaccinated, evidence has found that advancing global gender equity can play an important role in ensuring all children have access to vital health resources such as immunization.

Key Points

  1. Gender inequality can prevent people of either gender from accessing critical health resources such as vaccination for themselves and their children.
  2. Higher levels of gender inequality for women are correlated with higher child mortality and lower childhood immunization rates.
  3. The more empowered women are – i.e. have control over family decision-making, financial resources, and safe travel/transportation – the more likely their children are to be vaccinated.
  4. Maternal education is significantly associated with immunization coverage for children and a child’s immunization status has been found to predict greater educational attainment.
  5. At the national level, higher levels of gender inequality are associated with higher rates of zero-dose status for children (children who received no doses of the DTP vaccine).

Immunization interventions will only succeed in expanding coverage and widening reach when gender roles, norms and relations are understood, analysed and systematically accounted for as part of immunization service planning and delivery.”

Why Gender Matters: Immunization Agenda 2030

Global research has found that gender equality, “the absence of discrimination based on a person’s sex or gender” 1, can be closely linked to health outcomes across populations. Evidence from around the globe finds that “reducing gender inequality could improve health outcomes at a population scale, resulting in increased overall and healthy life expectancy and decreasing years of life lost, years lived with disability, and disease burden, in the general population, and in men as well as women.” 2

What is Gender Equity?

Sex is typically characterized as either male or female and refers to the biological attributes that a person is born with. Gender refers to the socially constructed roles, norms, and behaviors that a given society considers appropriate for individuals based on the sex they were assigned at birth. Gender also shapes the relationships between and within groups of women and men1Gender inequality can prevent people of either gender from accessing critical health resources such as vaccination for themselves and their children. However, because gender-related barriers are underpinned by power relations that extend across individuals to systemic levels, women and girls are often especially vulnerable to these inequalities.

A recent World Health Organization report on gender and immunization defines gender equity as “The process of being fair to women and men. It recognizes that men and women have different needs, power, and access to resources, which should be identified and addressed in a manner that rectifies the imbalance. Addressing gender equity leads to equality.” 1

The goal of gender equity is for people of all genders to have fair access to critical resources for themselves and their families. While equality means treating everyone exactly the same, equity acknowledges that each person has different circumstances that require resources or opportunities appropriate for their situation. Gender equity involves recognizing and rectifying the gender-based differences that exist, especially those related to needs, access, and control over resources.

The COVID-19 pandemic has highlighted and exacerbated existing global gender inequities that impact the accessibility of immunizations to women and children worldwide, influencing their access to health services, education, and economic opportunities. For example, data collected from 193 countries during the COVID-19 pandemic indicate that women were 1.21 times more likely than men to report ceasing their education for reasons other than school closures.3 Additionally, between March 2020 and September 2021, 26.0% of women reported employment loss compared to 20.4% of their male counterparts.3

Gender Equity and Immunization

Although girls and boys in most low- and middle-income settings are equally likely to be vaccinated, evidence has found that advancing global gender equity can play an important role in ensuring all children have access to vital health resources such as immunization.1

Several global studies have found associations between broad gender inequality and childhood immunization rates. A 2017 study examined the country-level factors influencing vaccination coverage in 45 low- and lower-middle income Gavi-supported countries, finding that countries with the least gender equality–as measured by factors such as reproductive health, women-held parliamentary seats, and educational attainment–also had lower rates of vaccine coverage. 4

How Gender-Related Barriers Impact Immunization Uptake

An increased effort to address existing gender barriers is necessary to achieve universal coverage in child immunization.5 Evidence suggests that increasing gender equality and empowering women have the potential to improve global childhood vaccination rates.

2018 discussion paper on immunization and gender barriers from the Equity Reference Group for Immunization identified several key gender-related barriers that limit women’s access to immunization for themselves and their children6. When women have lower status than men within their families or communities, they must rely on men to provide transportation, treatment costs, and permission to obtain immunization services for children.1,6

Several studies have shown that maternal education is significantly associated with immunization coverage for women and their children. Women with limited literacy or those with poor education are less likely to understand vaccination cards and may not know that multiple visits are required for some vaccination4An analysis of immunization equity in 45 Gavi-eligible countries concluded that “children of the most educated mothers are 1.45 times more likely to have received DTP3 than children of the least educated mothers.” 4

Gender Equity Can Improve Immunization Rates

Evidence indicates that empowering women and increasing gender equality increases the chance that mothers will immunize their children. Across various settings and countries, the association between gender inequality and higher levels of under-immunized children persists.

  • 2016 systematic review assessed women’s agency and vaccine completion among children under 5 in low-income countries. Largely, decision-making was positively associated with the odds of complete childhood immunization. The review found that in lower-income settings, “specific dimensions of women’s agency may enhance vaccination coverage for children, and that empowering women in such settings shows promise as a means to improve child health.” 7
  • 2017 review of Gavi-supported countries found that countries with higher levels of gender inequality had lower and less equitable levels of child vaccination coverage.4

Immunization Can Foster Gender Equality

Vaccines provide crucial protection for the most marginalized women and children, particularly those affected by poverty, conflict, and deprivation. The indirect benefits of vaccines reduce gender-based disparities by reducing health gaps and improving healthy life expectancy in women, thus improving their inclusion in the labor market8. This modeling study suggests that by preventing illnesses, childhood vaccination can lead to higher educational attainment and labor participation for women, resulting in reductions in socioeconomic gender disparities8.

  • A 2020 modeling case study8 found that HPV vaccination among girls can narrow socioeconomic gender disparities by reducing the cervical cancer burden of women. One model estimates that HPV vaccination can prevent up to 80% of cervical cancer cases and deaths. A 5% improvement in health from HPV vaccination was estimated to result in a 5.9% increase in female labor force participation.
  • large study in India9 demonstrated that childhood immunization was associated with improvements in adult schooling attainment in India by as much as 10%. This could lead to a higher income for women, as a woman’s wage in India is estimated to increase by 5-8% for each extra year of schooling.

Gender and Zero-Dose Status

Gender inequity also contributes to “zero-dose” status, which refers to children who have not received a single dose of DTP-containing vaccines10. Countries with higher gender inequity have been found to also have a greater prevalence of zero-dose children than countries with lower gender inequity5. With the spotlight on COVID-19, the 2022 WHO/UNICEF Estimates of National Immunization Coverage (WUENIC) show that 112 countries experienced stagnant or declining DTP3 coverage since 2019, with 62 countries declining by at least 5 percentage points11,12. Globally, an estimated 18 million children have not received a single vaccine12.

The pandemic has not only disrupted routine immunization worldwide, but has also had alarming direct and indirect consequences on progress toward Sustainable Development Goals related to gender equity and child health.

  • Children of mothers with high levels of social independence (a measure of indicators of a woman’s ability to achieve her goals) were found to be 8.3% less likely to be zero-dose than children of women with low independence.13
  • A study representing 165 countries between 2010–2019 found that on average, greater gender equality was associated with markedly better coverage for DTP3 immunization5. Countries with higher gender inequality (as measured by gender-based advantage or disadvantage in health, education, and control over economic resources) had higher zero-dose prevalence (10% vs. 3%) and lower DTP3 immunization coverage (81% vs. 94%) compared to countries with lower measures of gender inequality.
  • An analysis of DHS data from 50 countries14 (representing 74% of low-income, 40% of lower-middle, and 11% of upper-middle-income countries in the world) found that “children born to less empowered women are over three times more likely to belong to the zero-dose category compared to those born to women with a high level of empowerment.”

There is a Strong Association Between Maternal Education and Child Health

Across contexts, research consistently finds that mothers with more education are also more likely to have their children immunized. There is also evidence that women’s education has a “dispersion” or “spillover” effect on child health that can benefit communities more broadly.15

  • A systematic review and meta-analysis found a 31% reduction in under-5 all-cause mortality for children born to mothers with 12 years of education. One additional year of maternal schooling was associated with a 3% reduction in under-5 mortality.16
  • Women who are health literate—irrespective of their education levels—are more likely to vaccinate their children, in both rural and urban settings. A study of 1,170 women from 60 Indian villages found that a mother’s health literacy level was positively associated with children’s receipt of DPT3 vaccination after adjustment for confounding17.
  • An analysis of Nigerian DHS data collected in 2014 revealed that a mother’s education level influences the likelihood of their child being immunized. Furthermore, the average education level of women within a community was found to have a protective effect on children beyond the benefits of their own mother’s schooling that may lead to better opportunities. This dispersion of benefits may be associated with women’s capacity to take advantage of better access to power and resources that having an education can support.18

Solutions: Immunization as an Equity Catalyst

The Immunization Agenda 2030 (IA2030) emphasizes the importance of immunization as a catalyst for advancing gender equality by addressing gender-related barriers. To reach the goal of leaving no one behind, gender-related barriers need to be effectively addressed from both the demand- and supply-side by all stakeholders6,19. Special attention should be paid to setting and context when attempting to implement gender-responsive approaches to immunization.1

Improve the quality, accessibility, and availability of services

  • All people should be treated with dignity and should be provided with the knowledge to make informed decisions.
  • Immunization services should be close to areas where hard-to-reach populations frequently visit and should be bundled together with other health services.

Integrate services and collaborate across sectors while working with change agents

  • To overcome barriers, relationships should be established with organizations beyond the health sector, especially with grassroots organizations and community-based groups.
  • Immunization programs should empower change agents and civil society with the skills to voice their views.

Apply a gender lens to research and innovation by investing in gender data and analysis

  • Action must be informed by data. To best identify and respond to gender inequities, data should be sex-disaggregated and informed by a gender analysis.

