Immunisation is universally the most cost-effective and efficient way to control and eliminate vaccine-preventable diseases that cause childhood illnesses and deaths.

Nepal’s National Immunisation Programme has been the top government priority for the past 45 years. What began as the “Expanded Programme on Immunisation” in 1978 (2034BS) was taken across the country within a decade.

The programme was initially started with three basic antigens—BCG, DPT and measles. Now 13 antigens have been included in the routine immunisation programme.

The health authorities provide regular immunisation services through more than 16,000 centres across the country.

The programme is credited with reducing under-five mortality, infant mortality and neonatal deaths.

As per the latest studies, 80 percent of Nepali children aged between 12 and 23 months are fully vaccinated with basic antigens.

However, according to the Nepal Demographic and Health Survey-2022 carried out by the Ministry of Health and Population, at least four percent of children aged between 12 and 23 months have not been vaccinated, while the other 16 percent did not complete all vaccine doses.

Here is what you need to know about Nepal’s routine vaccination status.

Start of Nepal’s vaccination programme

In 1816 AD, following the end of the Anglo-Nepal war with the signing of the Sugauli Treaty, British Residency in Nepal was converted into an embassy and the title of Resident was officially changed to that of an envoy.

According to Dr Baburam Marasini, a retired health ministry official, prime minister Bhimshen Thapa requested Edward Gardner, the then British envoy, for a vaccine against smallpox. At the time Nepal’s relationship with Britain was cold, since the country had lost a large part of its territory as a result of the war. The British government provided the vaccine against smallpox to Nepal; Gardner took the initiative to bring the doses.

At the time, scores of people used to die of smallpox in the country. Following the British initiative, a large number of people were administered the smallpox vaccine. But not King Girvan Yuddha Bikram Shah (1797-1816), who succumbed to the virus.

With the help of the World Health Organisation smallpox control activities officially commenced in Nepal in 1962, and in 1967, an eradication programme was started. Smallpox was declared ‘eradicated’ on the first day of the Nepali year 2034.

Start of routine vaccination

Nepal initiated an Expanded Programme on Immunisation in the fiscal year 1978-1979. By the next decade, the programme had been expanded to all parts of the country. The vaccination programme was started with three different antigens, including BCG and DPT. Other vaccine doses have been included in the routine programme as diseases like measles and tuberculosis are still prevalent in the country.

Under routine immunisation, the government provides 13 types of vaccines against a range of diseases, including measles-rubella, pneumonia, tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, rotavirus, Japanese encephalitis and typhoid, free of cost. The vaccine doses get administered from more than 16,000 centres across the country.

The plan is to introduce the human papillomavirus vaccine soon, but on a small scale. The virus causes cervical cancer, which is the second-most common cancer in the developing world and a major cause of deaths among Nepali women.

The programme’s success

Regular immunisation is one of the most successful health programmes in Nepal, providing a wide coverage. The country has demonstrated remarkable progress in reducing under-five mortality and the regular immunisation programme is credited for that.

However, a recent report of the Nepal Demographic and Health Survey-2022 carried out by the Ministry of Health and Population showed that at least four percent of children aged between 12 and 23 months have received no vaccine at all. This figure was one percent in 2016.

Elimination of vaccine-preventable diseases

Nepal eradicated smallpox in 1977. The country got maternal and neonatal tetanus elimination status in 2005. In 2014, Nepal was declared polio-free by the World Health Organisation.

Officials say that the country has reduced deaths and the burden of most vaccine-preventable diseases.

Some impediments

Nepal’s current neonatal mortality rate is 21 per 1,000 live births, the same as in 2016, which means there has been no improvement in reducing the deaths.

The government’s target for the Sustainable Development Goals (SDGs) was to reduce neonatal mortality to 16 deaths for every 1,000 live births, by 2022.

The SDGs are a follow-up to the Millennium Development Goals (MDGs), aimed at ending poverty and hunger and all forms of inequality in the world, by 2030. Nepal has committed to meeting the goals.

The report showed that under-five mortality rate has declined to 33 from 39 in 2016 and the infant mortality rate to 28 from 32 in 2016, for every 1,000 live births.

The target was to cut the under-five mortality to 27 and infant mortality rate to 20 in every 1,000 live births by 2022 in order to meet the SDG goal.

Eighty-five percent of all deaths among children under five in Nepal occur before the first birthday, 64 percent in the first month of life, according to the study.

Timely administration of key vaccines is among the ways to cut the death rate, said Jhalak Gautam, former chief of the Immunisation Section of the Family Welfare Division of the Department of Health Services.

Measles outbreak

Nepal has been grappling with measles since the start of 2023. At least one person has died and more than 1,000 have been infected with the deadly virus in 16 districts from the west to east of the country, and in Kathmandu.

The country had committed to eliminating measles by 2023 after missing the earlier deadline of 2019. To declare measles as eliminated, the number of cases should be less than five in every 1,000,000 people throughout the year.

However, after the viral outbreak earlier this year, the health authorities have pushed the deadline to 2026.

A low vaccine coverage is blamed for the outbreaks. Officials say most measles cases have been found among the marginalised communities and religious minorities—Muslims and Catholics and some backward groups—where the level of awareness for regular immunisation is low.

Moreover, a floating population, scattered slums, working-class people, lack of awareness and poor access to health workers also pose challenges in meeting the targets. Officials say people who work as labourers in big and emerging cities are less aware of the importance of immunisation.

Measures taken to increase coverage

Health ministry officials said they have asked the agencies concerned to update micro-plannings to increase the vaccine coverage. They have also requested the school administration to make sure that children seeking new admission have received routine immunisation, and have initiated a vaccine awareness campaign. Officials at the Immunisation Section concede that there may have been errors in the health data of big and emerging cities.

“On paper, we achieve more than a 100 percent target every time, but every study shows big cities like Kathmandu and emerging ones lag behind,” said Dr Senendra Upreti, a former health secretary. “Lack of data on population size is responsible for low vaccinations and rising vaccine dropouts. We need macro- and micro-level planning to hit the targets.”

Health experts’ take

Immunisation is the most cost-effective, most powerful and most efficient way to control and eliminate vaccine-preventable diseases that contribute to childhood illnesses and deaths, according to public health experts. They say that the country has successfully reduced deaths and the burden of many diseases with the help of vaccines.

“Our investments have not been reduced, the priorities have not changed. Still, we are behind the target,” said Dr Marasini. “This shows there are a lot of things we need to do to meet targets. We need micro-planning— ward- and college-level plans to address local problems—and should ensure their effective implementation.”

Better coordination among the relevant agencies of all three tiers of government—federal, provincial and local—an awareness drive on the importance of vaccinations, recruitment of vaccine focal persons and taking the help of female community health volunteers could increase the coverage, health experts suggest.