EIP has been working for the past 7 years on overcoming barriers to vaccination uptake in childhood covering: HPV, influenza, meningitis, amongst others, at separate meetings across Europe, Middle East and Asia and have also included infectious disease sessions on the conference programmes and CME online courses on overcoming vaccine hesitancy.

For the past 3 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 the 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 amongst healthcare professionals themselves) across Europe.

• Mapping the latest opinions and barriers.
• Connecting vaccination key opinion leaders and frontline pediatric healthcare professionals, (who administer vaccines on a daily basis) with associations and policymakers.
• As well as connecting associations and organisations advocating vaccination uptake across Europe to better collaborate and work with with each other (the Together Network and Platform).

To help achieve and coordinate these goals, the 3rd LifeCourse Immunisation Meeting took place in Prague, 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, Chair of the General Medical Council of United Kingdom, welcomed the 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:

• to provide a comprehensive overview of current vaccines policies across Europe (Updates covering the European Commission and individual Countries);
• to examine changes made and positive steps taken on vaccination policies across Europe (and within European countries) during 2018;
• to outline vaccination priorities, reviewing surveillance data and current population coverage.

A second purpose of the Focus Group was to determine actions on vaccination across Europe that overcome barriers and increase uptake. In order to achieve these goals, several key speakers were invited to make a presentation which was proceed by an open discussion with speakers, experts and participants.

European Union related presentations in included:

• Update on Surveillance & Population Coverage Across Europe
  (Presenter: Anna Odone)
• Update on policies and actions in the European Union 2018/19
  (Presenter: Dr Daphne Holt)

Countries related presentations in included:

• Four Lessons from Italy
  (Presenter: Carlo Signorelli)
• Romania Vaccination Update – The Roma Population
  (Presenter: Marius Tudor)
• Czech Republic Vaccination Update
  (Presenter: Roman Prymula)
• Lithuania Vaccination Update
  (Presenter: Vytautas Usonis)
• Serbia Vaccination Update
  (Presenter: Radovan Bogdanovic)
• Comparison of Policies Between Norway and Poland
  (Presenter: Pawel Stefanoff)

After the presentations and debates, participants were divided into 5 working groups, covering:

1. Strategies to overcome healthcare professional hesitancy in adopting new vaccines
   (Led by Terence Stephenson)
2. Economic Value of LifeCourse Immunisation. What is known, what are the gaps, why is it important?
   (Led by David Sinclair)
3. Antimicrobial Resistance and Vaccines Policy and Practice: What are the practical steps?
   (Led by Sam Nye)
4. Mandatory Vaccination. A Solution or part of the problem?
   (Led by Daphne Holt)
5. Herd Immunity: Strategies to increase the awareness of the importance of herd immunity
   (Led by George Syrogiannopoulos)

Each working group then outlined the Group's ideas and suggested future actions.

The following summarises 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.

Updates on Surveillance & Population Coverage Across Europe

Presenter: Professor Ana Odone (Professor, Director School of Public Health - Uni San Raffaele in Milan, Italy)

A brief overview of what the EU currently does and arguably should be doing on immunization policy was delivered, namely providing the Focus Group with:

1. A contextual framework
2. EU surveillance of infectious diseases
3. EU role in technical support to Member States
4. EU role in policies
5. Immunization recommendations across MSs
6. Population coverage across MSs

Professor Odone started her presentation with a statement from Bruce Gellin (Director, National Vaccine Program U.S. Department of Health and Human Services), "Talking about vaccines is different from talking about vaccination".

Following, Professor Odone presented the contextual framework of vaccination which contains important levels ranging from Surveillance – Research and development - Marketing authorization (Efficacy and Safe vaccines) – Recommendations – Organization of supply and immunization services – Vaccine Demand and Uptake by target populations.

These levels can be measured by Coverage Rates which in turn may inform about the Impact of Immunization Policies as well as about Planning and Implementation.

Professor Odone continued by focusing on how surveillance of infectious diseases is carried out at an EU level. The European Centre for Disease Prevention and Control (ECDC) collects, analyses and disseminates surveillance data on 56 communicable diseases (some are vaccine-preventable diseases) and related special health issues from Member States. Reporting is made in a standardised way to allow data comparability across EU.

