Pakistan's 419,000 Zero-Dose Children Expose Gaps in Vaccination as 2030 Goals Approach

Hundreds of Thousands of Children Still Miss Routine Vaccines

Pakistan had approximately 419,000 children classified as zero-dose in 2023, the second highest number in South Asia after India, according to a global vaccination study published in The Lancet. The figure places Pakistan at the centre of a wider slowdown in childhood immunisation, leaving children exposed to diseases including measles, polio and tuberculosis.

The Global Burden of Disease Vaccine Coverage Collaborators examined vaccination trends from 1980 to 2023 and projected coverage to 2030. Their findings describe a troubling change: decades of gains have given way to stalled progress and, in some places, falling coverage. Pakistan's challenge is especially urgent because it remains one of only two countries where wild poliovirus is endemic.

Childhood vaccination has saved millions of lives by protecting children against diseases that can cause severe illness or death. The World Health Organization's Expanded Programme on Immunisation (EPI) has saved an estimated 154 million lives since its launch in 1974. Yet progress has slowed or reversed in some regions over the past two decades.

COVID-19 made those weaknesses harder to overcome. Disrupted health services, resources diverted to the pandemic and growing mistrust of vaccines left more children without routine protection. Pakistan has since reduced its number of zero-dose children, but gaps in access, uneven provincial coverage and vaccine refusals continue to complicate recovery.

For families, the consequences are practical and immediate. A vaccine may exist, but a child can still miss it because the clinic is too far away, transport costs too much, health workers cannot safely reach the neighbourhood or parents fear the injection. Pakistan's vaccination effort must address each of those barriers.

What Does Zero-Dose Mean?

Zero-dose children are children missed by routine immunisation, identified through the absence of a first dose such as the diphtheria, tetanus and pertussis vaccine, known as DTP1. That first dose is an important entry point into a schedule of vaccinations intended to protect children against several preventable diseases.

The global study estimated that 15.7 million children were zero-dose in 2023. More than half lived in just eight countries, while South Asia accounted for 13% of the worldwide total. Pakistan's approximately 419,000 children represented a substantial part of that regional burden.

Children who miss routine vaccination are often among the hardest to reach through other health services as well. They may live in crowded urban settlements, remote rural communities or areas affected by conflict. Missing vaccination leaves them particularly vulnerable to preventable illness and death.

Dr. Jonathan Mosser, the study's senior author at the University of Washington's Institute for Health Metrics and Evaluation, warned that the scale of missed vaccination demanded a stronger focus on children being left behind:

Large numbers of children remain under and un-vaccinated. The latest estimates should be taken as a clear warning that global immunisation targets for 2030 would not be achieved without transformational improvements in equity.

Equity, in this setting, means making protection available to children regardless of their family's income or where they live. Raising a national vaccination rate requires reaching communities where routine services are weakest, as well as maintaining coverage where programmes already work well.

How the Pandemic Interrupted Progress

Between 1980 and 2019, the number of zero-dose children worldwide fell by nearly 75%. That long improvement was followed by a major setback: from 2020 to 2023, an estimated 12.8 million additional children globally became zero-dose.

Lockdowns interrupted visits to health facilities, while staff and other resources were redirected to the COVID-19 response. Misinformation spread widely during the same period, adding another obstacle to restoring routine vaccination.

Pakistan experienced a sharp rise in missed vaccination before recovery efforts brought the number down. The main milestones show the scale of that disruption:

• 2019: Pakistan had approximately 639,000 zero-dose children.
• 2020: The number rose to more than 800,000 as routine immunisation activities were suspended during the pandemic.
• 2023: Recovery efforts reduced the estimated number to around 419,000.

Pakistan's 2023 zero-dose estimate was lower than its 2019 figure, although vaccination coverage had yet to return to levels before the pandemic. The number of children missing an initial dose and coverage across vaccination schedules describe different parts of the recovery.

