Experts from the 11th Excellence in Pediatrics Conference examined influenza vaccination uptake across Europe, from register-based effectiveness studies to the vaccination of healthy children and healthcare professionals. The Working Group set out targets to improve coverage rates, strengthen vaccine registers, and counter vaccine misinformation as part of a LifeCourse approach to flu prevention.
Meeting Report
Policy Focus Group Meeting on Influenza Vaccinations — 11th Excellence in Pediatrics Conference, 5 December 2019
Mira Kojouharova1, Hanna Nohynek2, Simon de Lusignan3, Steffen Amann4, Tilen Kozole5, Radovan Bogdanovic6, Roy Philip7, Barbara Rath8, Dace Zavadska9, Catherine Weil-Olivier10, Paolo Bonanni11, Gertraud Daye12, Lieke Sanders13, Elena Moya14, Gary Finnegan15, Philippe de Wals16, Carlo Signorelli17, Daphne Holt18, Kare Molbak19
1National Centre of Infectious and Parasitic Diseases, Bulgaria, 2Infectious Disease Control and Vaccinations Unit, Department of Health Security, National Institute for Health and Welfare THL Helsinki, Finland, 3University of Oxford, Nuffield Department of Primary Care; Director, Royal College of General Practitioners Research and Surveillance Centre, United Kingdom, 4European Association of Hospital Pharmacist (EAHP), Belgium, 5European Pharmaceutical Students' Association (EPSA), Belgium, 6Paediatric Association of Serbia, Serbia, 7University Maternity Hospital Limerick GEMS, University of Limerick, Ireland, 8Vienna Vaccines Initiative, Germany, 9Children Vaccination Centre under the Children's Clinical University Hospital, Riga, Latvia, 10Paris VII University, France, 11Faculty of Medicine, Specialization School for MDs in Hygiene and Preventive Medicine at the University of Florence, Italy, 12NGO Committee on Ageing, UN, Vienna, Austria, 13Utrecht University Medical Centre, Institute of Public Health and the Environment, Netherlands, 14CoMO — Confederation of Meningitis Organisations, Spain, 15Vaccines Today, Ireland, 16Department of Social and Preventive Medicine at Laval University, Quebec, Canada, 17University of Parma and University Vita-Salute San Raffaele of Milan, Post-Graduate School in Hygiene and Preventive Medicine, Italy, 18Coalition for Life-Course Immunisation (CLCI), France, 19Faculty of Health and Medical Sciences, University of Copenhagen, Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
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 goal is to promote a LifeCourse approach to vaccines.
Most notably, EIP believes that the following barriers remain: 1) Policy discrepancies — heterogeneous national vaccination policies, with differences in approach, prioritisation and decision-making processes. 2) Overarching barriers — a lack of policies to increase vaccine 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 the 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.
The following report summarises the invited experts' briefings, discussions, and proposed action plans debated during the proceedings of the Policy Focus Group on Influenza Vaccinations, which examined how best to work towards broad (LifeCourse) and optimal (increased Vaccine Coverage Rate, VCR) flu prevention across Europe.
Working Group Briefing
Presenter: Dr Hanna Nohynek, Chief Physician, Infectious Disease Control and Vaccinations Unit, Department of Health Security, National Institute for Health and Welfare THL Helsinki, FinlandDr Nohynek analysed several aspects of the register-based approach that Finland uses for influenza vaccination, and the need for vaccine registers more generally. She began with a brief timeline. The influenza vaccine was introduced into the national immunisation program in the 1980s, initially for medical risk groups on burden-of-disease grounds. In 2007, following a formal cost-effectiveness analysis, it was extended to children aged 6–35 months, but after the 2009 pandemic it became difficult both to enrol children and to raise universal vaccination rates. Healthcare workers were added to the program in 2011, social workers in 2012, pharmacy workers in direct contact with customers in 2014, and children up to six years of age in 2018, while a semi-mandatory law for healthcare-worker vaccination was introduced in 2017.