The EU also provides technical support to Member States mainly through scientific advice, communication and training. As an example, Professor Odone presented the ECDC handbook on the design and implementation of immunisation information systems (available here).

In terms of the EU role in immunization policies, Professor Odone denoted that although vaccination policy is not a competence of the EU but of the national authorities, the European Commission assists EU countries in coordinating their policies and programmes by making recommendations. As an example, Professor Odone highlighted the recent Council Recommendation to strengthen the EU cooperation on vaccine-preventable diseases (April 2018). The EU also funds research and scientific initiatives and programmes. As an example Professor Odone presented the Joint Action on vaccination, co-funded by the Health Programme at €3.55 million.

Regarding Immunization recommendations across Member States, Professor Odone referred to the EDCD platform containing the most recent recommendations, highlighting however, that there is heterogeneity of immunization offer and recommendations by member states. In regards to coverage, which data is not collected at EU level, Professor Odone explained that it is the World Health Organization who keeps track of the different vaccines, different recommendations and different programmes across countries.

As an example, Professor Odone provided a reference to: Jorgensen, P., Mereckiene, J., Cotter, S., Johansen, K., Tsolova, S., & Brown, C. (2018) work covering: How close are countries of the WHO European Region to achieving the goal of vaccinating 75% of key risk groups against influenza? Results from national surveys on seasonal influenza vaccination programmes, 2008/2009 to 2014/2015. Vaccine, 36(4), 442-452.

The paper concludes that: Despite policy recommendations, influenza vaccination uptake remains suboptimal. Low levels of vaccination is not only a missed opportunity for preventing influenza in vulnerable groups, but could negatively affect pandemic preparedness. Improved understanding of barriers to influenza vaccination is needed to increase uptake and reverse negative trends. Furthermore, implementation of vaccination coverage monitoring is critical for assessing performance and impact of the programmes.

Update on policies and actions in the European Union 2018/19

Presenter: Dr. Daphne Holt (Chair of the Coalition for LifeCourse Immunisation - CLCI)

Dr. Holt started her presentation by sharing that her sources of information come from official documents, notes and slide decks from meetings where the Commission's perspective on vaccination was discussed by experts such as: Martin Seychell – Deputy Director General, DGSanté (Health and Food Safety), John-F Ryan – Director Public Health, Country Knowledge and Crisis Management DGSanté, Geneviève Chêne - Directrice, Institut de santé publique, d'épidémiologie et de développement, Univ. Bordeaux, Coordinator of the Joint Action on Vaccination.

Dr Holt reiterated that the importance of life-course vaccination according to DGSanté, which is becoming more and more important, is that life-course vaccination maximises benefits of vaccination for individuals, public health and society. Life-course vaccination requires: political leadership, changing public perception of vaccination (it should be seen as the norm), engagement of healthcare professionals (they are at the frontline), integration of non-healthcare setting (e.g. workplace) and improved surveillance. Moreover, the promotion of life-course vaccination has to be evidence-based.

Past EU legislation on communicable diseases from 2000-2013 is available: Commission Decision 2000/96/EC (list of communicable diseases), Commission Decision 2002/253/EC (case definitions for communicable diseases), Regulation (EC) No 851/200417 (ECDC founding act, 2005), Decision No 1082/2013/EU on serious cross-border threats to health.

Regarding the Commission's current work on vaccination, Dr Holt highlighted: the coordination of preparedness, assessment and outbreak management of vaccine-preventable diseases, Guidance on communication activities relating to vaccination programmes, the monitoring benefits and risks to derive and disseminate evidence-based information on effectiveness and safety of vaccines / vaccination, organising a joint procurement for pandemic vaccines and other products (not forgetting that health is a member state competence is not a competence of the union itself).

The current EU policy initiatives on vaccination covers:

1. Proposal for a Council Recommendation and Commission Communication to strengthen the EU cooperation on vaccine-preventable diseases;
2. EU Joint Action on Vaccination, including life-course approach to vaccination in plans,
3. Taking into account research requirements for life-course vaccination.