Globally, there is a lack of data regarding the needs and experiences of gender-diverse and gender non-conforming people and barriers to immunization. The barriers to health services that gender-diverse people face are important and specific efforts should be made to collect data and include gender-diverse people in research.1,20


  1. World Health Organization. Why Gender Matters: Immunization Agenda 2030. World Health Organization; 2021. Accessed December 6, 2022.
  2. Veas C, Crispi F, Cuadrado C. Association between gender inequality and population-level health outcomes: Panel data analysis of organization for Economic Co-operation and Development (OECD) countries. EClinicalMedicine. 2021;39:101051. doi:10.1016/j.eclinm.2021.101051
  3. Flor LS, Friedman J, Spencer CN, et al. Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021. The Lancet. 2022;399(10344):2381-2397. doi:10.1016/S0140-6736(22)00008-3
  4. Arsenault C, Johri M, Nandi A, Mendoza Rodríguez JM, Hansen PM, Harper S. Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries. Vaccine. 2017;35(18):2479-2488. doi:10.1016/j.vaccine.2017.03.029
  5. Vidal Fuertes C, Johns NE, Goodman TS, Heidari S, Munro J, Hosseinpoor AR. The Association between Childhood Immunization and Gender Inequality: A Multi-Country Ecological Analysis of Zero-Dose DTP Prevalence and DTP3 Immunization Coverage. Vaccines. 2022;10(7):1032. doi:10.3390/vaccines10071032
  6. Feletto M, Sharkey A, Rowley E, Gurley N, Sinha A. A Gender Lens to Advance Equity in Immunization. Equity Reference Group for Immunisation; 2018.
  7. Thorpe S, VanderEnde K, Peters C, Bardin L, Yount KM. The Influence of Women’s Empowerment on Child Immunization Coverage in Low, Lower-Middle, and Upper-Middle Income Countries: A Systematic Review of the Literature. Matern Child Health J. 2016;20(1):172-186. doi:10.1007/s10995-015-1817-8
  8. Portnoy A, Clark S, Ozawa S, Jit M. The impact of vaccination on gender equity: conceptual framework and human papillomavirus (HPV) vaccine case study. Int J Equity Health. 2020;19(1):10. doi:10.1186/s12939-019-1090-3
  9. Nandi A, Kumar S, Shet A, Bloom DE, Laxminarayan R. Childhood vaccinations and adult schooling attainment: Long-term evidence from India’s Universal Immunization Programme. Soc Sci Med 1982. 2020;250:112885. doi:10.1016/j.socscimed.2020.112885
  10. Gavi, the Vaccine Alliance. Zero-dose children and missed communities. Published November 4, 2021. Accessed December 13, 2022.
  11. UNICEF. Vaccination and Immunization Statistics. UNICEF Data. Published July 2022. Accessed December 6, 2022.
  12. UNICEF. COVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows. Published July 15, 2021.
  13. Johns NE, Santos TM, Arroyave L, et al. Gender-Related Inequality in Childhood Immunization Coverage: A Cross-Sectional Analysis of DTP3 Coverage and Zero-Dose DTP Prevalence in 52 Countries Using the SWPER Global Index. Vaccines. 2022;10(7):988. doi:10.3390/vaccines10070988
  14. Wendt A, Santos TM, Cata-Preta BO, et al. Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys. J Glob Health. 12:04022. doi:10.7189/jogh.12.04022
  15. Feletto M, Sharkey A. The influence of gender on immunisation: using an ecological framework to examine intersecting inequities and pathways to change. BMJ Glob Health. 2019;4(5):e001711. doi:10.1136/bmjgh-2019-001711
  16. Balaj M, York HW, Sripada K, et al. Parental education and inequalities in child mortality: a global systematic review and meta-analysis. The Lancet. 2021;398(10300):608-620. doi:10.1016/S0140-6736(21)00534-1
  17. Johri M, Subramanian SV, Sylvestre MP, et al. Association between maternal health literacy and child vaccination in India: a cross-sectional study. J Epidemiol Community Health. 2015;69(9):849-857. doi:10.1136/jech-2014-205436
  18. Burroway R, Hargrove A. Education is the antidote: Individual- and community-level effects of maternal education on child immunizations in Nigeria. Soc Sci Med 1982. 2018;213:63-71. doi:10.1016/j.socscimed.2018.07.036
  19. USAID MOMENTUM. Now Is the Time to Recognize and Reduce Gender-Related Barriers to Immunization. USAID MOMENTUM. Published July 15, 2021. Accessed December 6, 2022.
  20. United Nations Office of the High Commissioner for Human Rights. The struggle of trans and gender-diverse persons. OHCHR. Accessed December 6, 2022.

Why Rotavirus Vaccine Introduction in Nigeria is a Milestone for Child Health

In August 2022, Nigeria became the most recent country to introduce the rotavirus vaccine into its national immunization program. The integration of the rotavirus vaccine into Nigeria’s routine immunization schedule is expected to help reduce at least 40% of morbidity and mortality associated with rotavirus infections amongst children.

Key Points

  • Nigeria’s recent introduction of rotavirus vaccine into its immunization schedule has the potential to save the lives of nearly 100,000 children under five over the next decade.
  • Immunization against rotavirus significantly reduces diarrhea-related hospitalizations and can relieve pressure on overburdened health systems.
  • Rotavirus vaccines provide a return on investment and protect families from potentially catastrophic medical expenses.
  • By preventing diarrheal disease and the malnutrition that may be associated with rotavirus infection, rotavirus vaccines can reduce the risk of stunting and promote healthy cognitive development.

Diarrheal diseases are one of the leading killers of children worldwide, claiming the lives of an estimated 484,000 children under five each year.1 Though many bacteria and viruses can cause diarrhea, rotavirus may be responsible for up to 38% of diarrhea-related hospitalizations in children under five in countries where the rotavirus vaccine has not yet been introduced2. The burden of rotavirus is concentrated in low- and middle-income countries, with a 2013 study reporting that nearly half of all global rotavirus deaths occurred in just four countries: India, Nigeria, Pakistan, and Democratic Republic of Congo3. Because rotavirus is so highly transmissible, preventing rotavirus infection with the use of rotavirus vaccines is more effective than treating symptoms after infection.

In August 2022, Nigeria became the most recent country to introduce the rotavirus vaccine into its national immunization program. This measure will protect millions of vulnerable children and significantly lower the global burden of rotavirus disease. “Nigeria’s rotavirus vaccine introduction has been a long-awaited event, making the inaugural rollout a milestone moment for Nigeria as well as the rest of the world united in efforts to reduce the mortality and morbidity of diarrheal diseases caused by rotavirus,” wrote ROTA Council Chair Mathu Santosham. “The implications of this launch event are tremendous.”

Due to the country’s high disease burden, introduction of the vaccine in Nigeria has the potential to avert a significant number of rotavirus hospitalizations and deaths. The mortality rate for rotavirus in children under five in Nigeria is estimated to be 136 per 100,000, accounting for 30% of all global rotavirus deaths in children under five4. Introducing the rotavirus vaccine into Nigeria’s national immunization program has the potential to protect 6.9 million children from this disease each year5, and it could potentially save the lives of nearly 100,000 children over the next decade6.

Relieving Pressure on Health Systems

Like other vaccines, evidence shows that rotavirus vaccines are highly effective in preventing severe illnesses that require children to be hospitalized. Reducing hospitalizations from preventable illnesses like rotavirus infection may be especially important for health system capacity at this time, as delivery of many health services in Nigeria has been disrupted by the COVID-19 pandemic7. Introducing rotavirus vaccine in Nigeria offers great potential to reduce the number of hospitalizations in children under five and alleviate pressure on an overburdened health system.

  • A 2018 study reported that 46% of children under 5 in Nigeria hospitalized for acute gastroenteritis tested positive for rotavirus8.
  • According to a review of 57 articles from 27 countries, hospitalizations due to rotavirus-related acute gastroenteritis (AGE) among children under 5 fell by a median of 67% in the first 10 years after the rotavirus vaccine was licensed9.
  • In Rwanda, hospital admissions due to rotavirus among children under five decreased up to 70% in the two years after the vaccine was introduced10.
  • In Botswana, gastroenteritis-related hospitalizations among children under five decreased by 23% in the two years following rotavirus vaccine introduction, with an even larger decline (43%) during the rotavirus season11.
  • A review of the vaccine’s impact in the United States found that in the first 11 years of its use, rotavirus hospitalizations declined by an average of 80% among children under five12. Rotavirus-related emergency visits declined by a median rate of 57%.

Rotavirus Vaccine is Cost-Effective & Reduces Financial Burdens on Families

Research shows that like other immunizations, the rotavirus vaccine is cost-effective and provides a positive return on investment for both governments and families.

  • In Nigeria, introduction of the rotavirus vaccine is estimated to save the government approximately US$28.5M in healthcare costs over a 10-year period13. These savings translate to a cost per DALY averted of US$116 (95% UI: $69-$169), just five percent of the country’s GDP per capita.
  • A meta-regression analysis of the cost-effectiveness of rotavirus vaccination across 195 countries found that it was cost-effective, particularly in LMICs with the highest disease burden14. Among countries eligible for Gavi support, the mean ICER was $255 per DALY averted (95% UI: $39–$918).
  • Studies from high-income settings have found that introduction of rotavirus vaccines can provide significant short-term returns on investment (ROI). For example, a series of studies in the United States estimated that once rotavirus vaccines were introduced, the average annual savings in direct healthcare costs from rotavirus and acute gastroenteritis were between US$121M and US$231M12. An economic evaluation of rotavirus vaccination in Italy determined that the cost of introducing the vaccine would be more than offset by savings from prevention of disease cases and hospitalizations within as early as two years15.

Families of those treated for diarrheal diseases face significant out-of-pocket expenditures, which can be especially burdensome for those already living in poverty. Many of these costs are considered catastrophic, meaning that they exceed 10 percent of the household’s monthly income. In addition to out-of-pocket medical costs for rotavirus-related illnesses, families who miss work to care for a sick child also face indirect costs due to lost wages. By reducing disease burden, the rotavirus vaccine protects vulnerable families from these catastrophic expenditures.

  • In Malaysia, families of those treated for acute gastroenteritis pay an average of US$101 in out-of-pocket costs16. These expenses disproportionately affect families in the lowest income quartile, representing 23% of their monthly household income, compared to less than 6% of monthly household income for families in the highest income quartile.
  • The average direct and indirect costs for rotavirus-related diseases among poor families in Bangladesh are US$105.2, including out-of-pocket expenditures for treatment, non-medical costs like transportation and lodging for caregivers, and the opportunity costs of lost wages17. This accounts for nearly one-third of their total monthly household income.
  • On average, families in Vietnam lose more than nine working days due to caring for a child with rotavirus18.

Reducing Rotavirus Infections Promotes Healthy Development

Enteric infections like rotavirus can have long-term effects on a child’s development. Diarrheal illnesses often lead to malnutrition, which can cause stunting and impact cognitive development—and which also makes children more susceptible to subsequent infections. Rotavirus vaccine can break this vicious cycle by preventing the malnutrition that accompanies diarrheal diseases to promote healthy growth and development. These vaccines are especially beneficial for children living in low-resource and marginalized communities who are more likely to experience undernutrition and stunting.

