Reaching zero-dose children in India: progress and challenges ahead
Authors: Manoj V Murhekar, Muthusamy Santhosh Kumar
Journal: The Lancet Global Health (2021)

Vaccination against childhood diseases is one of the most important public health interventions. The Expanded Programme of Immunisation, launched in 1974, targeted six childhood diseases. Although vaccines for more than 20 life-threatening diseases are now available, low vaccination coverage continues to be a problem, especially in low-income and middle-income countries (LMICs).1WHOImplementing the Immunization Agenda 2030: a framework for action through coordinated planning, monitoring & evaluation, ownership & accountability, and communications & advocacy.https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030_frameworkforactionv04.pdf?sfvrsn=e5374082_1&download=trueDate accessed: August 11, 2021Google Scholar The Global Burden of Disease (GBD) study2GBD 2020, Release 1, Vaccine Coverage CollaboratorsMeasuring routine childhood vaccination coverage in 204 countries and territories, 1980–2019: a systematic analysis for the Global Burden of Disease Study 2020, release 1.Lancet. 2021; 398: 503-521Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar estimated 14·5 million zero-dose children in 2019; 75% of them were from 14 LMICs. The Immunization Agenda 2030 (IA2030) has identified reaching out to zero-dose children as a strategic priority, and has set a target of a 50% reduction in the number of zero-dose children by 2030.1WHOImplementing the Immunization Agenda 2030: a framework for action through coordinated planning, monitoring & evaluation, ownership & accountability, and communications & advocacy.https://cdn.who.int/media/docs/default-source/immunization/strategy/ia2030/ia2030_frameworkforactionv04.pdf?sfvrsn=e5374082_1&download=trueDate accessed: August 11, 2021Google Scholar India's Universal Immunisation Programme, launched in 1985, targets approximately 26 million newborns annually. Over the years, the programme was strengthened by adding newer vaccines, achieving self-sufficiency in vaccine production, adopting an open vial policy, improving cold-chain and logistics management, strengthening surveillance for vaccine-preventable diseases, and reporting adverse events following immunisation. Despite these initiatives, the progress in improving full vaccination coverage has been slow; the coverage of fully-vaccinated children has only increased from 35·4% in 1992 to 62·0% in 2016.3Bhadoria AS Mishra S Singh M Kishore S National Immunization Programme—Mission Indradhanush Programme: newer approaches and interventions.Indian J Pediatr. 2019; 86: 633-638Crossref PubMed Scopus (6) Google Scholar In The Lancet Global Health, Mira Johri and colleagues4Johri M Rajpal S Subramanian SV Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.Lancet Glob Health. 2021; 9: e1697-e1706Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar have estimated the prevalence of zero-dose children in India over a 24-year period using the data from four National Family Health Surveys (NFHS) done between 1992 and 2016. The authors identified the determinants of zero-dose vaccination status and using the data from the fourth survey, NFHS-4 (2015–16), estimated the number of zero-dose children. Their analysis indicates that the proportion of zero-dose children in India has declined from 33·4% (95% CI 32·5–34·2) in 1992 to 10·1% (9·8–10·4) in 2016. They estimated 2·88 (2·86–2·89) million zero-dose children in 2015–16, with more than 80% living in eight Indian states. Johri and colleagues defined zero-dose children as all surviving children aged 12–23 months who did not receive the first dose of the diphtheria, tetanus, and pertussis containing vaccine (DTP-1). As some children who did not receive DTP-1 might have received other vaccines, the authors did a sensitivity analysis considering zero-dose children as those who did not receive any doses of the four basic vaccines (BCG, polio, DTP, and measles-containing vaccine). The prevalence of zero-dose children was 6·3% (95% CI 6·1–6·5) in 2015–16, as compared with 10·1% if non-receipt of DTP-1 was the criterion. In the GBD study,2GBD 2020, Release 1, Vaccine Coverage CollaboratorsMeasuring routine childhood vaccination coverage in 204 countries and territories, 1980–2019: a systematic analysis for the Global Burden of Disease Study 2020, release 1.Lancet. 2021; 398: 503-521Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar zero-dose children were defined as non-receipt of DTP-1 among children aged younger than 12 months. Another study5Cata-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: 4564-4570Crossref PubMed Scopus (7) Google Scholar estimated the zero-dose prevalence of 7·7% in 92 LMICs, and defined zero-dose as non-receipt of four basic vaccines in children aged 12–23 months.5Cata-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: 4564-4570Crossref PubMed Scopus (7) Google Scholar The use of a standard definition for zero-dose children will help countries monitor their progress towards IA2030 goals, and also enable comparisons across countries. In India, although differentials in the zero dose by gender, caste, and rural or urban status has substantially reduced between 1992 and 2016, the prevalence remained higher among households in the bottom wealth quintile, mothers in the lowest educational category, scheduled tribes, and Muslims.4Johri M Rajpal S Subramanian SV Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.Lancet Glob Health. 