Adult vaccination in 11 Central European countries - calendars are not just for children

As Europe's population ages, disease morbidity and treatment costs in the adult population are likely to rise substantially, making this a pertinent time to review and revise preventive strategies such as vaccination. Vaccine uptake remains a problem for adults and there is a lack of coordinated programmes for vaccination of adults. Countries in Western Europe have begun to identify the need to increase adult vaccination, but the situation in Central European countries remains poorly identified and inadequately described. This paper summarises the evidence to support the development of an adult vaccination calendar in the Central European Vaccination Awareness Group (CEVAG) member countries (Bulgaria, Croatia, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Romania, Slovakia, Slovenia and Turkey). CEVAG recommends the introduction of an adult vaccination calendar, which should include vaccination against diseases that represent a large burden in adults in terms of mortality and morbidity. This calendar could be modified to meet the priorities of individual countries.     

COVID-19 vaccination decisions among Gypsy,Roma, and Traveller communities: A qualitative study moving beyond “vaccine hesitancy”

BackgroundMany people refuse vaccination and it is important to understand why. Here we explore the experiences of individuals from Gypsy, Roma, and Traveller groups in England to understand how and why they decided to take up or to avoid COVID-19 vaccinations.MethodsWe used a participatory, qualitative design, including wide consultations, in-depth interviews with 45 individuals from Gypsy, Roma, and Traveller, communities (32 female, 13 male), dialogue sessions, and observations, in five locations across England between October 2021 and February 2022.FindingsVaccination decisions overall were affected by distrust of health services and government, which stemmed from prior discrimination and barriers to healthcare which persisted or worsened during the pandemic. We found the situation was not adequately characterised by the standard concept of “vaccine hesitancy”. Most participants had received at least one COVID-19 vaccine dose, usually motivated by concerns for their own and others’ health. However, many participants felt coerced into vaccination by medical professionals, employers, and government messaging. Some worried about vaccine safety, for example possible impacts on fertility. Their concerns were inadequately addressed or even dismissed by healthcare staff.InterpretationA standard "vaccine hesitancy" model is of limited use in understanding vaccine uptake in these populations, where authorities and health services have been experienced as untrustworthy in the past (with little improvement during the pandemic). Providing more information may improve vaccine uptake somewhat; however, improved trustworthiness of health services for GRT communities is essential to increase vaccine coverage.FundingThis paper reports on independent research commissioned and funded by the National Institute for Health Research (NIHR) Policy Research Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or its arm's length bodies, and other Government Departments.     

The cost-effectiveness of rotavirus vaccination: Comparative analyses for five European countries and transferability in Europe

Cost-effectiveness analyses are usually not directly comparable between countries because of differences in analytical and modelling assumptions. We investigated the cost-effectiveness of rotavirus vaccination in five European Union countries (Belgium, England and Wales, Finland, France and the Netherlands) using a single model, burden of disease estimates supplied by national public health agencies and a subset of common assumptions. Under base case assumptions (vaccination with Rotarix^®, 3% discount rate, health care provider perspective, no herd immunity and quality of life of one caregiver affected by a rotavirus episode) and a cost-effectiveness threshold of €30,000, vaccination is likely to be cost effective in Finland only. However, single changes to assumptions may make it cost effective in Belgium and the Netherlands. The estimated threshold price per dose for Rotarix^® (excluding administration costs) to be cost effective was €41 in Belgium, €28 in England and Wales, €51 in Finland, €36 in France and €46 in the Netherlands.     

Health care reform in six Central European countries

This study gives an overview of the health care reform in six Central European countries after the transition from a central planning system to a regulated market economy. We focused on cost containment policies for drugs, especially the requirements for submitting health economic data in the pricing and/or reimbursement processes. The literature review was supplemented with a survey with decision makers at national health authorities in each country. The study covered Croatia, Czech Republic, Hungary, Poland, Slovakia, and Slovenia. All countries had in common that health economic information was used in reimbursement rather than in pricing processes. Differences between the six countries were mainly variations in the relative importance of health economic data and the presence of explicit requirements and guidelines. Published health economic guidelines exist in two countries and one of the six countries applies a mandatory submission system for a selected range of new drugs. In most of the Central European countries it is more typical that authorities issue a brief list of required data for reimbursement submissions that include health economic information among other data. There is a generally widespread expectation towards more systematic and formalized requirements for health economic and outcomes research data appearing within the next 3–5 years in the region.     

