This report summarizes the 3rd LifeCourse Immunization Focus Group, held in Prague on 7th December 2018. It covers policy country-level immunization updates from various European countries and the recommendations of five working groups on healthcare professional hesitancy, economic value, antimicrobial resistance, mandatory vaccination, and community immunity.
Meeting Report
Date: Friday 7th December 2018
Location: 10th Excellence in Pediatrics, Prague, Czech Republic
EIP has been working for the past seven years on overcoming barriers to vaccination uptake in childhood, covering HPV, influenza, meningitis and other conditions, at separate meetings across Europe, the Middle East and Asia, and has also included infectious disease sessions on conference programmes and CME online courses on overcoming vaccine hesitancy.
For the past three years this approach has been broadened to take a LifeCourse approach linking with Adolescent Medicine and General Practitioners, to include as many partner organisations as possible in the Focus Groups and planned actions to achieve its mission of overcoming barriers to vaccination uptake (public and HCP uptake) across Europe.
The European LifeCourse Immunisation Initiative is tasked with uniting healthcare professionals to push for universal immunity at a policy level while overcoming vaccine hesitancy at the grassroots in healthcare systems, and among healthcare professionals themselves, across Europe:
To help achieve and coordinate these goals, the 3rd LifeCourse Immunisation Meeting took place in Prague on 7th December 2018, in parallel to the 10th Excellence in Pediatrics Conference, and in partnership with the WHO's Health Behaviour in School-aged Children (HBSC) and the Coalition for LifeCourse Immunisation (CLCI). All types of vaccine-preventable disease were in focus, with the desire to overcome barriers across the board.
Professor Sir Terence Stephenson, Professor of Paediatrics at University College London and Chair of the General Medical Council of the United Kingdom, welcomed participants to the 3rd LifeCourse Immunisation Focus Group and provided a brief overview of the agenda.
In summary, the overall purpose of the Focus Group was:
A second purpose of the Focus Group was to determine actions on vaccination across Europe that overcome barriers and increase uptake. To achieve these goals, several key speakers were invited to give a presentation, followed by an open discussion with speakers, experts and participants.
European Union related presentations included:
Countries related presentations included:
After the presentations and debates, participants were divided into five working groups, covering:
Each working group then outlined the group's ideas and suggested future actions. The following sections summarise the key points of each presentation and the key points debated during the open forum and in the working groups, before concluding on progress made in 2018 and actions, initiatives and campaigns needed in 2019/20.
Professor Odone gave a brief overview of what the EU currently does — and arguably should be doing — on immunization policy, covering: a contextual framework; EU surveillance of infectious diseases; the EU's role in technical support to Member States; the EU's role in policy; immunization recommendations across Member States; and population coverage across Member States.
Professor Odone opened with a statement from Bruce Gellin, Director of the U.S. National Vaccine Program, Department of Health and Human Services: that talking about vaccines is different from talking about vaccination.
She went on to present the contextual framework of vaccination, which spans surveillance, research and development, marketing authorization (efficacy and vaccine safety), recommendations, organization of supply and immunization services, and vaccine demand and uptake by target populations. These levels can be measured through coverage rates, which in turn inform the impact of immunization policies as well as planning and implementation.
On surveillance, the European Centre for Disease Prevention and Control (ECDC) collects, analyses and disseminates surveillance data on 56 communicable diseases — some vaccine-preventable — and related special health issues from Member States, reporting in a standardised way to allow data comparability across the EU. The EU also provides technical support to Member States mainly through scientific advice, communication and training; as an example, Professor Odone cited the ECDC handbook on the design and implementation of immunisation information systems.
On the EU's role in immunization policy, Professor Odone noted that while vaccination policy is a national rather than an EU competence, the European Commission assists countries in coordinating policies and programmes through recommendations — for example, the April 2018 Council Recommendation to strengthen EU cooperation on vaccine-preventable diseases. The EU also funds research and scientific initiatives, such as the Joint Action on Vaccination, co-funded by the Health Programme at €3.55 million.
