The Power of a Single Dose: Evidence for a Single-Dose HPV Vaccine Schedule 

HPV Vaccination: A Critical Cancer Prevention Tool 

Since 2006, vaccines have been available to protect against human papillomavirus (HPV), an extremely common infection that causes virtually all cases of cervical cancer – the fourth most common cancer in women globally – and is also a known cause of several other types of cancer that impact both men and women [1]. In most instances, the immune system can clear HPV without any need for treatment, but persistent infection with high-risk strains of HPV can lead to several types of cancer [2]. This leads to stark disparities in cancer burden for women living with HIV, whose compromised immune systems may not clear HPV infections as readily; these women are six times more likely to develop cervical cancer [3]. Geographical disparities in cervical cancer burden also persist. In 2020, more than 600,000 women around the world were diagnosed with cervical cancer, with up to 90% of new global cases occurring in low- and middle-income countries (LMICs) and the majority of cancer cases and deaths concentrated in sub-Saharan Africa, Central America, and Southeast Asia [2]. To address these inequities and reduce global disease burden, the World Health Organization (WHO) has committed to a global strategy to accelerate the elimination of cervical cancer as a public health problem. Along with screening and treatment, HPV vaccination is a key cornerstone of this strategy–by 2030, WHO aims to vaccinate 90% of girls against HPV by the age of 15 [4]. 

Although this is an ambitious goal, new evidence-based recommendations from WHO may contribute to increased HPV vaccination coverage, especially where it is needed most. WHO had previously recommended a two-dose schedule for HPV vaccines, but an off-label recommendation for a one-dose schedule was added in December 2022 based on recent efficacy data from single-dose trials [5]. The latest guidance recommends a one or two-dose schedule for girls aged 9–14 as well as those between 15–20-years old, with girls older than 21 and those who are immunocompromised or living with HIV recommended to receive a third dose. This change is expected to have important programmatic and financial implications for HPV vaccination programs, particularly in LMIC settings. Further, a single-dose schedule could be an important tool to improve health equity and reduce disparities in HPV-related cancers, protecting all girls everywhere against this preventable disease.  

Evidence for a Single-Dose HPV Schedule  

A number of rigorous studies have been conducted to determine the efficacy and immunogenicity of a single-dose regimen of HPV vaccines. Researchers have concluded that a single dose of HPV vaccine provides high levels of protection against high-risk strains of HPV, even several years after vaccination, and induces a robust immune response.  

  • In a randomized trial in Kenya (KEN SHE), a single-dose of HPV vaccine was found to be 97.5% effective in preventing cancer-causing strains of HPV among 15–20-year-old girls [6].  Researchers examined the efficacy of single-dose bivalent (a single shot that can protect against two strains of a virus) and nonavalent HPV vaccines (a single shot that can protect against nine strains of a virus) among 15–20-year-old girls. After 18 months of follow-up, both the bivalent and nonavalent vaccines demonstrated 97.5% vaccine efficacy against high-risk strains of HPV. Researchers subsequently published results demonstrating similar vaccine efficacy three years following vaccination: bivalent vaccine efficacy remained at 97.5% (95% CI 90.0–99.4%), while nonavalent vaccine efficacy was 98.8% (CI 91.3–99.8%) [7].  
  • In a Costa Rican study (CVT), a single dose of HPV vaccine was found to provide a similar level of protection (82.1%) against high-risk strains of HPV as two or three doses (83.8% and 80.2%, respectively), even 11 years following vaccination [8]. Researchers examined the dose-specific vaccine efficacy of the bivalent HPV vaccine among 18–25-year-old women and determined that vaccine efficacy against high-risk strains of HPV was high, regardless of the number of doses received. Protection persisted for approximately 11 years following initial vaccination. Vaccine efficacy was 80.2% (95% CI = 70.7% – 87.0%) for three doses, 83.8% (95% CI = 19.5% – 99.2%) for two doses, and 82.1% (95% CI = 40.2% to 97.0%) for a single dose, with no statistically significant differences in either vaccine efficacy or infection rates across the three groups.  
  • A cohort study in India (IARC India) found that the protection provided by a single dose of HPV vaccine was comparable to that provided by two or three doses, even 10 years after vaccination [9]. Researchers compared the vaccine efficacy of a single dose of quadrivalent HPV vaccine to two and three doses in protecting against high-risk HPV strains. After 10 years of following the cohort of women, there were no significant differences in the frequency of incident HPV infection among adolescent women who received one, two, or three doses of HPV vaccine. The vaccine efficacy of a single dose was found to be 95.4% (95% CI 85.0 – 99.0), which did not differ significantly from the efficacy of two or three doses.   
  • In Tanzania, a randomized trial among 9–14-year-old girls (DoRIS) found that two years after vaccination, a single dose of HPV vaccine produced a non-inferior immune response for a high-risk strain of HPV compared to two or three doses [10]. Researchers examined the immune response two years after vaccination with a single dose of HPV vaccine.  Compared to two or three doses, a single dose of either bivalent or nonavalent HPV vaccine produced non-inferior levels of antibodies against HPV 16. Although non-inferiority was not met for HPV 18 antibodies, at least 98% of girls who received a single dose of HPV vaccine were seropositive for these antibodies two years following vaccination.   

