This policy report examines how to identify and reach pockets of low vaccination coverage across Europe. It opens with an expert briefing on vaccination of the Roma population before widening to other excluded groups, including the homeless, drug users and undocumented people. The report brings together statements from the EU Commission, CPME, EPSA and EAHP, country updates from Croatia, the Netherlands, Spain, Bulgaria and Finland, and a proposed action plan for 2020/2021.
Meeting Report
Policy Focus Group Meeting on Excluded Groups — 11th Excellence in Pediatrics Conference, 6 December 2019
Mihai Craiu1, Martine Ingvorsen2, Jacques de Haller3, Tilen Kozole4, Steffen Amann5, Irena Bralic6, Patricia Bruijning-Verhagen7, Francisco Gimenez-Sanchez8, Mira Kojouharova9, Hanna Nohynek10, Zsofia Meszner11, Paolo Bonanni12, Daphne Holt13, Dace Zavadska14
1Carol Davila University of Medicine Bucharest, Romania, 2European Commission, Directorate-General for Health and Food Safety (SANTE), Unit for Crisis Management and Preparedness in Health, Belgium, 3Standing Committee of European Doctors (CPME), Belgium, 4European Affairs, European Pharmaceutical Students' Association (EPSA), Belgium, 5European Association of Hospital Pharmacist (EAHP), Belgium, 6University of Split, School of Medicine, Croatia, 7Department of Epidemiology, Julius Center Research Program Infectious Diseases, University Medical Center Utrecht, Netherlands, 8Hispalense Institute of Pediatrics, Balmis Institute of Vaccines, Spain, 9National Centre of Infectious and Parasitic Diseases, Bulgaria, 10Infectious Disease Control and Vaccinations Unit, Department of Health Security, National Institute for Health and Welfare THL Helsinki, Finland, 11National Institute of Paediatrics Heim Pal, Hungary, 12Faculty of Medicine, Specialization School for MDs in Hygiene and Preventive Medicine at the University of Florence, Italy, 13Coalition for Life-Course Immunisation (CLCI), France, 14Children Vaccination Centre under Children's Clinical University Hospital, Riga, Latvia
Since 2015 the Excellence in Pediatrics Institute (EIP) has worked with European and global partners to help overcome the many remaining barriers to vaccination uptake. By connecting and working with colleagues across Adolescent Medicine, General Practice, Pharmacy and Nursing, and uniting behind the EU Commission's Coalition on Vaccination, EIP's goals is to promote a LifeCourse approach to vaccines.
Most notably, EIP believes that the following barriers remain: 1) Policy discrepancies - Heterogeneous national vaccination policies. Differences in approach, prioritisation and decision making processes. 2) Overarching barriers - Lack of policies to increase vaccines confidence, counteract misinformation, increase awareness and mobilise medical communities, and 3) Failure to adopt a LifeCourse approach - Prevention Policies not adapted to demographic changes and an increasingly ageing population. Disease prevention in all stages of life is not yet a priority.
As part of EIP's work within the EU Coalition on Vaccination, 8 Stakeholder Working Groups, as well as a joint EU Commission and WHO plenary briefing, took place at 11th EIP Annual Conference in Copenhagen in December 2019. During the Working Groups, speakers were asked to share their opinions on ways to increase vaccination uptake in both the general public and healthcare professionals, on the current state and progress made in increasing vaccination coverage rates in different countries, and to mention the obstacles faced in the process. Four of the Working Groups looked at vaccine-specific barriers, while four looked at policies focusing on overarching barriers.
One of the Policy Focus Groups was tasked with looking at excluded groups, and specifically how we can identify pockets of low vaccine coverage and, once identified, increase uptake amongst these groups. During the Focus Group, several experts shared their thoughts on this crucial matter and described the current situation with excluded groups. The Group looked at the latest barriers to access and explored support interventions to increase access to vaccination for disadvantaged and socially excluded groups, including by promoting health mediators and grassroots community networks, in line with national recommendations.
The following report summarises the invited experts' briefings, discussions, and proposed action plans that were debated during the proceedings of the Excluded Groups Policy Focus Group.
