Using data from Demographic and Health Surveys conducted across 21 sub-Saharan African countries between 2015 and 2023, the authors mapped spatial variation in zero-dose prevalence and examined how sociodemographic and health service factors relate to zero-dose status at individual and population levels.
Key findings:
Widespread subnational heterogeneity: Zero-dose prevalence varied markedly within and between countries, with overall pooled prevalence around 26 %, and notable differences in antigen-specific zero-dose rates (e.g., measles ~43 %).
Spatial clustering: Most countries displayed significant geospatial clustering, revealing local “hotspots” of zero-dose children.
Structural disadvantage: Children in rural areas, from the poorest households, with low maternal schooling or literacy, and limited access to information were significantly more likely to be zero-dose.
Missed early contact with health system: Indicators such as home delivery and few or no antenatal care visits were strongly associated with higher odds of zero-dose status.
Population contribution: Structural factors explained substantial portions of the zero-dose burden, with both location/SES and literacy/information blocks contributing 30–60 % of the population-attributable risk, depending on country context.
Zero-dose status in sub-Saharan Africa is not randomly distributed but highly localized and tightly linked to structural inequities and weak early health system contact. These findings support the use of fine-scale mapping and equity-focused planning to inform strategies for reducing immunization gaps and accelerating progress toward global zero-dose targets such as those in IA2030.
Thumbnail image credit: WHO
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