Dr Nohynek described a drastic drop in coverage among children — from 40% to 13% — following the pandemic and the narcolepsy issue in Finland, where influenza vaccines were considered a possible cause of narcolepsy; there was no steady recovery in uptake until a live-attenuated vaccine was introduced in 2015. Turning to registers and coverage, she explained that, as nurses are mostly responsible for influenza vaccination in Finland, they complete patient records that are then transferred to the National Immunisation Register, now easily accessible by computer. Influenza coverage in the general population for 2018–2019 stood at 22%, though this may be an underestimate, since some private-sector vaccination data is not transferred to the national registers. The register nonetheless yields more trusted results and shows a steady increase in coverage — especially for specific age groups such as children or the elderly, who are vaccinated mostly in the public sector — and results can be broken down by region, providing a useful tool for community workers to monitor performance relative to neighbouring regions.
She emphasised the value of vaccination registers in influenza vaccine validation, allowing different study designs and long-term follow-up using data gathered as part of healthcare routines and statutory (infectious disease) notification systems, deterministically linked through a unique personal identifier that each person acquires at birth in Finland or on moving there permanently. As an example, she presented an influenza A vaccine effectiveness (IVE-A) of 47%, derived by linking data from the past influenza season for children aged 6 months to 6 years — a group with 40% coverage (160,000 vaccinated out of 344,000 eligible) — with laboratory-confirmed influenza cases, both outpatient and inpatient; as in any observational study, she noted, confounding, bias, possible misclassification and vaccine-specific factors must all be considered.
In the second part of her briefing, Dr Nohynek examined brand-specific effectiveness using the vaccine-register linkage approach, comparing two brands in 2-to-6-year-olds — the inactivated Vaxigrip Tetra and the nasal-spray live-attenuated Fluenz Tetra — which showed similar effectiveness (52% and 41% respectively), leading her to conclude they were equally performing vaccines. She introduced the IMI-funded DRIVE consortium (Development of Robust and Innovative Vaccine Effectiveness), which is investigating brand-specific influenza vaccine effectiveness across Europe, noting that most countries still lack reliable vaccine registers — Finland and Denmark being exceptions, with Denmark soon to join DRIVE — and that brand-specific test-negative-design studies are so demanding in sample size that they require complete register data.
In conclusion, Dr Nohynek summarised the strengths of the register-based approach: a large sample and participation, a semi-automated system that can provide real-time vaccine effectiveness, and the possibility of long-term follow-up (for example, on repeated doses and early imprinting) or of linking to other data sources to understand vaccine impact on either laboratory-positive disease or burden of disease — citing an ongoing Finnish study into whether influenza vaccination protects against cardio-respiratory events. The weaknesses include possible misclassification, bias or confounding, and the ability to monitor influenza vaccine effectiveness only to the level of type rather than subtype. Finland is addressing these, for instance by validating adults through a comparison of a national cohort study with a test-negative-design DRIVE hospital study. She closed by underlining the need to understand underlying trends, to have reliable denominator data when interpreting laboratory-positive observations, and to understand the impact of priming, imprinting and repeated vaccinations — a matter not only of influenza vaccine effectiveness but of the interplay between host and pathogen.
In response to questions from the Working Group, Dr Nohynek clarified that the Finnish Vaccination Registry has been running since 2009, after the narcolepsy issue, while the Infectious Disease Registry has been in place since 1995. She noted continuing difficulty in incorporating vaccination data from the private sector, such as pharmacies, because the different software in use does not necessarily communicate with the central register — a problem they are working to fix. She added that, for influenza vaccination in Finland, two doses of inactivated vaccine are used.
Working Group Briefing
Presenter: Prof. Simon de Lusignan, Professor of Primary Care and Clinical Informatics, University of Oxford; Director, Royal College of General Practitioners Research and Surveillance Centre, United KingdomProf. de Lusignan presented the latest UK influenza vaccination data on healthy children, drawn from the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC), and described the Centre's role, structure and practices. The RCGP RSC is one of Europe's oldest sentinel systems, with more than 50 years of service; it is recruited to be nationally representative, has a long-standing collaboration with Public Health England, and can be considered a different type of registry, using dashboards of vaccination data as feedback to motivate healthcare professionals. He noted that the Live Attenuated Influenza Vaccine (LAIV), introduced in 2013–2014 for 2-to-3-year-olds, is now offered under PHE advice to all children aged 2 to 10, as it has reasonable effectiveness against A/H3N2 and B, though it is more controversial against A/H1N1.