2021; 9: e1697-e1706Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Targeting such children would be the priority for immunisation programmes and would need strategies tailored to the local context. Reaching out to children living in hard-to-reach tribal areas would require coordination with the tribal welfare department and mobility support for vaccinating teams in organising outreach sessions, whereas targeting Muslim children would need adequate communication and social mobilisation plans to tackle vaccine hesitancy. Special attention would be required for urban slums where migration and lower awareness about vaccination might leave many children unvaccinated.6Ministry of Health and Family WelfareGovernment of IndiaIntensified Mission Indradhanush operational guidelines.http://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/Mission_Indradhanush_Guidelines.pdfDate accessed: August 11, 2021Google Scholar The progress towards the goal of zero-dose children is also negatively impacted by the COVID-19 pandemic. It is estimated that the disruption of routine immunisation services due to COVID-19 has led to 23 million children missing out on basic vaccines in 2020 globally.7WHOCOVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows.https://www.who.int/news/item/15-07-2021-covid-19-pandemic-leads-to-major-backsliding-on-childhood-vaccinations-new-who-unicef-data-showsDate accessed: August 10, 2021Google Scholar India has reported a drop in the coverage of the third dose of DTP (DTP-3) vaccine from 91% to 85%.7WHOCOVID-19 pandemic leads to major backsliding on childhood vaccinations, new WHO, UNICEF data shows.https://www.who.int/news/item/15-07-2021-covid-19-pandemic-leads-to-major-backsliding-on-childhood-vaccinations-new-who-unicef-data-showsDate accessed: August 10, 2021Google Scholar Furthermore, the large-scale displacement of migrant workers and school closures due to COVID-19 lockdowns could have interrupted the delivery of immunisation services to vulnerable population groups, especially in states with weaker health systems. The rapid decline of zero-dose children observed between 2005 and 20154Johri M Rajpal S Subramanian SV Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.Lancet Glob Health. 2021; 9: e1697-e1706Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar could be attributed to health system reforms through India's National Rural Health Mission. India launched Mission Indradhanush in 2014, and an intensified version in 2017, with a targeted approach to identify missing children and bridge the immunisation gap in selected districts or urban areas with poor immunisation coverage.8Gurnani V Haldar P Aggarwal MK et al.Improving vaccination coverage in India: lessons from Intensified Mission Indradhanush, a cross-sectoral systems strengthening strategy.BMJ. 2018; 363k4782Crossref PubMed Scopus (50) Google Scholar Although the analysis done by Johri and colleagues did not cover the time period when some of these initiatives were implemented, a recent study9Summan A Nandi A Deo S Laxminarayan R Improving vaccination coverage and timeliness through periodic intensification of routine immunization: evidence from Mission Indradhanush.Ann N Y Acad Sci. 2021; (nyas.14657.)Crossref PubMed Scopus (4) Google Scholar reported 27% higher rates of full immunisation among children living in districts where Mission Indradhanush was implemented as compared with other districts. India had also done two rounds of Intensified Mission Indradhanush 3.0 across 250 districts or urban areas in February, 2021, to identify children and pregnant women who have missed their vaccines during the COVID-19 pandemic.10Ministry of Health and Family WelfareGovernment of IndiaStates/UTs roll out Intensified Mission Indradhanush (IMI) 3.0.https://pib.gov.in/PressReleasePage.aspx?PRID=1700145Date accessed: August 11, 2021Google Scholar Johri and colleagues concluded that India is on track to meet the IA2030 zero-dose target if the same trend continues in future.4Johri M Rajpal S Subramanian SV Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveys.Lancet Glob Health. 2021; 9: e1697-e1706Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, further strengthening the routine immunisation programme with periodic intensification, targeting areas with low coverage and priority groups is needed to achieve the zero-dose target and address the disruption in the immunisation programme due to COVID-19. We declare no competing interests. Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveysOver a 24-year period in India, child zero-dose status was shaped by large-scale social inequalities and remained a consistent marker of generalised vulnerability. Interventions that address this cycle of intergenerational inequities should be prioritised. Full-Text PDF Open Access