The COVID-19 pandemic emerged as an unprecedented global health crisis, fundamentally disrupting health care systems and essential services worldwide [1]. Beyond the direct morbidity and mortality caused by SARS-CoV-2, the pandemic created far-reaching consequences for routine health care delivery, particularly impacting childhood immunization programs that are critical for preventing infectious diseases and maintaining population health [2,3].

Global evidence demonstrates substantial disruptions to vaccination services during the pandemic. The World Health Organization reported that at least 68% of countries experienced disruptions to childhood immunization programs, with low- and middle-income countries disproportionately affected [4]. These disruptions resulted from multiple factors including health care worker redeployment, supply chain interruptions, physical distancing measures, and reduced health care–seeking behavior due to fear of COVID-19 transmission [5,6].

In low- and middle-income countries, where health care infrastructure may be fragile and resources limited, the pandemic exacerbated preexisting challenges in vaccination delivery [7]. Countries in Latin America and the Caribbean faced particular difficulties, with studies showing that COVID-19 containment measures led to significant reductions in routine immunization coverage across the region [8]. Castro-Aguirre et al [9] conducted a comprehensive analysis of 39 countries and territories in Latin America and the Caribbean, finding significant reductions in diphtheria-pertussis-tetanus (DTP) vaccine coverage in 79% of assessed regions.

Ecuador, a South American country with diverse geographical regions and varying levels of health care access, operated a national immunization program that faced coverage challenges even before the pandemic [10]. The country’s immunization system demonstrated disparities across different geographical regions and socioeconomic groups, with rural and Indigenous populations often experiencing lower vaccination rates [11].

Prior to 2020, Ecuador’s routine childhood vaccination program included vaccines against tuberculosis (BCG), diphtheria-pertussis-tetanus-hepatitis B-Haemophilus influenzae type b (pentavalent), pneumococcal disease, poliovirus, rotavirus, measles-mumps-rubella, yellow fever, and varicella [12]. Coverage rates varied significantly across provinces, reflecting the country’s geographical challenges and socioeconomic disparities [13].

As of July 2021, only 57% of Ecuador’s population had received the first COVID-19 vaccine dose, highlighting significant challenges in reaching underserved populations in remote areas [14]. The pandemic’s impact on routine childhood vaccination was particularly concerning, given the potential for vaccine-preventable disease outbreaks in an already vulnerable population [15].

The implementation of movement restrictions, health care system overwhelm, and resource reallocation to COVID-19 response efforts created substantial barriers to routine immunization services [16]. Health care facilities experienced reduced capacity, parents delayed or avoided medical visits due to infection fears, and supply chains faced significant disruptions [17].

Understanding the specific impact of COVID-19 on Ecuador’s childhood vaccination program is crucial for developing targeted interventions to restore coverage levels and prevent future disruptions [18]. This analysis provides essential data for policymakers and public health officials working to strengthen immunization systems and improve pandemic preparedness [19].

The primary objective of this study is to quantify the impact of the COVID-19 pandemic on routine childhood vaccination coverage in Ecuador by comparing coverage rates before (ie, 2019) and during (ie, 2020‐2021) the pandemic and to identify geographical disparities in vaccination access during this period.

This study used a retrospective, observational design to analyze vaccination coverage data from Ecuador’s national immunization program. We conducted a comparative analysis examining routine childhood vaccination coverage for the prepandemic period (2019) and the pandemic period (2020‐2021) [20]. This design allowed for the examination of temporal trends and changes in vaccination coverage, providing insights into the pandemic’s impact on immunization services.

Primary data for this study were obtained from three key sources:

The study population consisted of children under 24 months of age in Ecuador, representing the target age group for routine childhood vaccinations according to the national immunization schedule [24]. Data were analyzed for all 24 provinces across 4 geographical regions: Costa (coast), Sierra (highlands), Amazonía (Amazon region), and Insular (Galápagos Islands) [25].

We analyzed coverage for the following vaccines according to Ecuador’s national immunization schedule [26]:

Coverage rates were calculated as the percentage of children in the target age group who received the recommended number of doses for each vaccine, following World Health Organization (WHO) guidelines for vaccination coverage assessment [27].

Statistical analyses were performed using SPSS (version 28.0; IBM Corp) [28]. The following analytical approaches were used:

This study used secondary, publicly available data from official government sources and did not involve direct human subjects research. Therefore, ethical approval from an institutional review board was not required [33]. All data were anonymized and analyzed in aggregate form, ensuring privacy protection [34].

Data quality was ensured through cross-referencing between the Ministry of Public Health and INEC sources. Limitations include the lack of detailed socioeconomic data at the individual level and the absence of data beyond 2021, which would allow assessment of recovery efforts [35].

Analysis of routine childhood vaccination data revealed a clear pattern of declining coverage between 2019 and 2021, demonstrating the significant impact of the COVID-19 pandemic on adherence to immunization schedules [36]. Table 1 presents comprehensive coverage data showing this concerning trend across all major vaccines.