He explained the use of the Centre's dashboard, whose vaccination page is the most popular, and the motivation methods employed — financial (reminding GPs that they are paid extra for vaccination) and competitive (allowing GPs to compare their practices with others on the network) — as well as the weekly publication of properly categorised case data, which GPs find highly motivating given the many associations it allows (flu versus other respiratory infections, vaccinated versus unvaccinated, or the eligible population that declines the flu vaccine). He also described data-quality issues around school-based vaccination and disparities in LAIV uptake by socioeconomic status — measured through the Index of Multiple Deprivation, with the least deprived showing the highest uptake — and by ethnicity, where white ethnicity had the highest uptake, followed by mixed ethnicity and then Black or Asian ethnicities.
In conclusion, Prof. de Lusignan underlined that the RCGP RSC holds individual-level data on the administration of LAIV to well children aged 2 to 10, with 2-to-3-year-olds vaccinated by GPs and older children at school, producing a weekly return of feedback data to practices via a dashboard designed to improve data quality and, in particular, capture school-administered LAIV. He argued that the disparities in uptake by socioeconomic status and ethnicity should be used to target specific educational programs, and that administering LAIV to well children is an important part of the routine vaccination program, offering enhanced protection across the whole community.
Prof. Sir Terence Stephenson asked why the data showed only around 28% LAIV uptake among children aged 2 to 10, when the recommendation is for all. Prof. de Lusignan replied that the figure is an underestimate, because pharmacy and school vaccination do not feed back into the GP record — hence the urgent need for data-exchange protocols between non-GP vaccinators. Prof. Philippe de Wals asked whether the decision to cap the vaccination age at 10 was based on epidemiology or operational considerations. Prof. de Lusignan replied that, as someone who mostly collects data rather than participating in the ongoing practical and political negotiations, he is not an expert in that area, but predicts continuing progress on the age limit, noting documents that look towards the goal of providing coverage from 2 to 16 years of age.
Working Group Briefing
Presenter: Dr Mira Kojouharova, Consultant Epidemiologist, National Centre of Infectious and Parasitic Diseases, BulgariaDr Kojouharova reported on the situation in Bulgaria, with a focus on healthcare-professional influenza vaccination uptake and the relationship between vaccination and the level of recommendation to the public. Vaccination against influenza began in 1957 with locally produced live-attenuated vaccine for nasal application, given only to adults working in large enterprises until the mid-1980s. The attenuated vaccine has been available since the early 1990s, when a series of studies investigated its safety and efficacy across five high-risk groups, children and adults; on the strength of those studies, in 1994 the Minister of Health issued an official recommendation for annual influenza vaccination, mainly for people at high risk, marking the start of an important immunization policy.
Dr Kojouharova explained that, while the national immunization program is compulsory for both the population and medical staff — with mandatory vaccination free of charge and almost all immunizations administered in the private sector — influenza vaccination itself is not compulsory, is not included in the Immunization Calendar, and is only recommended. The recommendations are almost the same as in the rest of Europe, except for two cases: pregnant women, and children aged 6 to 9 months. Influenza vaccines are available on the private market and are often administered by GPs in a dedicated immunization sector, but the patient must cover the full cost; in the event of a national influenza crisis, however, the costs are fully covered by the Ministry of Health, and the National Health Insurance compensates doctors for administering the vaccine. She added that a new national program to improve seasonal influenza vaccination begins this season and may run until 2022; though it targets only people aged 65 and over, vaccination will be voluntary and free of charge, with the hope of raising coverage by 2022.
Coverage rates are currently extremely low, and the system for registering vaccinations needs further improvement, which Dr Kojouharova suggested may reflect the complicated system for acquiring influenza vaccines in Bulgaria. Low influenza coverage is also observed among healthcare professionals, an observation that may significantly influence uptake in the general population. Presenting the results of a Bulgarian study, she reported that healthcare professionals do not perceive it as their responsibility to recommend vaccines that are not compulsory; that GPs in particular show a lack of knowledge about influenza, do not see it as their responsibility to inform patients of its benefits, and support only mandatory immunization. Around 76–78% of the general public named GPs as their main trusted source of information for vaccinating children, and although 73.8% thought vaccination should be mandatory, only half of them said they would actually vaccinate their own children. In a further 2016 study, around 76% of patients sought vaccination information from public health authorities and GPs, 64.2% said they would be vaccinated in the event of an epidemic or pandemic, and 80% believed vaccination should also be mandatory for healthcare providers.
