Vaccinating India: On Zero-Dose Children

India’s large number of zero-dose children underscores the urgent need to close persistent gaps in vaccine delivery.

About “Zero-Dose Children”

• “Zero-Dose Children are children who have not received the first dose of the diphtheria, tetanus, and pertussis (DTP) vaccine.
• Globally, significant improvements in vaccination efforts have been observed between 1980 and 2023, particularly for six diseases: DTP, Measles, Polio, and Tuberculosis. 
  • The number of zero-dose children globally has considerably decreased. 
  • Currently, 75% of countries still have some zero-dose children, while 25% of countries have successfully eliminated them entirely.

India’s Vaccination Status and Associated Challenges

• In 2023, India accounted for 1.44 million (14.4 lakh) zero-dose children. 
• India is the second-highest country globally in terms of the absolute number of zero-dose children.
• Notably, among the eight countries worldwide where zero-dose children constitute more than 50% of the total, India is unique because it is neither suffering from war nor experiencing a shortage of funds to procure vaccines. 
  • This highlights a paradox: despite not facing major conflict or severe financial limitations for vaccines, India ranks high in the number of zero-dose children.
  • In 2023, approximately 23 million (2.3 crore) babies were born in India, compared to 9.5 million (95 lakh) in China. 
  • Although the absolute number of zero-dose children in India is high, their percentage relative to the total births is 6.2%, which is considered “very low” in proportional terms. 
  • The large overall number of births in India contributes to the high absolute count of zero-dose children.

Historical Progress

• India has demonstrated impressive progress in reducing the percentage of zero-dose children over the years:
  • In 1992, 33.4% of children were zero-dose.
  • This percentage significantly decreased to 10.1% in 2016.
  • It further improved to 6.2% in 2023.

Impact of COVID-19

• In 2019, the number of zero-dose children was 1.4 million (14 lakh). This sharply increased to 2.7 million (27 lakh) in 2021 due to 
  • fear surrounding vaccines and 
  • the prioritization of managing the COVID-19 pandemic.
• While the number slightly decreased to 1.1 million in 2022, it rose again to 1.44 million in 2023.
  • This trend suggests that the improvements seen in the pre-COVID years have not been sustained recently, necessitating a re-evaluation of current strategies.

Regions and Communities Having A Higher Prevalence Of Zero-Dose Children

• Top States: Uttar Pradesh, Bihar, Maharashtra, Rajasthan, Madhya Pradesh, and Gujarat.
• North-Eastern States: Meghalaya, Nagaland, Mizoram, and Arunachal Pradesh also exhibit higher numbers of zero-dose children.

Reasons For Prevalence of Higher Zero Dose Children

• Mothers with Lower Education: Mothers with less education tend to have lower vaccination rates for their children.
• Poor Families and Lack of Awareness: Families living in poverty often lack sufficient awareness regarding the importance and benefits of vaccination.
• Scheduled Tribes and Muslim Communities(STs): These communities sometimes display hesitancy, which could be due to cultural beliefs, vaccine hesitancy, limited access to reliable information, or historical distrust of government initiatives.
  • Example: In the Nuh-Mewat region in Haryana, a Muslim-majority area, a WhatsApp video, falsely propagating that vaccines cause infertility or impotence, led to a sudden and drastic increase in vaccine hesitancy. 

Challenges In Increasing Vaccine Reach

• Difficult-to-Reach Areas: These include remote tribal forest areas, inaccessible hilly regions where transportation is a major challenge, and densely populated urban slums.
• Mobile Populations: In urban slums, the transient nature of migrant populations makes it difficult to track individuals who have been vaccinated and to ensure they receive all follow-up doses. 
  • Migrants frequently change their residences, making consistent tracking and vaccination a challenge for health authorities.

Strategies to Overcome Vaccination Hesitancy and Improve Coverage

• Targeted Approach and Micro-Planning: There is a need to develop detailed micro-plans specifically designed for vulnerable populations and areas that are difficult to access, such as tribal regions, urban slums, and areas with mobile populations. 
• Behavioral Communication: Implement effective behavioral communication strategies to address existing misconceptions and build trust within communities.
• Strengthening Health Infrastructure: Enhance existing health infrastructure to guarantee a reliable supply and proper storage of vaccines, along with the availability of adequately trained healthcare personnel, even in the most remote areas.
• Inter-Sectoral Convergence: Promoting strong collaboration among various government departments. 
  • For example, the Education Department, Women and Child Development Department, and Panchayati Raj institutions should work in unison with the Health Department.
• Community Participation and Local Influencers: There is a need to actively involve the community and local influencers and leaders in the planning and execution of vaccination drives.

Conclusion

India has much work to do to meet WHO’s Immunization Agenda 2030 (IA2030) of reducing zero-dose children by 50% compared to 2019 (aiming for approximately 7 lakh children) by 2030

• 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.