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. 2021 Aug 7;398(10299):503-521.
doi: 10.1016/S0140-6736(21)00984-3. Epub 2021 Jul 21.

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

GBD 2020, Release 1, Vaccine Coverage Collaborators
Collaborators

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

GBD 2020, Release 1, Vaccine Coverage Collaborators. Lancet. .

Abstract

Background: Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time.

Methods: For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development.

Findings: By 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4-82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5-42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4-41·3] in 1980 to 83·6% [82·3-84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4-44·1) in 1980 to 79·8% (78·4-81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6-60·9) to 14·5 million (13·4-15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019.

Interpretation: After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests Quique Bassat reports participation on a data safety monitoring board (DSMB) or advisory board as a member of the Independent Data Monitoring Committee for Respiratory Syncytial Virus vaccine development for the protection of infants (since October, 2015) (GlaxoSmithKline [GSK]) and as DSMB chair for the research project “Phase IV study to evaluate the effectiveness of the inactivated adsorbed vaccine against COVID-19 CoronaVac, among public safety and education workers with risk factors for severity, in Manaus (Amazonas)” outside the submitted work. Sonu Bhaskar reports a leadership or fiduciary role in other board, society, committee or advocacy groups, unpaid with the Rotary Club of Sydney Board of Directors, outside the submitted work. Irina Filip reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Avicenna Medical and Clinical Research Institute, outside the submitted work. Bradford D Gessner reports participation on a DSMB or advisory board at Sanofi Pasteur with participation on a dengue vaccine and general immunisation advisory board that included honoraria; stock or stock options in Pfizer; and other financial or non-financial interests as an employee of Pfizer, all outside the submitted work. Sheikh Mohammed Shariful Islam reports grants or contracts from the National Health and Medical Research Council (NHMRC) and National Heart Foundation of Australia, outside the submitted work. Nicholas J Kassebaum reports grant support for the present manuscript from the Bill & Melinda Gates Foundation; support for attending meetings or travel support, or both, to the Gates Grand Challenges and Group B Strep Vaccine meeting from the Bill & Melinda Gates Foundation; and travel support to the Group B Strep Vaccine meeting from WHO, outside the submitted work. Philippa C Matthews reports grants or contracts from the Wellcome Intermediate Fellowship (Ref 110110Z/15/Z) and the BRC Fellowship NIHR British Research Council (Oxford) senior fellowship, outside the submitted work. Jonathan F Mosser reports support for the present manuscript from the Bill & Melinda Gates Foundation; and support for attending meetings or travel support, or both, from the Bill & Melinda Gates Foundation, outside the submitted work. Maarten J Postma reports grants and personal fees from MSD, GSK, Pfizer, Boehringer Ingelheim, Novavax, BMS, Astra Zeneca, Sanofi, IQVIA, and Seqirus; personal fees from Quintiles, Novartis, and Pharmerit; grants from Bayer, DIKTI, LPDP, Budi, WHO, Antilope, FIND, EU, and BioMerieux; stock ownership in Health-Ecore, and PAG; and is an adviser to Asc Academics, outside the submitted work. Amir Radfar reports payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from the Avicenna Medical and Clinical Research Institute, outside the submitted work. Alyssa N Sbarra reports support for the present manuscript from the Bill & Melinda Gates Foundation; direct consultancy fees from the Pan American Health Organization for a short-term consulting project from January to December, 2018; and support for attending meetings or travel support, or both, from the Bill & Melinda Gates Foundation for costs of travel (September, 2019, and April, 2018) and reimbursements (August, 2019). Jasvinder A Singh reports consulting fees from Crealta/Horizon, Medisys, Fidia, Two Labs, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, FocusForward, Navigant Consulting, Spherix, MedIQ, UBM, Trio Health, Medscape, WebMD, and Practice Point communications; and the National Institutes of Health and the American College of Rheumatology; payment or honoraria for lectures, presentations, speakers' bureaus, manuscript writing, or educational events from Simply Speaking; support for attending meetings or travel support, or both, from OMERACT, an international organisation that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, when travelling bi-annually to OMERACT meetings; participation on a DSMB or advisory board