18 July 2023 – Each year, our Alliance partners WHO and UNICEF release estimates of national immunisation coverage (WUENIC). Based on country-reported data, WUENIC provides the world’s largest and most comprehensive data-set on immunisation trends for vaccinations against 13 diseases given through regular health systems.

The 2022 WUENIC estimates released by WHO and UNICEF today are based on data from 183 countries. This factsheet provides a deep dive into what these numbers mean for the 57 lower-income countries supported by Gavi, the Vaccine Alliance.

Top takeaways

OVERALL: Lower-income countries supported by the Alliance are on the road to recovery, with DTP3 vaccine coverage going up by 3 percentage points. Nearly half of lower-income countries are now at or above pre-pandemic levels of DTP3 coverage, while the other half are yet to fully recover. In 2022, Gavi-implementing countries reached roughly the same number of children as pre-pandemic, and these children now receive more essential vaccines than ever before.

• “DTP3” – or coverage with a third dose of the basic diphtheria-tetanus-pertussis vaccine – is often used as a proxy for the overall performance of a country’s health system in consistently reaching children with immunisation.
• In lower-income countries, DTP3 coverage rose to 81% in 2022, up from 78% in 2021, and countries immunised roughly the same number of children in 2022 (61.1 million) as in 2019 (61.6 million).
• The average coverage of the full set of essential WHO recommended vaccines against 11 key diseases – polio, measles, rubella, diphtheria, tetanus, pertussis, hepatitis B, haemophilus influenzae type B (hib), pneumococcus, rotavirus and HPV – has increased by 5 percentage points to 56%.
• Among the 57 lower-income countries, 46% have DTP3 coverage at or above 2019 levels, with 54% yet to return to pre-pandemic coverage levels.
• In 2023, Gavi and partners launched the “Big Catch Up”, a concerted effort to restore and strengthen routine immunisation in the countries most impacted by the COVID-19 pandemic.

MOST VULNERABLE COUNTRIES: Slower recovery trend in the 26 lowest-income countries merits greater analysis of the remaining challenges

• Of the countries Gavi works with, 26 are classified as “low-income” by the World Bank.
• DTP3 coverage across these countries fell by 1 percentage point in 2022, although if the outlier of the Democratic People’s Republic of Korea (DPR Korea) is removed, coverage held steady across this income group.
• Of the 26, 8 increased coverage, 8 decreased coverage, and 10 held constant – although many of the countries that held “constant” were due to data limitations.
• With signs of recent progress in some countries, and unclear data in others, a critical focus for Gavi and partners will be diving further into the unique context of each country to identify and overcome challenges.

CHILDREN MISSING OUT: In Gavi-implementing countries, the number of “zero-dose” children fell by 17% to roughly 10 million.

• The number of zero-dose children in lower-income countries (those who do not yet receive a single dose of DTP vaccine) fell from 12.4 million in 2021 to 10.2 million in 2022. While this is a positive trend, more work needs to be done to reach pre-pandemic levels (9 million in 2019).
• Since vaccines are the widest-reaching health intervention, a zero-dose child likely lives in a persistently missed community that does not have access to other health and essential services.
• The Gavi implementing countries with the most zero-dose children are all large populous countries: Nigeria, Ethiopia, India, Democratic Republic of Congo, and Pakistan.
• A key strategic focus for Gavi is leveraging innovative new partnerships and programmes to successfully reach these consistently missed children with life-saving vaccines – potentially also delivering benefits beyond immunisation.

A closer look: Vaccines

HPV: Coverage with the HPV vaccine, which protects against cervical cancer, has now surpassed pre-pandemic levels – but with average coverage well below ideal levels, efforts to revitalise HPV coverage remain critical to protecting the health of the most vulnerable women and girls.

• In 2022, HPV2 coverage rose 1 percentage point to 10%, mirroring the rise in the global average (from 14% to 15%).
• The HPV vaccine protects against the leading cause of cervical cancer.
• The burden of cervical cancer disproportionately impacts women and adolescent girls in lower-income countries, with more than 90% of all cervical cancer deaths in 2019 occurring in these countries. It is the most common cause of female cancer death in nearly half of sub-Saharan African countries.
• Gavi and Alliance partners announced a revitalisation of HPV efforts with an ambitious plan to reach millions of vulnerable girls in the next few years.

MEASLES: Coverage with first and second dose of measles-containing vaccine increased in 2022, but coverage remains below the critical 95% threshold – as demonstrated by the upward trend in measles outbreaks

• MCV1 and MCV2 are terms used to indicate coverage with the first and second dose, respectively, of a “measles-containing vaccine”.
• While MCV1 and MCV2 coverage in lower-income countries rose by 2 and 4 percentage points respectively compared to 2021 (to 79% for MCV1 and 64% for MCV2 in 2022), a major challenge with measles is the 95% coverage rate required for “herd immunity”, and preventing outbreaks.
• The impact of these less than desirable coverage numbers, and the impact of the COVID-19 pandemic, is reflected in the increasing number of measles outbreaks in lower-income countries.
• Gavi is supporting countries to introduce MCV2 into routine programmes, conduct catch-up and additional vaccination campaigns, and respond to outbreaks.