Moving to a Single Dose Schedule – Why it Matters  

Compared to many of the routine immunizations given to infants and adolescents, HPV vaccination presents unique programmatic, financial, and logistical challenges, many of which could potentially be addressed by the use of a single-dose vaccination schedule.  

Countries’ limited immunization budgets have put HPV vaccine introduction in direct competition with the introduction of several other life-saving vaccines, including pneumococcal conjugate vaccines and rotavirus vaccines [11]. Compared to a two-dose schedule, a single-dose schedule for HPV vaccines would significantly reduce procurement and delivery costs [11]. For example, an economic study in Tanzania estimated that compared to a two-dose HPV vaccination schedule, a single-dose schedule would reduce the cost per fully vaccinated girl by 51%, accounting for all financial costs including injection supplies, training, and outreach activities [12]. These cost savings could potentially stretch immunization budgets further, allowing countries to protect more girls against HPV and cervical cancer. Additional cost savings may be seen in reduced cold chain requirements, as fewer doses would require countries to purchase fewer refrigerators, for example [13]. 

Although countries are well-versed in delivering vaccines to children under 5, vaccines targeting older children are more difficult to integrate into existing immunization programs. A single dose of HPV vaccine could be delivered once per year during child health weeks or annual vaccination events, eliminating the need for follow-up and simplifying delivery to this hard-to-reach population [11].  

Additional Resources 

The resources below provide additional information about HPV vaccination and the evidence for a single-dose schedule. 