  • A pooled analysis of studies from five LMICs demonstrated the cumulative effects of repeat diarrheal episodes from 0–24 months20. For every five episodes of diarrhea that a child experiences, they are 13% more likely to be stunted at age two.
  • A study of children in Jamaica found that at age 11 or 12, children who had been stunted by age 2 performed significantly worse than non-stunted children on reading, spelling, and arithmetic tests, even when accounting for socio-economic factors21.
  • An analysis of 8,000 children in five LMICs estimated that children who were stunted by age 2 completed an average of approximately one year less of schooling22. They were also 16% more likely than non-stunted peers to have failed a grade.
  • Children with diarrhea have a greater risk of developing pneumonia or acute lower respiratory infections (ALRI). A study of children in Ghana estimated that more than 1 in 4 cases of ALRI were attributable to recent diarrheal illnesses, and therefore, preventing diarrheal illnesses would also prevent a large number of pneumonia cases23.

Nigeria’s introduction of rotavirus vaccine is promising, with the potential to protect millions of children from diarrheal diseases caused by rotavirus. Track immunization coverage for rotavirus and other essential vaccines through VIEW-hub, IVAC’s interactive data visualization platform.


  1. International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. (2022). Pneumonia and Diarrhea Progress Report 2022.
  2. Lanata CF, Fischer-Walker CL, Olascoaga AC, et al. Global causes of diarrheal disease mortality in children <5 years of age: A systematic review. PLoS One. 2013;8(9):e72788. doi:10.1371/journal.pone.0072788
  3. Tate JE, Burton AH, Boschi-Pinto C, Parashar UD; World Health Organization–Coordinated Global Rotavirus Surveillance Network. Global, Regional, and National Estimates of Rotavirus Mortality in Children <5 Years of Age, 2000-2013. Clin Infect Dis. 2016;62 Suppl 2:S96-S105. doi:10.1093/cid/civ1013
  4. Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2019 (GBD 2019) Results. Institute for Health Metrics and Evaluation (IHME) 2020; Available from: gbd-results-tool.
  5. International Vaccine Access Center. VIEW- hub. [cited 2022 January]; Available from:
  6. Giwa, Omotayo. Nigeria Writes a New Chapter for Child Health with the Introduction of Rotavirus Vaccine. DefeatDD. Published August 22, 2022. Accessed November 17, 2022.
  7. Shapira G, Ahmed T, Drouard SHP, et al. Disruptions in maternal and child health service utilization during COVID-19: analysis from eight sub-Saharan African countries. Health Policy Plan. 2021;36(7):1140-1151. doi:10.1093/heapol/czab064
  8. Tagbo BN, Mwenda JM, Eke CB, et al. Rotavirus diarrhoea hospitalizations among children under 5 years of age in Nigeria, 2011-2016. Vaccine. 2018;36(51):7759-7764. doi:10.1016/j.vaccine.2018.03.084
  9. Burnett E, Jonesteller CL, Tate JE, Yen C, Parashar UD. Global Impact of Rotavirus Vaccination on Childhood Hospitalizations and Mortality From Diarrhea. J Infect Dis. 2017;215(11):1666-1672. doi:10.1093/infdis/jix186
  10. Ngabo, F., Tate, J.E., Gatera, M., et al 2016. Effect of pentavalent rotavirus vaccine introduction on hospital admissions for diarrhea and rotavirus in children in Rwanda: a time-series analysis. Lancet Global Health. 4:e129-36.
  11. Enane LA, Gastanaduy PA, Goldfarb DM, et al. 2016. Impact of rotavirus vaccination on hospitalizations and deaths from childhood gastroenteritis in Botswana. Clinical Infectious Diseases. 2016(2).
  12. Pindyck T, Tate JE, Parashar UD 2018. A decade of experience with rotavirus vaccination in the United States – vaccine uptake, effectiveness, and impact. Expert Review of Vaccines. 17(7).
  13. Debellut, F., Clark, A., Pecenka, C., Tate, J., Baral, R., Sanderson, C., … & Atherly, D. 2019. Re-evaluating the potential impact and cost-effectiveness of rotavirus vaccination in 73 Gavi countries: a modelling study. The Lancet Global Health. 7(12).
  14. Janko MM, Joffe J, Michael D, et al. Cost-effectiveness of rotavirus vaccination in children under five years of age in 195 countries: A meta-regression analysis. Vaccine. 2022;40(28):3903-3917. doi:10.1016/j.vaccine.2022.05.042
  15. Carroll S, Rojas AJ, Glenngård AH, Marin C. Vaccination: short- to long-term benefits from investment. J Mark Access Health Policy. 2015;3:10.3402/jmahp.v3.27279. Published 2015 Aug 12. doi:10.3402/jmahp.v3.27279
  16. Loganathan, T., Lee, W.S., Lee, K.F., et al 2015. Household Catastrophic Healthcare Expenditure and Impoverishment Due to Rotavirus Gastroenteritis Requiring Hospitalization in Malaysia. PLOS One. 10(5).
  17. Ahmed S, Dorin F, Satter SM, et al. The economic burden of rotavirus hospitalization among children < 5 years of age in selected hospitals in Bangladesh. Vaccine. 2021;39(48):7082-7090. doi:10.1016/j.vaccine.2021.10.003
  18. Riewpaiboon A, Shin S, Le TP, et al. Cost of rotavirus diarrhea for programmatic evaluation of vaccination in Vietnam. BMC Public Health. 2016;16(1):777. Published 2016 Aug 11. doi:10.1186/s12889-016-3458-2
  19. Guerrant RL, DeBoer MD, Moore SR, Scharf RJ, Lima AA. The impoverished gut–a triple burden of diarrhoea, stunting and chronic disease. Nat Rev Gastroenterol Hepatol. 2013;10(4):220-229. doi:10.1038/nrgastro.2012.239
  20. Checkley, W., Buckley, G., Gilman, R.H., et al. 2008. Multi-country analysis of the effects of diarrhoea on childhood stunting. International Journal of Epidemiology. 37(4).
  21. Chang SM, Walker SP, Grantham-McGregor S, Powell CA. Early childhood stunting and later behaviour and school achievement. J Child Psychol Psychiatry. 2002;43(6):775-783. doi:10.1111/1469-7610.00088
  22. Martorell R, Horta BL, Adair LS, et al. Weight gain in the first two years of life is an important predictor of schooling outcomes in pooled analyses from five birth cohorts from low- and middle-income countries. J Nutr. 2010;140(2):348-354. doi:10.3945/jn.109.112300
  23. Schmidt WP, Cairncross S, Barreto ML, Clasen T, Genser B. Recent diarrhoeal illness and risk of lower respiratory infections in children under the age of 5 years. Int J Epidemiol. 2009;38(3):766-772. doi:10.1093/ije/dyp159

Leaving No Child Behind: Zero-Dose and UHC

December 12th is recognized worldwide as Universal Health Coverage (UHC) day. Universal health coverage “ensures all people, everywhere, can get the quality health services they need without financial hardship.” Equity is at the heart of the Sustainable Development Goal target 3.8, which seeks to achieve universal health coverage and financial risk protection for all. Immunization equity helps ensure that all children, regardless of where they live, have the opportunity to live a full, healthy life.

Key Points:

  • As of 2020, 17.1 million children are categorized as zero-dose, defined as never having received a single dose of life-saving DTP vaccine.
  • The number of children at risk due to zero-dose status or under-vaccination has increased according to 2020 reports.
  • Zero-dose children not only lack access to vaccines but lack access to other essential child health services.
  • As the most widely available health intervention in the world, childhood immunization can be leveraged to strengthen primary health care for missed communities, bringing us closer to UHC.

What Does Zero-Dose Mean?

As of 2020, an estimated 17.1 million children did not receive the first dose of Diphtheria-Tetanus-Pertussis vaccine (DTP1) – an increase of 3.5 million children from 20191. An estimated 80% of these zero-dose children live in Gavi-eligible countries1.

The term zero-dose refers to children who have not received a single dose of diphtheria, tetanus, and pertussis vaccine (DTP1). These zero-dose children are often concentrated among the most vulnerable and disadvantaged groups, including the lowest-income households. Zero-dose status can help act as a proxy indicator of access to immunization and health services access more generally: When young children aren’t protected against some of the most lethal infectious diseases it indicates they and their families may be missing out on additional basic services, like antenatal care or schooling2.

  • The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56.8 million to 14.5 million3.
  • By 2019, global coverage of the third dose of DTP (DTP3) was estimated at 81.6% globally – more than double from 1980 DTP3 coverage estimates of 39.9%3.
  • Over the past decade, global vaccine coverage has plateaued beneath global coverage goals. Since 2010, 94 countries and territories recorded decreasing DTP3 coverage3.

Where are Zero-Dose Children Located?

Over the last 20 years, national governments and international health organizations have made tremendous progress in ensuring that all children have access to a safe, and healthy start to life. By focusing on zero-dose children, we concentrate resources on the populations who compounded deprivation where access to resources is the most challenging for families:

  • Nearly 50% of zero-dose children live in three key geographic contexts: urban areas, remote communities, and populations in conflict settings4.
  • Six Gavi-supported countries are home to 65% of zero-dose children: Nigeria (20 percent), India (18 percent), Pakistan (9 percent), the DRC (6 percent), Indonesia (6 percent), and Ethiopia (5 percent)4.
  • Communities with many zero-dose children also tend to have girls who are not in school; women with limited agency; high rates of violence against women; and lack of contraceptive, reproductive, maternal, neonatal, and pediatric health services2.
  • These missed communities are often the epicenters of disease outbreaks (e.g., yellow fever, measles, meningitis, cholera, Ebola virus disease) and can thus be valuable targets for prevention efforts2.
Zero Dose Map

Immunization: Investing in Health Systems for All

When children are “zero-dose” this lack of vaccine access often indicates a dire lack of access to other key health services for communities. Unvaccinated children disproportionately live in households with limited access to other primary health care services, and routine vaccination services may provide the opportunity to bring caregivers into contact with the health system5.

  • When a child misses out on basic vaccines, they are also likely to be missing out on other essential health interventions. This also means that their families and communities are most likely to be missing out on basic health services like maternal and neonatal care, access to sexual and reproductive health services nutritional supplements, and malaria prevention6.
  • Mothers of zero dose children are twice as likely to miss out on antenatal care or skilled birth attendance and these families are less likely to have access to clean water or sanitation4.
  • Children from families without access to primary health care services – such as institutional delivery, antenatal care, and maternal vaccination – also tend to be less likely to be vaccinated5.

Deprivation, Missed Communities, and Poverty

A 2021 analysis7 looking at the risk of zero-dose status across 92 LMIC countries found a strong association between deprivation and zero-dose status: The most deprived group represented children who were not born in a health facility, to a mother who did not receive a tetanus vaccine before or during pregnancy and reported no antenatal care visits. The group characterized as the most deprived had the highest prevalence of zero-dose children (42%).