The EU Joint Action on Vaccination was launch in September 2018 and aims to improve vaccination coverage, and thus health security, in Member States. It's co-funded by EU and Member States and coordinated by INSERM, France. There are 20 partner countries (UK, Germany and Austria will join later). Main activities will include: public consultation to provide information and guide interventions/actions; coordinate cross-border measles vaccination campaigns and improve communication; annual competition of vaccination promotion in European schools; map and review electronic vaccination record systems that already exist and discuss how to best implement them.

A Stakeholder forum is envisaged to encourage participation from civil society. Regarding the new financial period 2021 – 2027, there is a new and improved European Social Fund plus (ESF+:) with €101.2 billion to spend and ESF+: health strand - €413 million (under direct management) to help member states modernise their health systems. Moreover, ESF+: projects under shared management (€100 billion allocated) will also have funding opportunities for health.

Horizon Europe programme health cluster; €7.7 billion - health through the life-course; environmental and social health determinants.

In addition, there is a new political environment based in the context of a change in the Commission starting in 2019 and the European Parliament elections. So this may represent an opportunity to fix new policy priorities in public health and for stakeholders to help set the new policy priorities in public health.

A member of the Focus Group interjected to update the Group that the Health Ministers of the EU 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.

Presenter: Professor Carlo Signorelli (Professor of Hygiene and Public Health at the Universities of Parma and Vita-Salute San Raffaele, Milan, Italy)

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.

However, Professor Signorelli set these in the context of recent events and shared information about four practice examples from Italy:

Suspension of mandatory vaccinations in Veneto region (2007)

In 2007 the Veneto Region in Italy (one of the regions in Italy with history of high vaccination coverage) suspended mandatory vaccinations and invested in educational and information campaigns to better counteract the spreading of anti-vaccination movements. As a result there was a greater coverage decrease in Veneto than in other Regions, showing that the nudge theory (a theory that states that people make wiser decision when their choices are presented better and their freedom of choice is kept) did not meet the goals. Professor Signorelli showed a graph illustrating that the suspension of mandatory vaccination decreased the coverage rates in Veneto from around 98% to 92%.

A strengthened political commitment (2014- to-date)

Since 2014, a strong political commitment started 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 about the usefulness of vaccination. The overall results of this commitment were considered positive since data shows that a new National Plan, new actions increased coverage rates. Moreover, there was a favourable increase of media coverage for vaccination compared to hesitancy. Nevertheless, in 2017 there was a decrease of favourable news on vaccination probably due to a parliamentary debate on mandatory vaccination.

Regarding coverage data, Professor Signorelli shared graphs illustrating that influenza coverage rates in the elderly and the national coverage rates for polio and measles increased since the 2014 political commitment. Another important fact is that the majority of the population agreeing that all vaccines should be mandatory or at least a small proportion all vaccines should be mandatory also increased since 2014.

An unexpected role player (2015-onwards) – Professor Roberto Burioni

Professor Signorelli gave the example of Dr Roberto Burioni, a Professor of microbiology at the Università Vita-Salute San Raffaele in Milan, who is trying to use social networks to oppose anti-vaxxers, with a rather aggressive tone, claiming that they are ignorant and that science is not a matter of democracy. According to the number of views, this approach had a positive impact on social media platforms, rebalancing scientific information against hesitancy and anti-vaccination.

Expansion of mandatory vaccinations (2017)

In 2017, there was a strong Italian policy to "stopgap" and raise vaccination uptake. Mandatory vaccinations rose from 4 to 10, certificates were asked at pre-school admission with fines (500€) for non-compliance, there was information strengthening and sanctions applied to anti-vax medical doctors. Professor Signorelli showed the Group an example graph illustrating how the coverage rates for Polio and Measles in the region of Emilia Romana increased from 2017 up to now (2016 - 93% to 2018 - 96% and 2016 - 87% to 2018 -95% respectively).

