The actual number of children missing doses could be much higher than shown
In a country where health workers once walked fourteen hours a day across Himalayan passes to vaccinate every last child in a remote village, Nepal's cities have quietly become the more dangerous frontier. Metropolitan vaccination coverage has fallen to 64 percent while rural areas hold at 95 percent, a reversal that exposes how the invisible populations of urban life—migrants, slum dwellers, the unregistered—can slip through systems designed for those who stay still. Measles outbreaks spreading across multiple districts in 2026 are the first consequence of this neglect, and they ask a question that public health has always struggled to answer: why is it sometimes easier to reach the hardest places than the nearest ones?
- Nepal's national vaccination rate has slid from 96% to 92% in a single year, with cities driving the decline as metropolitan coverage collapses to 64%—a 31-point gap below rural areas.
- Measles outbreaks have already infected hundreds of children across multiple districts since early 2026, concentrated among unvaccinated and marginalised urban communities where herd immunity has quietly eroded.
- Floating populations, migrant workers, and slum dwellers exist outside official registration systems, meaning the true number of unprotected children is almost certainly higher than government statistics acknowledge.
- Experts warn that standard health outreach was built for stable, registered populations—and that urban informality has rendered those systems structurally blind to the children most at risk.
- Authorities are being urged to develop targeted micro-plans for high-risk urban groups before the conditions that produced these outbreaks deepen into a sustained public health crisis.
In April, health workers from Dolpa spent four days trekking to Chharka Bhot, a village at 4,350 metres, walking fourteen hours daily across snow-covered passes above 5,100 metres to deliver HPV vaccines to girls there. Every eligible child was reached. The campaign was a complete success.
But that story of rural dedication now stands in uncomfortable contrast to what is happening in Nepal's cities. Ministry of Health data for the last fiscal year shows metropolitan areas achieved only 64 percent full immunisation coverage among children, while rural municipalities reached 95 percent. Nationwide, the full-immunisation rate fell from 96 percent in 2023-24 to 92 percent in 2024-25. Dr Abhiyan Gautam of the Family Welfare Division acknowledged the disparity plainly: urban children are far less likely to receive all recommended vaccines than those in the countryside.
The structural reasons are well understood, if poorly addressed. Floating populations, migrant workers, slum dwellers, and the urban poor move constantly and exist outside official registration systems. Immunisation expert Dr Shyam Raj Upreti noted that official statistics count only registered residents—meaning the real number of unprotected children is likely substantially higher than reports suggest.
The consequences are no longer theoretical. Since early 2026, measles outbreaks have spread across multiple districts, infecting hundreds of children, with cases concentrated among unvaccinated and marginalised communities. Nepal had declared itself a fully immunised nation just last year, but the data has made that declaration impossible to sustain.
Experts are calling for micro-plans targeting the specific groups falling through the cracks of standard health programming. The rural record—built by workers willing to cross mountain passes on foot—has demonstrated what commitment can achieve. Whether Nepal's cities, with far greater resources at hand, can extend that same commitment to their most invisible residents is now the urgent question.
In April, health workers from Dolpa set out on a journey that would take them four days to reach Chharka Bhot, a village perched at 4,350 metres in upper Dolpa—one of the highest permanently inhabited places on Earth. They walked fourteen hours each day, from dawn to dusk, carrying vaccine carriers through barren alpine terrain, across snow-covered passes that climbed above 5,100 metres, to deliver HPV vaccines to girls in the village. When they arrived, the reception was warm. The community embraced the effort. Every eligible girl received her dose. The campaign succeeded completely.
This story of rural vaccination success, however, masks a troubling reversal unfolding in Nepal's cities. According to data from the Ministry of Health and Food Safety covering the last fiscal year, metropolitan areas achieved only 64 percent full immunisation coverage among children, while rural municipalities reached 95 percent. The gap is stark—a 31-point chasm separating urban from rural Nepal. Dr Abhiyan Gautam, chief of the Immunisation Section at the Family Welfare Division, acknowledged the disparity plainly: children in cities and metropolitan areas were far less likely to receive all recommended vaccines than their rural counterparts.