A closer-look: Regions and countries

AFRICA: DTP3 coverage among Gavi-implementing countries in Africa began to recover in 2022, up 1 percentage point – as countries contend with additional challenges of population growth.

• Coverage improved from 72% in 2021 to 73% in 2022.
• This improvement was driven by increasing coverage in multiple smaller countries, including Niger, Rwanda and Tanzania, as well as larger countries such as DRC, Ethiopia and Nigeria maintaining steady coverage despite having to reach a larger number of children.
• There is still work to be done to recover to 2019 / pre-pandemic levels, when DTP3 coverage stood at 77%.
• An additional challenge for countries to contend with is population growth in Africa – between 2019 and 2022, the birth cohort of Gavi-implementing countries in Africa grew by more than 1.7m (5%) – meaning countries’ heath systems have to reach more children with routine immunisation just to maintain coverage levels.

HIGH PERFORMERS IN AFRICA: Of the top 10 lower-income countries showing the greatest increases in DTP3 coverage in 2022, half are in Africa

• Of the 10 Gavi-implementing countries that showed the most improvement in 2022 compared to 2021, half were in Africa. These include Liberia (+12pp to 78%), Rwanda (+10pp to 98%), Mauritania (+8pp to 76%), Tanzania (+7pp to 88%) and Guinea-Bissau (+7pp to 74%).

FRAGILE COUNTRIES: Some countries dealing with entrenched fragility and conflict showed recovery, with DTP3 coverage rising 2 percentage points in 2022, and nearing pre-pandemic levels.However, clear challenges remain.

• DTP3 coverage in countries Gavi categorises as fragile and conflict countries* rose to 69% in 2022, compared to 67% in 2021 – closing in on pre-pandemic levels of 70% in 2019.
• This trend was driven by estimated coverage improvements in countries such as Chad, Niger and South Sudan.
• However, challenges remain: 4 of the 6 countries with the lowest DTP3 rates in the world also fall into this category – Central African Republic, Papua New Guinea, Somalia, and the Syrian Arab Republic.

* For the purposes of Gavi programmes, these countries include Afghanistan, Central African Republic, Chad, Haiti, Mali, Niger, Papua New Guinea, Somalia, South Sudan, Sudan, Syrian Arab Republic, and Yemen.

BIGGEST DROPS: DPR Korea, Zambia, Malawi had the greatest drops in DTP3 coverage since 2021, although the latter two remain above the Gavi-implementing country average.

• DTP3 coverage in DPR Korea was estimated at 0%, down 41 percentage points compared to 2021. DTP3 coverage in Zambia dropped 9 percentage points to 82%. In Malawi, where climate change, natural disasters and outbreaks have put strain on the health system, DTP3 coverage dropped by 7pp to 86%.
• However, both Zambia and Malawi remain above the Gavi-implementing country average of 81%, with Malawi in particularly recently successfully combatting a sustained cholera outbreak, becoming one of the first African countries to introduce vaccines against typhoid fever, and undertaking vital vaccination campaigns to reach millions of children.

SELF SUFFICIENCY AND RESILIENCE: Former Gavi-supported countries saw significant recovery, with DTP3 coverage increasing by 9 percentage points in 2022.

• The Gavi model is built on the idea that countries should not need Gavi forever: instead building to self-sufficiency and sustainability by steadily increasing their financial contribution and capacity until they run and fund their own immunisation programmes.
• In 2022, these formerly Gavi-supported countries showed resilience with strong recovery – increasing DTP3 coverage by 9 percentage points to 79%.
• However, this is below the Gavi-implementing country average, highlighting the need for continued flexibility in support, for example through the targeted support Gavi provides to middle-income countries.

Frequently Asked Questions

What is DTP?

“DTP3” – or coverage with a third dose of the basic vaccine that protects against diphtheria, tetanus and pertussis (whooping cough)– is often used as a proxy for the overall performance of a country’s health system in consistently reaching children with immunisation. DTP1, or the first-dose of the vaccine, is often used indicate whether or not a child is being reached by the system at all.

What does the global WUENIC data say?

Global immunisation services reached 4 million more children in 2022 compared to the previous year, as countries stepped up efforts to address the historic backsliding in immunisation caused by the COVID-19 pandemic.Some key global trends are highlighted in the chart below. Find out more by reading the WHO-UNICEF press release.

Which 57 lower-income countries does Gavi work with?

Since its inception, Gavi has supported more than 70 countries with routine immunisation. Some of these have since transitioned out of Gavi support to self-sustain and finance their own immunisation programmes. 57 countries remain. The full list is available on page 12 of our 2021 Annual Progress Report. Find out more about our work by country and region: https://www.gavi.org/programmes-impact/country-hub

Which countries in Africa does Gavi work with?

Gavi works with 40 countries in Africa. Find out more here: https://www.gavi.org/programmes-impact/country-hub/africa

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WUENIC Immunisation in Gavi countries

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