Publication date: Oct 10, 2024

Background The adverse impact of the COVID 19 pandemic on Routine Immunisation (RI) coverage has been well-documented: most countries experienced backsliding or stagnation in coverage. Qualitative surveys indicated potential causes of such declines, including reduced health care seeking behaviour, lockdowns, and overwhelmed health systems. Methods We investigate determinants of RI resilience during COVID 19 at a national level for 119 countries from 2020 to 2022, using publicly available data on pre pandemic immunisation programme performance, health workforce capacity, health systems strength, health financing, global health security preparedness, COVID 19 burden, COVID-19 containment, economic, and health policy responses, population mobility changes, and country wealth. We employ a mixed methods approach: stepwise linear regression based on a causal inference framework, and Random Forest regression to identify potential nonlinear interactions and collinear effects. Results We provide evidence that stronger pre-pandemic immunisation programmes and more health workers, once above minimum thresholds (about 83% Diphtheria Tetanus Pertussis third dose coverage and 60 health workers per 10,000 population), are associated with improved RI resilience. Random Forest analysis suggests health financing and health system strength impact RI resilience. COVID 19 vaccinations and pandemic policies were not associated with RI coverage changes, implying, reassuring, these acute responses did not interrupt routine services. In addition to these findings, a large fraction of variation in pandemic RI resilience remains unexplained, highlighting the need for further research on RI performance determinants. Conclusion Our findings underscore the role of robust immunisation programmes and sufficiently sized health workforces in mitigating RI disruption during global health crises once above minimum thresholds. Reassuringly, we do not find evidence that COVID 19 vaccination campaigns nor pandemic containment policies impacted RI performance, counter to qualitative survey indications. We encourage continued efforts to identify RI disruption determinants to inform the evidence base for public health practitioners globally.

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