UNICEF's 2023 report on vaccine confidence found that public perceptions of the importance of childhood vaccines declined in 52 of the 55 countries studied during the pandemic. In Pakistan, fear and misinformation added to longstanding problems involving poverty, transport, limited healthcare access, security and low literacy.

Polio Shows the Cost of Gaps in Protection

Pakistan and Afghanistan remain the only two countries where wild poliovirus is endemic, meaning transmission continues within the population. Pakistan's repeated resurgences show how difficult it is to sustain protection when some communities remain poorly vaccinated.

According to the Centers for Disease Control and Prevention, Pakistan reported one wild poliovirus case in 2021, followed by 14 cases in just four months in 2022. Most of those cases occurred among populations with inadequate immunisation.

Khyber Pakhtunkhwa and Balochistan have been particular areas of concern. Health workers face logistical difficulties in reaching remote communities and places affected by conflict. Security threats, including targeted attacks on vaccination workers, can interrupt access further.

Persistent refusals also hamper polio eradication. Mistrust and misinformation can lead parents to reject vaccination even when teams reach their homes. These obstacles overlap: a community may face unreliable services, insecurity and doubts about vaccines at the same time.

Polio therefore reflects a wider problem in childhood immunisation. Reaching a child once is only part of the task. Programmes must also provide dependable access to the doses children need over time, while maintaining enough trust for families to accept them.

Urban Settlements Reveal Another Access Gap

A study by the Sabin Vaccine Institute and NIH Pakistan found that 11.3% of children younger than two in the urban slum communities studied were zero-dose. Karachi had the highest prevalence within those communities.

Many parents expressed a desire to vaccinate their children. Nevertheless, distrust of vaccines, belief in conspiracy theories and economic hardship prevented some families from obtaining vaccination. Living in a city did not guarantee that routine services were within practical reach.

Healthcare workers and programme managers described a combination of logistical problems, misinformation and complex social relationships that reduced vaccine uptake. For families under financial pressure, the cost and difficulty of reaching care could compound worries about vaccination itself.

The study recommended stronger training for community health workers, cooperation with local leaders and communication suited to the communities being served. Those measures aim to make services more accessible while giving parents explanations they can understand and trust.

Pakistan's urban and rural challenges share a central feature: children can remain outside routine care even when vaccination programmes exist. Identifying the particular reason each community is being missed is essential to choosing a useful response.

Why Some Parents Refuse Vaccination

A 2024 study in Peshawar found that 22% of parents refused vaccines for their children. Refusal was more common among employed mothers and in certain areas considered at high risk.

Vaccine hesitancy means reluctance or refusal to vaccinate despite vaccines being available. In the Peshawar study, concerns included vaccine safety and side effects, mistrust of government and health authorities, and the influence of religious or community leaders.

Fear of adverse effects was particularly prominent in conservative communities and communities with low literacy. Parents also faced practical barriers, including distance to health facilities and the costs associated with getting there.

The study recommended mobile immunisation units, longer clinic opening hours and engagement with community leaders. Mobile teams can bring vaccination closer to families, while extended hours can give parents more opportunities to attend. Working with trusted local figures addresses a different need: confidence in the service being offered.

Pakistan's response therefore has to account for both access and trust. A parent who cannot reach a clinic needs a practical change in service delivery. A parent worried about side effects needs clear information and a trusted person able to discuss those concerns.

What Lahore's Gains Show

Lahore district offers an example of improvement through targeted work. Immunisation rates rose from 69% to 85% within a few months after teams mapped urban pockets that were difficult to reach and deployed vaccinators equipped with digital tools.

The increase amounted to 16 percentage points. Mapping helped programmes locate missed communities, while digital tools supported the tracking of children who had not received routine vaccines.

Dr. Mukhtar Ahmed, Director of the Expanded Programme on Immunization Punjab, attributed the improvement to mobile health units, better infrastructure and close cooperation between government agencies, international partners and local communities.