After presenting the four examples from Italy, Professor Signorelli gave some insights on possible risks for a rebound due to the political context and the rise of populist ideas of anti-vaccination and discredited claims on dangerous risks of vaccines. As an example, Professor Signorelli cited a The Guardian News article divulging that the Italian health minister decided to discharge the entire board of Italy's most important committee of technical-scientific experts, who advise the government on health policy.

In conclusion, Professor Signorelli stated that vaccine uptake and hesitancy policies and behaviours are highly influenced by countries and regions social, cultural and political contexts.

Discussion

Group discussion followed with a debate around a possible continuum between mandatory vaccination and totally voluntary vaccination (the nudge theory).

A Group member gave the example of the UK's strategy of making vaccination mandatory unless people clearly state that they do not want to get vaccinated and asked if this could also be implemented in Italy. Professor Signorelli responded that in Italy, before 2017, there were four vaccines requirements for children enrolled in schools but these were never verified or checked. Since 2017, there was an improvement in such verification due to the mandatory law both in vaccines that are and are not mandatory.

The Focus Group commented on Professor Burioni's strategy outlined in the presentation and debated if the aggressive tone used by Professor Burioni is really helping or if he is "awaking the monster which is sleeping" in the sense that it might be risky to rely on someone that impulsive. Professor Signorelli responded that the "monster" was not sleeping since many anti-vaxxer were already reaching the media. In that sense Professor Burioni can be helpful because he reaches the media and disseminates scientific information.

The Group continued to share examples, including the case of France, which is a country with high rates of vaccine scepticism and with a new legislation on compulsory vaccination, and asked if political stability can help coverage rates and if changing the law every 3 years can be harmful. Professor Signorelli responded that changing legislation all the time is not always beneficial and that we as public health society should suggest governments to wait three years and evaluate the impact of new laws and only to change them if at all necessary.

The Group then pinpointed that 5% of not vaccinated population in Italy is a substantial number and asked if this percentage is related to conscientious objectors, in the sense that in the UK some parents have to show proof for a vaccination exemption (e.g. Religion exemption). Professor Signorelli stated that the 5% includes exemptions for medical reasons, migration (e.g. moved to other countries or regions) and errors in registration. According to data from the National Institute of Health the proportion of conscientious objectors is circa 0.7%.

Presenter: Roman Prymula (Deputy Minister of Health, Professor of Preventive Medicine at School of Medicine, Charles University, Czech Republic)

Professor Prymula briefly presented the Czech Republic's Immunisation Programme by explaining that some vaccinations are mandatory (e.g. Hexa + MMR) while others are voluntary but recommended (e.g. Pneumo + HPV).

Overall, the immunization is covered by the health insurance fund. In terms of coverage rates of the recommended vaccines, Professor Prymula stated that these range from 70% to 80% for Pneumo and from 65% to 68% of HPV in girls.

Regarding Pertussis, Czech Republic had a steep rise in cases, possibly related with the introduction of the acellular vaccine, reaching the highest point in 2014 and dropping until 2018. Adolescents were the most afflicted aged-group and therefore a booster shot was introduced at the age of 10-11 years old.

In summary, the history of the Immunization Program for Pertussis includes:

1. an Incidence until 1958 of 30,000-34,000 a year / 80 deaths a year;
2. In 1958 Vaccine was introduced;
3. Until 2006 Vaccination schedule for 3-5 month olds, a booster at 18-20 months and one at 5 years-old, and DTwP used (about 20% in Prague aP);
4. Since 2006 Vaccination schedule included 3-5 month olds, 1st booster 6 months later up to 18 months, 2nd booster at 5 years old, DTaP-IPV-Hib-HBV used; and
5. 3rd booster at 10-11th years old since 2009.

Professor Prymula commented that in terms of Influenzae B there is a high coverage rate and a large decrease in incidence disease following the introduction of routine vaccination. And in terms of Polio, there are no cases registered since 1960.

Mumps outbreaks have been registered in Czech Republic but there are almost no cases of Rubella. Regarding Measles there were 3 outbreaks in the last few years (2014 and 2017).

Reported Cases of tuberculosis TB have been decreasing since 1958 in the Czech Republic and vaccination is not mandatory and is only recommended for vulnerable groups.

