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Over the past 3 years, the COVID-19 pandemic has shown the power and potential of vaccination in real time. But it has also disrupted health services and caused supply chain challenges, resulting in stagnation and backsliding of routine vaccinations. For example, global coverage of the third dose of the diphtheria–tetanus–pertussis vaccine fell from 86% in 2019 to 81% in 2021—the lowest level since 2008. Many other routine vaccinations showed similar reductions. 25 million children missed out on life-saving measles, diphtheria, and tetanus vaccines in 2021. 18 million have never received a single dose of any vaccine (so called zero-dose children). To prevent further setbacks, World Immunization Week 2023, from April 24 to 30, calls for a catch-up to return to pre-pandemic vaccination levels. But what are the prospects of doing so? Central to any effort to improve global immunisation rates is Gavi, the Vaccine Alliance. The organisation works with the public and private sector to secure access to critical vaccines in low-income countries. More than 981 million children have been vaccinated through its programmes, preventing more than 16·2 million deaths. In August, Muhammad Ali Pate—formerly at the World Bank and Health Minister for Nigeria—will replace Seth Berkley as CEO. Pate says his priorities are to support countries to scale up critical routine immunisation programmes, reach more zero-dose children, expand access to new vaccines, transform primary health-care systems, and help fight outbreaks and future pandemics.

nk and Health Minister for Nigeria—will replace Seth Berkley as CEO. Pate says his priorities are to support countries to scale up critical routine immunisation programmes, reach more zero-dose children, expand access to new vaccines, transform primary health-care systems, and help fight outbreaks and future pandemics. With respect to bolstering national routine immunisations, the centrepiece of global efforts is WHO's Immunization Agenda 2030, launched in 2021, which aims to make immunisations accessible to all by integrating them into primary health-care services and encouraging the development of national strategy plans. As we argued in an Editorial in 2021, the Agenda's success depends on how well national plans are implemented and ensuring that financing is sustained. Whether any progress has been made will be revealed later this year in the Agenda's first monitoring and evaluation report. But the recent statistics on global immunisation coverage and continuous shortages of health-care workers do not bode well.

national plans are implemented and ensuring that financing is sustained. Whether any progress has been made will be revealed later this year in the Agenda's first monitoring and evaluation report. But the recent statistics on global immunisation coverage and continuous shortages of health-care workers do not bode well. Pate's mention of new vaccines is presumably an allusion to new malaria vaccines, which have the potential to safeguard millions of lives, although Gavi has not yet announced whether it will support funding and distribution. The RTS,S vaccine is undergoing pilot testing in Ghana, Kenya, and Malawi. A second vaccine, R21/Matrix-M, developed by the University of Oxford and manufactured by the Serum Institute of India, has been approved in Ghana; WHO is assessing whether to recommend it for wider use. There is also a great deal of hype around mRNA vaccines for diseases ranging from cancer to cardiovascular and autoimmune diseases, spurred on by the successes of COVID-19 vaccine development.

nufactured by the Serum Institute of India, has been approved in Ghana; WHO is assessing whether to recommend it for wider use. There is also a great deal of hype around mRNA vaccines for diseases ranging from cancer to cardiovascular and autoimmune diseases, spurred on by the successes of COVID-19 vaccine development. Whether or not these promises come to pass, a key lesson from the COVID-19 pandemic is the difficulty of ensuring global vaccine equity. While high-income countries hoarded vaccines, low-income and middle-income countries were left behind. COVAX, the global initiative to ensure fair and equitable distribution of COVID-19 vaccines, failed to deliver. The new proposed treaty on pandemic preparedness and response aims to avoid repetition of these failings but it is often vague, woolly, idealistic, and lacking in practical details. For Pate to fulfil his aim to do better in future pandemics—and to make new vaccines routinely available to all who need them—will require far more muscular and clearly articulated approaches to equity.

ms to avoid repetition of these failings but it is often vague, woolly, idealistic, and lacking in practical details. For Pate to fulfil his aim to do better in future pandemics—and to make new vaccines routinely available to all who need them—will require far more muscular and clearly articulated approaches to equity. One challenge Pate did not mention is vaccine hesitancy, which continues to threaten childhood immunisation. A new UNICEF report warns that public perception of the importance of childhood vaccines declined during the COVID-19 pandemic in 52 of 55 countries studied. A Lancet Viewpoint by Douglas J Opel published earlier this year, exploring how the COVID-19 pandemic might affect confidence in US childhood vaccinations, proposed a series of measures, including scientific literacy, further research on risk perception, reduction of childhood vaccination inequities, and restoration of trust in medicine and public health. Without tackling vaccine hesitancy, any attempt to boost coverage rates will struggle. Countries are facing many challenges in improving routine childhood immunisations. Reversing the downward trends will require action across several fronts. Pate's new leadership of Gavi—if he can fulfil his agenda—could be a timely chance to refresh. For more on World Immunization Week 2023 see https://www.worldimmunizationweek.org/ For more on the Immunization Agenda 2030 see https://www.immunizationagenda2030.org/ For more on World Immunization Week 2023 see https://www.worldimmunizationweek.org/

Countries are facing many challenges in improving routine childhood immunisations. Reversing the downward trends will require action across several fronts. Pate's new leadership of Gavi—if he can fulfil his agenda—could be a timely chance to refresh. For more on World Immunization Week 2023 see https://www.worldimmunizationweek.org/ For more on the Immunization Agenda 2030 see https://www.immunizationagenda2030.org/ For more on World Immunization Week 2023 see https://www.worldimmunizationweek.org/ For more on the Immunization Agenda 2030 see https://www.immunizationagenda2030.org/ In this photo taken on March 20, 2019, an Afghan health worker administers a polio vaccine to a child in Kandahar province's Arghandab district. - Polio immunisation is compulsory in Afghanistan, but distrust of vaccines is rife, and the programmes are difficult to enforce particularly in rural regions. Militants and religious leaders tell locals that vaccines are a Western conspiracy aiming to sterilise Muslim children, or that such programmes are an elaborate cover for Western or Afghan government spies. (Photo by JAVED TANVEER / AFP) / To go with 'AFGHANISTAN-CONFLICT-VACCINES-POLIO-TALIBAN', FEATURE by Rashid Durrani with Usman Sharifi Photo credit should read JAVED TANVEER/AFP via Getty Images)© 2023 Javed Tanveer/AFP via Getty Images2023