Zero-Dose Children and Missed Communities (2014 - present)

Context

In 2020, the World Health Assembly endorsed "Immunization Agenda 2030" (IA2030) a flagship immunisation strategy for the UN Sustainable Development Goals period. Developed with a strong focus on equity, IA2030 aims to ensure that immunisation services regularly reach all children and communities, especially those not receiving the full benefits of immunisation. To achieve this, it has made halving the number of “zero-dose” children (infants who do not receive even a single vaccine dose delivered through the routine immunisation system) a key target.

I have made significant contributions to this policy agenda, conducting research on zero-dose and under-vaccinated children, households, and communities in India, Latin America, and around the world.

(c) Raah Health & Social Development Foundation

Contributions

I have led descriptive and aetiological analyses of public datasets documenting prevalence, location, determinants, and possible consequences of child zero-dose status (and under-immunisation more generally).

• Until recently, attention focussed on under-vaccinated children; unvaccinated children were not a policy focus. In 2014, we published, to our knowledge, the first analysis distinguishing children unreached by any immunisation services from those unreached by routine immunisation (zero-dose), and advocated for strengthening of routine immunisation systems.(1)

• Our global (2,3), regional (4), national and sub-national (4-8) analyses have highlighted the role of child zero-dose status as a marker of generalised vulnerability to negative health and development outcomes.  Our landmark 2021 paper published in The Lancet Global Health demonstrated that, in India, zero-dose children belonged to socially disadvantaged groups and were also more likely to be stunted, placing them at the nexus of transmission of intergenerational inequities.(5)

• An analysis including 68 countries demonstrated that a single percentage point average annual decline in zero-dose prevalence was associated with an average annual decrease of 1.2 post-neonatal and child deaths per 1000 live births.(2)

• We analysed a population cohort to study the relationship between zero-dose vaccination status in early childhood and learning attainment in preadolescence, a critical child development milestone. We found that found that zero-dose vaccination status was associated with poor learning outcomes at ages 8-11 years for some, but not all, children, and that risk was differentiated by the level of community socioeconomic development. Specifically, zero-dose children living in contexts of very low socioeconomic development were at elevated risk of poor learning attainment in preadolescence. We concluded that a multisectoral intervention strategy focussing on zero-dose children in high-needs geographies could contribute to attainment of SDG 3 (good health and well-being) and SDG 4.1 (inclusive and equitable quality education) for transformative change.(7)

• An analysis of small-area variations in vaccination coverage in India recommended a strategic shift towards identification and targeting of low-immunity clusters at the sub-district level to achieve India's vaccination goals.(9)

• Bringing to light an understudied and modifiable risk factor, a new global analysis of 82 countries demonstrates that orphans and children lacking parental care are more likely to be under-vaccinated and zero dose. We recommend specific improvements to service delivery to bridge this gap.(3)

• I have also conducted reviews and evidence syntheses to inform policy design related to the zero-dose strategy for Gavi, the Vaccine Alliance and IA2030 partners.(10-12) This work has been conducted conducted in collaboration with cross-functional teams involving Gavi, my students at the University of Montreal, and Alliance partners. Notably, as a consultant at Gavi in 2023-2024, I led a high-priority synthesis of the published scientific literature on zero-dose (unvaccinated) children, providing timely evidence to inform the design and operationalisation of the Gavi 6.0 (2026-2030) strategy.(12) Work was performed under very tight time pressure so as to contribute effectively to the organisational dialogue. Findings were shared through presentations, and policy briefs with organisational leadership and Board committees as part of the Gavi 6.0 design phase concluded in June 2024. Enabling countries to extend immunisation to zero-dose children and missed communities, integrated with primary health care, was named as the first priority of the Gavi 6.0 strategy. Our results were also shared with 700+ Alliance partners in September 2024 as part of the 6.0 strategy operationalisation phase.

• Finally, at the field level, under my leadership, our team is currently implementing a cutting-edge field study to test a novel multisectoral intervention to benefit zero-dose children and missed communities (home to clusters of zero-dose and under-immunised children).(13)

Impact

Our research underscores that zero-dose children, their households, and communities often suffer from multiple deprivations, significantly hindering their ability to survive and thrive. It further recommends the need for comprehensive intervention strategies, such as integration with primary healthcare and multisectoral approaches, to address multiple risks.