Access of Roma to sexual and reproductive health services: Qualitative findings from Albania,Bulgaria and Macedonia

Abstract

The purpose of this study was to explore access of Roma in South-Eastern Europe to sexual and reproductive health services. We conducted 7 focus group discussions with a total of 58 participants from Roma communities in Albania, Bulgaria and Macedonia. Our study revealed a number of barriers for Roma when accessing sexual and reproductive health services. Among the most important were the overall lack of financial resources, requests by health care providers for informal payments, lack of health insurance and geographical barriers. Health systems in the region seem to have failed to provide financial protection and equitable services to one of the most vulnerable groups of society. There is also a need for overcoming racial discrimination, improving awareness and information and addressing gender inequalities.     

Influenza vaccination uptake and socioeconomic determinants in 11 European countries

Background

The objective of this study was to assess the predictive effects of socioeconomic factors to explain influenza vaccination coverage rates in 11 European countries.

Methods

Data from national household surveys collected over up to seven consecutive seasons between 2001/2002 and 2007/2008 were analyzed to assess the associations of socioeconomic factors with immunization against influenza.

Results

In total, data from 92,101 household contacts representative for the national non-institutionalized population aged above 14 years were analyzed. Influenza vaccination coverage rates in Europe remain suboptimal with little or no progress in the last years. The results of this study indicate that gender, household income, size of household, educational level and population size of living residence may significantly contribute to explain chances of getting immunized against influenza apart from the known risk factors age and chronic illness. The effect of these socioeconomic factors was differently expressed among the countries and could not be explained solely on basis of economic characteristics of these countries.

Conclusions

Future measures should address inequalities to achieve the WHO target by 2010 with an influenza vaccination rate of 75% in the elderly. National vaccination campaigns may need to take socioeconomic segments of the population here identified as less likely of getting the influenza vaccine into account.     

Treatment targets in patients with type 2 diabetes set by primary care physicians from Central and Eastern Europe

Background: Primary care physicians have an important role in the care of patients with Type 2 diabetes but little is known about this issue in Central and Eastern European countries.

Objectives: To investigate the treatment goals of patients with type 2 diabetes mellitus (type 2 DM) set by primary care physicians in Central and Eastern European countries and illustrate inter-country variation.

Methods: A cross-sectional survey of primary care physicians randomly chosen in nine countries. A validated questionnaire was used. Physicians reported treatment goals for patients with type 2 DM.

Results: A total of 44.1% of physicians, reported the acceptance of HbA1c < 6.5% (48 mmol/mol) as a treatment goal, whilst 40% chose lower levels (< 6.1%; 43 mmol/mol). In all countries, 62% of physicians set FPG at a level of < 6.0 mmol/l. Most respondents set low BP levels as a goal of therapy (47% of physicians in all countries: BP < 130/80 mmHg and 48% < 120/80 mmHg). A TC level < 4.5 mmol/l and a LDL-C level < 2.5 mmol/l were reported as the targets for patients with diabetes by 51% and 69% of all respondents, respectively. The overall differences between all the countries were statistically significant (P < 0.01).

Conclusion: For patients with diabetes approximately half of physicians set treatment goals at levels that were recommended within the international guidelines. Most of them set treatment goals for HbA1c and BP at very low levels. Educational efforts to raise awareness about new treatment goals are needed.     

The prevalence of disability among Roma and non-Roma children in four West Balkan countries

BackgroundVery little is known about the prevalence of disability among Roma children.ObjectiveTo estimate the prevalence of disability and significant cognitive delay among Roma and non-Roma children aged from 2 to 17 years in four West Balkan countries.MethodsSecondary analysis of data collected in Round 6 of UNICEF's Multiple Indicators Cluster Surveys. Nationally representative samples of 6290 Roma and 13,005 non-Roma children in Kosovo, Montenegro, the Republic of North Macedonia, and Serbia.ResultsRoma children were twice as likely to have a disability, a less severe disability, multiple disabilities, and severe cognitive delay than their peers and were more likely to have functional limitations in all but one of the domains investigated.ConclusionsDisability is significantly more prevalent among Roma children aged 2–17 years than among their non-Roma peers in four Western Balkan countries. Future research should focus on the extent to which differences in disability may be attributable to differential rates of exposure to a range of social determinants.     

