Immunisation coverage of children

Vaccination is one of the most effective healthcare interventions to prevent serious illnesses and death in young children. It entails giving injections or drops to young children, to protect them against potentially life-threatening illnesses such as tuberculosis, polio, hepatitis and measles. Since the introduction of the Expanded Programme on Immunisation (EPI) over 50 years ago, an estimated 154 million lives have been saved globally, of which 101 million were infants. In Africa alone, EPI-targeted diseases have reduced infant deaths by more than 50%.[1] In keeping with world standards, South Africa has an up-to-date immunisation programme which was last revised in 2024.

The revised EPI schedule for public health facilities includes immunisation at birth, and then at six weeks, 10 weeks, 14 weeks, six months and nine months.[2] Thus, by the time of their first birthday, all babies should have visited a health facility at least five times after birth for immunisation services, and these immunisations should be recorded in the child’s Road to Health Book. However, many children do not receive their scheduled immunisations. Low coverage is driven by both supply side issues, such as vaccine stockouts and a reluctance to administer multiple vaccines at once, and demand side barriers, including transport challenges, long distances to health facilities, a lack of information or fear of vaccine adverse effects. Those children are classified as ‘zero-dose’ – meaning that they have not received any doses of the BCG, polio, hexavalent or measles vaccines.

Some children could also be classified as ‘penta-zero’ dose which, in a South African context, means that they haven’t received the hexavalent (DTaP-IPV-Hib-HBV) vaccine – a marker of successful access to primary healthcare facilities.[3] A study using Demographic and Health Survey data of non-immunised children between 2010 and 2020 found that 5.8% of children aged 12 – 23 months were zero-dose, while 10.8% of children were penta-zero dose.[4]

In 2023, approximately 220,000 children in South Africa were considered zero-dose based on whether they had achieved access to the first dose of diphtheria, tetanus and pertussis (DTP) vaccine.[5] WHO and UNICEF estimates of National Immunisation Coverage show that coverage of DTP1 in babies younger than one year declined from 91% in 2021 to 76% in 2024. This amounts to a 15% drop in coverage of this lifesaving vaccine, far below the 95% target. The Immunisation Agenda 2030 aims to reduce the number of zero-dose children by 50%, prioritising equity in healthcare.

Immunisation coverage serves as a strong indicator of the extent to which young children access primary healthcare services. Immunisation coverage is also a proxy for the extent to which children access other health services, as the immunisation schedule provides a point of contact for identifying other health problems and for scheduling preventative child health interventions. Examples of these are the vitamin A supplementation programme, developmental screening, and prophylaxis for babies born to HIV-positive mothers.

Immunisation rates are tracked in the District Health Information System and are calculated as the number of children under one year who have received their complete primary course of immunisation divided by the child population under one year. Immunisation rates at district level are calculated in a similar way, by dividing immunisations administered by the infant population for a district. The percentages obtained in this way may be influenced by population movement in health seeking behaviour – for example, if children from one district or province are taken to a health facility in a neighbouring district or province. Currently, estimates of immunisation uptake are also compromised by the uncertainty around infant numbers at the national, provincial and district levels. 

The 2015 immunisation rate, as reported in the 2016 District Health Barometer, reflected high levels of immunisation for infants under a year, at 89.2% [6] but the population model for the country had under-estimated the number of children. Stats SA subsequently revised its population model and released a new series of mid-year population estimates [7] and the 2015 immunisation rate was revised downwards to 79.4%. The 2016 rate dropped to 71% after retrospective adjustment to the revised population estimates. The lower immunisation rate for that year was attributed to a global shortage of Hexavalent vaccine.² In 2017 the immunisation rate picked up to 77%, increasing further to 82% in 2018 and 83.5% in 2019. In 2020, the immunisation rate dropped to 79.5% nationally as a result of the COVID-19 lockdown, and as low as 61% in Limpopo. These fluctuations illustrate how the immunisation programme, which generally has high levels of compliance, is highly sensitive to disruptions in vaccine supply (as in 2016) or service delivery (as in 2020).