The introduction of Clinics on Wheels and the creation of thousands of new vaccinator posts have expanded the reach of immunisation services. These initiatives address the practical problem of getting staff and vaccines to families who would otherwise struggle to obtain them.

Community engagement has supported that work. Health workers have cooperated with local leaders and influential community members to build confidence and counter misinformation. Digital tracking has also helped identify zero-dose children who might otherwise be missed during vaccination campaigns.

Vaccines Need Reliable Transport and Fairer Reach

UNICEF and Gavi have provided 31 refrigerated trucks to strengthen Pakistan's vaccine transport system. The vehicles support the cold chain, the temperature controlled storage and transport needed to keep vaccines effective as they move towards the people receiving them.

Reliable refrigeration is especially important in hot regions and on journeys to remote communities. Expanding vaccination requires both a supply of doses and a dependable way to deliver those doses in usable condition.

Provincial differences show how uneven access remains. In 2021, only 45% of children in Balochistan received three doses of oral polio vaccine, compared with nearly 95% in Punjab. That was a gap of about 50 percentage points.

The contrast reflects wider differences in governance, infrastructure and social inequality. Punjab's stronger coverage and Lahore's recent gains offer examples of progress, while Balochistan's figures show the scale of work still needed elsewhere.

Dr. Zafar Mirza, a former federal health minister and WHO Director for Health Systems, called for greater attention to children living in poverty:

The immunisation of children living in poverty still needs more attention because poverty and health are quite linked with each other. We need to target such communities with more financing and responsibility to end this disparity.

Targeted investment, communication suited to local needs and a sustained commitment to marginalised communities are central to reducing those differences. National progress depends on improving protection in the places where children remain most exposed.

What Pakistan Needs to Reach the 2030 Goals

The Immunisation Agenda 2030 (IA2030), endorsed by the World Health Assembly, sets goals of 90% coverage for key vaccines and a 50% reduction in zero-dose children by 2030 compared with 2019.

The global study warned that Pakistan was unlikely to meet those targets without immediate, far reaching action. Only 18 of the 204 countries and territories examined had already met the 2030 target as of 2023.

Pakistan would need to increase immunisation coverage by at least two percentage points annually, a pace achieved by few countries historically. Sustaining that improvement would require progress across several connected parts of the vaccination programme:

• Address vaccine hesitancy through education based on evidence and engagement with communities.
• Expand access through mobile units, extended clinic hours and workplace vaccination programmes.
• Invest in health infrastructure, particularly in underserved regions.
• Strengthen data systems to identify zero-dose children and help vaccination teams reach them.

UNICEF and other global partners have called on governments to strengthen their commitment, make available resources accessible and accelerate catch-up vaccination. Catch-up efforts give children who missed scheduled doses another opportunity to receive protection.

Pakistan's experience brings together both the scale of the problem and examples of progress: approximately 419,000 zero-dose children in 2023, a large provincial gap in polio vaccine coverage, and a rise from 69% to 85% in Lahore district's immunisation rate. Expanding practical access while building trust is central to protecting children still outside routine services.

Key Points

• Pakistan had approximately 419,000 zero-dose children in 2023, the second highest number in South Asia after India.
• The global study estimated 15.7 million zero-dose children in 2023, with 13% in South Asia.
• Pakistan's number rose from 639,000 in 2019 to more than 800,000 in 2020 before falling during recovery efforts.
• Pakistan and Afghanistan remain the only countries where wild poliovirus is endemic.
• Studies identified missed vaccination in urban slum communities and a 22% parental refusal rate in Peshawar.
• Lahore district's immunisation rate rose from 69% to 85%, while major provincial differences persisted.
• Mobile services, community engagement, reliable vaccine transport and better tracking are central to reaching missed children.
• The 2030 goals call for 90% coverage for key vaccines and half as many zero-dose children as in 2019.