EXPH (EXpert Panel on effective ways of investing in Health). Opinion on Vaccination Programmes and Health Systems in the European Union.

Vaccination is one of the most cost-effective public health interventions available and the main tool for primary prevention of communicable diseases. However, the EU is facing increasing outbreaks of vaccine preventable diseases, while some fatal cases of measles and diphtheria have been reported. This opinion identifies the main factors (enablers and obstacles) influencing vaccination uptake, and assesses measures that can be expected to improve vaccination coverage. After providing a systems approach to national vaccination programmes (including an appropriate legislative framework, governance arrangements, existence of a register of the target population, funding mechanisms and monitoring), a range of obstacles and enablers of high rates of vaccination coverage are identified. Obstacles to vaccination coverage include individuals’ and parents’ concerns or fears about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths undermining confidence in vaccines, failure by some healthcare providers to counter these myths and provide evidence-informed advice, access barriers (e.g. poor availability, copayments), and failure to understand the underlying mechanisms that decrease vaccination confidence. Enablers include sources of reliable information about vaccination, exposure to positive media messages, building trust in institutions and providers, building confidence in vaccination, easy access and availability to healthcare services, ease of administration, active involvement and engagement by healthcare providers, and targeting of high-risk groups. There is a range of policy options that countries can implement to increase vaccination coverage. Communication strategies about the benefits of vaccination are important but need to be combined with opportunities for dialogue with vaccine hesitant groups and participatory approaches. These strategies need to be targeted not only at the uninformed (i.e. the lack of information) but also at the misinformed (when the information is incorrect) or disinformed (when information is spread with the intention to deceive). Vaccination is mandatory in some countries and recommended in others. When mandatory, it can be unpopular with some individuals or groups, which reinforces the case for good communication strategies to improve acceptability. One policy option is to allow individuals to opt out of vaccination subject to certain conditions to be determined depending on the institutional context (e.g. an exception process which includes a mandatory consultation and dialogue with a healthcare worker who can make individuals and parents aware of the risk of not being covered) but only if vaccination coverage levels are sufficiently high to ensure herd immunity. Family physicians are well positioned to improve child vaccination rates given frequent interactions with parents and children with other illnesses or attending check-ups. These interactions can be used as opportunities to raise awareness. Family physicians and nurses do not have to be the exclusive providers of vaccines. Better access could be achieved by improving availability of vaccines from other providers (e.g. pharmacists, providers of community services, subject to appropriate training) and ensuring equity- driven vaccination programmes. Healthcare and other workers engaging in communication and dialogue related to vaccination should be supported with specific training to address vaccine concerns from hesitant individuals, in particular in relation to safety and side effects.There is scope for strengthening the monitoring and the surveillance systems at international, national and sub-national level to ensure up-to-date data to guide policy and planning at a regional and country level that will optimise coverage and impact, and identifying areas where low coverage is concentrated. Finally, as a comprehensive programme considers populations and individuals, there is scope for close co-operation and better integration of public health and primary care services, strengthening accountability towards a population of primary care.