  • Two-thirds of zero-dose children live in households surviving below the international poverty line ($1.90 per day)2,7.
  • Among the highest risk group, 47% were in the poorest wealth quintile, 89% lived in a rural area, and 81% had mothers with no education7.
  • There are large inequalities in drop-out rates, with drop-out being twice as high for children from the poorest households, with a DPT1 to MCV drop-out rate of 18% compared to 9% in wealthier households8.

Gender Equity, Women’s Empowerment, and Zero-Dose Status

In many social contexts, women and mothers are primary caregivers for children and hold an important role in children’s immunization. Women’s empowerment relates to having the autonomy, agency and ability to make informed decisions, including seeking care and health services for children. Several studies have found that women’s empowerment can be associated with higher immunization coverage and better child health for children.

  • A 2022 analysis of standardized national house-hold surveys from 50 countries supports the importance of gender equity and women’s empowerment for child vaccination, especially in countries with weaker routine immunization programs. When data from all 50 countries was pooled, the analysis found that children from mothers in the low levels of social independence had 3.3 times higher prevalence of zero-dose status compared to mothers in the high levels of social independence group9. Assuming that this association is causal, these results show that “there would be 4.7 million fewer no-DPT children in the world if all of them had empowered mothers.”
  • Additionally, research from 2020 has also found routine childhood vaccination is associated with increased educational attainment and earnings for women. Women born after India’s Universal Immunization Program (UIP) rollout attained 0.29 more schooling grades compared to women from the same household born before UIP rollout10. Among unmarried women, the UIP was associated with an increment of 1.2 schooling years, which corresponds to as much as an INR 35 (US $0.60) increase in daily wages. Thus, the researchers concluded that the UIP is also likely to improve the economic status of women in India.
  • In a 2017 analysis of immunization coverage in 45 low- and lower-middle income Gavi-eligible countries, researchers found that overall, maternal and paternal education were two of the most significant drivers of coverage inequities in these countries11. Pooling the data from all countries, the authors found that “children of the most educated mothers are 1.45 times more likely to have received DTP3 than children of the least educated mothers.”
  • In a 2011 study in India, the children of mothers who participated in an empowerment program were significantly more likely to be vaccinated against DTP, measles, and tuberculosis than children of mothers not involved in the program12. This study also spillover effects: In villages where the program occurred, children of mothers not in the program (non-participants) were 9 to 32% more likely to be immunized against measles than in villages where the program did not occur (controls). Overall, measles vaccine coverage was nearly 25% higher in the program villages compared to the control villages.

New Efforts are Needed to Reach Every Child

The COVID-19 pandemic has disrupted health services and preventive interventions, including childhood immunizations, and new efforts are critically needed to ensure no one is left behind. Reaching zero-dose children and missed communities with health services like routine immunization is a key goal of UHC as well as Immunization Agenda 2030 and the Gavi Alliance’s 2021–2025 Strategy.

“Health for all means reaching those left furthest behind with live-saving vaccines as a pathway to providing other health services,” Gavi CEO Seth Berkley said in an International UHC Day video message from leaders around the world. “As countries roll-out COVID-19 vaccines we have a historic opportunity to strengthen routine immunization, to reach zero-dose and missed communities with a full course of vaccines, along with primary healthcare services and build resilience to future shocks.”


  1. Muhoza P. Routine Vaccination Coverage — Worldwide, 2020. MMWR Morb Mortal Wkly Rep. 2021;70. doi:10.15585/mmwr.mm7043a1
  2. Forum on Microbial Threats, Board on Global Health, Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine. The Critical Public Health Value of Vaccines: Tackling Issues of Access and Hesitancy: Proceedings of a Workshop. National Academies Press; 2021:26134. doi:10.17226/26134
  3. Galles NC, Liu PY, Updike RL, et al. Measuring routine childhood vaccination coverage in 204 countries and territories, 1980–2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1. The Lancet. 2021;398(10299):503-521. doi:10.1016/S0140-6736(21)00984-3
  4. Gavi. The Zero-Dose Child: Explained. Published April 26, 2021. Accessed April 13, 2022.
  5. Santos TM, Cata-Preta BO, Mengistu T, Victora CG, Hogan DR, Barros AJD. Assessing the overlap between immunisation and other essential health interventions in 92 low- and middle-income countries using household surveys: opportunities for expanding immunisation and primary health care. EClinicalMedicine. 2021;42:101196. doi:10.1016/j.eclinm.2021.101196
  6. Gupta A. Opinion: Reach “zero-dose” children to build back better. Devex. Published July 6, 2021. Accessed April 13, 2022.
  7. Santos TM, Cata-Preta BO, Victora CG, Barros AJD. Finding children with high risk of non-vaccination in 92 lowand middle-income countries: A decision tree approach. Vaccines. 2021;9(6). doi:10.3390/vaccines9060646
  8. Cata-Preta BO, Santos TM, Mengistu T, Hogan DR, Barros AJD, Victora CG. Zero-dose children and the immunisation cascade: Understanding immunisation pathways in low and middle-income countries. Vaccine. 2021;39(32):4564-4570. doi:10.1016/j.vaccine.2021.02.072
  9. Wendt A, Santos TM, Cata-Preta BO, et al. Children of more empowered women are less likely to be left without vaccination in low- and middle-income countries: A global analysis of 50 DHS surveys. J Glob Health. 2022;12:04022. doi:10.7189/jogh.12.04022
  10. Nandi A, Kumar S, Shet A, Bloom DE, Laxminarayan R. Childhood vaccinations and adult schooling attainment: Long-term evidence from India’s Universal Immunization Programme. Soc Sci Med. 2020;250:112885. doi:10.1016/j.socscimed.2020.112885
  11. Arsenault C, Harper S, Nandi A, Mendoza Rodríguez JM, Hansen PM, Johri M. Monitoring equity in vaccination coverage: A systematic analysis of demographic and health surveys from 45 Gavi-supported countries. Vaccine. 2017;35(6):951-959. doi:10.1016/j.vaccine.2016.12.041
  12. Janssens W. Externalities in Program Evaluation: The Impact of a Women’s Empowerment Program on Immunization. Journal of the European Economic Association. 2011;9(6):1082-1113. doi:10.1111/j.1542-4774.2011.01041.x

Vaccines are Key in Combating Antimicrobial Resistance (AMR)

Antimicrobial resistance (AMR) is a growing threat to the health of children worldwide. New evidence shows how vaccines are one promising way to combat the global spread of AMR. New research on typhoid conjugate vaccines (TCV) shows how immunization can protect children, families, and communities against the emergence of dangerously resistant superbugs.

Key Messages

  • WHO has declared that AMR is one of the top 10 global public health threats facing humanity.
  • With the identification of increasingly treatment-resistant typhoid strains, we are dangerously close to running out of options for oral antibiotic treatments.
  • Vaccines contribute to the battle against antimicrobial resistance (AMR) by preventing infections and by reducing the use of antibiotics.

Antimicrobial resistance (AMR) is one of the most urgent threats currently facing global health. Antimicrobials are medicines used to prevent and treat infections in humans, animals and plants and include antibiotics, antivirals, antifungals and antiparasitics. AMR occurs when bacteria, viruses, fungi, and parasites evolve over time and no longer respond to antimicrobial medicines. When pathogens become drug resistant, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat leading to more severe illness and risk of death.

Vaccines already save millions of lives every year by preventing infectious diseases like pneumonia and diarrhea. However, new research provides evidence that vaccines are an important tool in preventing the spread of AMR. For World Antimicrobial Awareness Week (WAAW)(18-24 November) the VoICE team is highlighting the important role of vaccines in saving lives and combating antimicrobial resistance.

According to a 2019 UNICEF report, “The emergence and spread of AMR is occurring at an alarming rate with current estimates indicating that at least 700,000 people die worldwide each year due to drug-resistant infections, which is expected to rise to 10 million deaths globally by 2050.”

AMR is a Major Threat to Child Survival

“Vaccines are among the most effective tools to prevent infections, and they have the potential to make a major contribution to the control and prevention of AMR.” – World Health Organization, 2020

AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. A Lancet analysis of the health impacts of AMR across 200 countries and territories found that AMR was directly responsible for an estimated 1.27 million deaths globally in 2019. For comparison, HIV/AIDS and malaria were estimated to have caused 860,000 and 640,000 deaths, respectively, in 2019. The highest rates of AMR burden occur in sub-Saharan Africa. Children living in low-resource settings with limited access to health and immunization services face some of the greatest risks of exposure to AMR.

While AMR poses a threat to people of all ages, children are particularly vulnerable to AMR infections as their immune systems are not fully developed.

Global AMR Deaths Prevented, 2019 graph

How #VaccinesWork to Counter the AMR Threat

How can vaccines combat the growing threat of “superbugs”? Vaccines against illnesses like typhoid, pneumonia, and diarrhea limit the spread of antimicrobial resistance through two main mechanisms:

  1. Vaccines lower the overall burden of infection, leading to a reduction in the transmission of resistant and susceptible pathogens.
  2. When children are vaccinated there are fewer infections, leading to less need for antibiotic medications. This reduces the selection pressure for pathogens to become resistant to antibiotics.
AMR Vaccine Prevention

A Vaccine Success Story Against XDR Typhoid

The Salmonella Typhi (S. Typhi) bacterium causes typhoid, an illness that kills between 128,000 and 161,000 people every year and sickens an another 11–20 million people.

Typhoid fever can be treated with antibiotics, however, an increasing resistance to antibiotics is making treatment for typhoid more difficult. Drug-resistant typhoid is an increasing threat for some countries, including Pakistan. Extensively drug-resistant (XDR) typhoid is resistant to five of the six available oral antibiotics, making these infections much more difficult and costly to treat.

An outbreak caused by an XDR strain of Salmonella Typhi was identified in Pakistan in 2016; within 4 years of its detection, XDR Salmonella Typhi constituted >80% of the entire Salmonella Typhi population in Pakistan, and it has since been detected in at least 10 countries.

2021 study of typhoid conjugate vaccine (TCV) immunization for children in Pakistan found that typhoid vaccines can be highly effective against drug-resistant typhoid.

  • TCV was 95% effective against culture-confirmed typhoid infection.
  • TCV was 97% effective against XDR typhoid strains.
  • TCV was 98% effective against non-XDR typhoid strains.

