Measles vaccination is estimated to have averted 13·8 million deaths between 2000 and 2012.
Persisting heterogeneity in coverage is a major contributor to continued measles mortality, and a
barrier to measles elimination and introduction of rubella-containing vaccine. Our objective is to
identify determinants of inequities in coverage, and how vaccine delivery must change to achieve
elimination goals, which is a focus of the WHO Decade of Vaccines. We combined estimates of
travel time to the nearest urban centre (550 000 people) with vaccination data from Demographic
Health Surveys to assess how remoteness affects coverage in 26 African countries. Building on a
statistical mapping of coverage against age and geographical isolation, we quantified how
modifying the rate and age range of vaccine delivery affects national coverage. Our scenario
analysis considers increasing the rate of delivery of routine vaccination, increasing the target age
range of routine vaccination, and enhanced delivery to remote areas. Geographical isolation plays a
key role in defining vaccine inequity, with greater inequity in countries with lower measles vaccine
coverage. Eliminating geographical inequities alone will not achieve thresholds for herd immunity,
indicating that changes in delivery rate or age range of routine vaccination will be required. Measles
vaccine coverage remains far below targets for herd immunity in many countries on the African
continent and is likely to be inadequate for achieving rubella elimination. The impact of strategies
such as increasing the upper age range eligible for routine vaccination should be considered.