New data from the WHO and Unicef show that globally childhood immunisation coverage stalled in 2023, while in South Africa it actually decreased, writes Elri Voigt for Spotlight, who asked local experts to put it in context.
The report, published this month, found that vaccination coverage rates worldwide have still not returned to levels seen in 2019, before the pandemic disrupted immunisation programmes, and that there was no meaningful change in immunisation coverage between 2022 and 2023. It means progress in immunisation coverage has effectively stalled, leaving 2.7m additional children who are either unvaccinated or under-vaccinated compared with pre-pandemic levels in 2019.
A marker used to measure this looks at whether children received three doses of the vaccine against diphtheria, tetanus and pertussis – referred to as DTP3. The report shows that global coverage for DTP3 stalled at 84% in 2023.
Simultaneously, the number of children who have not received any vaccinations has increased. We refer to them as zero-dose children. Ten countries account for 59% of all zero-dose children, with the global number in 2023 rising to 14.5m compared with 13.9m in 2022.
Coverage slightly down in SA
Data also showed a slight decrease for a number of outcome measures in South Africa between 2022 and 2023. It was one of 14 countries on the continent that saw a decrease in coverage for DTP1 (the first dose of the vaccine for diphtheria, tetanus and pertussis), slipping from 87% in 2022 to 81% in 2023. Coverage for DTP3 also decreased, falling from 85% in 2022 to 79% in 2023.
South Africa was also one of 10 countries in the region that saw a decrease in coverage for the first dose of the measles vaccine, being singled out as having the sharpest decline in coverage between 2022 and 2023: from 86% in 2022 to 80% in 2023.
Commenting on the accuracy of the report, Professor Shabir Madhi, dean at the Faculty of Health Sciences at the University of Witwatersrand (Wits), said it used administrative data, which can bias the estimate, and bases coverage on the number of vaccines procured by government and deployed to facilities. For example, if a facility gets 100 doses of the measles vaccine and ends up discarding 50 doses, that doesn’t necessarily get reported.
The WHO acknowledges the potential for data inaccuracies, saying it calculates the estimated percentage of immunisation coverage by dividing the number of doses administered to a target population by the estimated number of people in that target population.
Madhi said a more accurate picture of childhood immunisation coverage in the country can be found in National Vaccine coverage surveys, like the Expanded Programme on Immunisation (EPI) survey, the most recent being conducted in 2019.
Madhi said it appeared the new report did not incorporate data from the EPI survey. However, even without these data, he said the WHO estimates are not too far off the local data. He doesn’t feel “too strongly either way” about the accuracy of the WHO data since the bottom line is vaccine coverage in the country is lagging.
“Fluctuations in immunisation coverage are not uncommon,” Dr Haroon Saloojee, a professor of Child Health at Wits told Spotlight. “One should not make too much of a fall or increase in coverage rates over one year, unless it is drastic.”
Data from the WHO report for vaccine coverage in South Africa between 2018 and 2022 had actually showed an overall upward trend, which was “promising”, according to Saloojee. However, he said the latest data from the report “hold no good news for South Africa” because the dip in coverage in 2023 was noteworthy.
How does SA compare?
“South Africa’s performance is moderate when compared globally, and poor compared with other high-middle income countries,” he added. “Considering South Africa is a high-middle-income country, we should be performing much better in all of our health indicators.”
He said countries in a similar bracket like Cuba and Uruguay have achieved high immunisation coverage through robust healthcare systems and effective public health policies.
Regarding zero-dose children, the report ranked South Africa 6th worst in the region. In 2022, it ranked 13th. With a total of 220 000 zero-dose children, the country accounted for 3% of all zero-dose children on the continent. Nigeria had the highest percentage at 32% of all zero-dosed children, followed by Ethiopia with 14%.
‘Dysfunctionality of primary healthcare’
Apart from the international comparisons, Madhi pointed out that South Africa is not meeting its own targets of having at least 90% of children in each district fully vaccinated.
The EPI survey found that only seven of the 52 districts in the country were able to achieve the national target of 90% of children fully vaccinated under one year of age. The combined data from the survey and the WHO clearly show that childhood immunisation targets are not being met here.
For Madhi, the results from the EPI survey signify “dysfunctionality of primary healthcare in the country”. He said childhood immunisation, the bedrock of primary healthcare when it comes to children, acts as a “canary in the mine with regards to how well primary healthcare is working”.
South Africa is a leader in the field regarding evaluating and introducing vaccines to the public immunisation programme, he remarked, but when it comes to implementation, for the vast majority of districts we “are falling flat on our face and coming short of reaching our own targets”.
Implications for children
The health implications for children who are not unvaccinated or only partially vaccinated are significant.
“They are less protected against what can be life-threatening diseases, which include not just measles but also pneumonia, for instance,” Madhi said.
“We’re selling ourselves short as a country in addition to actually compromising their health by not doing everything possible to get children to be vaccinated. It also comes with other consequences, so it sort of lends South Africa to be more prone to outbreaks.”
The reasons for immunisation coverage lagging are complex and the responsibility for fixing the problem lies with more than just one entity.
Madhi said there needs to be a fundamental relook at the immunisation programme. Proper governance structures need to be put in place and the programme will need to be implemented all the way down to the sub-districts. Real-time data and monitoring of that data are vital, so interventions can be done when children miss their immunisations. He also suggested ring-fencing funds for vaccines, at either a national or provincial level, to ensure that money earmarked for vaccines is used for that purpose – and to ensure fewer stock-outs.
“The immunisation programme hasn’t changed much – from what I can gather – over the past 20 years, let alone the past decade. So we can’t expect a different outcome if the strategy we’re using, which has failed, is the strategy we continue pursuing,” he said.
Saloojee said the NDoH could play a pivotal role in strengthening the immunisation programme by “providing leadership, resources, and policy support”. He said that to his knowledge, the Department is currently preparing a national immunisation strategy “to take us to 2030, but the draft is not up to scratch”.
The strategy would need to offer clear objectives, establish realistic indicators of, and targets for, measuring success, and attract a fully funded mandate, he added.
Spotlight asked the NDoH for comment on the WHO report and how it plans to respond to improve immunisation coverage. While the Department acknowledged our questions, it did not provide comment by the time this article was published.
See more from MedicalBrief archives:
WHO, Unicef flag worst decline in childhood immunisations in 30 years
Immunisations drop as Africa’s faith in vaccines plunges
Vaccine hesitancy sees drop in childhood jabs post pandemic – Unicef