Flu vaccination policy in old adults: Need for harmonization of national public health recommendations throughout Europe

The reading of the paper by Jansen et al. in a recent issue of Vaccine (2008, October 16) showing the “decline in influenza-associated mortality among Dutch elderly following the introduction of a nationwide vaccination programme” was for us the opportunity to present the results of a recently conducted survey of national Flu vaccination policies at a meeting of Presidents and representatives from 24 National Geriatric Societies. Combined results of these two studies advocate for promoting efficient, cost-effective and sustainable vaccine programme endorsed by all the National governments in Europe.     

Hepatitis B vaccination coverage and uptake in prisons across England and Wales 2003-2010: a retrospective ecological study

Objective

To describe the custodial hepatitis B vaccination programme performance and examine these data by geographical region and prison category.

Design

Retrospective ecological study.

Data source

Health Protection Agency (HPA) published data.

Setting

Custodial primary healthcare providers located in prisons across England and Wales.

Participants

147 prisons which reported vaccination data between July 2003 and April 2010 to the HPA Prison Infection Prevention team.

Main outcome measures

Hepatitis B vaccination coverage (July 2003 to April 2010) and uptake (December 2007 to April 2010).

Results

Median hepatitis B vaccination coverage was 22% (interquartile range [IQR] 5–49%) and uptake was 36% (IQR 16–59%). Vaccination coverage varied significantly between July 2003 and November 2007 compared to December 2007 and April 2010 (median 12% [IQR 2–31%] versus median 48% [IQR 26–67%], Mann–Whitney W = 14,689,158.0, p < 0.001). There was significant variation between vaccination coverage (Kruskal–Wallis H = 613.44, DF = 9, p < 0.001) and uptake (Kruskal–Wallis H = 247.99, DF = 9, p < 0.001) across the HPA regions. Compared to England and Wales, estimated population median vaccination coverage was significantly (p ≤ 0.05) lower in three regions and one prison category and higher in four regions and seven prison categories; estimated population median vaccination uptake was significantly lower in three regions and three prison categories and higher in two regions and four prison categories.

Conclusion

Prisoners are a vulnerable group with a high prevalence of hepatitis B infection and the custodial setting plays an important role in the delivery of hepatitis B vaccination to this hard to reach group. This study suggests that variation in hepatitis B vaccination coverage and uptake may exist by geographical region and prison category. Further research is required to confirm and identify possible explanations for our findings.     

HTA and decision-making processes in Central,Eastern and South Eastern Europe: Results from a survey

Objective

To gain knowledge and insights on health technology assessment (HTA) and decision-making processes in Central, Eastern and South Eastern Europe (CESEE) countries.

Rationalizing the introduction and use of pharmaceutical products: The role of managed entry agreements in Central and Eastern European countries

This paper aims to provide an overview of the rationalization strategies for the introduction and use of pharmaceuticals, focusing on the role of managed entry agreements (MEA) in Central and Eastern European (CEE) countries, namely Bulgaria, the Czech Republic, Croatia, Hungary, Poland and Romania. We developed a conceptual framework on MEAs that was used as the basis for a standardized assessment questionnaire sent to country experts to capture their perceptions on their countries’ rationalization strategies and MEAs. Our study shows that the main role of MEAs and other related policies embedded in the health care system is to limit the budget impact of drugs in all examined 6 countries. Uncertainty about outcomes and appropriate utilization seem to be of lower priority. Finance-based MEAs are used by all countries. Performance-based MEAs are scarce and used to a limited extent by Hungary and Poland. The overall transparency of the existence and details of MEAs is limited. Expansion of the use and increased transparency of MEAs is recommended. Still, the informational infrastructure and competencies in implementing MEA’s need to be developed further.     

Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination

The World Health Organization (WHO), and European Agencies recommend influenza vaccination for individuals at-risk due to age (≥65 years), underlying diseases, pregnancy and for health care workers (HCWs) in Europe. Pneumococcal vaccine is recommended for those at-risk of pneumococcal disease. In Ireland, vaccination uptake among at-risk adults is not routinely available. In 2013, we conducted a national survey among Irish residents ≥18 years of age, to estimate size and vaccination coverage of at-risk groups, and identify predictive factors for influenza vaccination.We used computer assisted telephone interviews to collect self-reported information on health, vaccination status, attitudes towards vaccination. We calculated prevalence and prevalence ratios (PR) using binomial regression.Overall, 1770 individuals participated. For influenza, among those aged 18–64 years, 22% (325/1485) [95%CI: 17%–20%] were at-risk; 28% [95%CI: 23%–33%] were vaccinated. Among those aged ≥65 years, 60% [95%CI: 54%–66%] were vaccinated. Influenza vaccine uptake among HCWs was 28% [95%CI: 21%–35%]. For pneumococcal disease, among those aged 18–64 years, 18% [95%CI: 16%–20%] were at-risk; 16% [95%CI: 12%–21%] reported ever-vaccination; among those aged ≥65 years, 36% [95%CI: 30%–42%] reported ever-vaccination. Main reasons for not receiving influenza vaccine were perceptions of not being at-risk, or not thinking of it; and among HCWs thinking that vaccination was not necessary or they were not at-risk. At-risk individuals were more likely to be vaccinated if their doctor had recommended it (PR 3.2; [95%CI: 2.4%-4.4%]) or they had access to free medical care or free vaccination services (PR 2.0; [95%CI: 1.5%-2.8%]).Vaccination coverage for both influenza and pneumococcal vaccines in at-risk individuals aged 18–64 years was very low. Influenza vaccination coverage among individuals ≥65 years was moderate. Influenza vaccination status was associated with GP vaccination recommendation and free access to vaccination services. Doctors should identify and recommend vaccination to at-risk patients to improve uptake.     

Pharmacist role in vaccination: Evidence and challenges

Vaccines prevent an estimated 2.5 million deaths worldwide each year and are amongst the most cost-effective preventive measures against infectious diseases. Despite the effectiveness and availability of vaccines in many parts of the world, vaccination rates and service uptake remains suboptimal among both healthcare providers and the public. Pharmacists as established advocates, educators as well as qualified providers of vaccinations have a significant role to play in promoting and supporting the uptake of vaccination. Challenges and barriers to pharmacist vaccination are multifactorial, which needs effective strategies to address. Overcoming these barriers will increase the role of pharmacists as vaccinators that ultimately increases public access to vaccination and accurate and reliable information about vaccines.     

Future pandemics and vaccination: Public opinion and attitudes across three European countries

BackgroundUnderstanding public opinion and attitudes regarding vaccination is crucial for successful outbreak management and effective communication at the European level.MethodsWe explored national differences by conducting focus group discussions in The Netherlands, Poland and Sweden. Discussions were structured using concepts from behavioural models.ResultsThematic analysis revealed that participants would base their vaccination decision on trade-offs between perceived benefits and barriers of the vaccine also taking into account the seriousness of the new outbreak. Except for those having chronic diseases, participants expected a low infection risk, resulting in a low willingness to get vaccinated. Information about the health status of cases was considered important since this might change perceived susceptibility. Participants displayed concerns about vaccine safety due to the limited available time to produce and test vaccines in the acute situation of a new pandemic. Swedish participants mentioned their tendency of doing the right thing and following the rules, as well as to get vaccinated because of solidarity with other citizens and social influences. This appeared much less prominent for the Dutch and Polish participants. However, Swedish participants indicated that their negative experiences during the Influenza A/H1N1 2009 pandemic decreases their acceptance of future vaccinations. Polish participants lacked trust in their national (public) health system and government, and were therefore sceptical about the availability and quality of vaccines in Poland.ConclusionsAlthough participants overall expressed similar considerations, important differences between countries stand out, such as previous vaccination experiences, the degree of adherence to social norms, and the degree of trust in health authorities.     

Strengthening vaccination programmes and health systems in the European Union: A framework for action

Vaccination is one of the most cost-effective public health interventions. However, the EU is facing increasing outbreaks of vaccine preventable diseases, with some fatal cases of measles. This paper reviews the main factors influencing vaccination uptake, and assesses measures expected to improve vaccination coverage. Obstacles to vaccination include concerns about vaccine safety and side effects, lack of trust, social norms, exposure to rumours and myths, and access barriers. Responses fall into three broad categories. Regulation, including the introduction of mandatory vaccination, can be justified but it is important to be sure that it is an appropriate solution to the existing problem and does not risk unintended consequences. Facilitation involves ensuring that there is an effective vaccination programme, comprehensive in nature, and reducing the many barriers, in terms of cost, distance, and time, to achieving high levels of uptake, especially for marginalised or vulnerable populations. Information is crucial, but whether in the form of public information campaigns or interactions between health workers and target populations, must be designed very carefully to avoid the risk of backfire. There is no universal solution to achieving high levels of vaccine uptake but rather a range or combinations of options. The choice of which to adopt in each country will depend on a detailed understanding of the problem, including which groups are most affected.     

