Whether in the dense slums of urban Bangladesh, or amidst the serenity of coastal regions, or deep in the isolated wetlands of haor areas; thousands of children remain invisible to the health system. These children, referred to as zero-dose (ZD) and under-immunied (UI), are missing out on life-saving vaccines that shield against deadly diseases. A recent study conducted by the Country Learning Hub (CLH) for Immuniation Equity has shed light on this critical issue, offering insights and strategies that could transform the country’s immunisation landscape. 

Between December 2022 and May 2023, the study utilised innovative methods to locate ZD and UI children and identify the communities they belong to. Combining secondary data analysis from national surveys, primary data collected through Lot Quality Assurance Sampling (LQAS), and qualitative interviews, the research delved deep into the demand and supply-side barriers hindering vaccination efforts.

The study’s findings are not just academic. They have life-or-death implications. Unvaccinated children are at a higher risk of contracting diseases like measles, polio, and diphtheria. Moreover, missed immunisations not only compromise individual health but also threaten community-wide immunity, making outbreaks more likely and more devastating.

In Bangladesh, the ZD prevalence varies dramatically depending on geography. The study identified Gaffargaon Upazila in Mymensingh as having the highest prevalence (15.7%), followed closely by Jamalganj Upazila in Sunamganj. These areas—and others identified in 21 districts across the country—highlight the diverse challenges in reaching marginalised populations. For example, in urban slums, high migration rates make tracking children difficult, while in coastal and char regions, river erosion forces families to relocate frequently, disrupting vaccination schedules.

The study identified several barriers that lead to children being ZD or UI. On the demand side, migration, fear of side effects, and entrenched misconceptions about vaccines emerged as major obstacles. In some areas, particularly in Sunamganj, religious conservatism and distrust of outsiders delivering immunisation services further compounded the problem.

Supply-side barriers were equally daunting. Shortages of health assistants (HAs) and other field-level workers left large areas underserved. In some remote regions, a single HA is responsible for multiple wards, making it impossible to cover every site effectively. Poor infrastructure, limited transportation, and inaccurate population data further complicated vaccination efforts.

This research has real-world relevance. The innovative use of LQAS surveys proved to be an effective and replicable method for identifying pockets of ZD and UI children. By validating findings from secondary data through field assessments, the study ensures its recommendations are rooted in reality, not just theoretical projections.

The findings also offer actionable insights for policymakers. For example, addressing reproductive autonomy—identified as a key factor influencing ZD prevalence—requires empowering women through education and access to family planning services. Similarly, improving access to transportation and ensuring a stable health workforce could significantly boost immuniation rates in hard-to-reach areas. The lessons from this study go beyond Bangladesh. Other countries grappling with immunisation equity can adapt its methods to identify and address their own pockets of missed children. From India to Nigeria, examples abound of how targeted interventions based on rigorous data can yield significant results. 

In Bangladesh, the next step is clear. Policymakers, health managers, and communities must work together to design and implement interventions that address the root causes of immuniation gaps. The stakes are high: closing these gaps could save thousands of lives, protect millions more, and bring Bangladesh closer to achieving universal immunisation coverage. 

Reference: 

Identifying the zero-dose and under-immunized children in Bangladesh: Approaches and experiences [Internet]. Gavi.org. [cited 2025 Jan 6]. Available from: https://zdlh.gavi.org/resources/identifying-zero-dose-and-under-immunized-children-bangladesh-approaches-and-experiences