Working Group Briefing
Presenter: Prof. Mihai Craiu, Professor of Paediatrics, Carol Davila University of Medicine Bucharest, RomaniaProf. Craiu opened the Focus Group by exploring the current vaccination issues of the Roma population. He noted that in spite of many effective national immunization programs in Europe, some groups remain unvaccinated, and the Roma population is such a group. The Roma population is very mobile across EU borders, and the approach to increasing vaccination uptake needs a complex and integrated management plan in order to reduce outbreaks of vaccine-preventable diseases.
Prof. Craiu noted that Roma is not the only under-vaccinated group in Europe: five under-vaccinated groups were identified in the literature — Orthodox Protestant communities, Anthroposophists, Roma, Irish Travellers and Orthodox Jewish communities (Fournet et al., 2018). But due to their special characteristics — a transnational ethnic community with different languages, religions and lifestyles — they are the largest European minority group, with approximately 6-12 million people (Muscat, 2011). The Roma population also has a high overall birth rate, a long history of persecution and child neglect, and needs special treatment to achieve a desirable vaccination uptake.
In some Eastern European countries such as Romania and Bulgaria, the Roma population forms up to 10% of the total population. Major determinants of health in Romanian Roma are the age of first marriage (35% before 16 years, 31% at 17-18 years) (Zamfir & Preda, 2002), education (33-45% of adults are completely illiterate), the perception of health status (75% claim not to have health issues) and low income (86% claim they are barely surviving).
Prof. Craiu referred to a recent Roma study in eleven European countries and highlighted several key facts: one in two preschool children attend regular daycare, nine out of ten school children go to elementary school, yet only 15% of teenagers continue to higher education. One in three Roma adults (35-54 years old) have significant health issues or disabilities, and 45% of Roma houses lack elementary facilities such as running water, electricity or heating.
He shared a number of case studies showing that even where immunization coverage was very low for the Roma population, specific actions by health officials raised coverage significantly — emphasising that Roma are not intrinsically against immunization. In one case in the middle of Moldova, immunization coverage was 4% last year, but after a measles epidemic that generated more than 600 confirmed cases, the Health Minister and local authorities succeeded in reaching 95% coverage. They countered the immunization barriers — poverty, lack of knowledge and access — by organizing vaccination events in schools together with incentives. In two other cases, coverage was raised from 11% to 60% and from 70% to 97% within a couple of days, using a door-to-door approach, flyers, or even a blog where people of Roma origin describe their success stories and offer help.
Prof. Craiu argued that new approaches are needed, citing the "cell phone evolution" in Africa, where phone ownership rose from 20% to 90% over 15 years and the WHO has provided educational programs via telephone. He proposed that targeted TV and cell-phone-based campaigns can generate uptake, engagement and behaviour change (Roberts, Yaya & Manolis, 2014), and noted that the Roma population value their freedom highly, so when something looks compulsory they resist it. Finally, he emphasised that today's high-school students will be parents in ten years, offering a good chance to provide them with knowledge now (Andreassen, 2015). In conclusion, the Roma population is an under-served minority with low vaccination coverage; a conventional vaccination approach has failed, and new strategies — such as those tied to the digital revolution — are needed.
On a question from Policy Focus Group Chair Prof. David Salisbury regarding which HCPs can vaccinate in Romania, Prof. Craiu replied that both doctors and nurses can, but current legislation requires a medical check-up before vaccination, which is a great obstacle. He then commented on the "Kazakhstan vaccine" fake news: during a huge vaccine shortage, Romania brought in a hexavalent vaccine labelled in Russian, and the anti-vax movement claimed the government was experimenting on Romanian children. Unfortunately no official source stepped up to clarify it was the same vaccine in a different language — a governance issue as much as a legislation or healthcare one. He added that a group of people from various backgrounds — lawyers to physicians — across many organisations try to provide ideas to the Health Ministry, but politicians are not always open to discussion.
Dr Ingvorsen presented the EU Commission's work on Coverage Pockets, also called Immunity Gaps, defining a Coverage Pocket as a subpopulation or population group where vaccination coverage rates are lower than the rest of the population. She explained that countries can have high national vaccination coverage and still have Coverage Pockets — a serious problem, as it can lead to large outbreaks, threaten herd immunity, and endanger infants too young to be vaccinated or patients too sick to be vaccinated. Such pockets can spread disease across borders in Europe and beyond.