Vaccine hesitancy,refusal and access barriers: The need for clarity in terminology

Although vaccination uptake is high in most countries, pockets of sub-optimal coverage remain posing a threat to individual and population immunity. Increasingly, the term ‘vaccine hesitancy’ is being used by experts and commentators to explain sub-optimal vaccination coverage. We contend that using this term to explain all partial or non-immunisation risks generating solutions that are a poor match for the problem in a particular community or population. We propose more precision in the term ‘vaccine hesitancy’ is needed particularly since much under-vaccination arises from factors related to access or pragmatics. Only with clear terminology can we begin to understand where the problem lies, measure it accurately and develop appropriate interventions. This will ensure that our interventions have the best chance of success to make vaccines available to those who want them and in helping those who are uncertain about their vaccination decision.     

Timeliness and equity of infant pertussis vaccination in wales: Analysis of the three dose primary course

Infants aged under one year are at the highest risk of severe complications or death from pertussis infection. Prompt vaccination with a three dose course at two, three and four months of age decreases the amount of time they are vulnerable following waning of maternal antibodies. In Wales, uptake of all three doses of the primary course of pertussis containing vaccine is high. However, timeliness and equity at a population level have not been previously reported.This analysis included 163,733 children born from 1st January 2013 to 31st December 2017. In this cohort 87.9% received the first dose of a pertussis containing vaccine by 12 weeks of age, 87.1% had received all three doses by 24 weeks of age, and 96.3% received three doses by 52 weeks of age.Differences in uptake between those living in the most deprived and least deprived quintiles of Lower Super Output Area (LSOA) were smaller than differences in timeliness, but statistically significant. In 2017 the difference in timely uptake between those living in the most and least deprived quintiles was 4%, 5% and 7% for doses one, two and three respectively. There was a difference of 10% in the proportion of infants receiving all three primary vaccinations on time between the most and least deprived quintile of LSOAs.Consideration is needed on interventions that will help improve timeliness such as enhanced follow up of defaulters, electronic communication between primary care data systems, enhanced health visitor intervention and opportunistic vaccination in those who fail to attend scheduled vaccination appointments. There is also the need for routine monitoring of timeliness and further research into what influences delayed vaccination.     

Identifying barriers and drivers to vaccination: A qualitative interview study with health workers in the Federation of Bosnia and Herzegovina

BackgroundVaccination coverage in Bosnia and Herzegovina has been declining over recent years. A World Health Organization Tailoring Immunization Programmes (TIP) project is underway to gain insights into the underlying reasons for this, to develop tailored interventions. As part of TIP, this study aimed to investigate the views of health workers on their barriers and drivers to positive childhood vaccination practices.MethodsFace-to-face qualitative interviews explored 38 health workers’ views on vaccination coverage, their vaccination attitudes, and system, programme and institutional influences on their vaccination practices. The data were analysed using content analysis and organised by the COM (Capability, Opportunity and Motivation) factors.FindingsVery few differences in barriers and drivers were evident between high and low coverage primary care centres or across different professional roles.Capability: Drivers included awareness of the risks of low vaccination coverage, regular use of the Rulebook and Order, knowledge of how to advise parents on mild side effects and recognition of the importance of good communication with parents. Key barriers were the use of false contraindications to postpone vacination and poor skills in tailoring communication with parents.Opportunity: Drivers were sufficient time for adminstering vaccination and good availability of vaccines. Several barriers were evident: lack of implementation of mandatory vaccination, no uniform recall and reminder system or system for detecting under-vaccinated children, staff shortages and lack of time to discuss vaccination with parents.Motivation: Drivers were a belief in the value, safety and effectiveness of vaccination and seeing that they have an important role to play. Barriers were a tendency to blame external factors e.g. anti-vax movement and a fear of being blamed for adverse events.ConclusionsThe study identified complex and inter-related barriers and drivers to health worker positive vaccination practices. These insights will now inform a process to identify and prioritize interventions.