Variations in Routine Childhood Vaccination Gaps: A Decomposition Analysis Across 80 Low- and Middle-Income Countries

Background: Despite remarkable progress in expanding access to childhood vaccines in the last two decades, global coverage with the third dose of the diphtheria-tetanus-pertussis-containing vaccine (DTP3) has recently plateaued, with many countries yet to meet the targets of the Immunization Agenda 2030 (IA2030). As countries cluster around the 80% coverage mark, further gains require targeted interventions for unreached populations. This analysis disaggregates children missing DTP3 into three groups-zero dose (ZD), missed DTP (MD), and drop-out (DO)-which, with DTP3, form four mutually exclusive groups, and examines which of these groups contributes most to coverage changes across countries. Methods: A total of 295 Demographic and Health Surveys from 1986 to 2023 were analyzed across 80 countries, comprising over 2.4 million children. Children were classified into mutually exclusive groups: DTP3, ZD, MD, and DO. We described trends over time and conducted decomposition analyses using a naïve approach and a structural model with isometric log-ratio transformations and causal mediation pathways. Results: Among the 2.4 million children across 80 countries, 63.8% had received DTP3, while 16.2% were DO, 8.8% were MD, and 11.2% were ZD. Countries showed important variations: some mainly reduced ZD, others reduced MD or DO, many achieved balanced progress, and a few experienced setbacks. The naïve model showed that coverage changes reflected different combinations of shifts across ZD, MD, and DO depending on context. The structural model indicated that DO had the strongest direct association with DTP3 coverage, followed by MD and ZD. Conclusions: This analysis highlights the differential contribution of intermediate groups to coverage variations over time. Understanding the association between coverage gains and shifts in ZD, MD, or DO can complement existing strategies to inform targeted planning and accelerate progress towards IA2030 equity goals.