This work has contributed to the dialogue for Gavi, WHO, UNICEF and partners -- enhancing the focus on vaccine equity and prioritising holistic approaches to address the needs of the most vulnerable via the global strategy to reach zero-dose children & missed communities in the context of the United Nations Sustainable Development Goals.

Selected research

1. Daouda Sissoko*, Helen Trottier, Denis Malvy, Mira Johri. (2014) The influence of compositional and contextual factors on non-receipt of basic vaccines among children of 12-23-month old in India: A multilevel analysis. PLoS ONE 9(9): e106528 https://doi.org/10.1371/journal.pone.0106528

2. Omar Karlsson; Sunil Rajpal; Mira Johri; Rockli Kim; S V Subramanian. Prevalence and trends of not receiving first-dose of DPT-containing vaccine among children 12–35 months: An analysis of 100 low- and middle-income countries. J Epidemiol Glob Health (2024). https://doi.org/10.1007/s44197-024-00294-6

3. Johri M, Munir M, Medeiros RA, Shakya L, Damte B, Bolgrien A. The effects of orphanhood and lack of parental care on child vaccination: analyses of 189 cross-sectional UNICEF Multiple Indicator Cluster Surveys from 82 countries, 2005–2022. eClinicalMedicine. 2025;85:103314. https://doi.org/10.1016/j.eclinm.2025.103314

4. Fene, Fato*; Johri, Mira; Michel, Manassé Eliantus; Reyes-Morales, Hortensia, Pelcastre-Villafuerte, Blanca.  Multiple deprivations as drivers of suboptimal basic child vaccination in Latin America and the Caribbean: cross-sectional analysis of household survey data for 18,136 children across 211 regions in 15 countries. International Journal for Equity in Health. 2025;24(1):184. https://doi.org/10.1186/s12939-025-02561-9

5. Johri M, Rajpal S, Subramanian SV. Progress in reaching unvaccinated (zero-dose) children in India, 1992–2016: a multilevel, geospatial analysis of repeated cross-sectional surveys. The Lancet Global Health. 2021;9(12):e1697-e706. https://doi.org/10.1016/S2214-109X(21)00349-1

6. Rajpal S, Kumar A, Johri M, Kim R, Subramanian SV. Patterns in the Prevalence of Unvaccinated Children Across 36 States and Union Territories in India, 1993-2021. JAMA Network Open. 2023;6(2):e2254919. https://doi:10.1001/jamanetworkopen.2022.54919

7. Mira Johri, Edmond S.W. Ng, Georges K. Koné, Alyssa Sharkey, Delphine Bosson-Rieutort, S.V. Subramanian. The effects of zero-dose vaccination status in early childhood and level of community socio-economic development on learning attainment in pre-adolescence in India: A population-based cohort study BMJ Public Health 2023;1:e000022. https://doi:10.1136/bmjph-2023-000022

8. Gutiérrez JP, Johri M. Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021. Rev Panam Salud Publica. 2023;47:e35. https://doi.org/10.26633/RPSP.2023.35

9. Mira Johri, Sunil Rajpal, Rockli Kim, SV Subramanian. Small-area variation in child under-vaccination in India: A multilevel analysis of 36 states and Union Territories, 707 districts, and 22,086 small-area clusters. The Lancet Regional Health - Southeast Asia. 2025;32:100504. https://doi.org/10.1016/j.lansea.2024.100504

10. Ivanova, V.*; Shahabuddin, A.S.M.; Sharkey, A.; Johri, M. Advancing Immunization Coverage and Equity: A Structured Synthesis of Pro-Equity Strategies in 61 Gavi-Supported Countries. Vaccines 2023, 11, 191. https://doi.org/10.3390/vaccines11010191

11. Ducharme, J.*; Correa, G.C.; Reynolds, H.W.; Sharkey, A.B.; Fonner, V.A.; Johri, M. Mapping of Pro-Equity Interventions Proposed by Immunisation Programs in Gavi Health Systems Strengthening Grants. Vaccines 2023, 11, 341. https://doi.org/10.3390/vaccines11020341

12. Beaulieu A*, Ducharme J*, Thibeault C*, Akani BC*, Ziegler D, Correa GC, Reynolds HW, Hogan D, Johri M. The Immunization Agenda 2030 strategy to reach zero-dose children in low- and middle-income countries: a living scoping review 2025.(revision requested)

13. A cluster-randomised trial of a multifaceted intervention to promote child vaccination and linkage to social protection schemes.  https://doi.org/10.1186/ISRCTN15768745