According to the Coalition Against Typhoid these findings also show “…that TCV is highly effective against XDR typhoid, demonstrating its potential to protect children against even the most difficult-to-treat typhoid cases.”

AMR Typhoid Prevention

The VIEW-hub website provides maps and downloadable data on current typhoid vaccine introductions.


Atkins, Katherine E, Erin I Lafferty, Sarah R Deeny, Nicholas G Davies, Julie V Robotham, and Mark Jit. “Use of Mathematical Modelling to Assess the Impact of Vaccines on Antibiotic Resistance.” The Lancet Infectious Diseases 18, no. 6 (June 2018): e204–13.

Gottberg, Anne von, Linda de Gouveia, Stefano Tempia, Vanessa Quan, Susan Meiring, Claire von Mollendorf, Shabir A. Madhi, et al. “Effects of Vaccination on Invasive Pneumococcal Disease in South Africa.” New England Journal of Medicine 371, no. 20 (November 13, 2014): 1889–99.

Jakab, Zsuzsanna. “Children’s Immature Immune Systems Threatened by Increasing ‘Superbugs,’” November 20, 2020.

Oxford GBD Group. “Antibiotic Resistance Caused More Than 1.2M Deaths in 2019, According to Landmark GRAM Study,” January 20, 2022.

Qamar, Dr Farah Naz, Aga Khan University, and Pakistan. “Typhoid Conjugate Vaccine Is Effective against Drug-Resistant Typhoid.” Take on Typhoid, September 9, 2021.

Saha, Samir K, Nazifa Tabassum, and Senjuti Saha. “Typhoid Conjugate Vaccine: An Urgent Tool to Combat Typhoid and Tackle Antimicrobial Resistance.” The Journal of Infectious Diseases 224, no. Supplement_7 (December 20, 2021): S788–91.

UNICEF. “Time Is Running Out: A Technical Note on Antimicrobial Resistance,” November 2019.

Vekemans, Johan, Mateusz Hasso-Agopsowicz, Gagandeep Kang, William P. Hausdorff, Anthony Fiore, Elizabeth Tayler, Elizabeth J. Klemm, et al. “Leveraging Vaccines to Reduce Antibiotic Use and Prevent Antimicrobial Resistance: A World Health Organization Action Framework.” Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 73, no. 4 (August 16, 2021): e1011–17.

Integration: Leveraging Immunization for Health System Strengthening

A baby is being vaccinated

The battle to eliminate polio is one example of how immunization integration can be leveraged to strengthen health systems and build vaccine acceptance. Integration is one of the three pillars of the Endgame Strategy and is highlighted as a strategic priority in the Immunization Agenda 2030 (IA2030) and in Gavi’s 5.0 strategy.

Immunization programs are among the most successful and important public health programs across the globe, reaching an estimated 85% of the world’s children1. Although immunization programs like the Expanded Programme on Immunization (EPI) successfully reach the majority of the world’s children, other important health interventions may lack delivery mechanisms with the same scale as immunization. According to the CDC, “immunization reaches more children than any other single intervention.”2 The success of immunization programs means that they can also become an important platform for delivering additional health resources and services.

In many circumstances, populations may have particularly limited access or contact with services to address health issues such as malnutrition and vitamin deficiencies, malaria, access to family planning, and early infant diagnostics for HIV. Effective immunization integration can help strengthen health systems, providing more efficient and accessible health care for women and children.

The battle to eliminate polio is one of the examples for how immunization integration can be leveraged to strengthen health systems, particularly in the most vulnerable areas. Integration is one of the three pillars of the Endgame Strategy and is highlighted as a strategic priority in the Immunization Agenda 2030 (IA2030) and in Gavi’s 5.0 strategy to ensure no one is left behind with immunization.

The Integration Continuum

There are many possible permutations of integrated health services. The WHO recommends that integration be viewed as a continuum of potential options, rather than as zero-sum options of “integrated” and “not integrated.”  There are many different factors3 that need to be taken into account to determine the optimal strategy for integration of immunization services such as:

  • selecting interventions that can be feasibly integrated;
  • coordination across program levels;
  • ensuring adequate training and workload for health workers;
  • ensuring the participation of community based organizations, leaders, and volunteers
Continuum of Immunization Strategies

Integration and Community Acceptance of Vaccines

With vaccine hesitancy becoming a rising global threat, community engagement should serve as a cornerstone to the implementation and planning of health services. The co-delivery of immunizations with services that are prioritized by the target community can improve acceptability. Co-delivery of vaccines with priority services can also improve job satisfaction for frontline health workers by allowing workers to provide the range of services desired by community members. When community health workers in parts of India and Nigeria focused only on providing repeated polio campaigns, they were questioned by the community about why they only addressing a single disease that wasn’t a priority for many individuals in the area4.

“When talking about healthcare services in urban slums, an interviewee described that, ‘it’s not a matter of hard- to- reach but rather, hardly reached.’ Communities felt ignored by their government, and were thus mistrusting and sceptical of government or NGO intervention during polio vaccination rounds.”

Bellatin A, Hyder A, Rao S, et al. (2021)

In an investigation of 30 years of polio campaigns in Ethiopia, India, and Nigeria, researchers found that in all study countries, community hesitancy towards vaccines could be mitigated when health systems demonstrated responsiveness to the community’s priorities and needs4.

  • Among pastoralist communities in East Africa, co-delivery of polio vaccines along with high-priority services like veterinary care, improved community acceptance of the vaccines5.
  • In Ethiopia and Nigeria, OPV was increasingly delivered alongside Vitamin A, insecticide- treated nets, and deworming tablets, and CORE group volunteers engaged broadly in child health education6,7.
  • India’s 107 Block Plan, developed in 2009, focused on routine immunization, sanitation8 practices, breastfeeding rates, and reducing diarrheal disease. One of major challenges in the final years of polio elimination in India was resistance from vaccine hesitant groups. One factor for successful elimination of polio in Uttar Pradesh was improving vaccine acceptance by packaging other basic healthcare services such as routine check- ups and essential medications9.

Evidence from the VoICE Compendium

The integration of maternal and child health interventions into immunization campaigns can lead to improved rates of immunizations and related healthcare interventions.

In an effort to reach children with vitamin A deficiency in the African countries of Angola, Chad, Cote d’Ivoire, and Togo, vitamin A supplementation was administered during Polio vaccine campaigns. This led to a minimum coverage of 80% for vitamin A and 84% for polio vaccine in all of the immunization campaigns. During the second year of vitamin A integration into the polio vaccination campaign, coverage exceeded 90% for both vitamin A and polio vaccination in all four countries.

Immunization services can be integrated with family planning services to strengthen healthcare access for children and parents.

The total number of women accessing family planning services during the study period increased by 14% while DPT immunization rates for children remained consistent. In interviews, parents and providers found the integration of family planning and immunization services to be feasible and beneficial, indicating a win-win for both services.

Recent assessments of missed opportunities for vaccination (MOV) demonstrate that immunization coverage rates may also benefit from increased integration.

Children attending health facilities for vaccination, clinical care or other reasons, were not consistently being offered all of the recommended vaccines (57% for all clinic attendees, 25% for children attending for vaccination and 89% among those attending for medical consultation). Integrating immunization into primary care visits, health registers, and workflows can help reduce missed opportunities for vaccination.

Immunization programs provide opportunities for cost-sharing and external funding when used alongside other health interventions.

BCG and DPT have the highest coverage of any vaccines worldwide and are typically administered within 6 weeks of birth. This timing offers the opportunity to deliver a range of early childhood development interventions such as newborn hearing screening, sickle cell screening, treatment and surveillance, maternal education around key newborn care issues such as jaundice, and tracking early signs of poor growth and nutrition.

Integration in the COVID-19 Era: Opening New Doors

“…as billions of dollars are being spent to support vaccine rollout, as much as possible, these funds should be used in ways that not only distribute vaccines as quickly and equitably as possible but also strengthen – rather than detract from – underlying PHC systems.”

The impacts of the COVID-19 pandemic may present an opportunity for new ways of working across health campaigns, including promising applications of integration. The Primary Health Care Performance Initiative (PCPPI) has published a brief summarizing how the roll-out of COVID-19 vaccination efforts can be leveraged to support long-term primary health care strengthening.

  1. Building systems for population health management
  2. Strengthening surveillance and information systems
  3. Formalizing mechanisms for multi-sectoral action and social accountability
  4. Strengthening quality management infrastructure and building sustainable supply chains
  5. Sustaining investments in the health workforce

recent report published by WHO comprehensively documents the significant role played by polio eradication personnel during the pandemic, and urges strong action to sustain this network to deliver essential public health services after polio is eradicated.

Integrating with Intention

Simply integrating immunizations with other services is not sufficient to add value: It’s also key that integration must be implemented thoughtfully with appropriate attention paid to the context at hand. Well-integrated immunization programs can:

  • Improve efficiency and reduce redundancy for frontline workers – saving them valuable time.
  • Improve equity and coverage
  • Improve community vaccine acceptance

Implementation Glossary

Integrated  Service  Delivery – the  organization  and  management  of  health  services  so that  people get the  care they need, when they  need  it, in  ways  that  are  user-friendly,  achieve  the desired results and provide value for money.

Integration – The sharing of all or specific campaign components or functions by a specific program addressing a disease or health need with the broader health system and ongoing delivery of interventions through general health services.

Full Integration – Involves sharing of both operational and administrative functions and responsibilities and delivery of campaign interventions via primary health care (PHC). It occurs when interventions that were formerly delivered via independent health campaigns are delivered at the PHC level with other ongoing health services.

Partial Integration – Partial integration refers to a spectrum or continuum, in which campaigns share different operational and/or administrative components with any of the PHC system elements per the modified PHCPI framework—at the systems or inputs levels or both, while continuing to deliver services independently.

Health Campaign – A coordinated set of activities that targets resources to achieve a specific health goal or goals and is typically time-limited.

Collaboration of Campaigns – Partial integration of specific campaign components between vertical health programs (targeting different health problems) to improve efficiency and effectiveness of the vertical programs, but without co-delivery of interventions at the same service delivery points.

Periodic Intensification of Routine Immunization (PIRI) – A format with a range of options falling between the poles of routine services and campaigns. PIRI activities are intended to augment routine immunization services rather than be the primary means of providing it.