In conclusion, Dr Kojouharova summarised that there is a contradiction between patients and healthcare providers, and that GPs should be closer to their patients: if GPs supported and recommended influenza vaccination, coverage in the general public would be higher.
Mr Amann commented that hospital pharmacists have a very important role in promoting vaccination within hospitals and institutions, but that, judging from his own institution of 7,000 employees, healthcare-worker vaccination uptake remains too low at 30% — even after a 100% increase over the past five years.
Dr Hanna Nohynek added that, in Finland, both hospital and non-hospital pharmacists would like to engage in influenza vaccination, but government officials disagree on the grounds that register data would not be captured. Mr Amann replied that involving pharmacists in influenza vaccination — for both patients and employees — is very important and one of his priorities. Prof. Catherine Weil-Olivier noted that influenza vaccination uptake among pharmacists in France was good, and that in France one can be vaccinated in a pharmacy provided one has a prescription. Prof. Kare Molbak observed that in Denmark the influenza vaccine is widely distributed by pharmacies and by drug stores that sell cosmetic products, without the need for a prescription, because they hold contracts with doctors who carry out the vaccination — emphasising that accessibility is a major factor in raising uptake.
Dr Kozole underlined the importance of pharmacists in vaccination, noting that professions are shifting and reshaping and that all should promote collaboration in common fields for the same cause. He cited the US, where pharmacists have been involved in vaccinating against various diseases — influenza, pneumococcus, meningococcus, pertussis, HPV and hepatitis A and B — since the 1990s, and pointed to European examples such as Denmark; pharmacists, he argued, do not take vaccination coverage away from GPs but complement it.
He emphasised that pharmacists are perhaps the most accessible healthcare point in Europe, with two of every three Europeans able to reach a pharmacy within five minutes, and noted that pharmacist-led vaccination is already a reality in Portugal, Ireland, the UK, France, Denmark and Malta. Pharmacists go through certified training programs and refresher courses covering, among other things, vaccine administration; and in the many countries that keep health records, vaccinations are included and pharmacists are responsible for recording them, whether by informing the GP directly or through another written channel.
Dr Holt emphasised two points. On the question of voluntary versus mandatory vaccination, she described a recent pharmacist conference at which, although the general consensus favoured voluntary rather than compulsory vaccination, the healthcare professionals came out on the side of mandatory vaccination. On ease of access, she gave the example of a previous conference where a vaccine truck was stationed outside the venue; while she could not estimate the increase in uptake from so small an initiative, the long queue that formed suggested it worked.
She added that, from her experience in France, pharmacists can be nervous and hesitant about vaccinating because they have very little experience, and patients can be equally hesitant about asking them, for the same reason. Dr Holt underlined the need to give people the right incentives, with the ultimate aim of increasing uptake and giving everybody an advocacy role in vaccination.
Prof. Bogdanovic presented seasonal influenza vaccination data from Serbia for 2018–19. Of 238,400 people vaccinated, 66% were over 65 years of age and 33% were in the 20–64 age group. Vaccination in Serbia is free of charge, whether administered under mandatory or recommended indications. He described the mandatory and recommended groups, each comprising three categories: the first covering people at special risk, those with epidemiological indications, and staff in healthcare facilities; the second covering people without particular risk, those with clinical indications, and passengers in international transport.
On the statistics, he noted that healthcare-worker vaccination accounted for 5.5% of the total, and that of the flu-like disease cases reported in 2018 — 171,901 in all, or 2,388 per 100,000 population — the 1-to-14 age group ranked highly. Of 673 Severe Acute Respiratory Infection (SARI) cases, 48.7% were tested in the laboratory, with influenza virus confirmed in 44.2%. In conclusion, Prof. Bogdanovic pointed to growing interest in influenza vaccination — more than 300,000 people vaccinated since mid-October 2019 — particularly among older people, though not as much among children, since it is not as strongly recommended as it should be; steps are already being taken to achieve broader coverage.
