Vaccinating India: on zero-dose children
On the bright side, vaccine coverage globally, between 1980 and 2023, doubled for six diseases including measles, polio and tuberculosis. Also, at 75% globally, there has been a sharp fall in the number of zero-dose children — those who have not received the first dose of the diphtheria, tetanus, and pertussis (DTP) vaccine — during the same time period. The number of zero-dose children is a crucial performance marker and an indicator of vaccination coverage inequities. Despite increased immunisation coverage over the decades, in 2023, at 1.44 million, India, according to The Lancet, still had the second largest number of zero-dose children, and is among the eight countries with over 50% of the nearly 16 million zero-dose children globally. Most of the zero-dose children globally are in countries that are conflict-affected or with limited resources for vaccination programmes — India has neither of the two problems. However, about 23 million babies were born in 2023 in India, the highest in the world; in 2024, China, which has the second highest number of newborns globally, reported just 9.5 million newborns. Though the number of zero-dose children is staggering, when seen in the context of the number of newborns in 2023, the percentage of zero-dose children in India is 6.2%. A study in 2021 found that India had sharply reduced the percentage of zero-dose children, from 33.4% in 1992 to 10.1% in 2016. Before the COVID-19 pandemic, the number of zero-dose children was 1.4 million in 2019 but this swelled to 2.7 million in 2021 and then dropped to 1.1 million in 2022 before increasing to 1.44 million in 2023.
As in the 2021 study, a large percentage of zero-dose children are in Uttar Pradesh, Bihar, Maharashtra, Rajasthan, Madhya Pradesh, and Gujarat. There is also a relatively high proportion of them in Meghalaya, Nagaland, Mizoram and Arunachal Pradesh. Over the years, the difference in zero-dose children based on gender, caste, and rural-urban status has reduced substantially. However, prevalence remains high among the poor, mothers with low education, Scheduled Tribes and Muslims. Focus is needed to immunise children in hard-to-reach tribal areas, urban slums where there is a huge migrant population, and in reducing vaccine hesitancy among Muslim households with newborn children. India has much work to do to meet WHO's Immunization Agenda 2030 (IA2030) — halving zero-dose children relative to 2019. With the number of zero-dose children in 2023 (1.44 million) only about nearly reaching the 2019 level of 1.4 million, India needs greater and sustained efforts to halve this number in the next five years.
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