1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249. doi:10.3322/caac.21660 
2. Cervical Cancer. World Health Organization. Updated 17 November 2023. Accessed 25 January 2024. 
3. Stelzle D, Tanaka LF, Lee KK, et al. Estimates of the global burden of cervical cancer associated with HIV [published correction appears in Lancet Glob Health. 2021 Feb;9(2):e119]. Lancet Glob Health. 2021;9(2):e161-e169. doi:10.1016/S2214-109X(20)30459-9 
4. Global strategy to accelerate the elimination of cervical cancer as a public health problem. Geneva: World Health Organization; 2020 
5. World Health Organization. Human papillomavirus vaccines: WHO position paper (2022 update) Weekly Epidemiological Record. 16 Dec 2022, No 50, 97, 645-672. 
6. Barnabas RV, Brown ER, Onono M, et al. Single-dose HPV vaccination efficacy among adolescent girls and young women in Kenya (the KEN SHE Study): study protocol for a randomized controlled trial. Trials. 2021;22(1):661. Published 2021 Sep 27. doi:10.1186/s13063-021-05608-8 
7. Barnabas RV, Brown ER, Onono MA, et al. Durability of single-dose HPV vaccination in young Kenyan women: randomized controlled trial 3-year results. Nat Med. 2023;29(12):3224-3232. doi:10.1038/s41591-023-02658-0 
8. Kreimer AR, Sampson JN, Porras C, et al. Evaluation of Durability of a Single Dose of the Bivalent HPV Vaccine: The CVT Trial. J Natl Cancer Inst. 2020;112(10):1038-1046. doi:10.1093/jnci/djaa011 
9. Basu P, Malvi SG, Joshi S, et al. Vaccine efficacy against persistent human papillomavirus (HPV) 16/18 infection at 10 years after one, two, and three doses of quadrivalent HPV vaccine in girls in India: a multicentre, prospective, cohort study [published correction appears in Lancet Oncol. 2022 Jan;23(1):e16]. Lancet Oncol. 2021;22(11):1518-1529. doi:10.1016/S1470-2045(21)00453-8 
10. Watson-Jones D, Changalucha J, Whitworth H, et al. Immunogenicity and safety of one-dose human papillomavirus vaccine compared with two or three doses in Tanzanian girls (DoRIS): an open-label, randomised, non-inferiority trial. Lancet Glob Health. 2022;10(10):e1473-e1484. doi:10.1016/S2214-109X(22)00309-6 
11. Gallagher KE, LaMontagne DS, Watson-Jones D. Status of HPV vaccine introduction and barriers to country uptake. Vaccine. 2018;36(32 Pt A):4761-4767. doi:10.1016/j.vaccine.2018.02.003 
12. Hsiao A, Struckmann V, Stephani V, et al. Costs of delivering human papillomavirus vaccination using a one- or two-dose strategy in Tanzania. Vaccine. 2023;41(2):372-379. doi:10.1016/j.vaccine.2022.11.032 
13. Gallagher KE, Kelly H, Cocks N, et al. Vaccine programme stakeholder perspectives on a hypothetical single-dose human papillomavirus (HPV) vaccine schedule in low and middle-income countries. Papillomavirus Res. 2018;6:33-40. doi:10.1016/j.pvr.2018.10.004 

A Warming World Means Vaccination is More Important Than Ever

“The climate crisis threatens to undo the last fifty years of progress in development, global health, and poverty reduction, and to further widen existing health inequalities between and within populations.”1

With July 2023 confirmed as the hottest month on record2, the impacts of climate change are becoming impossible to ignore. In addition to rising temperatures, climate change is also responsible for increasingly frequent extreme weather events like intense storms, catastrophic floods, and record-breaking heat waves. A growing body of evidence suggests that the consequences of climate change pose a major threat not only to the planet, but also to human health.

Altogether, climate change is expected to cause around 250,000 excess deaths per year between 2030 and 2050 due to malnutrition, malaria, diarrhea, and heat stress alone1. In addition to the excess mortality that is directly attributable to natural disasters, the wide-ranging effects of climate change can also indirectly contribute to illness and death through several pathways. Warm, dry conditions trigger more frequent wildfires3, which in turn contribute to dangerous levels of air pollution4. The stress of living through an extreme weather event and the resulting loss of critical resources has been linked with poor mental health5. Furthermore, climate change is expected to increase the prevalence of several vaccine-preventable diseases, such as malaria, cholera, and typhoid, thanks to the expansion of mosquito habitats, scarcity of clean water, and disruptions to routine immunization, among others6.

No one is safe from the effects of climate change, but its impact reflects deep inequities. Already marginalized communities – particularly those in developing countries – will be disproportionately affected due to existing health disparities and insufficient health system infrastructure7. To minimize climate change-related health impacts, equitable access to vaccines must be a priority, especially for those who will be most affected in the years to come.

Rising Temperatures Increase Disease Transmission

In August 2023, global temperatures were approximately 1.5°C above preindustrial levels8. In addition to the illnesses and deaths caused directly by these dangerously high temperatures, such as those related to heat stroke9, collateral effects also include increased transmission of a number of vaccine-preventable diseases.

Warmer winters and hotter summers are expected to increase the evaporation of water sources, endangering the availability of safe, clean water and increasing the risk of diarrheal diseases10. This includes cholera, which has recently seen a global surge: The WHO reported 472,697 cases of cholera in 2022, nearly double the number reported in 202111. Rising temperatures reduce the availability of high-quality crops12, threatening food security and leading to dangerous malnutrition that weakens a child’s immune system and increases the risk of infectious disease.