Prof. Philip reported enormous progress on vaccination in Ireland in recent years, a trend that began after the HPV incident and was achieved through combined public and private participation and advertising, alongside government efforts to encourage the public to get involved. Coverage among healthcare professionals rose from 25% six years ago to 51% last year, with a target of 60% this year. He attributed the increase predominantly to hospital-level campaigns aimed specifically at healthcare professionals, citing key messages such as the fact that HCPs in Ireland are up to ten times more likely to catch flu than the general public, and that being vaccinated protects not only oneself but also one's family and friends.
He noted a clearly improved campaign over the last two years, using e-learning together with the effective use of social media and Twitter to counter anti-vaccination campaigns. In Ireland, he added, the public are aware that GPs are paid for vaccinating — which is understandable and accepted — while the vaccine is free at the point of delivery. Finally, Prof. Philip emphasised the importance of maternity vaccination, noting that flu vaccination during pregnancy has improved significantly over the past three years.
Dr Rath reported that influenza vaccination recommendations in Germany are unclear, with a general belief among the public that anyone who feels healthy does not need to be vaccinated. The main problem with vaccination policy is that it is not uniform: recommendations differ from state to state, and the paediatric recommendation is still not explicit, in contradiction with WHO guidelines.
Coverage among pregnant women is extremely low, at about 3–5%, when it should be 100%. To raise it, Dr Rath argued, healthcare professionals should focus on how patients think about vaccination, inform and guide women about vaccination throughout pregnancy, and avoid inconsistencies in their communication that can lead to confusion at best and mistrust at worst. She concluded that people should be better informed by healthcare professionals about vaccines, antiviral therapies and antibiotics, and about the intended use and benefits of each.
Dr Zavadska explained that only the inactivated formulation of the influenza vaccine is available in Latvia, that it is mandatorily administered, and that its cost is fully covered by the state. Under the National Program, pregnant women and children up to two years of age, or with an underlying condition, must be vaccinated against influenza, again at full state cost. Healthcare professionals and hospital employees, however, are not compensated for influenza vaccination, and as a result only 34% of healthcare professionals are vaccinated.
In conclusion, Dr Zavadska pointed out that the economic losses caused by the disease are very high, and that prevention against influenza ultimately costs less than treating the symptoms of infection.
Working Group members were asked how to increase routine vaccination among children and family members. In previous years, the main obstacle to introducing influenza vaccination in children was the scarcity of data on its efficacy; since then, experience from several countries and clinical trials demonstrating the efficacy and benefits of vaccinating children have accumulated. Nonetheless, the global proportion of vaccinated children is only about 5%, high-risk groups remain unprotected, and vaccination policies therefore need to change. It was noted that vaccinating children would prevent complications and transmission to other age groups, such as the elderly.
The main obstacle to increasing routine vaccination was identified as organizational: annual vaccination demands a large workforce, and each country has its own resources and organization. One proposed route to routine childhood vaccination was to deliver it in schools, as some countries already do. Communication was also raised as an issue: it is difficult to persuade parents to vaccinate their children against influenza when the vaccine's efficacy reaches only around 40%, whereas the meningococcal vaccine approaches 90%. Communication strategies should therefore change, underlining and promoting the benefits of influenza vaccination and the complications it can avert, supported by media campaigns and publicity — through television, posters and advertisements — on the benefits of vaccinating children.
Speakers were asked how to increase influenza vaccination uptake among healthcare professionals. With only 30% of HCPs vaccinating themselves, they neither protect themselves adequately nor avoid the risk of transmitting the disease to their patients. In the Netherlands, a campaign promoting HCP vaccination still produced low uptake, at around 24%; a proposal to make vaccination mandatory met considerable public protest, and a lack of common ground among hospital and institute leaders meant there was no unanimous effort — something that needs to change, since higher HCP uptake would in turn encourage the wider public. In Spain, where HCP coverage is around 47%, health authorities are seeking to raise it further, and it was proposed that successful small-scale regional initiatives be studied, taken as examples and publicised.