as a US Food and Drug Administration (FDA) Arthritis Advisory Committee member; a leadership or fiduciary role in other board, society, committee, or advocacy groups, paid or unpaid, with OMERACT as a member of the steering committee, with the Veterans Affairs Rheumatology Field Advisory Committee as a member, and with the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis as a director and editor; and stock or stock options in TPT Global Tech, Vaxart pharmaceuticals, and Charlotte's Web Holdings, and previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals, all outside the submitted work. Andrea Sylvia Winkler reports grants or contracts from the German Federal Ministry of Education and Research for various global health projects where payments were made to her institution, the Technical University of Munich. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Global vaccine coverage by vaccine, 1980–2019 The dotted line represents the GVAP target of reaching at least 90% coverage by 2020. The solid lines represent the mean estimates for each vaccine. The lighter-coloured shading surrounding the solid lines represents the 95% uncertainty intervals. GVAP=Global Vaccine Action Plan. DTP1=diphtheria-tetanus-pertussis vaccine, first dose. DTP3=diphtheria-tetanus-pertussis vaccine, third dose. HepB3=hepatitis B vaccine, third dose. Hib3=Haemophilus influenzae type b vaccine, third dose. MCV1=measles-containing vaccine, first dose. MCV2=measles-containing vaccine, second dose. PCV3=pneumococcal conjugate vaccine, third dose. Pol3=polio vaccine, third dose. RCV1=rubella-containing vaccine, first dose. RotaC=completed rotavirus series.
Figure 2
Figure 2
Changes in DTP3 coverage, by decade, from 1980 to 1989 (A), 1990 to 1999 (B), 2000 to 2009 (C), and 2010 to 2019 (D) For each decade, maps (left) and scatterplots (right) are colour-coded to reflect absolute changes in DTP3 coverage. Locations not estimated for GBD are shown in grey. Each circle on the scatterplot represents a country or territory, and the same colour is reflected on the corresponding map. For the scatterplots, the horizontal dashed line at 0 indicates no coverage change within the decade; the vertical dashed lines mark 60% and 90% coverage, with the latter being the national GVAP target for 2020. DTP3=diphtheria-tetanus-pertussis vaccine, third dose. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. GVAP=Global Vaccine Action Plan.
Figure 3
Figure 3
Percentage of locations reaching the GVAP national coverage target in 2010 and 2019, globally and by GBD super-region Each cell represents the percentage of locations, globally and by GBD super-region, that have reached the GVAP 90% national coverage target in 2010 and 2019 for the assessed vaccines. Percentages are shown for each vaccine separately meeting the target, for at least any single vaccine meeting the target, and for all assessed vaccines listed as meeting the target. Percentages are calculated on the basis of the total number of locations in the GBD super-region, irrespective of whether locations included the vaccine in their national schedule in 2010 or 2019. GVAP=Global Vaccine Action Plan. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. DTP3=diphtheria-tetanus-pertussis vaccine, third dose. MCV1=measles-containing vaccine, first dose. Pol3=polio vaccine, third dose. HepB3=hepatitis B vaccine, third dose. Hib3=Haemophilus influenzae type b vaccine, third dose. MCV2=measles-containing vaccine, second dose. RCV1=rubella-containing vaccine, first dose. PCV3=pneumococcal conjugate vaccine, third dose. RotaC=completed rotavirus series.
Figure 4
Figure 4
Relationships between national DTP3 coverage and SDI, 1980–2019 The solid red line represents the global average relationship between DTP3 coverage and SDI alone, as estimated across locations and over time; the shading represents the 95% uncertainty interval. Observed SDI estimates and DTP3 coverage estimates for each location are shown in light grey. For selected countries (ie, Burkina Faso, India, and Angola), the colour of each point represents the estimation year, from yellow (1980) to purple (2019). Each location's vaccine coverage estimates relative to SDI can be found in the appendix (figure S15). DTP3=diphtheria-tetanus-pertussis vaccine, third dose. SDI=Socio-demographic Index.
Figure 5
Figure 5
Proportion (A) and total number (B) of zero-dose children, globally and by GBD super-region, 1980–2019 The solid lines represent the proportion of zero-dose children for each GBD super-region, and the lighter-coloured shading surrounding the solid lines represents the 95% uncertainty intervals. Zero-dose children are approximated by subtracting estimates of DTP1 coverage from 100%, and then multiplying percentages by population estimates from GBD. Bar colours denote each GBD super-region. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. DTP1=diphtheria-tetanus-pertussis vaccine, first dose.
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