Figure 1 illustrates the temporal trends in vaccination coverage for key vaccines from 2019 to 2021. The visualization clearly demonstrates the progressive decline in coverage rates, with the most dramatic decreases occurring between 2020 and 2021. A heatmap provides an alternative visualization of the comprehensive data presented in Table 2, highlighting the widespread nature of the coverage decline (Figure 2).

We conducted an analysis on vaccine-specific coverage and found the following:

Table 2 presents population data across Ecuador’s 4 main regions and 24 provinces, providing context for understanding vaccination disparities. Analysis revealed significant geographical variations in pandemic impact [42] (Figure 4):

Comparative analysis revealed that approximately 137,000 fewer vaccine doses were administered in 2020 compared to 2019, with further decreases in 2021 [47]. The pentavalent vaccine showed the most substantial absolute reduction (17.7%), followed by poliovirus, rotavirus, and pneumococcal vaccines [48].

The sustained decline in vaccination coverage through 2021 indicates that pandemic effects on childhood immunization were not temporary disruptions but represented persistent challenges to the health system [49]. Coverage rates falling below critical thresholds (particularly those below 80%) increase the risk of vaccine-preventable disease outbreaks, especially in areas with clustered susceptible populations [50].

Our findings reveal a concerning pattern of declining routine childhood vaccination coverage in Ecuador during the COVID-19 pandemic, with sustained decreases through 2021. These results align with global trends documented worldwide, where the pandemic disrupted essential health services beyond the direct impact of SARS-CoV-2 infection [51]. The magnitude of decline in Ecuador—with some vaccines showing coverage drops exceeding 20 percentage points—represents one of the more severe impacts documented in Latin America [52].

The observed patterns are consistent with findings from other Latin American countries. Castro-Aguirre et al’s [9] regional analysis of 39 countries showed significant reductions in DTP vaccine coverage in 79% of assessed regions, with Ecuador among the most affected. Our data add valuable country-specific detail to this regional picture, demonstrating the heterogeneous impact across different vaccines and geographical areas [53].

Several interconnected factors contributed to the vaccination coverage declines observed in Ecuador [54]:

The geographical analysis revealed significant disparities in pandemic impact across Ecuador’s regions [62]. Coastal and highland provinces experienced the most severe reductions, while some Amazon provinces showed variable patterns. These disparities reflect preexisting inequalities in health care access that were exacerbated during the pandemic [63].

Urban centers like Quito and Guayaquil, despite having better health care infrastructure, experienced substantial coverage declines, likely due to higher COVID-19 transmission concerns and stricter lockdown measures [64]. Rural provinces faced the dual challenge of limited health care access and additional pandemic-related barriers [65].

Indigenous and rural populations, who already faced coverage gaps before the pandemic, were disproportionately affected [66]. Arce Becerra et al’s [42] study of Quito’s metropolitan district showed stark urban-rural differences, with rural parish coverage declining more severely than that in urban areas.

The sustained decline in vaccination coverage has serious implications for child health in Ecuador [67]. Coverage levels below 80% for most vaccines place the population at risk of vaccine-preventable disease outbreaks [68]. Of particular concern are the following:

Addressing the vaccination coverage decline requires comprehensive, multifaceted interventions [72]:

Lessons learned from Ecuador’s experience should inform pandemic preparedness for future health emergencies [78]:

International experience suggests that recovery of vaccination coverage requires sustained effort and multiple strategies. Countries like Rwanda and Bangladesh have demonstrated successful catch-up campaigns using innovative approaches including door-to-door vaccination and integration with COVID-19 vaccine delivery [82,83].

Several limitations should be acknowledged in interpreting these findings [84]:

Future research should examine [90]:

The COVID-19 pandemic profoundly impacted routine childhood vaccination coverage in Ecuador, with declines persisting through 2021. The evidence demonstrates that, while the immediate focus on the pandemic response was necessary, the collateral damage to essential health services created new public health challenges requiring urgent attention [91].

The sustained decline in vaccination coverage—with some vaccines showing decreases exceeding 20 percentage points—places Ecuador’s children at increased risk of vaccine-preventable disease outbreaks [92]. Regional disparities highlight how the pandemic exacerbated existing health inequities, with vulnerable populations facing compounded challenges in accessing immunization services [93].

Recovery requires comprehensive strategies addressing both immediate catch-up vaccination needs and longer-term health system strengthening [94]. Priority actions include implementing targeted mass vaccination campaigns, strengthening routine immunization services, and developing more resilient health systems capable of maintaining essential services during future health emergencies [95].

The findings underscore the critical importance of maintaining routine immunization programs during health crises and the need for pandemic preparedness plans that explicitly protect essential health services [96]. As Ecuador works to rebuild and strengthen its immunization program, the lessons learned from this pandemic experience must inform strategies to ensure no child is left unprotected against vaccine-preventable diseases [97].

Continued monitoring, evaluation, and research are essential to track recovery progress, evaluate intervention effectiveness, and inform evidence-based strategies for achieving and maintaining optimal vaccination coverage [98]. The protection of children’s health through sustained immunization programs remains a cornerstone of public health that must be safeguarded against future disruptions [99].