In Canada, influenza coverage among healthcare professionals is very high but extremely low in other population groups; making vaccination mandatory was not welcomed by the public, who objected on the basis of limited data showing its benefits — pointing to a crucial need for more data on efficacy, safety and benefit. A further point concerned the discrepancy between doctors, whose coverage is relatively high, and nurses, whose coverage is extremely low. Finally, it was noted that diagnostic issues and a lack of feedback from vaccinations also need to be addressed to raise coverage rates.
The final discussion addressed the role of pharmacists and nurses in promoting vaccination among risk groups. In Italy there is an effort to involve pharmacists in order to increase coverage, not only for influenza but for other diseases too. For high-risk groups, nurses are thought to play the larger role in promoting vaccination, while pharmacists help to raise coverage in the general public; involving more pharmacists would ease access to vaccination and so increase coverage rates.
As in the previous discussion, it was noted that coverage among nurses remains extremely low despite the available information and education — raising the question of how to influence the public to be vaccinated when healthcare professionals do not protect themselves. In one effort to increase HCP vaccination rates, Denmark provided badges to those who had been vaccinated, and rates did indeed rise. It was underlined that pharmacists and nurses play a crucial role in promoting vaccination: pharmacists by providing easier access, and nurses through their influence on the general public who come to hospitals.
This Working Group was dedicated to influenza vaccination, its uptake rates across Europe and its coverage within different population groups. The Group agreed that healthcare professionals should do more to promote the benefits of the seasonal flu vaccine, which can prevent serious complications caused by the influenza virus; that coverage among infants and children remains relatively low and needs to change, as it would help prevent transmission to other population groups such as the elderly; and that healthcare professionals should be routinely — but not compulsorily — vaccinated, both to protect their own health and their patients' and to encourage the general public to follow suit.
In particular, the Working Group raised the following areas that need to be explored in more detail, with the necessary actions taken to achieve broad (LifeCourse) and optimal (increased Vaccine Coverage Rate, VCR) flu prevention:
Low levels of influenza coverage are still observed among healthcare professionals, an observation that may significantly influence influenza vaccine uptake in the general population.
A hospital campaign targeted specifically at healthcare professionals to promote HCP uptake and limit the spread of influenza, including the provision of badges to those vaccinated as a simple step to increase rates and publicise HCP support for vaccines.
1) GPs often show a lack of knowledge about influenza, do not perceive it as their responsibility to inform patients of its benefits, and support only mandatory immunization. 2) Pharmacists are arguably the most accessible healthcare point in Europe and should be better utilised to increase uptake. 3) Nurses are thought to play a bigger role in promoting vaccination among high-risk groups.
Three separate but linked online training courses developed for GPs, pharmacists and nurses. The first two modules of each course would be specific to that profession, with a third, combined module for GPs, pharmacists and nurses on how to work together and complement one another's efforts in increasing influenza vaccination.
Improved registers, embedded in healthcare routines and statutory (infectious disease) notification systems, should be supported and developed to give a better understanding of vaccine uptake and coverage across borders. There is also a clear need for a data-exchange protocol between non-GP vaccinators, as pharmacy and school vaccination are often not updated on GP records.
A dedicated Expert Working Group on how HCPs can support the development of a universal vaccination register across Europe, together with a best-practice approach and protocol for how vaccination information should be shared across GPs, pharmacies, school-based programmes and all those who administer vaccinations — helping all countries work towards a centrally coordinated register system.
There is a need to make better use of e-learning and the effective use of social media and Twitter to counter anti-vaccination campaigns. People should be better informed by healthcare professionals about vaccines and antiviral therapies, coupled with media campaigns and publicity — through television, posters and advertisements — on the benefits of influenza vaccines.
The formation of a pro-vaccine panel of healthcare professionals trained to use social media channels to actively counter anti-vaccination activity online. In particular: 1) a dedicated campaign to equip young healthcare professionals with the skills to counter misinformation on social media; and 2) training and mobilising all interested HCPs to engage on social media against vaccine misinformation, through a free-to-view modular online series of practical webinars.