Regarding Tick-borne Encephalitis (TBE) vaccination is being considered for mass vaccination but it is not mandatory at present. The number of Varicella cases has also been decreasing since 2014.

Professor Prymula presented a chart with the Czech Republic Vaccination Calendar, highlighting the Mandatory and Recommended vaccinations in 2018. Professor Prymula also summarized the main changes in the Czech Immunization schedule in 2018 namely:

• Novel law 48/1997 30.6. 2017 for reimbursed services;
• HPV for boys aged 13 years (girls covered already since 2012);
• 2+1 schedule for Pneumococci – (3+1);
• New chronic diseases (IMD, IPD, Hib, flu);
• and new immunization for seniors 65+ PCV13; DTaP-Hib-HBV-IPV vaccination changes (2 doses since Week 9, 2 months apart;
• Booster between 11-13 month; Preterm newborns: 3+1;
• Booster DTaP-IPV at 5-6 years old;
• Booster DTaP-IPV at 14 years;
• MMR at 5-6 years old (second shot); and first shot fixed till 18th months).

To conclude, Professor Prymula shared his concern regarding the rise in vaccine hesitancy, mainly because this topic is increasingly and more successfully reaching mass media and also because it is very difficult to argue purely scientifically against anti-vaccination ideas. Moreover, Professor Prymula stated that there are steps being taken in Czech Republic towards the adoption of a law for vaccine-related injuries compensation due to mandatory vaccination.

Discussion

Following the conclusion of the briefing the Focus Group asked if countries in Central and Eastern Europe, such as Czech Republic, should be concerned about increases in incidence of tick-borne diseases due to climate change. Professor Prymula responded that this is a worrisome situation since climate change/warming is changing the distribution of ticks and there is a widespread presence of ticks in the Czech Republic.

The Group the asked if the shift made in measles vaccination from 5 to 6 years old is being effective in terms of higher coverage. Professor Prymula answered that this was introduced very recently and there is no data available yet.

The Group went on to question Professor Prymula about Meningococcal disease in Czech Republic. Professor Prymula explained that in the last years there was a rise in MenC cases and because of this a 2+1 schedule for MenB is being considered for the youngest children and a one shot of MenC 1+.

Presenter: Professor Vytautas Usonis (Professor of Paediatrics at Vilnius University and currently Head of the Vilnius University Clinic of Paediatrics)

Professor Usonis started by presenting an historical and political background of Lithuania and by stating that the first National Programme on immunisation (NIP) was established in 1992 and is updated every 4 years.

The latest NIP was approved for the period of 2019-2023. The first immunisation calendar was inherited from the time of former Soviet Union, and since 1993 only vaccines of international standard are used in Lithuania. Therefore, in the children immunization calendar the 3rd dose of BCG is no longer included.

Regarding the Milestones of the development of NIP, Professor Usonis explained that since 1996 in addition to the vaccines provided by State other vaccines are available but not reimbursed, and that in 1998 the 2 dose of MMR vaccination was introduced and high MMR coverage ensures sporadic low measles level in Lithuania.

Also in 1998 there was the introduction of Hep-B starting from newborns and in 2002 for teenagers that were not vaccinated earlier.

In terms of MMR coverage in 2002-2016, among children aged 2 years, Professor Usonis presented a graph showing that, although decreasing, coverage is still high. Regarding children aged 7 years old thre coverage rate is a little lower but still acceptable.

Professor Usonis went on to provide the Group with a brief overview on vaccine preventable diseases in Lithuania, showing that for the case of Diphtheria, and following its outbreak in 1994-1995, a very effective vaccination campaign was implemented which resulted in a decrease in cases (the last case detected was in 2011 – a 55 year old with immunisation status unknown).

Regarding Tetanus, during 2005-2015 there were 20 cases detected (among them there were 7 deaths reported all over 60 years of age) and 2 cases in 2016 (A 74 and a 84 years old) resulting in 1 death.

Regarding Polio the last case reported was in 1972. Lithuania has been polio-free since 2001 and there is no OPV since 2007 with the exception of cases of children coming from Georgia, Russia or Ukraine.