  1. PMNCH Knowledge Summary #25 Integrating immunization and other services for women and children. WHO. 2013.
  2. CDC. CDC Global Health – Immunization – Reaching Every Child. Published May 21, 2019.
  3. World Health Organization. Working Together: An Integration Resource Guide for Immunization Services throughout the Life Course. World Health Organization; 2018.
  4. Neel AH, Closser S, Villanueva C, et al. 30 years of polio campaigns in Ethiopia, India and Nigeria: the impacts of campaign design on vaccine hesitancy and health worker motivation. BMJ Global Health. 2021;6(8):e006002. doi:10.1136/bmjgh-2021-006002
  5. Haydarov R, Anand S, Frouws B, Toure B, Okiror S, Bhui BR. Evidence-Based Engagement of the Somali Pastoralists of the Horn of Africa in Polio Immunization: Overview of Tracking, Cross-Border, Operations, and Communication Strategies. Global Health Communication. 2016;2(1):11-18. doi:10.1080/23762004.2016.1205890
  6. Asegedew B, Tessema F, Perry HB, Bisrat F. The CORE Group Polio Project’s Community Volunteers and Polio Eradication in Ethiopia: Self-Reports of Their Activities, Knowledge, and Contributions. The American Journal of Tropical Medicine and Hygiene. 2019;101(4_Suppl):45-51. doi:10.4269/ajtmh.18-1000
  7. Bawa S, McNab C, Nkwogu L, et al. Using the polio programme to deliver primary health care in Nigeria: implementation research. Bull World Health Organ. 2019;97(1):24-32. doi:10.2471/BLT.18.211565
  8. Sukla P, Sharma KD, Rana M, Zaidi SHN. Polio eradication in India: New intiatives in sanitation. Indian J Community Health. 2013;25(1):74-76.
  9. Bellatin A, Hyder A, Rao S, Zhang PC, McGahan AM. Overcoming vaccine deployment challenges among the hardest to reach: lessons from polio elimination in India. BMJ Glob Health. 2021;6(4):e005125. doi:10.1136/bmjgh-2021-005125

World Immunization Week 2021 Social Media Toolkit

Banner for VoICE World Immunization Week 2021

With all eyes on vaccines, World Immunization Week 2021 (April 24-30) offers an unprecedented opportunity to build public trust in the value of all vaccines and help build long-term support for immunization. Our VoICE social media toolkit provides messaging for immunization advocates on the vital role that vaccines play in strengthening economies, equity, and health for all people across the globe. Use the VoICE toolkit to share how #VaccinesWork to bring us closer by helping improve the health of everyone, everywhere throughout life.

Join us in promoting the message that #VaccinesWork to bring us closer by sharing these social media messages on the value of vaccines.

VoICE Social Media Toolkit for World Immunization Week 2021

Vaccines bring us closer to a world where all children are protected against preventable illnesses like measles, pneumonia, and diarrhea. Investment in immunization brings us closer to ending the COVID-19 pandemic and brings closer to a healthier future for all.

The Value of Immunization Compendium of Evidence (VoICE) is a searchable database of peer-reviewed scientific evidence paired with advocacy messaging immunization advocates can use this World Immunization Week to show that #VaccinesWork for better health, better economies, and improved equity.

Download the VoICE World Immunization Week 2021 Toolkit for a series of social media messages, graphics, and videos that highlight key evidence on the many ways that #VaccinesWork to bring us closer.

The VoICE social media toolkit can be downloaded as a PDF and individual graphics and animations can be downloaded from the VoICE Media Library, along with many other free visual resources for immunization advocates.

Vaccines bring us closer to a world where no one suffers or dies from a vaccine-preventable disease.

Every child has the right to be protected from the world deadliest diseases.

In just the last 30 years, child deaths have decreased by over 50%, thanks in large part to vaccines. #VaccinesWork to help protect against more than 20 diseases, from pneumonia to cervical cancer to Ebola.

Find VoICE resources on how #VaccinesWork to keep children in school and protect them from long-term disability and outbreaks.

Over 10 million children around the world still lack access to even a single dose of basic vaccines.

#VaccinesWork to bring us closer to a more equitable world where no one suffers or dies from a vaccine-preventable disease.

Although more children than at any point in history are now protected against vaccine-preventable diseases, millions of zero-dose children are still missing out on the life-saving benefits of immunization entirely. These children often live in the world’s most marginalized communities where inequities are clustered and compounded by poverty, geography, gender, and conflict.

Thanks to vaccines, today billions of people live healthy lives protected from vaccine-preventable diseases like measles and whooping cough. Learn more about how #VaccinesWork to protect millions of children around the world.

“More than any other cancer, cervical cancer reflects striking global health inequity.”

HPV #VaccinesWork to help enhance global equity for women and girls #HPVelimination

Cycle of undernutrition and infectious disease

Malnourished kids suffer the most from pneumonia, diarrhea and other vaccine-preventable infections. #VaccinesWork to help all children get a healthy start! Recurrent disease, severe disease and undernutrition interact to shape the trajectory of a child’s growth and cognitive development in the critical first 1000 days of life with long-term implications. Vaccines are an important component of breaking this vicious cycle.

Investments in vaccines not only help save lives—vaccine programs have a high return on investment (ROI) and produce billions of dollars in economic benefits. Using a Value of a Statistical Life approach to model the value of immunization, vaccine programs returned an estimated US $52 for every $1 invested.

Every US $1 invested in vaccine programs returned an estimated $20 in saved healthcare costs, lost wages, and lost productivity, according to new research from the Decade of Vaccine Economics (DoVE) Project.

The more empowered women are the more likely their children are to be vaccinated. Learn more about how #VaccinesWork for gender equity.

For #WIW2021 VoICE is highlighting the many benefits of immunization:
• Support healthy growth
 Improve education outcomes
• Promote economic stability
• Reduce equity gaps

Learn more about the far-reaching benefits of immunization!

The Value of Vaccines: Investments in Immunization Yield High Returns

Medical professional preparing vaccine shot in-front of children

Vaccines provide incredible value in more ways than one. In addition to saving the lives of millions of children, vaccine programs also provide a high economic return on investment. New research demonstrates the incredible impact and value of vaccination for policymakers.

Key Messages

  • The COVID-19 pandemic has disrupted routine immunization services across the globe. Maintaining pre-pandemic progress in routine immunization programs can save millions of lives and billions of dollars.
  • Every US $1 invested in vaccine programs returned an estimated $20 in saved healthcare costs, lost wages, and lost productivity, according to new research from the Decade of Vaccine Economics (DoVE) Project.
  • Using a Value of a Statistical Life approach to model the value of immunization, vaccine programs returned an estimated US $52 for every $1 invested.
  • Between 2020 – 2030, vaccination programs against 10 pathogens in 98 countries are projected to save 32 million lives, the vast majority (28 million) will be children under 5 years old.

Sustaining Pre-Pandemic Immunization Projected to Save Millions of Lives

A comprehensive study of the impact of vaccination programs, published in The Lancet, estimates that vaccine programs targeting 10 diseases will have saved 69 million lives in 98 low- and middle-income countries (LMICs) between 2000 and 2030. With the COVID-19 pandemic disrupting routine immunization programs across the globe, this research highlights “what might be lost if current vaccination programs are not sustained.” This new analysis provides important evidence demonstrating the value of sustained investment in vaccination coverage, particularly in LMICs.

“In a time when the world desperately awaits a COVID-19 vaccine to help return our lives to normal, this study demonstrates how vaccines have transformed the health of the world, and given 36 million children another chance at life,” said lead study author, Dr. Xiang Li.

The 10 vaccine-preventable diseases included in the analysis were: hepatitis B, Haemophilus influenzae type b (Hib), human papillomavirus (HPV), Japanese encephalitis, measles, meningitis A (Neisseria meningitidis serogroup A), pneumococcal disease (Streptococcus pneumoniae), rotavirus, rubella, and yellow fever.

Key Findings: Lives Saved 2000 – 2019

  • From 2000 through 2019, these 10 vaccines have saved 37 million lives across 98 countries. The vast majority of deaths prevented by these vaccines – 36 million – were children younger than 5 years old.
  • Between 2000 and 2019 vaccination against these 10 common infectious diseases reduced deaths in children under 5 by nearly half (45%). That is, in the absence of vaccination, all-cause mortality among children younger than 5 years would be 45% higher than currently observed.
  • Across 73 Gavi countries, 35 million deaths were averted between 2000 and 2019.
  • Of the ten pathogens included in the analysis, vaccination against measles had the largest impact, with 33 million estimated deaths averted between 2000 – 2019: The equivalent to over 1.6 million deaths averted every year. The analysis projects that vaccination against measles will continue to save even more lives in the next decade (2020 – 2030) with an average of over 2.1 million deaths averted per year.
2000-2019 Cumulative Deaths Averted by 10 vaccines in Children <5 Years
This tool shows the Vaccine Impact Modelling Consortium’s estimates of health impact from vaccination against 10 pathogens in 98 low and middle income countries from 2000 to 2019. Check out to create your own visualizations.

Maintaining Progress: Saving Lives in the Next Decade

Maintaining progress on immunization is essential to preventing millions of unnecessary deaths over the next 10 years, particularly in children under 5. The Lancet study, conducted by the Vaccine Impact Modelling Consortium, predicts that if pre-pandemic immunization progress is sustained over the next decade (2020 – 2030) that vaccines will continue to play a vital role in protecting children across the world, particularly those living in the world’s poorest communities.

  • From 2020 – 2030, these 10 vaccines are projected to save 32 million lives across all ages and 28 million children under age 5.
  • “A child born in 2019 will experience a massive reduction in their risk of dying from these 10 pathogens over their lifetime, with their mortality falling by 72% due to vaccination alone,” explained study author Dr. Katy Gaythorpe.
  • The study also calculated disability-adjusted life years (DALYs) averted by vaccination. One DALY represents the loss of the equivalent of one year of full health. The study estimates that in the next decade (2020 – 2030) vaccines will avert 2.1 billion DALYs across all ages and 1.8 billion DALYs in children younger than 5 years old.

The Economic Benefits of Vaccine Programs far Outweigh Their Costs

Preventing illness through vaccination doesn’t just save lives, it also keeps people out of poverty and provides countries with a high economic return on investment. When children get sick, parents can be burdened with crippling financial costs. These costs can include medical care, transportation for treatment, and lost wages.

Investing in immunization programs in the world’s poorest countries yields a significant return on the initial investment. New research from the Decade of Vaccine Economics (DoVE) project, published in Health Affairs, measured the impact of immunization programs against ten pathogens (Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serotype A, Streptococcus pneumoniae, rotavirus, rubella, and yellow fever) in 94 low- and middle-income countries from 2011 through 2030.

Understanding the DoVE Approach

This new DoVE study modeled the return on investment of immunization programs by using two analytical modeling approaches to capture different aspects of the economic benefits of immunization.