Undernourished child cycle
Source: The Value of Immunization Compendium of Evidence – The vicious cycle of undernutrition and infectious disease: How does it work and what role do vaccines play?

An analysis of 14 countries in sub-Saharan Africa13 demonstrated that for every 1°C increase in average maximum temperature, the prevalence of diarrhea increased by about 1%. The reasons for this association are not entirely clear, but researchers point to the impact of heat on the growth and survival of diarrhea-causing bacteria, as well as the potential for heat-related changes in hygiene or food storage. This increase in disease burden may significantly impact vulnerable populations, especially young children, as diarrhea is currently the second most deadly infectious disease worldwide and kills over 480,000 children under 5 each year14. We already have the means to prevent rotavirus infection, the leading cause of diarrhea-related mortality among children around the world – a 2018 analysis estimated that if 100% of children globally had access to rotavirus vaccination, more than 83,000 child deaths could be prevented in a single year15 – yet millions of children around the world are still unprotected against this disease16. As global temperatures continue to rise, efforts to increase access to lifesaving rotavirus vaccines will remain critical.

Rising Temperatures graph

Temperature changes are also expected to impact transmission of vector-borne diseases, including malaria. About 80% of the world’s population lives in a region that is at risk of at least one vector-borne disease17, and this number could grow as temperatures continue to rise. The malaria parasite develops more quickly at higher temperatures, increasing the chance that a mosquito will survive long enough to transmit the disease18. Additionally, areas that are presently too cold for malaria transmission may warm up enough to allow malaria parasites to survive, exposing new populations to this deadly disease. One recent analysis estimated that around 1.4 billion additional people will be at risk of malaria and dengue in urban areas in Africa and southeast Asia due to changes in climate19. On the other hand, areas where malaria is currently being transmitted may become too warm, which could actually decrease incidence of the disease. Controlling malaria is already complex, but additional climate-related factors such as temperature, rainfall, and humidity may be important considerations for preventing outbreaks.

The Dangerous Consequences of Floods and Droughts

“Climate change is exacerbating both water scarcity and water-related hazards (such as floods and droughts), as rising temperatures disrupt precipitation patterns and the entire water cycle.”20

Between 2001–2018, nearly two-thirds of natural disasters were water-related21, and floods and droughts are only expected to become more intense and more frequent as climate change worsens. These events threaten the availability of safe drinking water and can increase transmission of enteric diseases. For example, both droughts and floods have been found to be significantly associated with cholera outbreaks in sub-Saharan Africa22; in this region, a cholera outbreak can be expected in 1 out of every 3 droughts. During a drought, communities searching for water can be forcibly displaced, often to overcrowded refugee camps with poor sanitation and limited access to cooking tools, increasing the risk of contamination and disease transmission.

Conversely, floodwater can overflow sewage systems and contaminate drinking water23. This contaminated water can also destroy WASH facilities, further putting communities at risk of disease transmission. Additionally, the heavy rainfall and stagnant water associated with flooding can create new mosquito habitats and increase breeding. In 2007, for example, areas in China impacted by flooding saw significantly higher numbers of cases of both malaria and diarrhea than non-flood-affected areas24. Lastly, floods and other disasters can seriously disrupt the delivery of health services, including vaccination25. Not only can flood water damage hospitals and health clinics, making it difficult or even impossible to provide routine immunization services, but it can also block roads, potentially leading to supply chain gaps that can impact the availability of vaccines and other critical medical supplies.

Infographic showing links between flooding, enteric disease, new mosquito habitats and damage to health facilities

Disproportionate Impact to Disadvantaged Populations

Every year, approximately 21.5 million people around the world26 are forced to leave their homes due to climate-related disasters like floods, storms, wildfires, and extreme temperatures, and this number is only expected to continue growing27. These individuals are often referred to as “climate refugees”, though this includes those internally displaced within their own countries as well as those pushed across borders to seek safety. Climate-related displacement disproportionately impacts those living in low-resource settings, who are less able to prepare for and withstand natural disasters. Even within low- and middle-income countries (LMICs), climate change is more likely to impact those who are already most deprived. According to an analysis in Pakistan, the regions with worse socioeconomic conditions are also the most vulnerable to climate change28. The same analysis also found that some regions which should be most exposed to climate change due to their precipitation and temperature patterns are actually less vulnerable, most likely because their populations have higher socioeconomic status and thus a higher capacity to adapt, suggesting that strengthening a community’s resilience is one potential solution to fight the impacts of climate change.

