Declining booster uptake after vaccine schedule change in England

By Dr. Liji Thomas, MDReviewed by Lauren HardakerApr 7 2026

A major shift in England’s childhood vaccination strategy is revealing unintended gaps in protection, with falling booster uptake and rising inequality potentially leaving the most vulnerable children at greater risk of serious infection.

Study: Inequalities in childhood pneumococcal conjugate vaccine uptake in England before and after the change from a 2 + 1 to 1 + 1 schedule: a longitudinal study. Image credit: Aleksandar Malivuk/Shutterstock.com

Pneumococcal conjugate vaccines (PCVs) have significantly reduced pneumococcal disease in England. However, a 2020 schedule change, coinciding with broader disruptions including the COVID-19 pandemic, could risk undermining some of these gains if booster uptake declines, especially among underprivileged communities. The findings published are published in The Lancet Regional Health – Europe. 

PCVs and vaccine schedules

PCVs are part of the routine childhood immunization schedule in England. They target vaccine-preventable diseases caused by infection with Streptococcus pneumoniae. The program began with PCV7 (containing antigens from seven PCV serotypes), which was later upgraded to PCV13, targeting 13 serotypes.

The new PCV schedule replaced the two primary doses plus one booster dose (at 8 and 16 weeks, and 12 months, respectively) with one primary dose at 12 weeks and a 12-month booster dose. These are referred to as the 2+1 and 1+1 schedules, respectively. To date, the UK is the only European country with this schedule.

While earlier immunogenicity studies suggested broadly comparable protection, the latter depends on its success in timely booster uptake. However, interpretation of post-change patterns is complicated by pandemic-related reductions in infectious disease transmission during the coronavirus disease 2019 (COVID-19) period.

Persistent vaccine-type pneumococcal diseas

In England, the introduction of both vaccines was followed by stable, lower vaccine-type (VT) IPD rates across all age groups within 4 years. In contrast, global trends reveal that VT IPD rates decreased and then stabilized in the under-five age group at seven years after introducing PCV13. For individuals older than this, infection rates continued to go down for up to nine years.

Despite these gains, VT IPD persists, underlining the need for effective prophylaxis.

Booster gap widens

Pediatric vaccine uptake has fallen across England since 2019. In keeping with this, national PCV booster coverage at 24 months peaked at 92.5 % in 2012-13 but fell to 88.2 % in 2023-24. For reference, the World Health Organization (WHO) target is 95 %.

Primary PCV dose uptake prior to 2020 was 93.2 %, but booster coverage at 24 months was 91.2 %. Thus, with the 2+1 schedule, the mean gap was 2.32 %, which increased to 4.79 % under the revised schedule.

While this coincided with pandemic-related drops in vaccine coverage, the study notes this may reflect both broader changes in vaccination uptake patterns and pandemic-related disruption rather than the schedule change alone.

At the local authority level, about 42 % reported 95 % coverage at 12 months under either schedule. With the 2+1 schedule, only 23.3 % achieved 95 % coverage at 24 months. This dropped to 10.7 % with the revised schedule, with an overall average of 17.8 % of local authorities meeting the target.

Deprivation-related inequalities

This disproportionately affected deprived groups. Based on deprivation index data, the gap in PCV booster coverage between the least and most deprived quintiles increased from 2-3 % before 2020 to 4-6 % afterwards. In a separate analysis of primary and booster coverage in London (due to its distinct demographic profile compared to the rest of England), the city showed very low booster retention rates.

Prior to the adoption of the revised schedule, booster coverage in some local authorities was higher than primary dose uptake, likely reflecting catch-up vaccination or reporting variation. After 2020, booster coverage dropped in many parts of London, with the nadir in Hackney, at 65.5 %.

IPD burden in deprived populations

IPD incidence was 7 per 100,000 people in the least deprived compared with 13.6 per 100,000 among the most deprived, respectively, indicating a greater burden among the socially underprivileged.

With the reduced booster uptake rates, model-based estimates suggest higher susceptibility to VT IPD in more recent cohorts, particularly in deprived areas. It ranged from 22.4 % to 47.8 % in the least versus the most deprived local authorities.

PCVs with higher valency may have reduced potential for preventing carriage due to lower immunogenicity, and may thus not prevent the asymptomatic carrier state. Together, these effects could reduce herd immunity.

Study limitations

The study used deprivation measures encompassing neighborhoods covering a wide range of socioeconomic status. They could overlook severely deprived areas within more affluent areas, as with many London boroughs, or vice versa.

Vaccine effectiveness estimates for the 1+1 schedule remain to be fully validated, and therefore susceptibility calculations used European studies based on the earlier schedule. Catch-up vaccination was not accounted for, and the pandemic’s effects on vaccine coverage may confound those due to the new schedule.

As an ecological analysis, the study cannot establish individual-level causality and may be influenced by area-level confounding factors such as ethnicity, health status, and other demographic variables.

Implications for health policy

The revised PCV schedule may risk undermining program impact if high and equitable booster uptake is not maintained. Ensuring universal booster uptake is a crucial component of the program. Moreover, the increasing gap in booster coverage between the haves and have-nots may contribute to a higher and more unequal VT IPD burden in the community.

“The success of the 1 + 1 schedule depends on maintaining equitable, high booster uptake.” These areas require focused support and the establishment of improved follow-up systems.

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