In relation to Haemophilus influenza, Professor Usonis explained that Hib vaccination was introduced to Lithuania's NIP in 2004 and a total of 7 cases of Haemophilus influenzae spp cases were registered in 2016 and 14 in 2015 (all were hospitalised and there were no deaths reported).

Official data regarding Invasive pneumococcal diseases from 2016 stated that there were registered 56 cases (no death cases were registered). Professor Usonis cited his prospective study carried out in 2012-2013 to evaluate the circulation of SPn serotypes among young children in five cities of Lithuania before the introduction of universal vaccination with pneumococcal conjugate vaccine (PCV), in which it was found that the SPn colonisation rate was 40.8% (367/900), with a peak at two and three years old (48.8% and 45.4%, respectively). Of the 367 SPn isolates, the most common serotypes were 6B (15.8%. n = 58), 19F (13.9%. n = 51), 23F (13.9%, n = 51), 15 (10.1%, n = 37), 14 (9.5%, n = 35), 6A (9.3%, n= 34), 11 (4.6%, n = 17), 3 (3.0%, n = 11) and 18C (3.0%, n = 11); less frequent were 23 (non-23F) (2.7%, n = 10), 19A (2.2%, n = 8) and 9V (1.6%, n = 6). (Streptococcus pneumoniae nasopharyngeal colonisation in children aged under 6 years with acute respiratory tract infection in Lithuania, February 2012 to March 2013. Eurosurveillance, 20(13), 21079.).

Another important outcome from this study was that it provided important information for PCV vaccination. Therefore, PCV 10 was introduced to Lithuania's NIP since 2014.

Invasive meningococcal disease is highly prevalent in Lithuania and the highest incidence if found in the Vilniaus county. MenB serogroup is the most prevalent, therefore since July 1st 2018 vaccination was introduced. The uptake of MenB vaccine has been increasing from 2014 to 2016.

Regarding Rotavirus there has been an increase of cases among all age groups with the higher incidences in children below 3 years old. Vaccination for Rotavirus has been included in the calendar.

To conclude, Professor Usonis highlighted that Lithuania is also focusing on vaccination throughout adult life and that the state covers: Rabies vaccination (postexposure), TD for every 10 years or after trauma, Influenza - >65 of age or risk groups and PCV for risk groups regardless of age, and vaccination after bone marrow transplantation.

Discussion

The Group then asked how the current uptake rates are with respect to adult vaccinations in Lithuania. Professor Usonis responded that these are very low, even among target populations (e.g. the flu vaccine is about 10-15%) and that there is still a long way to go to reach good coverage rates. The Focus Group then commented on the high levels of pneumococcal disease in the data presented by Professor Usonis, and asked how can such data helped make the case for increasing vaccination uptake. Professor Usonis responded that the study and its data have huge importance in demonstrating the burden of pneumococcal disease in Lithuania. These have implications for public health and for organizing universal vaccination.

The Focus Group then asked Professor Usonis for his view on how to best convince countries health authorities to have MenB vaccine in the national calendar. Professor Usonis explained that countries should not be compared and strategies should be different. In the case of Lithuania what sparked the intention for MenB vaccination were 2 death cases in one day that had high coverage in the media, and subsequently many discussions were held in the parliament about cost-effectiveness (e.g. money vs. preventable death cases). Yet, in the end there is no recipe or a strategy that could fit all countries (e.g. different incidence rates).

Presenter: Dr. Pawel Stefanoff (Epidemiologist, Norwegian Institute of Public Health)

Dr. Stefanoff summarised the objectives of his presentation were to: 1) To compare immunisation programmes in both Norway and Poland and 2) To identify the best practices that could improve the Polish programme.

Dr. Stefanoff presented to the Group the contrasts between the countries Immunisation programmes, in terms of structure. Namely:

Dr. Stefanoff shared that in Norway there is maximization of the number of antigens (12) and minimization of number of visits (7), which contrasts with Poland high number of visits (11) and high number of monovalent vaccines (single antigen).

In terms of Immunisation programme governance, Dr. Stefanoff compared the two countries namely: