Virtually every country on Earth vaccinates babies. The World Health Organization’s Expanded Programme on Immunization, launched in 1974, now spans its member states, and WHO and UNICEF track infant vaccination coverage in every nation annually. What differs from country to country is not whether babies get vaccinated but which vaccines they receive, when they receive them, and whether vaccination is legally required or simply recommended. Those differences reveal a lot about how geography, disease burden, economics, and culture shape the way societies protect their youngest members.
The Global Baseline
WHO and UNICEF produce yearly estimates of national infant vaccination coverage for a core set of vaccines: BCG (tuberculosis), three doses of diphtheria-tetanus-pertussis (DTP), three doses of polio vaccine, three doses of hepatitis B, three doses of Haemophilus influenzae type b (Hib), and at least one dose of a measles-containing vaccine.1PubMed Central. WHO and UNICEF estimates of national infant immunization coverage: methods and processes These are the antigens that form the floor of what most countries consider the minimum for infant health. Global coverage for the first dose of measles vaccine, for instance, climbed back to about 83% in 2022 after dipping during the pandemic, though that was still below pre-pandemic levels.2MMWR Morbidity and Mortality Weekly Report. Routine Vaccination Coverage — Worldwide, 2022
Modelling of the first 50 years of the EPI, covering 14 pathogens, has shown the enormous scale of what routine childhood vaccination has accomplished worldwide.3PubMed Central. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization Separate estimates put the figure at roughly 87 million deaths averted between 1990 and 2019 from just four childhood vaccines (DTP, measles, rotavirus, and Hib), representing about a 24% reduction compared to a world without those vaccines.4PubMed Central. Global vaccine coverage and childhood survival estimates: 1990–2019 These numbers are not driven by one or two wealthy nations. They reflect gains across more than 200 countries and territories, because infant vaccination really is a near-universal practice.
How Schedules Differ From Country to Country
Saying every country vaccinates babies does not mean every country uses the same schedule. A cross-sectional study of 32 countries (the United States plus 31 European nations) found that 20 out of 24 available pediatric vaccines appeared on at least one country’s schedule, but only 9 of those were recommended by all 32 countries. The total number of vaccines on any given national schedule ranged from 11 to 18.5PubMed. Characterizing the landscape of pediatric immunization schedules in the US and Europe For most shots, countries agreed on the number of doses and roughly when the first dose should be given. Bigger disagreements showed up around meningococcal vaccines, hepatitis B timing, and COVID-19 vaccines for children.
Japan is an instructive example of how national history shapes a schedule. Compared to the United States, Japan was historically slower to add newer vaccines to its routine program, a gap that researchers have attributed to specific adverse-event controversies that made Japanese regulators and the public more cautious. Efforts to close what has been called the “vaccine gap” between Japan and other high-income countries have been ongoing.6PubMed. Comparison of immunization systems in Japan and the United States – What can be learned? Japan’s experience is a reminder that two countries can both vaccinate their babies yet end up with meaningfully different lists of antigens.
Even the way vaccines are physically combined varies. Peru, for example, evaluated a switch from a five-in-one (pentavalent) vaccine plus separate polio doses to a six-in-one (hexavalent) vaccine that bundles an acellular pertussis component, hepatitis B, Hib, and inactivated polio into a single shot for the 2-, 4-, and 6-month visits.7PubMed Central. Introduction of a hexavalent vaccine containing acellular pertussis into the national immunization program for infants in Peru: a cost-consequence analysis of vaccination coverage Combination vaccines reduce the number of injections a baby receives, which can improve parent acceptance and simplify cold-chain logistics, but they cost more per dose and are not available everywhere.
Vaccines That Only Some Countries Use
Certain vaccines appear on some national schedules and not others because the diseases they target are not present everywhere. BCG, the tuberculosis vaccine given at birth in many countries, is the clearest example. Over 80% of the world’s countries still recommend universal BCG vaccination for newborns, and every country in sub-Saharan Africa, Latin America, and East and South Asia follows that policy. Countries that have stopped giving BCG universally, or that target it only to high-risk groups, are almost exclusively low-burden nations with fewer than 20 tuberculosis cases per 100,000 people.8BMJ Open. Tracking changes in national BCG vaccination policies and practices using the BCG World Atlas Most of Western Europe, the United States, and Canada fall into that latter category.
Malaria vaccination is newer and even more geographically targeted. The RTS,S/AS01 vaccine, the world’s first malaria vaccine, was recommended by WHO in October 2021 for children living in areas with moderate-to-high transmission of Plasmodium falciparum malaria.9PubMed Central. Subnational introduction of the RTS,S/AS01(E) malaria vaccine into routine immunization: experience and lessons from the three pilot countries Ghana, Kenya, and Malawi piloted the vaccine and have since integrated it into their routine immunization services. Cameroon and Burkina Faso became the first countries outside those pilot nations to incorporate it, and Uganda and Guinea have plans to follow.10PubMed Central. Policy uptake and implementation of the RTS,S/AS01 malaria vaccine in sub-Saharan African countries: status 2 years following the WHO recommendation No one in Scandinavia or Japan needs a malaria vaccine on their infant schedule, but for children in sub-Saharan Africa, it fills a gap that no other routine vaccine does.
Rotavirus and pneumococcal conjugate vaccines occupy a middle ground. They protect against diseases that exist worldwide but cause disproportionate death in low-income settings. Modelling has shown that scaling up pneumococcal vaccine in low- and middle-income countries could reduce the number of households experiencing catastrophic health costs by about 30%, and expanding rotavirus vaccination could cut those costs by roughly 40%.11BMJ Global Health. Poverty reduction and equity benefits of introducing or scaling up measles, rotavirus and pneumococcal vaccines in low-income and middle-income countries: a modelling study Yet adoption has been slow in many countries precisely because these are newer, more expensive vaccines that were not part of the original EPI.
Mandatory Versus Recommended
Countries also split on whether childhood vaccination is legally required. A global assessment of 193 countries found that about 54% had evidence of a nationwide vaccination mandate as of 2018.12PubMed Central. Global assessment of national mandatory vaccination policies and consequences of non-compliance Among those with mandates, roughly 59% defined at least one penalty for non-compliance. The most common penalty was restricting school enrollment: about 69% of countries with penalties used educational consequences, and most of those refused school entry until vaccination requirements were met.
Within Europe, the picture is split almost down the middle. As of 2024, 13 European countries had at least one mandatory pediatric vaccination, with France, Hungary, and Latvia requiring nearly all childhood vaccines. Meanwhile, 17 European countries had no mandates at all and relied entirely on recommendations. Between 2014 and 2024, six European countries introduced or extended mandatory vaccination policies, a trend often triggered by falling coverage and measles outbreaks.13PubMed Central. Childhood Mandatory Vaccinations: Current Situation in European Countries and Changes Occurred from 2014 to 2024 Some of the countries with no mandates, like the Nordic nations, maintain very high coverage through public trust and accessible health systems alone. The absence of a mandate does not necessarily mean low uptake, and the presence of one does not guarantee high uptake.
The United States takes a different approach by tying vaccination requirements to school entry, with each state setting its own list and exemptions. Federal funding through the Vaccines for Children (VFC) program provides vaccines at no cost to children who are uninsured, underinsured, or eligible for Medicaid, with CDC distributing funds to 61 state, local, and territorial immunization programs.14Centers for Disease Control and Prevention. Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program — United States, 1994–2023 A comprehensive database tracking mandatory childhood vaccination policies across 149 countries has categorized them on a scale from fully mandatory, to mandatory for school entry, to recommended only, showing that most of the world falls somewhere on that spectrum rather than at one extreme.15PubMed. Charting mandatory childhood vaccination policies worldwide
Funding and Logistics in Lower-Income Countries
For the wealthiest countries, paying for childhood vaccines and keeping them cold is straightforward. For the rest, international funding plays a decisive role. Gavi, the Vaccine Alliance, has provided over $16 billion in funding for vaccination in low- and middle-income countries since 1999. Research exploiting the staggered timing of Gavi support across countries and vaccines has found that Gavi’s involvement raised coverage rates by 2 to 5 percentage points across all vaccines and by 10 to 20 percentage points for newer vaccines.16American Economic Journal: Economic Policy. Effective Health Aid: Evidence from Gavi’s Vaccine Program A separate analysis estimated that through 2016, Gavi support was directly attributable to vaccinating about 46.6 million children with pneumococcal conjugate vaccine, 75.2 million with pentavalent vaccine, and 12.3 million with rotavirus vaccine.17PubMed. Effect of donor funding for immunization from Gavi and other development assistance channels on vaccine coverage: Evidence from 120 low and middle income recipient countries
Quasi-experimental evidence has shown that on average, Gavi increased DPT immunization rates by about 12 percentage points and measles vaccination rates by roughly 9 percentage points above baseline levels in eligible countries.18BMJ. Has Gavi lived up to its promise? Quasi-experimental evidence on country immunisation rates and child mortality Those gains are real and substantial, but they depend on functional delivery systems. An evaluation of rural health facilities in Kenya found that many lacked adequate vaccine carriers, icepacks, and functional temperature-monitoring devices for their refrigerators, and that routine maintenance and contingency planning remained persistent challenges.19PubMed Central. Evaluation of vaccine storage and distribution practices in rural healthcare facilities in Kenya The vaccine itself might be free, paid for by Gavi, but getting it from a regional warehouse to a health post in a remote area at the right temperature is the harder problem.