In addition to equity considerations, forced migration can also lead to increased risks of vaccine-preventable disease outbreaks. Disruption to health services, malnutrition, overcrowded settlements, and insufficient sanitation resources all contribute to infectious diseases, such as pneumonia and diarrhea, which are the leading causes of death during humanitarian emergencies29. Vaccination programs that target measles, S. pneumoniae, H. influenzae type-b, and rotavirus have already been recognized as critical tools for reducing the health impacts of complex humanitarian emergencies.

Mitigating the Impact of Climate Change with Vaccines

At this point, the impact of climate change is inevitable, but there are steps we can take to mitigate its effects on human health. We must strengthen efforts to increase access to vaccines for diseases that will become more prevalent as extreme weather events continue, prioritizing disadvantaged communities that will be hardest hit by climate-related disasters. Beyond vaccine introduction, we must work to make sure that adequate supplies are made available to those who need them most. For example, millions of doses of life-saving malaria vaccines30 are being rolled out in Africa over the next two years, but there is still significant work to be done to meet the global demand for these vaccines and to ensure that LMICs can afford them31. Similarly, the global supply of oral cholera vaccine (OCV) is currently unable to meet the needs of more and more frequent cholera outbreaks and must be allocated equitably32.

Over the last decade, enormous victories have been won in protecting children from preventable illnesses. As climate change has been recognized as a serious threat to public health, policymakers must take decisive action now to safeguard vulnerable populations from potentially catastrophic infectious diseases and counteract immunization backsliding.

Additional Reading

Will the Earth’s changing climate make TB spread faster? [Bhekisisa Centre for Health Journalism]

Children displaced in a changing climate: Preparing for a future that’s already underway [UNICEF]

Vaccines for a sustainable planet [Science Translational Medicine]


