Childhood vaccine coverage in SA declined in 2023, World Health Organization report finds

28 Jul 2024

New data from the World Health Organization and UN Children’s Fund show that globally, childhood immunisation coverage stalled in 2023, while in South Africa it decreased.

A new report has found that vaccination coverage rates around the world have not yet returned to levels seen in 2019, before the Covid-19 pandemic disrupted immunisation programmes.

There has been no meaningful change in immunisation coverage between 2022 and 2023, according to a World Health Organization (WHO) and UN Children’s Fund report published in July. It means progress in immunisation coverage has effectively stalled, leaving 2.7 million additional children who are either unvaccinated or under-vaccinated compared to pre-pandemic levels in 2019.

A marker used to measure immunisation coverage is to look at whether children received three doses of the vaccine against diphtheria, tetanus and pertussis – referred to as DTP3. Global coverage for DTP3 stalled at 84% in 2023, according to the report.

At the same time, the number of children worldwide who have not received any vaccinations has increased. We refer to these kids as zero-dose children. Ten countries account for 59% of all zero-dose children, with the global number in 2023 rising to 14.5 million compared with 13.9 million in 2022, according to the report.

Coverage slightly down in SA

Data from the report showed a slight decrease for a number of outcome measures in South Africa between 2022 and 2023. It was one of 14 countries in the African region 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 African region that saw a decrease in coverage for the first dose of the measles vaccine, and was singled out by the report as having the sharpest decline in coverage in the region between 2022 and 2023. Measles coverage dropped from 86% in 2022 to 80% in 2023.

Commenting on the accuracy of the new data, Professor Shabir Madhi, the dean at the Faculty of Health Sciences at the University of Witwatersrand, said it used administrative data that can bias the estimates. He explained that the report bases vaccine coverage on the number of vaccines procured by the 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. It stated that it calculated 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 could be found in national vaccine coverage surveys, like the Expanded Programme on Immunisation National Coverage survey. Spotlight previously reported on results from the most recent immunisation survey conducted in 2019.

“Not being afraid to speak out, it does get me into trouble quite often,” says Professor Shabir Madhi. He added that it appeared the new report did not incorporate data from the Expanded Programme on Immunisation survey. However, even without this data, he said the WHO estimates were not too far off the local data. He remarked that he didn’t feel “too strongly either way” about the accuracy of the WHO data since the bottom line was that vaccine coverage in the country was lagging.

Fluctuations in immunisation coverage

“Fluctuations in immunisation coverage are not uncommon,” Dr Haroon Saloojee, a professor of Child Health at Wits University, 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 shown an overall upward trend, which was “promising”, according to Saloojee. However, he said the latest data from the report “holds no good news for South Africa” because the dip in coverage in 2023 was noteworthy.

Read More in Daily Maverick: Getting people onto ARVs — tracking SA’s progress is tricky, so we broke down the data

“South Africa’s performance is moderate when compared globally, and poor compared to other high-middle income countries,” said Saloojee. “Considering that South Africa is a high-middle-income country, we should be performing much better in all our health indicators.”

He pointed out that countries in a similar bracket, like Cuba and Uruguay, had achieved high immunisation coverage through robust healthcare systems and effective public health policies.

Regarding zero-dose children, the report ranked South Africa the 6th worst in the African region. In 2022, the country ranked 13th. With a total of 220,000 zero-dose children, the country accounted for three percent of all zero-dose children in the African region. Nigeria had the highest percentage at 32% of all zero-dosed children in the region, followed by Ethiopia with 14%.

‘Dysfunctionality of primary healthcare’

Apart from the international comparisons, Madhi pointed out that South Africa was not meeting its own targets of having at least 90% of children in each district fully vaccinated.

The Expanded Programme on Immunisation 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. Together, the data from the survey and the WHO clearly shows that childhood immunisation targets are not being met in the country.

Read More in Daily Maverick: Documents reveal how Pfizer and Moderna ‘profiteered’ in Covid-19 vaccine negotiations

For Madhi, the results from the immunisation survey “speak to the dysfunctionality of primary health care in the country”. He said the immunisation of children, which was the bedrock of primary healthcare when it came to children, acted as a “canary in the mine with regards to how well primary healthcare is working”.

He said South Africa was a leader in the field when it came to evaluating and introducing vaccines to the public immunisation programme. But when it came to implementation, for the vast majority of districts we “are falling completely flat on our face and coming short in terms of reaching our own targets”.

Implications for children

The health implications for children who are unvaccinated or only partially vaccinated are significant.

“They are less protected against what can be life-threatening diseases. And those life-threatening diseases include measles and other life-threatening diseases such as pneumonia,” Madhi said.

“We’re selling ourselves short as a country in addition to actually compromising the health of children by not ensuring that we’re doing everything that’s possible to actually get children to be vaccinated,” Madhi added. “It also comes with other consequences, so it sort of makes South Africa more prone to outbreaks.”

Saloojee said that it was also likely that children who were not fully vaccinated were “not receiving many of the other health, education and social development services all children require and that are being provided by the government, such as early childhood development services and child support grants”.

The reasons for immunisation coverage lagging were complex, and the responsibility for fixing the problem lay with more than just one entity. Spotlight previously reported on some of the reasons children remained unvaccinated or under-immunised as identified by the Expanded Programme on Immunisation survey.

'Fundamental relook needed'

Madhi said there needed to be a fundamental relook at the country’s immunisation programme. Proper governance structures need to be put in place, and the programme would need to be implemented all the way down to the sub-districts. There is also a need for real-time data and monitoring of that data so that interventions could be conducted when children were missing their immunisations. He also suggested ring-fencing funds for vaccines, at either a national or provincial level, to ensure that money earmarked for vaccines was used for that purpose so as to ensure less stock-outs.

“The immunisation programme hasn't changed much from what I can gather over the past 20 years, let alone the past 10 years. So we can’t expect a different outcome if the strategy that we’re using which has failed is the strategy that you continue pursuing,” Madhi said.

Saloojee said the National Department of Health could play a pivotal role in strengthening the immunisation programme by “providing leadership, resources, and policy support”. He said that to his knowledge the health department was currently preparing a national immunisation strategy to take us to 2030, but the draft was not up to scratch. The strategy, he said, would need to offer clear objectives, establish realistic indicators of, and targets for, measuring success, and attract a fully funded mandate.

Spotlight asked the National Department of Health for comment on the new WHO report and how it planned to respond to improve immunisation coverage. While the department acknowledged our questions, it did not provide comment by the time this article was first published. DM

*This article was first published by Spotlight – health journalism in the public interest. Sign up to the Spotlight newsletter.

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Coverage slightly down in SA

Fluctuations in immunisation coverage

‘Dysfunctionality of primary healthcare’

Implications for children