Zero-dose children and measles risk in Punjab, Pakistan: magnitude, geographic distribution, and programmatic implications, 2022–2026

Background Zero-dose children, defined by absence of a first diphtheria-tetanus-pertussis-containing dose, are the priority of the Immunization Agenda 2030. Measles cases include many unvaccinated children, but those too young for vaccination are rarely separated from those the programme could have reached. We describe the magnitude, age, and geographic distribution of measles zero-dose status among confirmed cases in Punjab, Pakistan. Methods We analysed 19,569 laboratory-confirmed and epidemiologically linked measles cases among 73,223 surveillance records, epidemiological week 1 of 2022 to week 25 of 2026. Measles zero-dose meant no measles-containing dose through routine or campaign immunization. Cases were split into vaccine-ineligible (under 9 months) and eligible (9 months or older). Analyses included trend tests, Spearman correlation, and adjusted Poisson regression. Results Of 19,569 cases, 9706 (50%) were zero-dose, and 5740 of these (59%) were infants under 9 months. Among 13,825 vaccine-eligible cases, 3963 (29%; 95% CI 28–29) were zero-dose: 21% in 2022, 40% in 2024, and 17% in 2026. Dera Ghazi Khan (59%) and Lodhran (52%) had the highest district shares, unrelated to administrative MCV1 coverage (rho = −0.24, p = 0.15). Case fatality was 0.71% in zero-dose and 0.26% in vaccinated eligible cases (adjusted relative risk 2.65, 95% CI 1.52–4.60). Conclusions About three in ten cases were too young for vaccination, and about three in ten of the rest had never received a measles dose. Cases over-represent unvaccinated children, so these proportions guide field investigation, not prevalence. District prioritisation should combine counts and proportions, not administrative coverage.