The Cost of Illness approach captures the observable impact of immunization programs on household costs, health care costs, and labor productivity.

The Value of a Statistical Life approach reflects the less tangible costs associated with societies’ willingness to pay for saving lives.

Key Findings: Vaccines are a Smart Investment

  • The economic benefits of vaccine programs far outweigh their costs. With an investment of just a few dollars per child, vaccination can prevent life-threatening illnesses, life-long disability, and medical impoverishment for families.
  • The analysis estimates that from 2011 to 2030 vaccine programs will generate a net benefit of billions of dollars in savings across countries: $1,445.3 billion using the Cost of Illness modeling approach and $3,371.5 billion with the Value of a Statistical Life approach.
  • From 2021 to 2030, every US $1 invested in vaccine programs averted around $20 in healthcare costs, lost caregiver wages and missed work, and lost productivity.
  • Assessing return on investment based on the value societies place on saving lives (a Value of a Statistical Life approach), vaccine programs returned about US $52 for every $1 spent from 2021 to 2030.
  • For comparison, publicly traded American companies in the S&P 500 have returned an average of US $2.16 for every $1 invested after ten years.
  • Across all countries and years included in the analysis, vaccination against measles accounted for the majority of economic benefits (76.4% using the Cost of Illness modeling approach and 58.5% using the Value of a Statistical Life approach modeling approach) generated by vaccine programs.
Vaccine Return On Investment: 2021-2030

Visualizing Immunization Program Costing and Economic Burden

VIEW-hub, a map-based platform for visualizing data on vaccine use and impact, recently released a new interactive module on immunization economics.

The new module displays cost-of-illness and program costing information from recent DoVE publications in interactive maps and informative country profiles.

Want to find more evidence on the return on investment for vaccines? Brows the VoICE Compendium to find advocacy messaging and evidence summaries!

HPV Vaccines: New Momentum in Eliminating Cervical Cancer

Group of girls laughing

In August of 2020, the World Health Assembly adopted the global strategy to accelerate the elimination of cervical cancer as a public health problem. Vaccines against the human papillomavirus (HPV) can prevent the vast majority of the world’s 570,000 annual cases of cervical cancer. Increasing access to the HPV vaccine, as well as screening and treatment, for women and girls living in low- and middle-income countries is an important step for global gender equity, potentially leading to the elimination of cervical cancer within the next 100 years.

HPV Vaccination is a Critical Step Towards Cervical Cancer Elimination

Human papillomavirus (HPV) is a vaccine-preventable infection that causes nearly all cases of cervical cancer. According to the Global Cancer Observatory1, infection with HPV led to an estimated 570,000 cases of cervical cancer and 311,000 cervical cancer deaths worldwide just in 2018.

The overwhelming majority of women impacted by this preventable cancer live in low- and middle-income countries (LMIC). According to a 2020 study2 from The Lancet Global Health, “Approximately 84% of all cervical cancers and 88% of all deaths caused by cervical cancer occurred in lower-resource countries.” Across many regions of Africa, cervical cancer caused by HPV is the leading cause of cancer-related deaths among women.

In August 2020, a global strategy to accelerate the elimination of cervical cancer as a public health problem was adopted by the Member States of the World Health Organization (WHO).

WHO recommends the following targets or milestones that each country should meet by 2030 to be on track to eliminate cervical cancer within the century:

  • 90% of girls fully vaccinated with the HPV vaccine by the age of 15;
  • 70% of women screened using a high-performance test by the age of 35, and again by the age of 45; and
  • 90% of women identified with cervical disease receive treatment.

The results of a 2020 analysis3 from Brisson et al. found that just by meeting HPV vaccination targets, cervical cancer cases could drop by 89% within a century in the 78 countries worst affected by the disease. Meeting targets for cervical cancer screening and treatment would further reduce cervical cancer cases by 97%, averting 72 million cervical cancer cases over the next century.

VIEW-hub: Mapping HPV Vaccine Progress

VIEW-hub is an interactive mapping platform for visualizing up-to-date data on vaccine use and impact. In 2020, VIEW-hub launched a new module on HPV vaccination providing users with updated maps and data tables to track country-level progress for rollout of vaccines.

Through VIEW-hub, users can access and download immunization advocacy resources including global data downloads, maps and country profiles.  For HPV vaccination, VIEW-hub provides data on current program types, current/planned vaccine product, current dosing schedule, current or planned distribution sites and target populations by sex.

Broad Benefits of HPV Vaccine

While HPV is most commonly associated with cervical cancer, this viral infection also can cause a number of other cancers in both men and women. These other cancers include anal, vulvar, vaginal, penile, and head and neck cancers.

Currently, three vaccines are available which offer varying levels of protection against HPV-associated cancers. The vaccines all contain protein particles without live virus but they differ in the number of viral subtypes that are included.  Bivalent (2 subtypes) and quadrivalent (4 subtypes) vaccines are prequalified by the WHO and the third option is a nonavalent (9 subtypes) vaccine that is primarily available in high-income countries. All three vaccines include HPV genotypes 16 and 18, which account for about 70% of cervical cancer cases worldwide. The quadrivalent and nonavalent vaccines further protect by preventing infection with HPV genotypes 6 and 11 which cause anogenital warts. The nonavalent vaccine offers the highest level of protection by including an additional five HPV genotypes.

Enhancing Global Equity for Women and Girls

The vast majority of women and girls who have been protected by receiving an HPV vaccine are based in high-income countries, while the most vulnerable populations with the highest burden in terms of cervical cancer incidence and mortality remain largely unprotected in low-resource settings.

  • Only 1% of the 118 million women and girls included in HPV vaccine programs between 2006 and 2014 were from low- or lower-middle-income countries, according to an analysis from 20164.
  • High initial prices for HPV vaccines have limited access for women in low-income countries: high-income countries comprise only 14% of cervical cancer cases, but almost 70% of women receiving HPV vaccines4.
  • Women from low- and middle-income countries can also face compounded health risks due to high burdens of HIV: rates of cervical cancer are estimated to be four to five times higher among women who are living with HIV compared to HIV-negative women, according to a 2016 UNAIDS report5.

Economic Impacts and Cost-Effectiveness

High prices have been cited as a major barrier limiting HPV vaccine access. Countries that face the greatest challenges in financing HPV vaccines often may have the most to gain from implementing these valuable vaccination programs.

  • 2016 health economics analysis6 of return on investment for vaccines in 94 low- and middle-income countries estimated that HPV vaccines would yield a 3-fold return on investment between 2011 and 2020.
  • 2020 cost-effectiveness analysis7 using the PRIME (Papillomavirus Rapid Interface for Modelling and Economics) tool found that “HPV vaccination provides greater health benefits and is more cost-effective than was previously estimated” and recommended, “The WHO African region is expected to gain the greatest health benefits and should be prioritised for HPV vaccination.”
  • 2020 proof-of-concept health economics framework8 described how HPV vaccination could lead to increased labor participation and economic output, potentially enhancing gender equity for women. “The improvements in economic productivity from years of employment gained by female workers could be approximately $4.7 million in Tanzania, $24 million in India, and $18 million in the United Kingdom (in US$2015).”

Overcoming Low Knowledge and Awareness of HPV Vaccination

One obstacle to increased uptake of HPV vaccination in LMICs is limited public knowledge about cervical cancer, HPV, and the benefits of HPV immunization. Despite current low levels of knowledge about the HPV vaccine, several studies have reported high acceptability and a willingness among women and girls to receive the vaccine for themselves or their daughters.

  • In Bangladesh, a 2018 study9 among ever-married women showed that even with low knowledge of cervical cancer or HPV vaccine, more than 90% of women were willing to receive the HPV vaccine themselves or to have their daughters receive it.
  • In Mozambique, a 2018 study10 among school-aged girls found that while only 33% had heard of HPV, 91% were willing to receive the vaccine.
  • In Haiti, a 2017 study11 presented similar findings from adult women over age 18. Only 27% had heard of HPV and 10% knew of the HPV vaccine but 96% were willing to vaccinate their daughters once they learned about the purpose of the vaccine.
  • Several systematic reviews focused on African and Asian populations have also found that even when knowledge about HPV and the HPV vaccine is low, acceptability of the vaccine was often high. A 2014 systematic review12 of HPV vaccine acceptability in Africa found that across 14 unique studies, acceptability of the HPV vaccine for daughters ranged from 59–100%.

Successful HPV Vaccine Delivery Campaigns

Several key obstacles limit HPV vaccine expansion efforts including inadequate health system capacity, inconsistent vaccine supply, lack of general knowledge about the vaccines, and unique implementation challenges associated with vaccinating older children and adolescents. Innovative approaches for delivering the vaccine to girls in the target age range have shown some promise to advance HPV vaccination.

  • In 2010, Bhutan13 became the first low- or middle-income country to implement a national HPV vaccination program through a school-based delivery model. This program achieved coverage between 90% and 99% in the target populations of school-aged girls.
  • Rwanda’s national HPV vaccination program14 is another example of a successful school-based rollout. This school-based delivery approach was so successful that it was able to obtain 93% coverage among girls in grade six based on completion of a three-dose series.
  • Despite potential gains though successful school-based vaccination programs, it is also important to ensure equitable access to HPV vaccination for girls who are not currently enrolled in or attending school. Girls who represent hard-to-reach populations may be more vulnerable and at higher risk of HPV infection and cervical cancer, particularly if they are human immunodeficiency virus (HIV) positive15.

Meeting Unprecedented Demand

Despite cost barriers, high demand for HPV vaccines in 2018 led to a supply shortage of HPV vaccine due to, “the unprecedented uptake of HPV support in Gavi-eligible countries, combined with increased global demand for HPV vaccines from higher-income countries.”

In June 2020, Gavi announced that five manufacturers were committing to the prioritization of HPV vaccine supply to support Gavi-supported countries.  This commitment will ideally increase the affordability and promote accessibility of the vaccine.

Gavi’s most recent estimate is that up to 84 million girls in the world’s poorest countries could have access to HPV vaccine over the next 5 years which would advance public health by preventing 1.4 million cases of cervical cancer deaths worldwide.