Immunisation rates improved significantly to 85.5% in 2021, dropping back slightly to 82.2% in 2022. This increase in the year following the hard lockdown, followed by a slight decline the next year, occurred across all provinces and might have been the result of a catch-up in delayed infant immunisations. When comparing the baseline immunisation rates in 2015 with those in 2023, the overall rates are quite similar despite some volatility in the intervening years.[i] The average rate for the country was slightly higher in 2023 (83%) than in 2015 (79%).

Underlying the overall increase between 2015 and 2023 are some quite contrasting patterns across provinces. Immunisation rates over the period increased substantially in KwaZulu-Natal and, to a lesser extent, in the Eastern Cape, Free State, Mpumalanga and North West. At the same time, immunisation rates dropped in the Northern and Western Cape, Limpopo and Gauteng.

Provinces that experienced a notable increase from 2022 to 2023 were Limpopo (+6.8%) and North West (+7.1%). While provinces who experienced a significant decline in immunisation coverage were the Eastern Cape (-3.7%) and Free State (-3.5%). The highest immunisation rates for 2023 were in KwaZulu-Natal (94.5%) and Mpumalanga (88.2%), while the lowest rates were in Limpopo (74.3%), Western Cape (74.8%) and the Free State (76.2%).

Effective immunisation requires high levels of coverage to achieve a certain level of immunity within the broader community. This is known as ‘herd immunity’ and it means that, if immunisation coverage has reached a high enough level, even the most vulnerable who have not been immunised in that community will be protected – including young children and those with low immunity. Herd immunity depends on the disease’s reproductive number: the higher the reproductive number (that is, the more people one infected person can transmit the disease to) the larger the proportion of the population that needs to be immune to achieve herd immunity. The World Health Organization recommends a target of 95% coverage to achieve herd immunity and eliminate infectious childhood diseases. While no province was able to achieve this target, KwaZulu-Natal came relatively close.

The indicator used to estimate coverage of the second dose of the measles vaccine administered at 12 months was derived from the 2025 edition of the District Health Barometer. Over the past decade, at global and national level, there have been numerous outbreaks of measles, emphasizing how important it is to administer this booster dose. In South Africa, coverage of the second measles dose in children has varied between 2015 and 2023. After a peak in 2016 (83.6%), coverage dropped and stayed around 76% between 2017 and 2020 with a slight deviation of 79.6% in 2019. Coverage increased sharply to 84% in 2021 and remained at that level in 2022 and 2023. Measles coverage has consistently been the lowest in the North West and Limpopo provinces, the very same provinces that were most severely affected by the 2023 measles outbreak. To prevent outbreaks of this nature and protect children from preventable infectious diseases, we need to advocate for increased uptake of both the first and second measles dose to more than 95%.

Even though immunisation is freely available, and the goal is for it to be universal, it is voluntary and there is growing evidence that some parents choose not to immunise their children. A “worldwide increase in vaccine hesitancy and refusal” has been described as a threat to the public health achievements in controlling and preventing infectious diseases.[8] Internationally, vaccine sentiment and voluntary compliance is inversely correlated with socio-economic status (i.e. compliance is lower in wealthy countries than in poorer ones).[8] Following a campaign of misinformation about vaccines during the COVID-19 pandemic, a concerted effort needs to be made to ensure that all mothers and caregivers are educated about the importance of immunising their children.

The completion rates for ‘basic immunisation’ in the South African Demographic and Health Survey of 2016 were substantially lower than those recorded in the District Health Information System for the same year (at 61%, compared with 77%). The reason for this discrepancy is not clear, but it is important to note that compliance was highest in the poorest wealth quintile (66%) while the richest quintile was lower, at 60%.[9] This suggests that there is also an inverse correlation between socio-economic status and immunisation in South Africa, a highly unequal country.