# Routine Immunisation Coverage Shows Signs of Recovery at Global Level Postpandemic, but Important Declines Persist in About 20% of Countries

## TL;DR

Global routine immunization coverage is recovering post-pandemic, but about 20% of countries still show significant declines.

## Contribution

This study evaluates global immunization recovery post-pandemic and identifies countries with persistent disruptions.

## Key findings

- Global DTP third-dose coverage in 2023 was 2.7% lower than expected, but fewer children needed immunization due to lower fertility.
- Over thirty countries (16.8%) still had coverage below expectations in 2023.
- No clear factors were identified to explain the continued disruption in immunization coverage.

## Abstract

Background/Objectives: Routine immunisation (RI) coverage declines during the COVID-19 pandemic, from 2020 to 2022, are well-reported. With the declared end to the Public Health Emergency of International Concern in May 2023, and the cessation of most nonpharmaceutical interventions that were introduced to prevent or minimise COVID-19 spread, we (I) assess whether routine immunisation coverage has rebounded to the level of prepandemic trends and (II) seek to identify factors that help predict whether country performance has exceeded, maintained, or declined compared with expectations (based on time-series forecasting). Methods: We quantified global and country-level routine immunisation diphtheria–tetanus–pertussis (DTP) coverage trends postpandemic (2023) compared with prepandemic trends using time-series forecasting across 190 countries. We used discriminant analysis of principal components and random forests to identify relevant predictors of country-level coverage performance, including twenty-eight indicators of health system strength, health workforce, country income, pandemic containment, economic and health policies, and demographic aspects. Results: We show that mean global DTP third-dose coverage levels remained on average 2.7% [95% confidence intervals: 1.1–4.3%] lower than expected in 2023. However, once accounting for temporal demographic changes, we find that this translated to the total number of immunised children almost reverting to expected levels because of decreasing fertility reducing global-level immunisation target populations. At the country level, notable disruption remained in over thirty countries (16.8% of countries below expectations, 81.6% within expected ranges, and 1.6% above expectations). Neither predictive method performed well at identifying factors associated with coverage disruptions. Conclusions: Despite the end of COVID-19 pandemic measures, RI remains below expectations in about 20% of countries. No clear drivers of this continued disruption were identified. Further research is required to inform recovery efforts and prevent future epidemic and pandemic disruptions to routine health services.