The numbers tell a story of decline. Nationwide, the full-immunisation rate dropped from 96 percent in fiscal year 2023-24 to 92 percent in 2024-25. This means thousands of children who should have been protected were not. The government provides fourteen types of antigens free of cost—protection against measles, rubella, pneumonia, tuberculosis, diphtheria, pertussis, tetanus, hepatitis B, rotavirus, Japanese encephalitis, typhoid, and human papillomavirus. Yet in urban areas, coverage has fractured.
The reasons are structural and human. Floating populations—people without fixed addresses—slum dwellers, migrant workers, and the urban poor exist in the gaps of official record-keeping. They move constantly. They lack stable contact with health systems. They scatter across dense, informal settlements where government outreach has historically been limited. Dr Shyam Raj Upreti, an immunisation expert and former director general of the Department of Health Services, pointed out that official statistics are based on registered population figures for urban areas. The actual number of children missing vaccine doses, he said, is likely far higher than government reports suggest. When you count only those on the books, you miss those living in the margins.
The consequences are already visible. Since the start of 2026, measles outbreaks have erupted across multiple districts. Hundreds of children have been infected. Health officials report that most cases cluster among marginalised communities and those never vaccinated in the past. The disease spreads where immunity is thin. Low vaccination coverage in cities creates conditions for outbreaks that rural areas, with their 95 percent protection, have largely avoided.
This represents a paradox in Nepal's public health story. Routine immunisation has been one of the country's most successful programmes, credited with dramatic reductions in under-five mortality. The government declared the entire nation fully immunised and sustained just last year. Yet the data contradicts the declaration. A large proportion of urban children have not received all doses offered under the routine programme. The gap between what was announced and what is actually happening on the ground has become impossible to ignore.
Experts are calling for urgent action. They argue that authorities must design micro-plans targeting high-risk groups—the floating populations, the slum dwellers, the migrant workers who fall through the cracks of standard health programming. Without such focused effort, they warn, the risk of vaccine-preventable disease outbreaks in cities will only deepen. The rural areas, reached by workers willing to walk for days through snow and altitude, have shown what is possible. The question now is whether cities, with all their resources and infrastructure, can learn the lesson.
Citações Notáveis
Children living in cities and metropolitan areas were much less likely to receive all recommended vaccines than children living in rural municipalities— Ministry of Health and Food Safety report
The actual number of children missing doses of routine vaccines could be much higher than what is shown in the government report— Dr Shyam Raj Upreti, immunisation expert and former director general of the Department of Health Services
A Conversa do Hearth Outra perspectiva sobre a história
Why would rural areas, which seem harder to reach, have better vaccination rates than cities?
Because rural communities are often more stable. People stay put. Health workers know who lives where. In cities, you have constant movement—migrants coming and going, people living in informal settlements that don't appear on official maps. The government's vaccination system was built for populations that don't move.
So the official numbers are lying?
Not lying, exactly. They're incomplete. The statistics count registered urban populations. But they miss the floating populations, the people in slums, the migrant workers. The actual gap is probably wider than 31 points.
What happens when vaccination coverage drops like this?
Disease finds its way in. You've already seen it—measles outbreaks across multiple districts since early 2026. Hundreds of children infected, mostly in unvaccinated and marginalised communities. Once coverage falls below a certain threshold, herd immunity breaks down.
Why didn't the government see this coming?
They did. Experts have been warning about it. But the systems that work in rural areas—walking for days, building community trust—don't automatically scale to cities. Cities need different strategies. Micro-plans targeting specific high-risk groups. Mobile clinics. Outreach to slums. That takes different resources and different thinking.
Is there a way to fix this quickly?
Not quickly, but yes. The rural success shows it's possible. But it requires treating urban vaccination as a distinct problem with distinct solutions. You can't just apply the rural playbook to cities and expect it to work.