The future impact of zero-dose children in inaccessible conflict-affected areas of Somalia: aligned with the immunization agenda 2030

Abstract

Background: The Immunization Agenda 2030 (IA2030), led by WHO and partners, targets the global challenge of zero-dose children, who face higher risks of vaccine-preventable diseases. Globally, 18 million children remain zero-dose, with over half in conflict or humanitarian settings. In Somalia, about 60% of children are zero-dose, and during the 2022–2024 drought, over 70,000 deaths occurred, with nearly 40% among children under five. This review explores the burden, determinants, and geographic distribution of zero-dose children in Somalia's conflict-affected regions. Methods: This narrative review followed SANRA guidance. We searched PubMed, Scopus, Web of Science, Google Scholar, and key institutional sites (WHO, UNICEF, ReliefWeb, MoH Somalia, NGOs) for English-language literature (1990–July 31, 2025). From 197 records were identified, 82 new studies were included, resulting in a total of 279 studies after de-duplication and two-reviewer screening. Evidence was synthesized thematically and aligned to Immunization Agenda 2030 (IA2030) priorities. Results: Zero-dose hotspots are concentrated in rural, nomadic, and conflict-affected zones, with Lower Juba reaching a peak of 62%. Key challenges include insecurity, limited access, disrupted supply chains, workforce shortages, and demand-side barriers like mistrust and misinformation. Humanitarian efforts are frequently hindered by checkpoints, blockades, and security concerns. From 2000 to 2024, Somalia's routine immunization program showed significant progress, with MCV-1 coverage rising from 50 to 71%, and MCV-2 from 5 to 55%, as per the WHO/UNICEF WUENIC data for the African region. Conclusion: Zero-dose children in inaccessible Somali districts are a pressing equity and health-security challenge. Sustaining recent national gains while fulfilling Immunization Agenda 2030 (IA2030)’s “leave no one behind” requires tailored outreach to remote communities, strengthened surveillance and e-registries for defaulter tracing, resilient cold-chain and WASH linkages, empowered community health workers (especially women), negotiated humanitarian access, and a progressive domestic co-financing roadmap alongside partner support.