  1. World Health Organization. Climate change and health. Updated 30 October 2021. Accessed September 28, 2023.
  2. World Meteorological Organization. July 2023 confirmed as hottest month on record. 14 August 2023.
  3. National Oceanic and Atmospheric Administration. Wildfire climate connection. Updated 24 July 2023. Accessed September 28, 2023.
  4. World Health Organization. Wildfires. Accessed September 28, 2023.
  5. Cianconi P, Betro S, Janiri L. The Impact of Climate Change on Mental Health: A Systematic Descriptive Review. Frontiers in Psychiatry. Mar 6 2020;11(74). doi:10.3389/fpsyt.2020.00074
  6. Joi P. Five key links between climate change and health. VaccinesWork blog. 2023.
  7. Byers E, Gidden M, Leclere D, et al. Global exposure and vulnerability to multi-sector development and climate change hotspots. Environmental Research Letters. 31 May 2018. doi:10.1088/1748-9326/aabf45
  8. World Meteorological Organization. Earth had hottest three-month period on record, with unprecedented sea surface temperatures and much extreme weather. 6 September 2023, 2023.
  9. World Health Organization. Heatwaves. Accessed September 28, 2023.
  10. International Federation of Red Cross and Red Crescent Societies, 2021. Climate Change Impacts on Health: Malawi Assessment. April 2021.
  11. World Health Organization. Weekly Epidemiological Record. Vol. 38. 2023:431-452. 22 September 2023.
  12. Zhao C, Liu B, Piao S, et al. Temperature increase reduces global yields of major crops in four independent estimates. Proceedings of the National Academy of Sciences. 2017;114(35):9326-9331. doi:10.1073/pnas.1701762114
  13. Bandyopadhyay S, Kanji S, Wang L. The impact of rainfall and temperature variation on diarrheal prevalence in Sub-Saharan Africa. Applied Geography. April 2012;33:63-72. doi:10.1016/j.apgeog.2011.07.017
  14. International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. (2022). Pneumonia and Diarrhea Progress Report 2022.
  15. Troeger C, Khalil IA, Rao PC, et al. (2018). Rotavirus vaccination and the global burden of rotavirus diarrhea among children younger than 5 years. JAMA Pediatrics. Oct 2018;172(10). doi: 10.1001/jamapediatrics.2018.1960
  16. International Vaccine Access Center (IVAC), Johns Hopkins Bloomberg School of Public Health. VIEW-hub. Accessed 10/19/2023.
  17. Alonso P, Engels D, Reeder J. Renewed push to strengthen vector control globally. The Lancet. June 10 2017;389(10086):2270-2271. doi:10.1016/S0140-6736(17)31376-4
  18. Agyekum T, Botwe P, Arko-Mensah J, et al. A Systematic Review of the Effects of Temperature on Anopheles Mosquito Development and Survival: Implications for Malaria Control in a Future Warmer Climate. International Journal of Environmental Research and Public Health. 7 July 2021;18(14).doi:10.3390/ijerph18147255
  19. Colon-Gonzalez FJ, Sewe MO, Tompkins AM, et al. Projecting the risk of mosquito-borne diseases in a warmer and more populated world: a multi-model, multi-scenario intercomparison modelling study. The Lancet Planetary Health. July 2021;5(7):E404-E414. doi:10.1016/S2542-5196(21)00132-7
  20. United Nations. Water – at the center of the climate crisis. Accessed September 28, 2023.
  21. UNICEF. Water and the global climate crisis: 10 things you should know. Updated 2 March 2023.
  22. Rieckmann A, Tamason CC, Gurley ES, et al. Exploring Droughts and Floods and Their Association with Cholera Outbreaks in Sub-Saharan Africa: A Register-Based Ecological Study from 1990 to 2010. The American Journal of Tropical Medicine and Hygiene. 2018;98(5):1269-1274. doi:10.4269/ajtmh.17-0778
  23. ten Veldhuis JAE, Clemens FHL, Sterk G, et al. Microbial risks associated with exposure to pathogens in contaminated urban flood water. Water Research. May 2010;44(9):2910-2918. doi:10.1016/j.watres.2010.02.009
  24. Gao L, Zhang Y, Ding G, et al. Identifying Flood-Related Infectious Diseases in Anhui Province, China: A Spatial and Temporal Analysis. The American Journal of Tropical Medicine and Hygiene. 2016;94(4):741-749. doi:10.4269/ajtmh.15-0338
  25. Pradhan NA, Najmi R, Fatmi Z. District health systems capacity to maintain healthcare service delivery in Pakistan during floods: A qualitative study. International Journal of Disaster Risk Reduction. August 2022;78. doi:10.1016/j.ijdrr.2022.103092
  26. UNHCR. Frequently asked questions on climate change and disaster displacement. Updated 6 November 2016. Accessed September 28, 2023.
  27. Institute for Economics & Peace. Over one billion people at threat of being displaced by 2050 due to environmental change, conflict and civil unrest. September 9, 2020.
  28. Malik SM, Awan H, Khan N. Mapping vulnerability to climate change and its repercussions on human health in Pakistan. Globalization and Health. 2012;8(31). doi:10.1186/1744-8603-8-31
  29. Close RM, Pearson C, Cohn J. Vaccine-preventable disease and the under-utilization of immunizations in complex humanitarian emergencies. Vaccine. 2016;34(39):4649-4655. doi:10.1016/j.vaccine.2016.08.025
  30. World Health Organization. 18 million doses of first-ever malaria vaccine allocated to 12 African countries for 2023–2025: Gavi, WHO and UNICEF. 5 July 2023.–gavi–who-and-unicef
  31. Gavi, the Vaccine Alliance. Gavi outlines plans to build sustainable supply of malaria vaccines. 25 April 2023.
  32. Gavi, the Vaccine Alliance. Global vaccine alliance outlines path to sustainable cholera vaccine supply. 22 May 2023.

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
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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!