On immunization recommendations across Member States, Professor Odone pointed to the ECDC platform's most recent recommendations, while highlighting heterogeneity in immunization offer and recommendations between countries. Coverage data is not collected at EU level; it is the World Health Organization that tracks the different vaccines, recommendations and programmes across countries.
As a reference, she cited Jorgensen, Mereckiene, Cotter, Johansen, Tsolova & Brown (2018), which examined how close WHO European Region countries are to the goal of vaccinating 75% of key risk groups against influenza, based on national surveys of seasonal influenza vaccination programmes from 2008/09 to 2014/15 (Vaccine, 36(4), 442–452). The paper concludes that despite policy recommendations, influenza vaccination uptake remains suboptimal — a missed opportunity for preventing influenza in vulnerable groups that could also negatively affect pandemic preparedness. Improved understanding of barriers to influenza vaccination is needed to increase uptake and reverse negative trends, and implementation of coverage monitoring is critical to assessing programme performance and impact.
Dr Holt explained that her sources of information were official documents, notes and slide decks from meetings where the Commission's perspective on vaccination was discussed by experts including Martin Seychell (Deputy Director General, DG Santé — Health and Food Safety), John F. Ryan (Director, Public Health, Country Knowledge and Crisis Management, DG Santé), and Geneviève Chêne (Director, Institut de santé publique, d'épidémiologie et de développement, University of Bordeaux, and Coordinator of the Joint Action on Vaccination).
She reiterated that, according to DG Santé, life-course vaccination is becoming increasingly important because it maximises the benefits of vaccination for individuals, public health and society. Life-course vaccination requires political leadership, changing public perception so vaccination is seen as the norm, engagement of healthcare professionals at the frontline, integration of non-healthcare settings such as the workplace, and improved surveillance — all underpinned by an evidence-based approach.
Dr Holt referenced past EU legislation on communicable diseases from 2000–2013, including Commission Decision 2000/96/EC (list of communicable diseases), Commission Decision 2002/253/EC (case definitions for communicable diseases), Regulation (EC) No 851/2004 (ECDC founding act, 2005), and Decision No 1082/2013/EU on serious cross-border threats to health.
On the Commission's current work, she highlighted coordination of preparedness, assessment and outbreak management for vaccine-preventable diseases; guidance on communication activities relating to vaccination programmes; monitoring of benefits and risks to derive and disseminate evidence-based information on vaccine effectiveness and safety; and organising joint procurement for pandemic vaccines and other products — while noting that health remains a Member State competence rather than a competence of the Union itself.
The current EU policy initiatives on vaccination cover: a proposal for a Council Recommendation and Commission Communication to strengthen EU cooperation on vaccine-preventable diseases; the EU Joint Action on Vaccination, including a life-course approach in its plans; and consideration of research requirements for life-course vaccination.
The Council's recommendation on vaccination is aimed at:
The EU Joint Action on Vaccination was launched in September 2018, co-funded by the EU and Member States and coordinated by INSERM, France, with 20 partner countries (the UK, Germany and Austria to join later). It aims to improve vaccination coverage and, in turn, health security in Member States. Main activities include public consultation to guide interventions and actions; coordination of cross-border measles vaccination campaigns and improved communication; an annual competition promoting vaccination in European schools; and mapping and reviewing existing electronic vaccination record systems to discuss best implementation.
A stakeholder forum is envisaged to encourage participation from civil society. On the new 2021–2027 financial period, the new European Social Fund Plus (ESF+) will have €101.2 billion to spend, with a health strand of €413 million under direct management to help Member States modernise their health systems; projects under shared management (€100 billion allocated) will also offer funding opportunities for health. The Horizon Europe programme's health cluster carries €7.7 billion for health through the life course, and environmental and social health determinants.
Dr Holt also noted a new political environment linked to the change in the Commission starting in 2019 and the European Parliament elections, which may represent an opportunity to fix new public health policy priorities and for stakeholders to help set them.
A member of the Focus Group added that the EU's Health Ministers adopted the Council Recommendation on strengthened cooperation against vaccine-preventable diseases, focused on three main pillars: tackling vaccine hesitancy and improving vaccination coverage; sustainable vaccination policies in the EU; and EU coordination and contribution to global health.