She explained the relation of Coverage Pockets to measles — a highly contagious virus requiring 95% coverage for both doses to sustain herd immunity — and highlighted a 2019 ECDC risk assessment, "Who is at risk of measles in the EU/EEA?", focused on pockets in certain age groups due to current coverage or low historic health data. The publication proposes strategies to eliminate pockets, including: 1) routine vaccination programmes, 2) ample opportunities for check-up and catch-up vaccination, 3) improved outreach services for hard-to-reach groups such as the Roma population, and 4) calls on HCPs to make every encounter with the health system an opportunity to suggest measles vaccination.
She also mentioned the 2018 Council Recommendation, which calls on EU countries to work towards reduced immunity gaps across all age groups and to facilitate access to vaccination services for the most vulnerable, including socially excluded groups. As a direct result, the Commission recently set up a coalition for vaccination bringing together HCPs and student associations. She described two further relevant actions: identifying barriers to access and supporting interventions to increase access for disadvantaged and socially excluded groups, and considering investment in behavioural and social science to determine vaccine hesitancy across sub-groups. She concluded that Coverage Pockets are not only about certain social-economic groups but also about certain age groups, and that the EU Commission would like to look at groups like the Roma but must first collect enough data. Prof. David Salisbury commented that the underlying frustration is that we know a lot about where and who the pockets concern, but are arguably lacking the strategies that will actually address effective vaccination access.
Dr de Haller made two points: we must be aware of prejudice and the need for data and real facts to understand Coverage Pockets; and HCPs are aware of the problem but need support to achieve results. He described how Switzerland had many measles cases, mostly in certain religious schools of the Anthroposophist movement — but on contacting them, realised not all were opposed to vaccination; the ones who opposed were the upper-middle-class parents.
On the second point, he underlined that physicians try to be active in health politics and already have policies on Coverage Pockets, such as the 2013 policy on Childhood Immunization stating that stakeholders — particularly doctors and representatives of hard-to-reach groups — should be involved in developing campaigns, and that good practices should be exchanged between Member States. But they need the means, provided by governments and administrations, to support HCPs' goodwill. Prof. David Salisbury commented that there are many other disadvantaged communities without access to vaccination, and that we should recognise all groups who for whatever reason have vulnerable, unprotected children, thinking more widely than only Roma communities.
Dr Kozole highlighted the increased accessibility of pharmacies in both urban and rural areas and the importance of connecting pharmacists with vaccination — serving as recommenders and as vaccination points — to achieve better coverage. As an example, he described flu vaccination in Ireland: before pharmacist vaccination, doctors delivered around 500,000 vaccines; afterwards, doctors reached 750,000 and pharmacists 150,000, emphasising the added value of the collaboration.
He noted that the European countries allowing pharmacists to vaccinate without a doctor present are Portugal, Ireland, the UK, France, Denmark, Malta and Switzerland. On whether pharmacists can submit data to the register when they vaccinate national-program vaccines, he answered that it depends on the country's e-health records — where implemented, the pharmacist can record the vaccination so it is accessible by the GP. Prof. Mihai Craiu noted that Romania may have an electronic national registry but not an e-health platform. Prof. David Salisbury described the steps that could give pharmacist vaccination an impact on Coverage Pockets such as the Roma: pharmacists being allowed to vaccinate, having a wide range of vaccine availability, and being trusted by the Roma community as a good place to vaccinate their children. Dr Kozole underlined that pharmacy coverage is much better than GP coverage in areas where Roma groups live, and Prof. Salisbury added that we must come up with creative solutions, because shouting at people will never make the problem go away.
Mr Amann underlined the importance of dealing with Coverage Pockets, stating that hospital pharmacists are trying to support this effort, and agreed that preventing pre-judgement is a very important step. He added that in Germany there are many beggars and refugees who can also be considered part of Coverage Pockets, and pointed out that outsourced service workers in his hospital are not covered by any official activities. Prof. David Salisbury noted that we need to be creative in thinking about where pockets of low coverage are, rather than only viewing them as traditional refusers or groups we have worried about before.