Vaccine Confidence Around the World
Even when vaccines are available and affordable, parents have to agree to bring their children in. A 67-country survey found that overall sentiment toward vaccination is positive worldwide, but with enormous variability. Vaccine-safety concerns were highest in Europe, where 7 of the 10 least confident countries were located. In France, 41% of respondents disagreed that vaccines are safe, compared to a global average of 13%. Bosnia and Herzegovina was close behind at 36%.20EBioMedicine. The State of Vaccine Confidence 2016: Global Insights Through a 67-Country Survey A separate survey of parents in 18 European countries found that about 24% described themselves as “somewhat hesitant” about childhood vaccines, with confidence highest in Portugal and Cyprus and lowest in Bulgaria and Poland.21PubMed. Vaccine confidence among parents: Large scale study in eighteen European countries
A large-scale temporal modelling study spanning multiple years and countries identified the factors most consistently linked to whether parents actually vaccinate their children. High confidence in vaccines themselves was associated with higher uptake in 66 countries. Trusting healthcare workers more than family, friends, or social media for health advice mattered in 43 countries. Higher levels of science education helped in 35 countries. Women were more likely than men to report having their child vaccinated in 41 countries. Religion and income were less consistently linked to uptake, though when religion did matter, it was minority religious groups that tended toward lower vaccination rates.22PubMed Central. Mapping global trends in vaccine confidence and investigating barriers to vaccine uptake: a large-scale retrospective temporal modelling study
What Happens When Vaccination Breaks Down
The consequences of disrupted vaccination programs show up fast. Measles, because of its extreme infectiousness, is usually the first disease to resurge. Research has found that disruptions lasting six months or longer, especially in areas where measles vaccine coverage was already below target, produce an observable increase in measles cases.23PubMed Central. Impact of disruptions to routine vaccination programs, quantifying burden of measles, and mapping targeted supplementary immunization activities The 2014–2015 Ebola outbreak in West Africa provided a grim natural experiment. As health systems in Guinea, Liberia, and Sierra Leone collapsed under the weight of Ebola, routine childhood vaccination fell apart. Modelling projected that after 18 months of disruption, a large cluster of unvaccinated children would accumulate across the three countries, increasing the expected size of a regional measles outbreak from about 127,000 to 227,000 cases and causing 2,000 to 16,000 additional deaths.24PubMed Central. Reduced vaccination and the risk of measles and other childhood infections post-Ebola
The polio eradication effort has demanded its own form of global coordination. All 47 member states in the WHO African Region carried out a synchronized switch from trivalent oral polio vaccine to bivalent oral polio vaccine, a step meant to eliminate vaccine-derived type 2 poliovirus while maintaining protection against the remaining types.25The Journal of Infectious Diseases. Introduction of Inactivated Poliovirus Vaccine and Trivalent Oral Polio Vaccine/Bivalent Oral Polio Vaccine Switch in the African Region That kind of continent-wide, simultaneously executed policy change only makes sense in a world where every country in the region is already vaccinating its babies as a matter of course.
Refugee and Migrant Children Fall Through the Gaps
One population that consistently gets shortchanged on vaccination is children on the move. A systematic review of vaccination coverage among migrant and refugee children in the Middle East and North Africa found dropout rates between roughly 12% and 39% across routine vaccines from the first dose to subsequent doses.26eClinicalMedicine. Vaccination coverage and access among children and adult migrants and refugees in the Middle East and North African region: a systematic review and meta-analysis That means even among families who start the series, a significant share do not finish it.
In Europe, a review of the evidence identified several overlapping barriers. Migrant families frequently move between countries, making multi-dose schedules hard to complete. Their immunization records are often lost or never existed. Host countries sometimes face economic strain that limits health system capacity. Some migrants avoid registering with medical authorities out of fear of legal consequences. And poor coordination between neighboring countries’ public health systems means doses get duplicated in some cases and skipped in others.27PubMed Central. Vaccinations in migrants and refugees: a challenge for European health systems. A systematic review of current scientific evidence These are not problems caused by anti-vaccine sentiment. They are logistical and systemic failures that leave mobile children under-protected even when both the families and the host countries intend for vaccination to happen.
Regulatory Barriers and Access to Pediatric Formulations
Even beyond the question of which vaccines a country recommends, there is the matter of whether age-appropriate versions of medicines and vaccines are actually available. A multi-country comparative analysis found that the availability of authorized pediatric medicines and formulations in countries like Brazil, Kenya, Russia, and South Africa was lower than in Europe and the United States. Generic versions of medicines often lacked pediatric-specific formulations even when the original manufacturer made them. Regulatory barriers included a lack of harmonized pediatric research requirements and poor availability of products with pediatric use information. In several of these countries, broader health-system problems like financing and supply chain weaknesses compounded the regulatory gaps.28Heidelberg University (heiDOK). Multi-country comparative analysis of paediatric regulatory frameworks and their impact on access to medicines in times of pandemic and beyond
This means that even when a country has adopted a vaccine on paper, the specific formulation designed for infants may not be consistently stocked or registered in that market. A vaccine that exists and is recommended is not the same as a vaccine that is sitting in a clinic refrigerator ready to go into a baby’s arm. The regulatory pathway, the supply agreements, and the domestic manufacturing or importation capacity all have to line up. For wealthier nations this alignment is almost invisible. For countries building or rebuilding their health systems, each link in that chain is a place where access can quietly fail.