Professor Signorelli provided a brief introduction of Italy's history of having championed several vaccination policies such as smallpox, polio and acellular pertussis vaccines, and being the first to introduce universal vaccination against hepatitis B virus in 1991 and against HPV in 2007. He then set these achievements in the context of recent events and shared four practice examples from Italy.
In 2007 the Veneto Region — one of the regions in Italy with a history of high vaccination coverage — suspended mandatory vaccinations and invested in educational and information campaigns to better counteract the spread of anti-vaccination movements. As a result there was a greater coverage decrease in Veneto than in other regions, showing that the nudge theory (the idea that people make wiser decisions when their choices are presented better and their freedom of choice is kept) did not meet its goals. Professor Signorelli showed a graph illustrating that the suspension of mandatory vaccination decreased coverage rates in Veneto from around 98% to 92%.
Since 2014, a strong political commitment led by the Ministry of Health in collaboration with the National Health Institute, the Italian Chief Medical Officer, the Italian Agency for Medicine (AIFA), pharma companies and scientific associations has positively influenced scientists, journalists and judges on the usefulness of vaccination. Results were considered positive: a new National Plan and new actions increased coverage rates, and there was a favourable increase in media coverage for vaccination compared with hesitancy. Nevertheless, in 2017 there was a decrease in favourable vaccination news, probably due to a parliamentary debate on mandatory vaccination. Coverage data showed that influenza coverage in the elderly and national coverage for polio and measles increased since the 2014 political commitment, and the proportion of the population agreeing that all — or at least some — vaccines should be mandatory also increased since 2014.
Professor Signorelli gave the example of Dr Roberto Burioni, a professor of microbiology at Università Vita-Salute San Raffaele in Milan, who uses social networks to oppose anti-vaxxers with a rather aggressive tone, claiming they are ignorant and that science is not a matter of democracy. According to view counts, this approach had a positive impact on social media platforms, rebalancing scientific information against hesitancy and anti-vaccination.
In 2017 a strong Italian policy raised vaccination uptake as a "stopgap": mandatory vaccinations rose from 4 to 10, certificates were required at pre-school admission with fines (€500) for non-compliance, information was strengthened, and sanctions were applied to anti-vax medical doctors. Professor Signorelli showed coverage rates for polio and measles in Emilia Romagna increasing from 2016 to 2018 (93% to 96%, and 87% to 95%, respectively).
After presenting the four examples, Professor Signorelli gave insights on possible risks of a rebound due to the political context and the rise of populist anti-vaccination ideas and discredited claims about vaccine risk. As an example, he cited a Guardian News article on the Italian health minister discharging the entire board of Italy's most important technical-scientific advisory committee on health policy. In conclusion, Professor Signorelli stated that vaccine uptake, hesitancy policies and behaviours are highly influenced by countries' and regions' social, cultural and political contexts.
Group discussion followed on a possible continuum between mandatory and totally voluntary vaccination (the nudge theory). A member gave the example of the UK's strategy of making vaccination mandatory unless people clearly opt out, and asked whether this could be implemented in Italy. Professor Signorelli responded that before 2017 there were four vaccine requirements for school-enrolled children in Italy, but these were never verified; since 2017 verification has improved due to the mandatory law, for both mandatory and non-mandatory vaccines.
The Group debated whether Professor Burioni's aggressive tone was helping or "awakening the sleeping monster," given the risk of relying on someone so impulsive. Professor Signorelli responded that the "monster" was not asleep, since many anti-vaxxers were already reaching the media — so Burioni's ability to reach the media and disseminate scientific information could be helpful.
The Group discussed France, a country with high vaccine scepticism and new compulsory-vaccination legislation, asking whether political stability helps coverage rates and whether changing the law every three years could be harmful. Professor Signorelli responded that constant legislative change is not always beneficial, and that public health bodies should recommend governments wait three years to evaluate the impact of new laws before changing them further.
