Apr 24, 2021 Volume 397 Number 1028 4p1519-1596
2021: the beginning of a new era of immunisations?
While the world is firmly focused on the efficacy, adverse events, licensing, and roll-out of COVID-19 vaccines, the disruption of and barriers to routine immunisations during the pandemic have garnered much less attention. World Immunization Week (April 24–30) presents an opportunity to reflect on the state of immunisation efforts for vaccine-preventable diseases, how the COVID-19 pandemic has affected progress, and what lessons can accelerate efforts to prevent diseases through immunisation.
The Immunization Agenda 2030 (IA2030) will be officially launched on April 26. This agenda provides a new global vision and strategy for vaccines for the next decade, following on from the Global Vaccine Action Plan (2011–20). Before the beginning of the pandemic, progress in vaccine coverage had already been stalling between 2010 and 2019. For example, according to WHO and UNICEF data, global rates of immunisation with the first dose of measles-containing vaccine remained at 84–85%. The Global Vaccine Action Plan was important to bring partners together and broadened the vaccine coverage to include newer vaccines, such as those for rotavirus and hepatitis B. However, the conclusion of a WHO evaluation was that it did not make progress in addressing inequity and was only partly successful in influencing national actions as a top–down approach.
IA2030 sets out a very ambitious plan, taking lessons learnt into account and hoping that COVID-19 prevention provides a stark reminder of the importance and power of vaccines. The agenda, which was designed with the cooperation of countries, puts much more emphasis on an approach tailored to the national context and integrated into primary health-care services, particularly to prioritise populations that have not been reached. Immunisation at all ages should be part of such a national plan and will vary in national strategies according to demographics. The agenda aims to be adaptable to changing circumstances brought on by, for example, increased migration, civil unrest, climate change, or future pandemics, but the specifics on how such resilience can be achieved are not established. The four overarching principles the IA2030 puts forward are a people-centred, country-owned, partnership-based, and data-guided approach.
Nobody would disagree with the agenda’s aims. It is laudable that previous shortcomings have been considered and health systems strengthening, especially at the primary care level, is seen as crucial for sustainable progress. The key to success, however, will be how to implement the national plans and to ensure financing is sustained. The COVID-19 pandemic has made this task much more difficult by severely disrupting routine immunisation. Because of travel restrictions, deployment of scarce health workers to COVID-19 care, shortage of personal protective equipment, and disruption of supply chains, many countries will have to provide catch-up services and risk severe outbreaks of vaccine-preventable diseases when easing lockdown. Interruptions in survey data collection will mean data gaps will make it harder to identify those most in need. COVID-19 has further exacerbated inequities and poverty and has led to mass migration from urban to rural areas in many countries, making it difficult to keep track of people needing vaccinations.
But COVID-19 has also catalysed new approaches to vaccine development and mass vaccination efforts that could be taken forward in national routine immunisation plans and vaccine development more generally. For example, house-to-house COVID-19 vaccinations, as offered in some high-income countries to vaccinate individuals shielding or unable to travel, might reach those otherwise missed. Short-term vaccination centres could be used, and school-based or work-based vaccinations could be offered. Electronic immunisation registries should be rolled out widely to facilitate data collection and identification of gaps with attention to data protection and security. Accelerating vaccine development, testing in trials, and licensing with robust post-licensing surveillance should become the new norm. Techniques used for COVID-19 vaccines, such as the use of mRNA, might be applicable to other diseases. Early-phase research for mRNA and vector-based vaccines for HIV has started.
Much has been achieved through vaccination, with many lives saved and disabilities prevented. Science has brought us options for many diseases, with further possibilities on the horizon. A new era of immunisations is much needed and the IA2030 sets out a very good framework. But vaccine hesitancy remains an important issue to tackle. And without addressing the fundamental underlying barriers of inequity, poverty, political posturing, and commercial interest protection, the next decade will not achieve much more than the past.