  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018;68(6):394-424. doi:10.3322/caac.21492
  2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. The Lancet Global Health. 2020;8(2):e191-e203. doi:10.1016/S2214-109X(19)30482-6
  3. Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income countries. The Lancet. 2020;395(10224):575-590. doi:10.1016/S0140-6736(20)30068-4
  4. Bruni L, Diaz M, Barrionuevo-Rosas L, et al. Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis. The Lancet Global Health. 2016;4(7):e453-e463. doi:10.1016/S2214-109X(16)30099-7
  5. HPV, HIV and Cervical Cancer: Leveraging Synergies to Save Women’s Lives. UNAIDS; 2016.
  6. Ozawa S, Clark S, Portnoy A, Grewal S, Brenzel L, Walker DG. Return On Investment From Childhood Immunization In Low- And Middle-Income Countries, 2011–20. Health Affairs. 2016;35(2):199-207. doi:10.1377/hlthaff.2015.1086
  7. Abbas KM, van Zandvoort K, Brisson M, Jit M. Effects of updated demography, disability weights, and cervical cancer burden on estimates of human papillomavirus vaccination impact at the global, regional, and national levels: a PRIME modelling study. The Lancet Global Health. 2020;8(4):e536-e544. doi:10.1016/S2214-109X(20)30022-X
  8. Portnoy A, Clark S, Ozawa S, Jit M. The impact of vaccination on gender equity: conceptual framework and human papillomavirus (HPV) vaccine case study. Int J Equity Health. 2020;19(1):10. doi:10.1186/s12939-019-1090-3
  9. Islam JY, Khatun F, Alam A, et al. Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: a population based, cross-sectional study. BMC Women’s Health. 2018;18(1):15. doi:10.1186/s12905-018-0510-7
  10. Bardají A, Mindu C, Augusto OJ, et al. Awareness of cervical cancer and willingness to be vaccinated against human papillomavirus in Mozambican adolescent girls. Papillomavirus Research. 2018;5:156-162. doi:10.1016/j.pvr.2018.04.004
  11. Gichane MW, Calo WA, McCarthy SH, Walmer KA, Boggan JC, Brewer NT. Human Papillomavirus Awareness in Haiti: Preparing for a National HPV Vaccination Program. Journal of Pediatric and Adolescent Gynecology. 2017;30(1):96-101. doi:10.1016/j.jpag.2016.07.003
  12. Cunningham MS, Davison C, Aronson KJ. HPV vaccine acceptability in Africa: A systematic review. Preventive Medicine. 2014;69:274-279. doi:10.1016/j.ypmed.2014.08.035
  13. Dorji T, Tshomo U, Phuntsho S, et al. Introduction of a National HPV vaccination program into Bhutan. Vaccine. 2015;33(31):3726-3730. doi:10.1016/j.vaccine.2015.05.078
  14. Binagwaho A, Wagner C, Gatera M, Karema C, Nutt C, Ngaboa F. Achieving high coverage in Rwanda’s national human papillomavirus vaccination programme. Bull World Health Org. 2012;90(8):623-628. doi:10.2471/BLT.11.097253
  15. Scaling-up HPV Vaccine Introduction. World Health Organization; 2016. Accessed August 20, 2020.

Equity and Immunization: Shrinking the Gaps

Although more children than at any point in history are now protected against vaccine-preventable diseases, millions of zero-dose children are still missing out on the life-saving benefits of immunization entirely. These children often live in the world’s most marginalized communities where inequities are clustered and compounded by poverty, geography, gender, and conflict. In order to keep making progress against preventable deaths and illness, leaders will need to integrate equity across global, national, and sub-national immunization strategies.

Key Messages

  • Health inequities are “the unjust differences in health between persons of different social groups, and can be linked to forms of disadvantage such as poverty, discrimination and lack of access to services or goods,” as defined in the WHO Handbook on Health Inequality Monitoring.
  • Both between and within countries, vaccine coverage is often distributed unequally across populations – those in the highest socioeconomic status groups and those with the most education often have the highest immunization rates while marginalized populations, those living in poverty, and those with lower education have the least access to immunization.
  • Improving equitable access to vaccines aligns with achieving the Sustainable Development Goals.
  • Prioritizing equity requires multisectoral strategies designed to reach communities that have previously been excluded from access to health services based on geography, educational status, and sociocultural group.

Compounded Vulnerability

Record numbers of children are protected from preventable illnesses thanks to immunization, yet millions of children, often the poorest and most vulnerable, continue to be left behind. Vaccine-preventable diseases disproportionately affect those who experience both poor overall health and low economic standing; the children who miss out on life-saving vaccines are often those in the poorest households and the most remote locations, and whose families lack access to clean water, education, and adequate nutrition.

Over 13 million ‘zero-dose’ children have never received any vaccines at all, based on a 2019 analysis from UNICEF. These children and their families already experience a disproportionate burden of vaccine-preventable illnesses like measles, diphtheria, and polio. With life-saving immunization services around the world disrupted by the COVID-19 pandemic, these children are at even great risk from disastrous outbreaks of vaccine-preventable illnesses.

On June 4th, 2020 the Global Vaccine Summit will aim to raise at least $7.4 billion for Gavi, the Vaccine Alliance. This funding will help support the mass vaccination campaigns and rebuilding of health systems needed over the coming years to help address the damage done by the COVID-19 pandemic. Gavi’s strategic plan for 2021-2025 prioritizes immunization equity and the need to reach the communities that have missed out on previous immunization efforts, especially those most marginalized by poverty, geography, and conflict.

Combating inequities in health and wealth through immunization

Evidence has shown that vaccines have the greatest health and economic benefit amongst the poor. Globally, the poorest populations often experience the worst impacts of vaccine-preventable diseases, both in terms of health burdens in illness and death as well as carrying potentially crushing costs associated with medical care, missed work, and lasting disability.

Research shows that vaccines are one tool that can help break the pernicious cycle of poverty and ill health, improving equity across both health and wealth. By preventing disease, vaccination also prevents the costs associated with medical treatment and thus helps to reduce the likelihood that households will fall into or remain in poverty.

  • 2018 modeling study of the economic impact of 10 childhood immunizations in 41 low- and middle-income countries found that with the lowest income households received the greatest financial risk protection from costs of measles, pneumococcal disease, and rotavirus. The authors conclude that: “Including equity components into economic evaluations will allow policy makers to opt for interventions that target specifically the most vulnerable populations.”
  • 2015 study from Ethiopia looking at the impact of pneumococcal vaccine introduction in Ethiopia found that 30-40% of all deaths averted would be expected to occur in the poorest wealth quintile. The greatest resulting financial risk protection would also be concentrated among the lowest income quintile.
  • 2018 cost-effectiveness analysis found that expanding rotavirus vaccination coverage among the poorest and most vulnerable populations of children would substantially increase the overall impact of rotavirus immunization in Pakistan; children in the poorest households would experience a three to four times greater mortality reduction benefit compared to children in the richest households.

Empowering and educating women can lead to greater rates of vaccination among children

Although girls and boys are immunized at similar rates globally, barriers that inhibit women’s ability to access healthcare and immunizations for their children may still exist at subnational levels and across different populations. Research in several LMIC contexts has found that access to education, particularly for women and girls, is often strongly associated with higher rates of immunization in children.

Figure 1. Brinda, E.M., Rajkumar, A.P. & Enemark, U. Association between gender inequality index and child mortality rates: a cross-national study of 138 countries. BMC Public Health 15, 97 (2015).
  • 2015 ecological study of 138 countries found that greater gender inequality was significantly correlated with lower immunization coverage and higher neonatal, infant, and under-5 mortality.
  • 2018 study in Nigeria found a robust association with maternal education and immunization coverage for children at both the individual and at the community levels. The researchers concluded that maternal education had a spillover effect that benefited immunization rates of all community members, not only a mother’s own children. This suggests that even children of uneducated mothers can benefit from the education of women in the community overall.
  • 2017 systematic analysis of equity in vaccine coverage across 45 low- and middle-income countries found that maternal education is a strong predictor of child vaccine coverage. Children of the least educated mothers were 55% less likely to have received measles vaccine and three doses of DTP vaccine compared to children of the most educated mothers.
  • 2015 review of health equity and disparities data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys conducted in 70 developing countries found that “with respect to immunization, the greatest disparity exists for children born to women with no education compared with those born to women with secondary (or higher) education.” The global coverage of the third dose of DTP is 26% higher among children born to mothers with some secondary education compared to mothers with no education.

Geography and Sociocultural inequities and the immunization gap

Where a child is born often dictates their access to health resources like vaccines. Despite improvements in vaccination rates at the national level, local level disparities continue to persist. This means that children born in remote, rural, or urban slum settings may have significantly less access to immunization compared to their peers born in urbanized settings near health facilities. Inequities also exist for marginalized populations and minority groups who may have restricted access to health services such as immunizations. Conflict and migration are additional factors that threaten access to immunization for many children and their families.

These inequities in vaccination rates—often concealed in national averages—call for special efforts to improve immunization rates in this rapidly growing sub-population to reduce both health inequities and the risk of infectious disease outbreaks in the wider society.

Restrepo-Méndez, María Clara, Barros, Aluísio JD, Wong, Kerry LM, Johnson, Hope L, Pariyo, George. et al. (‎2016)‎. Inequalities in full immunization coverage: Trends in low- and middle-income countries. Bulletin of the World Health Organization, 94 (‎11)‎, 794 – 805B. World Health Organization.
  • 2015 immunization equity review found that globally, coverage of the third dose of DTP among 1-year-olds is 8% higher among urban dwellers compared to children living in rural environments.
  • Children from families that have migrated from other parts of the country have less access to health services and lower vaccination rates compared to the general population. According to a 2016 systematic review and meta-analysis, children who are rural-urban migrants in China, India, and Nigeria were less likely to be fully immunized by the age of one year than non-migrant urban residents and the general population.
  • 2019 study in New Zealand found that the use of pneumonia conjugate vaccines (PCV) appears associated with reductions in ethnic and socioeconomic disparities in invasive pneumococcal disease (IPD), all-cause pneumonia (ACP), and otitis media hospitalization among Māori and Pacific children. Following the introduction of conjugate vaccines in the country, Maori and Pacific children’s rates of admission for IPD dropped by 79% and 67%, respectively.
  • 2019 study examining immunization rates in urban and rural populations in Tanzania found that wealth and mother’s education were significant predictors of vaccination rates in both urban and rural settings. However, low paternal education, lack of antenatal care, and home births were significantly associated with low vaccination rates only in rural settings, suggesting a need for tailored vaccine programs.
  • The results of a 2016 cross-sectional polio serosurvey found that the Jordan Ministry of Health’s proactive campaign to locate and vaccinate high-risk populations has been successful in maintaining high population immunity—even with a recent influx of refugees from Syria. The study included a community sample of 479 children under 5 years old living in areas of Jordan identified as high risk due to being hard-to-reach, having high numbers of refugees, and lower vaccine coverage (under 90%).