Prof. Bralic noted that vaccination against various diseases has been mandatory for pre-school and school children for many years. In 2007, vaccination against Haemophilus influenzae and hepatitis also became mandatory, and last year they started vaccinations against pneumococcal disease and HPV in 8th-grade boys and girls. Influenza vaccinations are free for medical staff, children and adults over 65, all contributing to high coverage.
After 2008 they observed vaccine hesitancy and low MMR coverage, so began organising conferences and catch-up vaccination programs to reverse this. In 2018 they managed to increase coverage in almost all diseases except HPV, for which they organised special educational campaigns. Regarding the Roma community, she reported that in Croatia this community is very limited, so there are not big problems in vaccination coverage.
Prof. Bruijning-Verhagen commented that there is a group of reformed Protestants who do not vaccinate for religious reasons — a small but strong community. Fortunately, things are changing as people move from more traditional conservative Protestant churches to more liberal progressive forms, increasing their coverage. Within one generation there is about a 50% increase in coverage, reaching up to 65% now versus around 40% previously — so peer pressure seems very important in determining whether people vaccinate.
She noted they also have groups where vaccine hesitancy is increasing, where peer pressure may again be key to promoting a healthy lifestyle. Regarding immigrant groups, vaccination coverage is not a significant problem, but they should reach out to them more. It was commented that the true drivers of possible low coverage are budget, health policies, the lack of proper vaccination registration cards, and communication difficulties due to different languages.
Dr Gimenez-Sanchez said that in 2019 Spain had 300 measles cases, all related to imported ones — many from Romania, some from the Roma population — prompting a targeted vaccination campaign in specific neighbourhoods. HPV vaccination coverage reaches about 72% in girls, and to protect unvaccinated girls, HCPs should also promote HPV vaccination in boys.
He suggested the European Parliament should push countries to take action on measles circulation, though it was commented that the Parliament can only make suggestions and recommendations. Nonetheless, the ECDC shares a portal where different country experiences are documented in written, video or other formats, so other countries can learn from them.
Dr Kojouharova described insufficient vaccination coverage in the Roma population, which has caused several measles outbreaks. There was a measles outbreak from 2009 to 2011 with more than 24,000 cases and 24 deaths, 90% of the infected being Roma; another in 2017 again saw 90% of infected people being Roma, with half their communities still unvaccinated, and there is currently an ongoing outbreak affecting mostly Roma communities.
To fight these outbreaks, Bulgarian Health Authorities organised the Roma Health Mediators in the early 2000s — Roma people able to speak their local language, trained for two months on healthcare subjects such as infectious diseases and vaccine prophylaxis, serving as the connection between GPs and the Roma community. One positive result is that HPV immunization in Roma girls has been better than in the rest of the Bulgarian female population. On HPV, it was again commented that boys should also be vaccinated — because girls can be infected by boys who are carriers, and because children this young have not matured sexually — though WHO advises against starting to vaccinate boys due to an HPV vaccine shortage.
Dr Nohynek commented that although there are very few Roma people in Finland, they do have pockets of low coverage — mainly Vietnamese, Russian and Somali people. Most immigrants came seeking asylum, and among these, Russians seem to have the worst coverage. Interestingly, Vietnamese and Somali people appear to have better coverage even than native Finns. The main reason is the long distance and difficulty of access Finns face — one might need to travel 200km for vaccination shots, making it hard to keep up with the calendar. She pointed out that the healthcare system is failing due to centralization and lack of funds, leaving out those in remote places.
Finally, she mentioned another pocket of low coverage: Immigrant Occupational Health Groups. Finnish health authorities are unaware of these groups' coverage because they are subcontracted and come from other countries but work in Finland.
Each Focus Group member shared the vaccine coverage situation in their countries. Dr Zsofia Meszner (Director of Methodology, Paediatrician and Specialist in Infectious Diseases, National Institute of Paediatrics Heim Pal, Hungary) reported that although there are many Syrian refugees, the Hungarian government reserves a budget for immunization as well as housing and schooling for children. There are also many Chinese and Vietnamese people, who do not cause immunization problems as they accept vaccination — sometimes with even better coverage than Hungarians. A law in Hungary states that every child under 6 who will stay over 3 months can get all National Immunization Program vaccines free.