The Group also asked whether the 5% unvaccinated population in Italy reflects conscientious objectors, noting that in the UK some parents must show proof of a vaccination exemption (e.g. religious exemption). Professor Signorelli stated that the 5% includes exemptions for medical reasons, migration, and registration errors; according to National Institute of Health data, the proportion of true conscientious objectors is around 0.7%.
Professor Prymula briefly presented the Czech Republic's Immunisation Programme: some vaccinations are mandatory (e.g. Hexa + MMR), while others are voluntary but recommended (e.g. Pneumo + HPV). Immunisation overall is covered by the health insurance fund. Coverage rates for recommended vaccines range from 70% to 80% for Pneumo, and 65% to 68% for HPV in girls.
Regarding pertussis, the Czech Republic had a steep rise in cases, possibly related to the introduction of the acellular vaccine, peaking in 2014 and dropping until 2018; adolescents were the most affected age group, prompting a booster at age 10–11. In summary, the Pertussis immunisation programme history includes: an incidence until 1958 of 30,000–34,000 cases and 80 deaths a year; vaccine introduction in 1958; a 2006-era schedule of doses at 3–5 months, a booster at 18–20 months and one at age 5 (DTwP, ~20% in Prague aP); since 2006, doses at 3–5 months, a first booster 6 months later up to 18 months, a second booster at age 5 (DTaP-IPV-Hib-HBV); and a third booster at age 10–11 since 2009.
Professor Prymula noted high coverage and a large decrease in Haemophilus influenzae B incidence following routine vaccination, and no polio cases registered since 1960. Mumps outbreaks have occurred but almost no rubella cases; measles saw three outbreaks in recent years (2014 and 2017). Tuberculosis cases have been decreasing since 1958 and vaccination is not mandatory, only recommended for vulnerable groups. Tick-borne encephalitis (TBE) vaccination is being considered for mass vaccination but is not yet mandatory; varicella cases have also been decreasing since 2014.
Professor Prymula presented the Czech Vaccination Calendar and summarised the main changes in the 2018 immunisation schedule:
Professor Prymula shared concerns about rising vaccine hesitancy, given how successfully it reaches mass media and how difficult it is to argue against purely scientifically. He noted that steps are being taken toward a law on compensation for vaccine-related injuries due to mandatory vaccination.
The Group asked whether Central and Eastern European countries like Czech Republic should be concerned about rising tick-borne disease incidence due to climate change. Professor Prymula responded that this is a worrisome situation, as climate change is shifting tick distribution and ticks are now widespread in the Czech Republic.
Asked whether shifting measles vaccination from age 5 to 6 has improved coverage, Professor Prymula noted it was introduced too recently for data to be available. On meningococcal disease, he explained that a rise in MenC cases has led to consideration of a 2+1 schedule for MenB in the youngest children and one MenC dose from age 1+.
Professor Usonis presented Lithuania's historical and political background, noting that the first National Immunisation Programme (NIP) was established in 1992 and is updated every four years; the latest NIP covers 2019–2023. The first immunisation calendar was inherited from the Soviet era, and since 1993 only internationally standard vaccines have been used — the 3rd dose of BCG is no longer included in the children's calendar.
Milestones include: since 1996, additional non-reimbursed vaccines have become available alongside those provided by the State; in 1998, the 2-dose MMR schedule was introduced, and high MMR coverage keeps measles at a sporadic low level. Also in 1998, Hepatitis B vaccination began for newborns, extended in 2002 to previously unvaccinated teenagers. MMR coverage among 2-year-olds (2002–2016) remains high though decreasing; coverage among 7-year-olds is somewhat lower but still acceptable.
On vaccine-preventable diseases: following a 1994–1995 diphtheria outbreak, an effective vaccination campaign reduced cases (the last detected case was in 2011, a 55-year-old with unknown immunisation status). Tetanus saw 20 cases during 2005–2015 (7 deaths, all over age 60) and 2 cases in 2016 (ages 74 and 84, one death). The last polio case was reported in 1972; Lithuania has been polio-free since 2001, with no OPV use since 2007 except for children arriving from Georgia, Russia or Ukraine.
