COVID-19 Vaccination Coverage — World Health Organization African Region, 2021–2023

Discussion

Despite the improved supply of COVID-19 vaccine starting by late 2021, coverage in the African Region increased slowly. Regional coverage with a primary series reached 32% in 2023, with 38% of the population receiving ≥1 dose. Among the subset of countries that reported coverage for high-risk groups, 48% of health care workers and 52% of older adults received a primary series. Variation in coverage among countries was substantial. Four (9%) of the 47 countries in the region achieved the WHO target of 70% primary series coverage in the total population in 2022 (Liberia, Mauritius, Rwanda, and Seychelles); 29 (62%) countries reported primary series total population coverage <40%. Eritrea has not introduced COVID-19 vaccines, and Burundi delayed introduction in the general population and focused on vaccination of health care workers.

Several reasons likely account for low coverage with COVID-19 vaccines, including limited political commitment, logistical challenges, low perceived risk of COVID-19 illness, and variation in vaccine confidence and demand (3). Country immunization program capacity varies widely across the African Region. Challenges include weak public health infrastructure, limited number of trained personnel, and lack of sustainable funding to implement vaccination programs, exacerbated by competing priorities, including other disease outbreaks and endemic diseases as well as economic and political instability. The total population for each country was used as the denominator for vaccination coverage calculations. However, the eligible population for COVID-19 vaccination differed among countries; most countries targeted persons aged ≥16 or ≥18 years, but some countries vaccinated persons aged ≥5 years. In countries with large populations aged <18 years, meeting coverage targets was not possible (7).

Vaccination of high-priority groups remains critical for optimizing the impact of COVID-19 vaccines (4). Morbidity and mortality are highest among older adults and those with comorbidities (5), yet only two countries in the African Region have achieved >70% coverage among older age groups. The low coverage emphasizes the importance of targeted approaches to generate demand and address population concerns and of new delivery strategies to reach high-priority groups.

In May 2023, the public health emergency of international concern was officially declared over by WHO (8). In October 2023, SAGE recommended using a simplified primary vaccination series of a single dose of any COVID-19 vaccine and updated recommendations on revaccination for high-priority groups (5). SAGE recommended the continued prioritization of high-risk groups as described in the updated SAGE roadmap (5). The recommendations also reinforced the need for sustainable programs and COVID-19 vaccination integration into primary health care and other relevant services. The aim was to optimize resources and build sustainable immunization delivery platforms throughout the life course in alignment with the Immunization Agenda 2030 goals (9).

In November 2023, the Regional Immunization Technical Advisory Group for the African Region endorsed the SAGE recommendations, encouraging countries to continue COVID-19 vaccination as aligned with national priorities (10). Many countries in the African Region are integrating COVID-19 vaccination into their routine health services and exploring new entry points for vaccinating high-priority populations as part of primary care and other relevant services, including through multiantigen periodic intensified routine immunization activities.

Limitations

The findings in this report are subject to at least three limitations. First, immunization coverage estimates are based primarily on administrative data, which might contain inaccuracies resulting from errors in recording doses administered or in population estimates. Second, although reporting is highly encouraged, in 2023, many countries stopped reporting COVID-19 vaccination data because of competing priorities. In addition, fewer than one half of the countries are reporting doses administered among high-priority groups, including doses for health care workers and older persons. Finally, population estimates for high-priority groups are available only in some countries in the African Region, making assessing coverage challenging.

Implications for Public Health Practice

The African Region has low COVID-19 vaccination coverage. Community engagement is needed to better understand drivers of vaccine confidence and develop more targeted strategies to improve vaccine demand (4). Integration of COVID-19 vaccination into routine immunization and primary health care services would help build sustainability and support recovery of routine immunization services (9). Strengthening adult immunization platforms would contribute to pandemic preparedness and global disease prevention goals (4). To protect vulnerable populations and prevent additional COVID-19 morbidity and mortality in the African Region, progress must continue to be made in vaccination of priority populations at highest risk for disease.