Regarding the Roma, who make up about 6% of the total population, Dr Meszner said they live in less populated areas and have serious immunization problems. The average age of GPs and primary care paediatricians is around 60, and no young doctor wants to go to Roma communities. A program taking young Roma girls from their communities to be educated as nurses had poor outcomes because the girls later refused to return. As a last resort, small clinics were organised in the Roma communities, which helped increase coverage but were later abandoned due to funding shortage.
Prof. Paolo Bonanni (Full Professor of Hygiene, University of Florence, Italy) presented the situation in Italy, where there is a lower Roma population than in other countries, though coverage is not the same as the general population and there have been a few measles outbreaks. In the last measles outbreak in 2017, HCPs were one of the risk groups infected: of 5,400 measles cases, 320 were healthcare professionals — 85% of whom were not vaccinated at all, and 89% of whom had received only one dose.
Dr Daphne Holt (Chair, Coalition for Life-Course Immunisation, France) pointed out that there should be special funds at the European level reserved for vaccination, which countries could apply for in emergencies. It was commented that although countries can apply for health funding, a special vaccination fund would be promising and should be looked into, and that the ECDC can provide technical assistance and advice.
Dr Dace Zavadska (Paediatric Infectious Diseases Specialist, Riga, Latvia) spoke about pockets in Latvia. One is homeless people — GPs are stationed overnight in clinics attending them, but performance is not good. Another at-risk group is drug users, who are hard to reach, often suffer from influenza and hepatitis B, and have a government budget reserved for vaccination; social workers have a crucial role and should be more active. Finally, it was commented that another pocket left unmentioned is paperless people: in Helsinki a clinic has been established where paperless people can be vaccinated incognito. Despite political dispute over whether it should exist, the city decided to provide anyone coming to that clinic with national program vaccines, simply to avoid increasing the number of people at risk to themselves and to those living close by.
The Policy Focus Group was dedicated to looking at pockets of excluded groups across Europe and how these can be addressed to increase vaccination coverage. Although the session first focused on the Roma, many other different pockets of low coverage emerged and were discussed.
Regarding the Roma population, it was stated that this is a community that, when provided with healthcare services, avails itself of them — its main issue being incomplete access to vaccination. In other vulnerable pockets, the circumstances behind low coverage might be social, economic and/or immigration-based factors. Nonetheless, if we want to maintain the integrity of our immunization programs and the absence of disease, we must ensure we provide appropriate service for pockets of low immunization wherever they are, and for whatever reasons they occur. Getting from 30% to 70% coverage in a national program is relatively easy, but getting from 70% to 90% is more difficult — yet still achievable.
It is essential that we find strategies suited to our circumstances so that nobody is disadvantaged through lack of access. If people choose not to be vaccinated, they make that choice — but it should not be due to failure of access to the service. There is a moral obligation on healthcare professionals to do their best to overcome that lack of access, whatever its reason.
In addition to the concluding points above, the following areas were raised that need to be explored in more detail with necessary actions taken to achieve improved vaccination coverage for currently excluded groups, they include:
Pockets of low vaccination coverage are spread across Europe. Cultural characteristics and religious beliefs play a significant role in coverage rates among Roma communities and certain religious/ideological groups. There is a need for HCPs at a local level to establish a relationship of mutual respect and understanding, communicating the benefits of vaccination.
An HCP campaign and webinar series covering: 1) understanding the excluded-group community and its specific needs; 2) how to work with community leaders and mothers who are sensitive about their children's health; 3) training HCPs on what is important for each group and how they should be approached regarding vaccination; and 4) creating specific information materials for excluded groups based on their needs.
We must help align national policies and guidelines for vaccinating excluded groups wherever they are identified across Europe. To maintain the integrity of our immunisation programs and the absence of disease, we should ensure appropriate service for pockets of low immunisation. We must also motivate health workers to partner with communities and improve access from a central European level, providing leadership support.
A dedicated policy meeting on creating a central European fund to support excluded-group vaccination across borders.