Hib vaccination was introduced to the NIP in 2004; 7 cases of Haemophilus influenzae were registered in 2016 and 14 in 2015 (all hospitalised, no deaths). Invasive pneumococcal disease data from 2016 showed 56 registered cases (no deaths). Professor Usonis cited his own 2012–2013 prospective study of SPn serotype circulation among young children in five Lithuanian cities prior to universal PCV vaccination, finding an SPn colonisation rate of 40.8% (367/900), peaking at ages two and three (48.8% and 45.4% respectively). The most common serotypes among 367 isolates were 6B (15.8%), 19F (13.9%), 23F (13.9%), 15 (10.1%), 14 (9.5%), 6A (9.3%), 11 (4.6%), 3 (3.0%) and 18C (3.0%); less frequent were 23 non-23F (2.7%), 19A (2.2%) and 9V (1.6%). This study informed the introduction of PCV10 to the NIP in 2014.
Invasive meningococcal disease is highly prevalent in Lithuania, with the highest incidence in Vilniaus county; MenB is the most prevalent serogroup, prompting vaccination from 1 July 2018, with MenB uptake increasing from 2014 to 2016. Rotavirus cases have increased across all age groups, with the highest incidence in children under 3; rotavirus vaccination has since been added to the calendar.
Professor Usonis concluded by noting Lithuania's focus on adult-life vaccination: rabies (post-exposure), tetanus-diphtheria every 10 years or after trauma, influenza for those over 65 or at risk, PCV for risk groups regardless of age, and vaccination after bone marrow transplantation.
Asked about current adult vaccination uptake rates, Professor Usonis noted these are very low even among target populations (e.g. flu vaccine uptake is around 10–15%), with a long way to go to reach good coverage. On the high pneumococcal disease burden shown in his data, he explained that this evidence is important for demonstrating the disease burden and its public health and universal-vaccination implications. Asked for his view on convincing national authorities to add MenB to national calendars, he noted that countries should not be directly compared, as strategies must differ; in Lithuania's case, two same-day death cases with high media coverage sparked the push for MenB vaccination, followed by parliamentary discussion of cost-effectiveness — but no single strategy fits all countries given differing incidence rates.
Dr Stefanoff summarised his presentation's objectives as: 1) comparing immunisation programmes in Norway and Poland, and 2) identifying best practices that could improve the Polish programme.
Dr Stefanoff shared that Norway maximises the number of antigens (12) while minimising the number of visits (7), contrasting with Poland's higher number of visits (11) and higher use of monovalent (single-antigen) vaccines.
Dr Stefanoff explained that Poland's National Sanitary-Epidemiological Council advises on all public health problems, not specifically vaccination, and that unpublished reports and the lack of a dedicated budget line limit transparent, sustainable decision-making.
Norway's electronic registry allows real-time, stratifiable monitoring, whereas Poland's paper-card system suffers because people move around and frequently lose their cards.
In Norway, nurses are the main information source; in Poland, physicians are — making communication and access more difficult in the Polish system. Dr Stefanoff noted MMR uptake in 3-year-olds has been declining in Poland (95% first dose) despite being mandatory, while increasing in Norway. On measles (2007–2016), both countries are near elimination, though Norway shows a clearer decrease while Poland has seen a slight increase in recent years. Mumps cases are near zero in Norway (bar a 2015 outbreak) and trending downward in Poland. Rubella has no reported cases in Norway, but Poland saw a 2013 compensatory outbreak among unvaccinated young males (historically only girls were vaccinated). AEFI rates are higher in Norway than Poland but decreasing, while in Poland they are still increasing.
To improve immunisation, Dr Stefanoff recommended Poland should:
The Working Group commented that vaccine hesitancy seems to be rising in Poland, and asked how this might have influenced the data presented, along with the influence of political context and trust in Polish politicians. Dr Stefanoff responded that a survey conducted ten years ago showed that people in Poland do not trust governmental institutions, the opposite of Norway — reasons that may be linked to cultural background but also to Poland's authoritarian political history until the 1990s, which did not invest in vaccination education or communication.
Professor Bogdanovic briefed the Group that Serbia had a very good reputation for vaccination policy and results until the last 3–4 years, after which coverage rates dropped due to two main reasons: short supply of vaccines, and growth of the anti-vaccine movement (with hesitancy especially high for MMR). Within this context, measles outbreaks peaked in early 2018, with 5,500 cases recorded; among those aged 13–14, around 30% were hospitalised due to pneumonia or other complications.
New measles cases are still occurring, and the authorities' response has been somewhat delayed. Coverage rates are improving in some regions to target level, yet remain below 90% in others, showing a disjointed picture with huge regional variation. In conclusion, Professor Bogdanovic noted that a stronger concerted effort against the anti-vaccine movement is needed, including addressing hesitant anti-vaccine doctors and paediatricians.
Asked what could help hesitant paediatricians, Professor Bogdanovic explained that paediatricians undertake continued annual training exploring vaccination topics, alongside efforts to influence the general public through press and media to stress the importance of vaccination and overcome hesitancy among healthcare professionals in Serbia.
Mr Malcolm Taylor gave a brief update on the Coalition for LifeCourse Immunisation, a network of experts and associations from civil society — including public health NGOs, patient groups, academics, and health professionals from across Europe — aiming to prevent infectious disease over the life course through wide-scale immunisation.
To achieve this, CLCI aims to help governments and regulators recognise the benefits of preventing infectious disease, combating antimicrobial resistance (AMR), the value of the herd effect, and the benefits to individuals, society and the economy — by encouraging reporting, comparison and sharing of best practice, increasing uptake, overcoming hesitancy, and cooperating with stakeholders such as healthcare professionals and patient groups.
Recent CLCI activities include: the 2nd EIP LifeCourse Immunisation Focus Group (Vienna, 9th EIP, Dec 2017); a Policy Forum on Antimicrobial Resistance and Vaccines (European Parliament, Brussels, June 2018); co-hosting an EHFG session on the life-course approach to immunisation with Health Policy Partnership (Oct 2018); and the 3rd EIP LifeCourse Immunisation Focus Group (Prague, 10th EIP, Dec 2018). CLCI also participated in the Active Citizenship Network Meeting on European Patients' Rights Day (Apr 2018), a Euractiv meeting on "Empowering citizens to protect their health" (Apr 2018), and a Futures Workshop on "Immunisation in a digital world" organised by the International Longevity Centre – UK (Jun 2018).
CLCI's plans for 2019 include finding interested individuals among patient groups, parents and older-persons groups to provide with sound knowledge so they can "spread the good news," and increasing peer learning — often more efficient than top-down information — through the formation of working parties.
Mr Gary Finnegan explained the Vaccines Champions Communication Challenge 2018, hosted by Vaccines Today and open to healthcare workers, scientists, students and other EU residents who actively contribute to raising awareness and positively promoting vaccination through social media.
Dr Mihai Craiu, a paediatrician at the National Institute for Mother and Child Health in Bucharest, Romania, won the competition and presented his work joining online vaccine conversations to help parents understand the need for immunisation. He runs a Facebook page called "Virtual Hospital for Children," and gave an overview of Romania's immunisation situation: according to WHO-UNICEF estimates, national immunisation coverage in Romania is below the herd-immunity threshold, and the National Institute of Romania reported 59 deaths during the measles epidemic (out of 15,519 cases up to 1 December 2018).
Dr Craiu explained that Romania's declining immunisation coverage has many determinants — hesitancy, anti-vaxx champions, doctors and authorities — with the main sources of hesitancy including bad science, fake news (e.g. Andrew Wakefield and autism), and anti-vaxx champions such as TV stars, religious leaders and some doctors. Overall, doctors and paediatricians feel they have weak tools to combat this movement.
In response, Dr Craiu began attending NGO-organised meetings (rather than only medical congresses, which reach GPs but not the public) and moved online, where patients often look for information. He explained that social media education became necessary once he realised patients get frustrated with in-person patient-doctor dialogues and go online instead, and that doctors can identify patients' real fears and perceptions by observing what people write online. He concluded that social media empowers patients to ask questions they might feel unable to raise in a GP's office, and can — and should — be used to improve basic health literacy.
Professor George Syrogiannopoulos, Professor and Chairman of Paediatrics at the University of Thessaly, gave an overview of EIP's European LifeCourse Vaccination Initiative strategy. He explained that frontline paediatricians play a crucial role in the successful implementation of vaccination programmes, as they educate parents, advocate for vaccination, and administer vaccines in everyday practice — and have valuable insights into what works and doesn't when addressing parents' concerns, insights that could shape more efficient policy. He stated the Initiative's primary targets are to:
The strategic approach rests on the conviction that there is a direct relationship between healthcare professionals' own vaccine uptake and their willingness to advocate vaccination to patients. Establishing this relationship could open numerous interventions to increase vaccination uptake among colleagues, drive behavioural change, and mobilise the wider medical community. A further target is addressing fragmented information on vaccination promotion activities across Europe — establishing what is happening, when, how much, and how efficient current actions are — to focus on gaps country-by-country and region-by-region. Training frontline healthcare professionals to address patients' concerns is also a focus, offering educational resources, in collaboration with partners, on addressing concerns, overcoming hesitancy and driving behavioural change.
Mr Russell Hale, General Manager at EIP, summarised the four pillars of the Vaccines Initiative:
Mr Hale explained that 2019/2020 will bring additional campaigns and potential working groups established through the Together Network, targeting specific conditions/vaccines (influenza, meningitis B, varicella, boosters, etc.) and addressing hesitancy and educational gaps. EIP's member database of 45,000+ provides the base to focus on specific regions and countries where problems are identified, and to adjust strategies and messaging accordingly.
Focus Group participants then divided into five parallel working groups, each tasked with debating and reporting on possible ways to overcome barriers on the following topics: Overcoming HCP Hesitancy; Economic Value of Vaccinating Across the Life Course; Antimicrobial Resistance and Vaccines; Mandatory Vaccination; and Herd Immunity. A summary of each group's initial findings and recommendations follows.
The Working Group discussed strategies to overcome healthcare professional hesitancy in adopting new vaccines, and prioritised the following recommendations:
The second Working Group discussed the economic value of vaccinating across the life course, prioritising the following recommendations:
Participants discussed practical steps to combat antimicrobial resistance (AMR) through improved life-course vaccination coverage, prioritising the following recommendations:
Participants were asked to debate whether mandatory vaccination is a solution or part of the problem, given that several European countries have made childhood vaccination mandatory, and whether this is the right approach for adult or healthcare-professional vaccination. Prioritised recommendations:
Participants were asked to recommend strategies to increase awareness of the importance of herd immunity. Prioritised recommendations:
Professor Stephenson concluded the 3rd LifeCourse Immunisation Focus Group by thanking participants and co-chairs, and sharing a personal concern regarding healthcare professionals at his own hospital who do not take up the flu vaccine even when offered free of charge — average uptake is around 50%. One solution trialled this year has been a drop-in vaccination point staffed by a responsible person, requiring no appointment. He also raised a concern that we should empathise with HCPs on the front line: as more doctors feel pressed by patient volume, they lack time to tackle difficult vaccine-hesitancy conversations, and the simplest response is often conflict avoidance.
To build on the broad consensus that collaboration and joint action in tackling vaccine hesitancy and increasing vaccination rates is vital, the European LifeCourse Vaccination Initiative in 2019/20 has been tasked with bringing together all stakeholders to discuss in depth, build consensus on the steps ahead, and produce a roadmap of actions to increase vaccination coverage in Europe, with targets to:
Discussion at the 3rd LifeCourse Immunisation Focus Group in Prague made clear that decision makers are often not informed, or do not always act on, scientific evidence, recommendations, guidelines, and the outcomes of successful implementations. In addition, the public often remains confused and misinformed without tools to filter social-media information; the medical community is often unable to step up and build vaccine confidence; and efforts by organisations remain fragmented, unaligned, and often overlapping.
To counter this, EIP and partners will host five Stakeholder Working Group Meetings in 2019, targeting to help countries improve their immunisation strategies and revise and update their policies and recommendations. Researchers and experts, key opinion leaders, medical associations, public health experts and officials, government organisations and regulatory authorities from EU Member States will be invited to actively participate in open discussions, share experiences and ideas, and contribute to the meetings' goals.
The Stakeholder Working Group Meetings aim to build consensus on vaccinations where significant policy discrepancies exist. Despite official guidelines, countries have often adopted heterogeneous vaccination strategies resulting in differing coverage rates across Europe; decision-making remains country-specific, reflecting varying epidemiology as well as country-specific differences in healthcare systems, level of evidence, vaccine acceptability and financing. The meetings target helping countries improve their immunisation strategies using evidence-based, transparent and sustainable processes.
Each multi-stakeholder one-day meeting is dedicated to one vaccination where significant discrepancies are identified across Europe. Each meeting examines the latest scientific data on the disease and available vaccines, reviews current vaccination policies and coverage across European countries, builds stakeholder consensus on the steps ahead, and produces a roadmap of actions and a position paper to help decision makers revise and update their policies. Each meeting is structured around four themes — Recommendations, Policies, Evidence, and Barriers — leading to Actions (a roadmap, aligned efforts, and an actions toolkit per country). Meeting 1 (Varicella) covers existing recommendations and coverage, funding and co-payment models, coverage/hospitalisation/complications data, and barriers including low public health priority, cost-effectiveness and MMRV-associated febrile seizure safety concerns. Meeting 2 (Rotavirus) covers similar themes with barriers including cost-effectiveness, funding, and safety/commitment gaps among HCPs. Meeting 3 (Meningitis) covers recommendations against all Neisseria serogroups, lessons from MCC and MenB vaccination programmes, and barriers of awareness, cost-effectiveness and HCP support. Meeting 4 (Influenza) covers quadrivalent vs. trivalent vaccine policy, vaccination of healthy children, and barriers of awareness and cost-effectiveness. Meeting 5 (Imported infections) covers newly arrived migrants, travellers, dengue fever, tick-borne encephalitis and climate change, national policies for immigrant and traveller vaccination, and barriers of awareness, cost-effectiveness and education gaps.
N.B. — agendas and the final focus of each Working Group may change through stakeholder consultations in Q1–Q2 2019.
In addition to the 2019 Working Groups, EIP will once again host the 4th LifeCourse Immunisation Policy Focus Group Meeting in Copenhagen, Denmark, on Friday 6th December 2019, focusing on policies to address the multiple, simultaneous challenges that complicate achieving and maintaining high vaccine uptake across Europe. The meeting is held in collaboration with the WHO Collaborating Centre for International Child & Adolescent Health Policy and 20 other government and non-government organisations and medical associations involved in vaccination across Europe, tasked to:
This approach reflects that although national immunisation strategies have traditionally focused on infants and children, experts increasingly urge policymakers to protect the wider population against infectious disease by moving towards a life-course immunisation approach. The meeting focuses on multiple, simultaneous challenges complicating high vaccine uptake: an increasingly vocal anti-vaccination movement among the public, underserved populations and minority ethnic and religious groups, and a lack of commitment among HCPs to personally vaccinate and advocate vaccination to patients.
As highlighted during discussion at the 3rd Focus Group, adolescents are a very challenging group in which to change behaviour and increase vaccination rates, as they rarely visit HCPs and often fall between the responsibility of paediatricians and adult practitioners. EIP is suggesting a campaign that aims to utilise all available communication channels to reach adolescents and their parents and promote adolescent vaccinations, with schools, universities and cities (controlling education and sports facilities) working together with the medical community to increase vaccination uptake among adolescents.
In addition, anti-vaccination rhetoric utilises social media to foster online spaces that strengthen and popularise anti-vaccination discourse. Social media often acts as a "breeding ground" for false and harmful information about vaccine safety, fuelling parents' fears of side effects. Young healthcare professionals, using social media at a personal level, are best placed to step up and counteract this, shifting the balance towards credible, evidence-based information on vaccination benefits — an EIP focus for 2019/20.
Activities in 2019/20 build on the achievements and plans to date, most notably:
