Variation in adult vaccination policies across Europe: an overview from VENICE network on vaccine recommendations, funding and coverage

Populations Addressed in Vaccines Approved via the European Medicines Agency

Therapeutic and prophylactic agents require robust evidence before patient use. Randomized controlled trials are essential for evaluating safety and efficacy but often exclude specific populations that are also targets for the intervention. This study assessed which populations are included in vaccine registration studies and/or addressed in label indications, and if special populations are considered at any point in the regulatory life cycle of vaccines approved in the European Union. We analyzed product labels, pivotal studies, risk management plans, and post-authorization studies for all vaccines centrally approved via the European Medicines Agency between 2012 and 2022. For the 31 vaccines approved, we identified 90 pivotal studies supporting initial marketing authorizations and 46 studies supporting product revisions. At the end of our follow-up, 27 vaccines (87%) were approved for adults, 19 (68%) for pediatric patients, 3 (11%) were recommended for pregnant populations, 4 (14%) for breastfeeding populations, and 7 (23%) for immunocompromised populations. Pregnant, breastfeeding, and immunocompromised individuals were rarely included in studies supporting regulatory actions. We observed a slight increase in the inclusion of special populations in post-marketing studies, yet this had limited impact on product indications or information availability on labels. Pivotal studies supporting vaccine registrations were also highly selective and predominantly conducted in high-income settings. These findings highlight significant variations in how different populations are considered during vaccine development and by regulators. Greater inclusion of special populations in the evidence-generation chain is essential to ensure that vaccines respond to unmet medical needs equitably.

Pertussis Notification Rate and Tdpa Vaccine/Booster Coverage in Adults: An Opportunity for an Epidemiological Observatory in Primary Care

Background: In recent years, Europe has experienced a significant increase in pertussis cases. One reason behind this rise is the decline in diphtheria-tetanus-pertussis (dTap) booster coverage among adults. Currently, Italy lacks a reliable monitoring system to track pertussis infections and vaccine coverage among adults. We therefore evaluated the reliability of a primary care framework to respond to this need. Methods: Using an Italian primary care database for individuals aged 15 or above, we determined the pertussis infection notification rate and dTap vaccine/booster coverage for the timeframe of 2009-2022. Results: In the overall population, we obtained a lifetime occurrence rate of pertussis infections of 7.52 per 10,000 individuals. The annual incidence rates of pertussis infections ranged from 0.008 to 0.001 per 10,000 person-years between 2009 and 2022. A rising trend in dTap vaccine coverage rate (ranging from 8.72 to 16.54 vaccines per 10,000 individuals) was observed during the same period. Notably, those aged 65 or older, smokers, and/or individuals with immunodeficiencies were more likely to receive the dTap vaccine compared to the general population. Conclusions: Given the organization of the Italian public health system, this primary care network might act as a reliable epidemiological monitoring system to keep track of pertussis infections and dTap vaccine coverage in adults. Pertussis cases were underreported, and there was a low uptake of vaccines and boosters. Therefore, it is crucial to closely monitor pertussis notifications and dTap administrations and develop intervention strategies at the national level to enhance vaccine-related prevention.

Effectiveness of educational interventions for healthcare workers on vaccination dialogue with older adults: a systematic review

BACKGROUND

Healthcare workers (HCW) significantly influence older adults' vaccine acceptance. This systematic review aimed to identify effective educational interventions for HCWs that could enhance their ability to engage in a dialogue with older adults on vaccination.

METHODS

Medline, Scopus, Cochrane library and grey literature were searched for comparative studies investigating educational interventions concerning older adult vaccinations. The search encompassed all languages and publication years. Analysis was performed on the outcomes 'vaccines offered or ordered' and 'vaccination rates'. Whenever feasible, a sub-analysis on publication year was conducted. Methodological limitations were assessed using the RoB 2 for RCTs and the GRADE checklist for non-randomized studies. Study outcomes were categorized according to the four-level Kirkpatrick model (1996) for effectiveness: reaction, learning, behaviour, and results.

RESULTS

In total, 48 studies met all inclusion criteria. Most studies included reminder systems signalling HCWs on patients due for vaccination. Other interventions included seminars, academic detailing and peer-comparison feedback. Four articles reporting on the reaction-level indicated that most HCWs had a favourable view of the intervention. Two of the six articles reporting on the learning-level observed positive changes in attitude or knowledge due to the intervention. Seventeen studies reported on the behaviour-level. An analysis on eleven out of seventeen studies focusing on vaccines 'ordered' or 'offered' outcomes suggested that tailored reminders, particularly those implemented before 2000, were the most effective. Out of 34 studies reporting on the result-level, 24 were eligible for analysis on the outcome 'vaccination rate', which showed that compared to usual care, multicomponent interventions were the most effective, followed by tailored reminders, especially those predating 2000. Nonetheless, tailored reminders often fell short compared to other interventions like standing orders or patient reminders. In both the behaviour-level and result-level 'education only' interventions frequently underperformed relative to other interventions. Seventeen out of the 27 RCTs, and seven of the 21 non-randomized studies presented a low-to-medium risk for bias in the studies' findings.

CONCLUSIONS

Tailored reminders and multicomponent interventions effectively assist HCWs in addressing vaccines with older adults. However, education-only interventions appear to be less effective compared to other interventions rates, attitude, knowledge.

Associations of health literacy with missed free influenza immunization in people with chronic diseases

There is a gap in understanding specific features of health literacy that might be associated with adherence to influenza immunization. The aim of this study was to examine the association of health literacy with avoidance of influenza immunization and beliefs about the influenza vaccine among people with chronic diseases. Selection of study participants was based on a case-control study design in a population of people with chronic illnesses living in the Foča region (Republic of Srpska, Bosnia and Herzegovina) and who were entitled to receive a free influenza shot in season 2017/2018. The cases represented all non-vaccinated people (a total of 146) and the controls were vaccinated people (a total of 149) matched according to town of residence. Participants were interviewed in person from April to December 2018 using a socio-demographic questionnaire, Health Literacy Questionnaire (HLQ) and Health Belief Model Applied to Influenza (HBMAI). Better score on 'Feeling understood and supported by healthcare providers', 'Social support for health' and 'Ability to actively engage with healthcare providers' was associated with more perceived benefits of influenza immunization in men, but not in women. Perceiving more Barriers to influenza immunization was associated with lower scores on 'Feeling understood and supported by healthcare providers', 'Have sufficient information to manage health', 'Social support for health' and 'Ability to actively engage with healthcare providers' in both men and women. Health literacy may be associated with the perception of susceptibility to influenza, benefits and barriers to influenza immunization and motivations to receive influenza vaccine.

Vaccination coverage and immunization safety among children with special health status in Chongqing, China

Vaccination of children with special health status has become one of the most urgent issues in China. We aim to evaluate vaccination coverage and safety as well as its associated factors among children with special health status in China during 2016‒2020. We conducted a retrospective cohort review of all children with special health status recorded in the Electronic Immunization Registries System in Chongqing, China, between 2016 and 2020. Univariate and multivariate logistic regression analyses were used to analyze the influence factors. Among the 2,175 children with special health status enrolled in the study, the overall vaccination coverage rate was lower than that among the general population, and the incidence of adverse event in them following immunization was very rare. Children with congenital heart disease were better vaccinated (aOR = 1.508-6.331), while most of the jaundice children had missed vaccination (aOR = 0.441‒0.556). The purchase of vaccine compensation insurance was associated with higher completion rate of basic immunization for Bacillus Calmette-G vaccine (aOR = 1.706, 95% CI: 1.249‒2.329) and rotavirus vaccine (aOR = 1.346, 95% CI: 1.061‒1.708). Children with special health status can be safely vaccinated. However, the vaccination coverage in these huge and vulnerable group is too low to protect them from vaccine-preventable diseases through immunization. More researches and interventions should be conducted to ensure a higher vaccination rate among the children with special health status.

Coalition Shaping the Vaccination Landscape

In 2022, the National Program for Influenza Prevention coalition will have its 10th anniversary; it is one of Poland's oldest educational initiatives. The National Program for Influenza Prevention was initiated to prevent a further decline and promote influenza prevention in the A(H1N1) post-pandemic years. In this review, we summarize the structure and operational model of the coalition and identify core functional elements that make it a key non-governmental organization involved in the prophylactics of communicable diseases. The coalition-based organization can operate in a complex environment, such as vaccinations requiring scientific, economic, social, and psychological involvement, and communications with different groups. Anchored to the history of the National Program for Influenza Prevention, we review Poland's vaccination landscape changes from the last ten years.

Tdap Booster Vaccination for Adults: Real-World Adherence to Current Recommendations in Italy and Evaluation of Two Alternative Strategies

Background: While the effectiveness of tetanus-diphtheria-pertussis childhood immunization programs is unquestionable, the actual need for a periodic boosting vaccination in adults is controversial. In Italy, the Ministry of Health recommends a Tdap booster vaccination every 10 years. The aim of this study is to assess the real-world adherence of Italian regional healthcare services to national recommendations and to evaluate two alternative strategies. Methods: Annual Tdap vaccine requirements by the 21 Italian regions were retrieved from related tender announcements, and regional and national vaccination coverage rates (VCRs) were estimated for three scenarios, namely the currently recommended 10-year booster vaccination, a single booster shot at age 50 and at age 65. Results: In Scenario 1, no region reached a VCR > 30%, and the national VCR was 10.6%; in Scenario 2, five regions achieved the optimal vaccination coverage of ≥95%, but the vast majority continued to have inadequate VCRs, with a national VCR of 54.4%; in Scenario 3, five regions reached VCRs exceeding 100%, with VCRs from other regions significantly improving and a national VCR of 74.8%. Conclusions: A substantial lack of adherence by Italian regional healthcare services to current national recommendations on tetanus-diphtheria-pertussis adult vaccination was shown. Scenario 3 is the most feasible, i.e., a single booster shot at age 65, possibly administrable along with other already-recommended, age-specific vaccines.

An evaluation of people's knowledge of adult vaccination information level and attitudes during the pandemic Era

OBJECTIVE

This research was carried out to evaluate people's knowledge of adult vaccination and their attitude and to observe the effect of the pandemic era on this situation.

METHODS

A total of 1,425 people (18-80 years old) were included in this study. The types of questions like the province where they live, age, gender, occupation, education status, and the presence of chronic diseases, as well as knowing which vaccines are used in adult vaccination, which of these vaccines they had in the last 10 years, which ones they plan to have this year, and whether COVID-19 pandemic changed their perspective on adult vaccinations or not were asked to people.

RESULTS

In the last 10 years, while participants stated that they had the highest rate of tetanus vaccine with 29.8%, hepatitis B vaccine with 23.1%, influenza vaccine with 22.7%, human papillomavirus vaccine with 1.3%, and zoster vaccine with 0.3% were the lowest levels of vaccines.

CONCLUSIONS

As a result, it seems that we are far from the goals set by the health authorities for adult vaccination. We observed that the COVID-19 pandemic raised awareness toward pneumococcus and influenza vaccines and interest toward adult vaccinations and at the same time changed the thoughts against adult vaccinations.

Healthcare workers' perceptions and experiences of communicating with people over 50 years of age about vaccination: a qualitative evidence synthesis

BACKGROUND

Infectious diseases are a major cause of illness and death among older adults. Vaccines can prevent infectious diseases, including against seasonal influenza, pneumococcal diseases, herpes zoster and COVID-19. However, the uptake of vaccination among older adults varies across settings and groups. Communication with healthcare workers can play an important role in older people's decisions to vaccinate. To support an informed decision about vaccination, healthcare workers should be able to identify the older person's knowledge gaps, needs and concerns. They should also be able to share and discuss information about the person's disease risk and disease severity; the vaccine's effectiveness and safety; and practical information about how the person can access vaccines. Therefore, healthcare workers need good communication skills and to actively keep up-to-date with the latest evidence. An understanding of their perceptions and experiences of this communication can help us train and support healthcare workers and design good communication strategies.

OBJECTIVES

To explore healthcare workers' perceptions and experiences of communicating with older adults about vaccination.

SEARCH METHODS

We searched MEDLINE, CINAHL and Scopus on 21 March 2020. We also searched Epistemonikos for related reviews, searched grey literature sources, and carried out reference checking and citation searching to identify additional studies. We searched for studies in any language.

SELECTION CRITERIA

We included qualitative studies and mixed-methods studies with an identifiable qualitative component. We included studies that explored the perceptions and experiences of healthcare workers and other health system staff towards communication with adults over the age of 50 years or their informal caregivers about vaccination.

DATA COLLECTION AND ANALYSIS

We extracted data using a data extraction form designed for this review. We assessed methodological limitations using a list of predefined criteria. We extracted and assessed data regarding study authors' motivations for carrying out their study. We used a thematic synthesis approach to analyse and synthesise the evidence. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We examined each review finding to identify factors that may influence intervention implementation and we developed implications for practice.

MAIN RESULTS

We included 11 studies in our review. Most studies explored healthcare workers' views and experiences about vaccination of older adults more broadly but also mentioned communication issues specifically. All studies were from high-income countries. The studies focused on doctors, nurses, pharmacists and others working in hospitals, clinics, pharmacies and nursing homes. These healthcare workers discussed different types of vaccines, including influenza, pneumococcal and herpes zoster vaccines. The review was carried out before COVID-19 vaccines were available. We downgraded our confidence in several of the findings from high confidence to moderate, low or very low confidence. One reason for this was that some findings were based on only small amounts of data. Another reason was that the findings were based on studies from only a few countries, making us unsure about the relevance of these findings to other settings. Healthcare workers reported that older adults asked about vaccination to different extents, ranging from not asking about vaccines at all, to great demand for information (high confidence finding). When the topic of vaccination was discussed, healthcare workers described a lack of information, and presence of misinformation, fears and concerns about vaccines among older adults (moderate confidence). The ways in which healthcare workers discussed vaccines with older adults appeared to be linked to what they saw as the aim of vaccination communication. Healthcare workers differed among themselves in their perceptions of this aim and about their own roles and the roles of older adults in vaccine decisions. Some healthcare workers thought it was important to provide information but emphasised the right and responsibility of older adults to decide for themselves. Others used information to persuade and convince older adults to vaccinate in order to increase 'compliance' and 'improve' vaccination rates, and in some cases to gain financial benefits. Other healthcare workers tailored their approach to what they believed the older adult needed or wanted (moderate confidence). Healthcare workers believed that older adults' decisions could be influenced by several factors, including the nature of the healthcare worker-patient relationship, the healthcare worker's status, and the extent to which healthcare workers led by example (low confidence). Our review also identified factors that are likely to influence how communication between healthcare workers and older adults take place. These included issues tied to healthcare workers' views and experiences regarding the diseases in question and the vaccines; as well as their views and experiences of the organisational and practical implementation of vaccine services.

AUTHORS' CONCLUSIONS

There is little research focusing specifically on healthcare workers' perceptions and experiences of communication with older adults about vaccination. The studies we identified suggest that healthcare workers differed among themselves in their perceptions about the aim of this communication and about the role of older adults in vaccine decisions. Based on these findings and the other findings in our review, we have developed a set of questions or prompts that may help health system planners or programme managers when planning or implementing strategies for vaccination communication between healthcare workers and older adults.

Age-Related Dynamics in Post-Vaccine Antibody Immune Response to Diphtheria and Tetanus Toxoid in Bulgarian Subjects

In this study, we investigated the age-related dynamics in post-vaccine humoral immunity to diphtheria (DT) and tetanus (TT) toxoids in the Bulgarian population. In addition, we attempted to correlate the titers of specific antibodies with the predisposition to more common infectious pathology among our study participants. The 208 individuals tested were divided into five age groups: 0-4, 4-6, 6-12, 12-17 and 17-66 years, based on the vaccines received according to the immunization schedule in Bulgaria. Vaccine response was determined by measuring the concentrations of specific IgG antibodies using commercial ELISA kits. Sufficient protective levels of diphtheria (> 0.1 IU/mL) and tetanus (> 0.15 IU/mL) antitoxin were detected in 63.5% and 85.1% of all subjects, respectively. The highest rates of protection against both TT (94.3%) and DT (79.2%) were observed in the youngest age group (0-4 years). We also observed a relatively high rate of insufficient protection (< 0.1 IU/ml) against diphtheria (36% of individuals tested across all age groups) in comparison to tetanus (14.9% of all subjects). The rate of insufficient protection against both antigens was higher among children with frequent infections. Moreover, 77.1% of the individuals having low antibody titers against the highly immunogenic tetanus toxoid, also had low levels of diphtheria antibodies. The level of seroprotection is better for tetanus than for diphtheria toxoid at any age. In conclusion, our data provide information on the level of immunity to diphtheria and tetanus among vaccinated individuals in Bulgaria and allows for the identification of persons suspected of having an immune deficiency. Additional investigations are needed in order to provide reliable recommendations for the national vaccine program and personalized vaccinations.

Vaccine attitudes among young adults in Asia: a systematic review

Introduction: Young adults may be facing growing threats from vaccine-preventable diseases (VPDs). However, vaccination of young adults may not have drawn adequate attention. In Asia, adensely populated region with ahigh proportion of low-income countries, VPDs impose more of an economic and social burden than in western countries. However, knowledge about attitudes toward vaccines among young Asians is limited. This study aims to fill that gap by describing attitudes toward vaccines and how well they are accepted among young Asian adults through asystematic review of relevant Chinese and English publications.Methods: A three-stage searching strategy was adopted to identify eligible studies published during 2009-2019 according to the selection criteria, resulting in 68 articles being included.Results: The review finds that vaccination coverage among young Asians is generally lower than among their western peers, and there is a lack of relevant study in many Asian countries. Factors influencing young Asians' attitudes toward vaccines are categorized into contextual level, individual and social level, and vaccine-specific level.Conclusion: These suggest that there is a need to strengthen young adults' vaccination programs and to promote vaccine-related information and government.

Seroprevalence of Antibodies against Diphtheria, Tetanus and Pertussis in Adult At-Risk Patients

Patients with chronic diseases are at increased risk of complications following infection. It remains, however, unknown to what extend they are protected against vaccine-preventable diseases. We assessed seroprevalence of antibodies against diphtheria, tetanus and pertussis to evaluate whether current vaccination programs in Belgium are adequate. Antibody titers were assessed with a bead-based multiplex assay in serum of 1052 adults with chronic diseases. We included patients with diabetes mellitus type 1 (DM1) (n = 172), DM2 (n = 77), chronic kidney disease (n = 130), chronic obstructive pulmonary disease (COPD) (n = 170), heart failure (n = 77), HIV (n = 196) and solid organ transplant (SOT) recipients (n = 230). Factors associated with seroprevalence were analysed with multiple logistic regression. We found seroprotective titers in 29% for diphtheria (≥0.1 IU/mL), in 83% for tetanus (≥0.1 IU/mL) and 22% had antibodies against pertussis (≥5 IU/mL). Seroprotection rates were higher (p < 0.001) when vaccinated within the last ten years. Furthermore, diphtheria seroprotection decreased with age (p < 0.001). Tetanus seroprotection was less reached in women (p < 0.001) and older age groups (p < 0.001). For pertussis, women had more often a titer suggestive of a recent infection or vaccination (≥100 IU/mL, p < 0.01). We conclude that except for tetanus, the vast majority of at-risk patients remains susceptible to vaccine-preventable diseases such as diphtheria and pertussis.

Vaccination coverage of recommended vaccines and determinants of vaccination in at-risk groups

Upon exposure to vaccine-preventable diseases, certain individuals are at increased risk for complications due to preexisting diseases, age or immunosuppressive treatment. Vaccination against influenza, pneumococcal disease and hepatitis B (for some groups) is advised in addition to standard vaccination against diphtheria, tetanus and pertussis. We estimated the vaccination coverage and determinants of recommended vaccinations in patients with diabetes mellitus type 1 (n = 173) and type 2 (n = 177), chronic kidney disease (CKD) (n = 138), heart failure (n = 200), chronic obstructive pulmonary disease (COPD) (n = 187), HIV (n = 201) or solid organ transplantation (SOT) (n = 201) in a monocentric study. Vaccination data were retrieved from documents provided by patients and general practitioners, and from the Flemish vaccination register. Less than 10% had received all recommended vaccines. Overall, 29% of subjects were vaccinated against diphtheria-tetanus, 10% against pertussis, 44% against influenza, 32% against pneumococcal disease and 24% of HIV patients and 31% of CKD patients against hepatitis B. Age was positively associated with vaccination against influenza (OR:2.0, p < .01) and pneumococcal disease (OR:2.6, p < .001). Patients with COPD, HIV and SOT were more likely to be vaccinated against influenza (OR:2.8, p < .001, OR:1.8, p < .05; OR:2.0, p < .001, respectively) and pneumococcal disease (OR:2.9, p < .001, OR:25.0, p < .001; OR:2.6, p < .001, respectively) than patients with heart failure. Reason for non-vaccination were concerns about effectiveness, necessity and side effects of influenza vaccines, and not being aware of the recommendation for pneumococcal disease. Initiatives to monitor the vaccination status of vulnerable patients are needed, which is why we advocate systematic vaccination registration and frequent communication about vaccination.

Archetype analysis of older adult immunization decision-making and implementation in 34 countries

The global population of adults over 65 years of age is growing rapidly and is expected to double by 2050. Countries will face substantial health, economic and social burden deriving from vaccine-preventable diseases (VPDs) such as influenza, pneumonia and herpes zoster in older adults. It will be essential that countries utilize several public health strategies, including immunization. Understanding the different approaches countries have taken on adult immunization could help provide future learnings and technical support for adult vaccines within life-course immunization strategies. In this study, we describe the priorities and approaches that underlie adult immunization decision-making and implementation processes in 32 high-and-middle-income countries and two territories ("34 countries") who recommend adult vaccines in their national schedule. We conducted an archetype analysis based on a subset of two dozen indicators abstracted from a larger database. The analysis was based on a mixed-methods study, including results from 120 key informant interviews in six countries and a landscape review of secondary data from 34 countries. We found four distinct archetypes: disease prevention-focused; health security-focused; evolving adult focus; and, child-focused and cost-sensitive. The highest performing countries belonged to the disease prevention-focused and health security archetypes, although there was a range of performance within each archetype. Considering common barriers and facilitators of decision-making and implementation of adult vaccines within a primary archetype could help provide a framework for strategies to support countries with similar needs and approaches. It can also help in developing context-specific policies and guidance, including for countries prioritizing adult immunization programs in light of COVID-19. Further research may be beneficial to further refine archetypes and expand the understanding of what influences success within them. This can help advance policies and action that will improve vaccine access for older adults and build a stronger appreciation of the value of immunization amongst a variety of stakeholders.

Diphtheria in Belgium: 2010-2017

In Western Europe, the incidence of both respiratory and cutaneous diphtheria, caused by toxin-producing Corynebacterium diphtheriae, Corynebacterium ulcerans or Corynebacterium pseudotuberculosis, has been low over the past few decades thanks to the use of an effective vaccine and a high level of vaccination coverage. However, the disease has still not been eradicated and continues to occur in all of Europe. In order to prevent sequelae or a fatal outcome, diphtheria antitoxin (DAT) should be administered to suspected diphtheria patients as soon as possible, but economic factors and issues concerning regulations have led to poor availability of DAT in many countries. The European Centre for Disease Prevention and Control and World Health Organization have called for European Union-wide solutions to this DAT-shortage. In order to illustrate the importance of these efforts and underline the need for continued diphtheria surveillance, we present data on all registered cases of toxigenic and non-toxigenic C. diphtheriae, C. ulcerans and C. pseudotuberculosis in Belgium during the past decade, up to and including 2017.

Immunisation of migrants in EU/EEA countries: Policies and practices

In recent years various EU/EEA countries have experienced an influx of migrants from low and middle-income countries. In 2018, the "Vaccine European New Integrated Collaboration Effort (VENICE)" survey group conducted a survey among 30 EU/EEA countries to investigate immunisation policies and practices targeting irregular migrants, refugees and asylum seekers (later called "migrants" in this report). Twenty-nine countries participated in the survey. Twenty-eight countries reported having national policies targeting children/adolescent and adult migrants, however vaccinations offered to adult migrants are limited to specific conditions in seven countries. All the vaccinations included in the National Immunisation Programme (NIP) are offered to children/adolescents in 27/28 countries and to adults in 13/28 countries. In the 15 countries offering only certain vaccinations to adults, priority is given to diphtheria-tetanus, measles-mumps-rubella and polio vaccinations. Information about the vaccines given to child/adolescent migrants is recorded in 22 countries and to adult migrants in 19 countries with a large variation in recording methods found across countries. Individual and aggregated data are reportedly not shared with other centres/institutions in 13 and 15 countries, respectively. Twenty countries reported not collecting data on vaccination uptake among migrants; only three countries have these data at the national level. Procedures to guarantee migrants' access to vaccinations at the community level are available in 13 countries. In conclusion, although diversified, strategies for migrant vaccination are in place in all countries except for one, and the strategies are generally in line with international recommendations. Efforts are needed to strengthen partnerships and implement initiatives across countries of origin, transit and destination to develop and better share documentation in order to guarantee a completion of vaccination series and to avoid unnecessary re-vaccination. Development of migrant-friendly strategies to facilitate migrants' access to vaccination and collection of vaccination uptake data among migrants is needed to meet existing gaps.

Knowledge, Attitudes, and Behaviors of Parents towards Recommended Adult Vaccinations: An Explanatory Survey in the Geographic Area of Naples, Italy

The purposes of this study were to explore the knowledge, attitudes, and behaviors towards the recommended vaccinations for adults between 19–64 years of age and the associated factors among parents. The survey was conducted from October to December 2018 among a sample of parents randomly selected from five preschools and primary, secondary, and high schools in the geographic area of Naples, Italy. The mean age of participants was 45.2 years (range 19–71). Only 16% of the parents knew all vaccinations recommended to adults between 19–64 years of age. Those being healthcare professionals, having a chronic condition, having received information about vaccinations from physicians, and having a lower educational level were more likely to know the vaccinations recommended to adults between 19–64 years of age. Female participants, those who had received information about vaccinations from physicians, and those who had a lower number of children were more likely to have a positive attitude toward the usefulness of the administration of vaccinations recommended to adults between 19–64 years of age. Among unvaccinated respondents, more than half reported a positive attitude toward willingness to receive a recommended vaccination. This positive attitude was significantly higher among those who considered vaccinations as being useful and among who had received information from physicians. Only 16.9% self-reported to have received at least one vaccination recommended to adults between 19–64 years of age. Those who were healthcare professionals, who had at least one chronic condition, and who considered the administration of the vaccinations as being useful were more likely to have received at least one recommended vaccination. Greater efforts by policy makers and healthcare providers are needed to increase parents’ knowledge on recommended vaccines, and it is also crucial that healthcare providers have a high knowledge and favorable attitudes in order to increase vaccine coverage.

A qualitative study of vaccination behaviour amongst female Polish migrants in Edinburgh, Scotland

Vaccine hesitancy is increasing and failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. In Lothian and Scotland, low vaccine uptake has been seen in migrants - notably in the Polish group who have arrived since 2004. The recent Vaccine Confidence in European Union report highlights a concerning recent decline in vaccine confidence in Poland. We held three focus groups containing 13 Polish women about the childhood vaccination programme in Lothian, with specific focus on influenza and Human Papillomavirus vaccinations. Key emergent themes were: trust in the national vaccination policy, trust in the vaccination providers (health professionals), trust in the individual vaccines, balancing the risk of disease, and language and communication. Polish norms, beliefs and behaviours shape how Polish migrants navigate the UK health system and its vaccination programme. While not confident in the Scottish primary care model and its generalist practitioners, the participants liked the ethos of informed consent in Scotland and compared this favourably with the compulsory vaccination policy in Poland. There was a belief that vaccines in Scotland were of higher quality than Poland and with fewer adverse effects. Respondents reported returning to Poland for specialist clinical appointments and diagnostic testing. They regularly access Polish clinical expertise and their opinions about health are influenced by Polish friends and family. They say they have difficulty finding official UK Government and health authority vaccination material and often access Polish media, online resources and information. They are familiar with anti-vaccination activities in Poland. Consequently, there are important unmet information needs for this group of parents who may not be making truly informed choices about vaccination. This requires further investigation especially as migration continues and declining immunisation uptake is reported in many countries across Europe.

Life-course immunization as a gateway to health

INTRODUCTION

Extending the benefits of vaccination against infectious diseases from childhood throughout the entire life-span is becoming an increasingly urgent priority in view of the world's aging population, emergence and reemergence of infectious diseases, and the necessity to invest more on prevention versus cure in global healthcare. Areas covered: This perspective discusses how life-course immunization could benefit human health at all stages of life. To achieve this, the current vaccination paradigm should be changed and all stakeholders have a role to play. Expert commentary: To enhance immunization confidence in the population, it is essential that stakeholders eliminate complacency toward infectious diseases, improve vaccination convenience, remove barriers among different healthcare specialties, and address prevention as a single entity. They must also consider societal and cultural mindsets by understanding and including public viewpoints. A new "4Cs' model encompassing convenience, confidence, complacency, and cultural acceptance is proposed to convert 'vaccine availability' to 'vaccination acceptance' throughout life. Life-course vaccination should become the new social norm of a healthy life-style, along with a healthy diet, adequate physical exercise, and not smoking. We are 'all in' to make life-course immunization a gateway for all people to lead longer, healthier lives.

A Phase III Study to Evaluate the Immunogenicity and Safety of GC1107 (Adult Tetanus Diphtheria Vaccine) in Healthy Adults

BACKGROUND

This study was conducted to assess the immunogenicity and safety of GC1107 (adult tetanus diphtheria [Td] vaccine). The primary goal was to evaluate the non-inferiority of the immunogenicity of GC1107 compared to the control vaccine. Additionally, the safety profiles of GC1107 and the control vaccine were compared.

METHODS

The subjects were adults ≥ 18 years old who were not injected with Td or adult tetanus-diphtheria-pertussis (TdaP) vaccine within the recent 5 years. A total of 253 subjects were enrolled and randomized to either the GC1107 group or the control group. For immunogenicity assessment, blood samples were collected at baseline and 28 days after vaccination and antibody titer of diphtheria and tetanus were assessed.

RESULTS

The seroprotection rates of diphtheria and tetanus were 89.76% and 91.34%, respectively, in the GC1107 group, and 87.80% and 86.99% in the control group. The geometric mean titer (GMT) of the anti-diphtheria antibody increased after vaccination in both groups, showing no significant difference between the groups (P = 0.139). The anti-tetanus GMTs after vaccination also showed comparable increases in both groups, and showed no significant difference (P = 0.860). In the safety evaluation, solicited local adverse reactions occurred in 81.2% of the subjects in the GC1107 group and in 86.4% of the subjects in the control group. Solicited systemic adverse events occurred in 33.2% of the subjects in the GC1107 group and in 47.2% of the subjects in the control group, which did not reach statistical significance.

CONCLUSION

This phase III study demonstrated non-inferiority in immunogenicity and comparable safety of GC1107 compared with the control Td vaccine.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02361866.

Low uptake of nasal influenza vaccine in Polish and other ethnic minority children in Edinburgh, Scotland

Failure to vaccinate is well-recognised in Europe as a contributing factor to outbreaks of infectious diseases. Low immunisation rates are often associated with religious, social and ethnic minorities, including refugees or migrant groups. Polish people form Scotland's newest and largest migrant group. They have moved to Scotland since 2004, joining established ethnic minorities from China, the Indian subcontinent and Africa. Scotland has had a seasonal influenza nasal vaccination programme for all primary school children since 2013. We investigated three primary schools in Edinburgh, which had reported low influenza vaccination uptake rates in 2016 and 2017 and found that these schools contained many pupils from ethnic minorities, the majority of whom were Polish. Pupils were categorized as one of three ethnic groupings: White British, Polish and Other Identified Ethnic Minority (OIEM). We ascertained ethnicity using NHS and Education Department information sources and name recognition. We examined vaccine acceptance, declination and non-return of consent forms. In 2017, nasal influenza vaccine uptake was 70.7% (65.2-75.6%, p < 0.001) in White British, 60.9% (53.9-67.6%%, p < 0.001) in other identified ethnic minorities and 25.0% (20.9-29.6%, p > 0.001) in Polish children. White British children were more likely to return completed forms (78.9%) than other groups (OIEM 68.2% and Polish 61.8%). 36.8% of Polish families completed a consent form declining vaccination compared to 6.2% of White British families. These findings demonstrate that significant differences exist in nasal influenza vaccination uptake rates, which have important implications for the trans-national study of vaccine hesitancy. Further qualitative work and an investigation of uptake rates of other childhood immunisations in Polish and other migrant groups is required to assess differences in uptake and behaviours.

Challenges in adult vaccination

Life-long primary prevention interventions beginning and continuing throughout an individual's lifetime are increasingly seen as key to meeting the global healthcare challenges that accompany demographic changes - a concept referred to as "Healthy aging". In this perspective, vaccination is seen as part of a triad, together with healthy diet and exercise. Current adult vaccine coverage is lower than target vaccination rates in most developed countries, and so vaccine preventable diseases continue to present a substantial burden on health and healthcare resources, especially in older individuals. In part, this is due to lack of knowledge and understanding of the benefits of vaccination, inconsistent recommendations by providers and uncertainties about cost benefits. However, lower vaccine effectiveness in older adults plays a part, and new vaccines with novel characteristics to improve effectiveness in older adults are required. A life-course immunization approach to ensure optimal vaccine uptake across adults of all ages can be expected to reduce morbidity and mortality in later life. To achieve this, greater emphasis on public and healthcare provider education is necessary, based on appropriate economic analyses that demonstrate the overall value of vaccination. This article introduces the technical, economic, political and demographic issues that make establishing effective adult vaccination programs such a difficult, but pressing issue, and outlines some of the steps that are now being taken to address them. Key messages Life-long preventive activities that start and continue throughout life are essential, especially as the world's population is "getting older". This "Healthy aging" approach includes not only healthy diet and physical exercise; vaccination is critical in reducing some infectious diseases and their complications. Many adults, especially older adults (who have lower immunity than younger people) develop infections such as influenza and shingles that could potentially be prevented through vaccination. This review provides a perspective on the challenges in delivering a life-course immunization program. While some vaccines are less effective in older people, newer vaccines have been developed which provide stronger and longer protection in older patients than standard existing vaccines. However, the benefits of vaccination can only be realized if the vaccines are recommended and used. For that purpose, greater education of patients and their healthcare providers is necessary. Better knowledge of vaccines and making sure that all adults are up to date with all their recommended vaccines is an essential part of "Healthy aging". This should prevent not only vaccine-preventable diseases but also reduce the risk of complications in later life.

Vaccination programs for older adults in an era of demographic change

OBJECTIVES

Populations are aging worldwide. This paper summarizes some of the challenges and opportunities due to the increasing burden of infectious diseases in an aging population.

RESULTS

Older adults typically suffer elevated morbidity from infectious disease, leading to increased demand for healthcare resources and higher healthcare costs. Preventive medicine, including vaccination can potentially play a major role in preserving the health and independence of older adults. However, this potential of widespread vaccination is rarely realized. Here, we give a brief overview of the problem, discuss concrete obstacles and the potential for expanded vaccination programs to promote healthy aging.

CONCLUSION

The increasing healthcare burden of infectious diseases expected in aging populations could, to a large extent, be reduced by achieving higher vaccination coverage among older adults. Vaccination can thus contribute to healthy aging, alongside healthy diet and physical exercise. The available evidence indicates that dedicated programs can achieve substantial improvements in vaccination coverage among older adults, but more research is required to assess the generalizability of the results achieved by specific interventions (see Additional file 1).

Effectiveness of pneumococcal and influenza vaccines to prevent serious health complications in adults with chronic liver disease: a protocol for a systematic review

INTRODUCTION

In advanced chronic liver disease, diseases caused by common bacteria Streptococcus pneumoniae or influenza virus put people at an increased risk of serious health complications and death. The effectiveness of the available vaccines in reducing the risk of poor health outcomes, however, is less clear.

METHODS AND ANALYSIS

We will search Medline (Ovid), Embase (Ovid), PubMed and Cochrane Central Register of Controlled Trials for published reports on randomised controlled trials and observational studies on the effectiveness of pneumococcal and influenza vaccines in people with chronic liver disease. Two independent reviewers will screen the studies for eligibility, extract data and assess study quality and risk of bias. Random effects meta-analyses will be performed as appropriate.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as no primary data will be collected for this study. We will publish results of this study in relevant peer-reviewed medical journal or journals. Where possible, the study results will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO REGISTRATION NUMBER

CRD42017067277.

Evaluation of the Immunization Program in the Federation of Bosnia and Herzegovina - Possible Modalities for Improvement

INTRODUCTION

Immunization is a lifelong preventive activity that helps prevent/reduce disease, prevent/ reduce mortality and prevent disability from specific infectious diseases.

MATERIAL AND METHODS

Authors of this paper researched the WHO extended program of mandatory immunization of children from birth to the age of 18 years and analyzed how it has been implemented in the Federation of Bosnia and Herzegovina (FB&H), because the guidelines of the specialist physician societies on immunization of adults, elderly people and risk groups of the population are missing.

RESULTS

The paper presents the basic characteristics of the immunization program in the FB&H and the world, points to the most frequent problems that the doctor practitioner has in carrying out immunization, and also presents possible modalities of improving immunization. It is pointed out the need to develop the national guidelines and individual immunization booklets, introduction of electronic registration of immunization, and continuous education of health professionals of all profiles, population, educators, teachers and harmonious partnership relations of health workers, population, social entities and the media with the aim of achieving an appropriate lifelong vaccination.

National immunization strategies targeting migrants in six European countries

Over the last three years an unprecedented flow of migrants arrived in Europe. There is evidence that vaccine preventable diseases have caused outbreaks in migrant holding centres. These outbreaks can be favored by a combination of factors including low immunization coverage, bad conditions that migrants face during their exhausting journey and overcrowding within holding facilities. In 2017, we conducted an online survey in Croatia, Greece, Italy, Malta, Portugal and Slovenia to explore the national immunization strategies targeting irregular migrants, refugees and asylum seekers. All countries stated that a national regulation supporting vaccination offer to migrants is available. Croatia, Italy, Portugal and Slovenia offer to migrant children and adolescents all vaccinations included in the National Immunization Plan; Greece and Malta offer only certain vaccinations, including those against diphtheria-tetanus-pertussis, poliomyelitis and measles-mumps-rubella. Croatia, Italy, Malta and Portugal also extend the vaccination offer to adults. All countries deliver vaccinations in holding centres and/or community health services, no one delivers vaccinations at entry site. Operating procedures that guarantee the migrants' access to vaccination at the community level are available only in Portugal. Data on administered vaccines is available at the national level in four countries: individual data in Malta and Croatia, aggregated data in Greece and Portugal. Data on vaccination uptake among migrants is available at national level only in Malta. Concluding, although diversified, strategies for migrant vaccination are in place in all the surveyed countries and generally in line with WHO and ECDC indications. Development of procedures to keep track of migrants' immunization data across countries, development of strategies to facilitate and monitor migrants' access to vaccinations at the community level and collection of data on vaccination uptake among migrants should be promoted to meet existing gaps.

Vaccines for the elderly: current use and future challenges

Age-related changes of the immune system contribute to increased incidence and severity of infections in the elderly. Vaccination is the most effective measure to prevent infections and vaccination recommendations in most countries include specific guidelines for the elderly. Vaccination against influenza and Streptococcus pneumoniae is usually recommended for persons with underlying diseases and for the elderly with heterogeneous age limits between ≥ 50 years and ≥ 65 years. Some countries also recommend vaccination against herpes zoster. Several vaccines are recommended for all adults, such as regular booster shots against tetanus/diphtheria/pertussis/polio, or for specific groups, e.g. vaccination against tick-borne encephalitis in endemic areas or travel vaccines. These are also relevant for the elderly. Most currently used vaccines are less immunogenic and effective in the elderly compared to younger adults. Potential strategies to improve their immunogenicity include higher antigen dose, alternative routes of administration, and the use of adjuvants, which were all implemented for influenza vaccines, and induce moderately higher antibody concentrations. Research on universal vaccines against influenza and S. pneumoniae is ongoing in order to overcome the limitations of the current strain-specific vaccines. Respiratory syncytial virus causes significant morbidity in the elderly. Novel vaccines against this and other pathogens, for instance bacterial nosocomial infections, have tremendous potential impact on health in old age and are intensively studied by many academic and commercial organizations. In addition to novel vaccine developments, it is crucial to increase awareness for the importance of vaccination beyond the pediatric setting, as vaccination coverage is still far from optimal for the older population.

[Immunizing is not only a children's matter! : Why vaccinations are also important for adults]

Vaccinations belong to the ten most effective public health achievements worldwide. While immunization programms for children are installed in Europe, vaccinations for adults are not established. However, adult vaccination is extremely meaningful: increasing age means a higher susceptibility to infectious diseases, health problems and multimorbidity will increase. The burden of vaccine-preventable diseases is still high in Europe. Due to immunosenescence (older) adults are less protected against pathogens, antibody titers after vaccinations are lower and immunity lasts shorter. There is striking lack of data of adult vaccination rates and an international consensus regarding adult vaccination recommendations or guidelines are not available in Europe. In only six countries a comprehensive document describing recommended vaccinations for adults is available, among them Austria. The awareness of the importance of adult vaccination over the whole lifetime is not present to the necessary extent in Europe and has to be promoted.

Focusing on the implementation of 21st century vaccines for adults

Adult immunization is a priority for public health, particularly in countries where an aging population has become increasingly more numerous. Protection against diseases which typically affect adults (like flu, pneumococcal diseases and Herpes zoster), the shift of age of infections which originally affected children (like measles), the decreasing protection with time for infections which need periodical booster doses of vaccines (Tdap), the availability of vaccines which can also impact on adult health (HPV) are only some examples of the importance of implementing targeted vaccination strategies. The possibility to reach high coverage with immunizations that can guarantee a fundamental improvement of health for adults and the elderly can only be achieved through a coordinated effort where all stakeholders, under the coordination of public health, contribute to issue recommendations; create a functioning database for vaccine coverage registration; promote formative courses for healthcare workers and continuous information for the public; increase vaccines uptake among healthcare workers, who need to give the first testimony on the relevance of immunization.

Perceptions and Attitudes of Patients About Adult Vaccination and Their Vaccination Status: Still a Long Way to Go?

BACKGROUND Immunization is one of the most effective public health measures to prevent disease, but vaccination rates in adult populations still remain below the targets. Patient and physician attitudes about vaccination are important for adult vaccination. In this study, we aimed to determine patient attitudes and perceptions about vaccination and the vaccination coverage rates of adult patients in a university hospital in Turkey. MATERIAL AND METHODS A survey was conducted between October 2014 and May 2015 at the Internal Medicine Outpatient Clinics of a university hospital. Adult patients were asked to fill out a questionnaire on their perceptions and attitudes about vaccination and their vaccination status. RESULTS We interviewed 512 patients ages 19-64 years. Eighty percent of the study population thought that adults should be vaccinated, while only 36.1% of the patients stated that vaccination was ever recommended to them in their adult life. Forty-eight percent of the patients stated that they were vaccinated at least once in their adulthood. The most commonly received vaccine was tetanus vaccine in general, while influenza vaccine was the leading vaccine among patients with chronic medical conditions. While 71.4% of the patients to whom vaccination was recommended received the vaccine, 34.9% of the patients received a vaccine without any recommendation. CONCLUSIONS Although the vaccine coverage rates among adults in this survey were low, the perceptions of patients about adult vaccination were mainly positive and of many of them positively reacted when their physician recommended a vaccine.

Immunization Strategies Targeting Newly Arrived Migrants in Non-EU Countries of the Mediterranean Basin and Black Sea

Background: The World Health Organization recommends that host countries ensure appropriate vaccinations to refugees, asylum seekers and migrants. However, information on vaccination strategies targeting migrants in host countries is limited. Methods: In 2015-2016 we carried out a survey among national experts from governmental bodies of 15 non-EU countries of the Mediterranean and Black Sea in order to document and share national vaccination strategies targeting newly arrived migrants. Results: Four countries reported having regulations/procedures supporting the immunization of migrants at national level, one at sub-national level and three only targeting specific population groups. Eight countries offer migrant children all the vaccinations included in their national immunization schedule; three provide only selected vaccinations, mainly measles and polio vaccines. Ten and eight countries also offer selected vaccinations to adolescents and adults respectively. Eight countries provide vaccinations at the community level; seven give priority vaccines in holding centres or at entry sites. Data on administered vaccines are recorded in immunization registries in nine countries. Conclusions: Although differing among countries, indications for immunizing migrants are in place in most of them. However, we cannot infer from our findings whether those strategies are currently functioning and whether barriers to their implementation are being faced. Further studies focusing on these aspects are needed to develop concrete and targeted recommendations for action. Since migrants are moving across countries, development of on-line registries and cooperation between countries could allow keeping track of administered vaccines in order to appropriately plan immunization series and avoid unnecessary vaccinations.

Effect of dementia on receipt of influenza vaccine: a cohort study in French older adults using administrative data: 2007-2012

Despite guidelines stating the vaccine benefit in this population, older adults with dementia may be less likely to receive influenza vaccine than cognitively intact older adults. But no study has yet reported on vaccine uptake in patients newly diagnosed with dementia or whether years since dementia diagnosis influences vaccine uptake. We conducted a cohort study in the French Health Insurance database (Echantillon Généraliste de Bénéficiaires) which contains hospital data and claims for a 1/97th random sample of the French population. Diseased subjects were ≥65 years and had a new record of dementia diagnosis between September 1, 2007, and August 31, 2008. Vaccine receipt was measured via influenza vaccine dispensing in community pharmacies. We described influenza vaccination rates up to 2011-2012 and estimated adjusted relative risks (aRR) for vaccine receipt each year using multivariate modified Poisson models controlling for sociodemographics, comorbidities, and health resources use. Four hundred and seven subjects with dementia (mean age 81.8 years, 69.3% females) and 4862 subjects (mean age 75.2 years, 61.3% females) without dementia were included. In 2008-2009, influenza vaccination prevalence was 70.0% (95% CI = [65.3-74.4]) and 70.2% (95% CI = [68.9-71.4]) in subjects with and without dementia, respectively (aRR = 0.93; 95% CI = [0.87-1.00]). In 2009-2010, the aRR was of the same magnitude (aRR = 0.96, 95% CI = [0.90-1.03]), but in 2010-2011 and 2011-2012, the aRR was 1.02 (95% CI = [0.94-1.11]) and 1.05 (95% CI = [0.96-1.14]), respectively. Subjects with dementia had a slightly nonsignificant lower receipt of influenza vaccine in the year following dementia diagnosis than subjects without dementia. In subsequent years, divergent trends were observed in vaccine uptake according to dementia status.

Tetanus-diphtheria-acellular pertussis vaccination for adults: an update

Although tetanus and diphtheria have become rare in developed countries, pertussis is still endemic in some developed countries. These are vaccine-preventable diseases and vaccination for adults is important to prevent the outbreak of disease. Strategies for tetanus, diphtheria, and pertussis vaccines vary from country to country. Each country needs to monitor consistently epidemiology of the diseases and changes vaccination policies accordingly. Recent studies showed that tetanus–diphtheria–acellular pertussis vaccine for adults is effective and safe to prevent pertussis disease in infants. However, vaccine coverage still remains low than expected and seroprevalence of protective antibodies levels for tetanus, diphtheria, and pertussis decline with aging. The importance of tetanus–diphtheria–acellular pertussis vaccine administration should be emphasized for the protection of young adult and elderly people also, not limited to children.

Shingles (Herpes Zoster) Vaccine (Zostavax(®)): A Review in the Prevention of Herpes Zoster and Postherpetic Neuralgia

Zostavax(®) is a live attenuated shingles (herpes zoster) vaccine approved in the EU for the prevention of herpes zoster (HZ) and postherpetic neuralgia (PHN) in adults aged ≥50 years. Zoster vaccine protected against HZ in adults aged 50-59 years (ZEST trial) and ≥60 years [Shingles Prevention Study (SPS)], and also reduced the burden of illness associated with HZ and the risk of PHN in adults aged ≥60 years (SPS). A large amount of real-world data also supports the efficacy of zoster vaccine. Results of the SPS Short- and Long-Term Persistence Substudies and real-world studies indicate that zoster vaccine provided continued benefit in the longer term, albeit with a gradual decline in vaccine efficacy over time; long-term effectiveness studies are ongoing. The need for a booster dose is still unknown, but a study showed that, if necessary, a booster dose administered to adults aged ≥70 years who received their first dose of zoster vaccine ≥10 years previously was immunogenic. Zoster vaccine had a favourable safety and tolerability profile, with the most commonly reported adverse events being non-severe injection-site reactions. In conclusion, zoster vaccine reduces the incidence of HZ and PHN, thereby reducing the burden of illness associated with HZ; improved uptake of zoster vaccine is needed.

Is It Time for Vaccination to "Go Viral"?

To promote and sustain excellent vaccination coverage, while preserving the key core values of ethics, truth, transparency and trust, the vaccine community should adopt modern digital communication strategies. This article summarizes our views-as experts in multidisciplinary field of vaccinology (consisting of an anthropologist, a public health policy advisor, a vaccine industry expert, a health care journalist and a practicing physician)-which were presented at a satellite symposium held at the 33rd European Society of Paediatric Infectious Disease conference in Leipzig, Germany, in May 2015. This article aims to suggest and recommend strategies to promote vaccination awareness, and highlight proactive measures for building, maintaining and enhancing trust in vaccination through innovative communication and evidence-based interaction with the end user. We believe that converting the results of vaccine research into a successful vaccination program, and replacing misinformation with evidence-based communication, will require a multidisciplinary approach that embraces modern digital and tailored applications to reach out to all populations.

Effects of annual influenza vaccination on mortality in patients with heart failure

The objective was to evaluate the effect of influenza vaccine on all-cause mortality in a cohort of patients with heart failure followed up in primary care centres of the Community of Madrid, Spain, during the period 2006-10. Results of the Cox proportional-hazard model were adjusted for age and sex and, after 1:1 nearest neighbour matching, for propensity score. The analysis was further stratified by season. Having received annual influenza vaccine was associated with a decreased risk of death during the influenza season (hazard ratio = 0.59, 95% CI = 0.41-0.84), but no protective effect was observed before or after the influenza season.

ADVICE for a healthier life: Adult Vaccination Campaign in Europe

Immunization is one of the most effective public health measures to prevent disease. Despite relatively good vaccination rates in childhood in many parts of the world, vaccines to prevent diseases are underused in the adult population and adult vaccination rates are still far below the target. The European Federation of Internal Medicine (EFIM), declared that 'internal medicine must focus on better care for individuals, better health care for populations and lower costs'. Adult vaccination is a good example of a public health initiative aimed at reducing morbidity and mortality, but awareness of the need for adult vaccination and uptake of the programs across Europe is variable. The Adult Vaccination Campaign in Europe (ADVICE) was developed with an aim to raise awareness for adult vaccination and to understand the dynamics of the vaccination practices and the possible barriers against achieving targeted vaccination rates in Europe. In order to reach vaccination targets, we need evidence based, up to date guidelines; recommendations at national and international levels; surveillance for vaccination rates; and opportunities to provide vaccines more readily. Leadership at a European level and a firm research and action agenda are crucial. The European Federation of Internal Medicine can take the lead as it declared its interest on 'better care for individuals, better health care for populations'. Hence, we consider ADVICE a very timely and very valuable initiative to draw a roadmap to improve adult vaccination rates in Europe.

Adult vaccination against tetanus and diphtheria: the European perspective

Besides immunizations against influenza, Streptococcus pneumoniae and herpes zoster, which are recommended specifically for elderly people, regular booster vaccinations against tetanus, diphtheria and in some cases pertussis and polio are recommended in many European countries for adults, including elderly people. Vaccination recommendations for adults differ greatly between individual countries and coverage data is scarce. Tetanus-specific antibody concentrations are generally higher than diphtheria-specific antibodies, and a substantial proportion of adults, and particularly of elderly people, do not have protective antibody concentrations against diphtheria. Antibody levels increase upon booster vaccination in all age groups, but diphtheria-specific antibody concentrations remain below protective levels in some older individuals, even immediately after vaccination and long-term protection is frequently not achieved. Future vaccination strategies should therefore include regular and well-documented booster shots, e.g. against tetanus and diphtheria, throughout life.

A cross-sectional serosurvey on hepatitis B vaccination uptake among adult patients from GP practices in a region of South-West Poland

BACKGROUND

Hepatitis B is a significant health burden in Poland with nosocomial transmission being the main source of infection. Therefore, HBV vaccination is widely recommended for those not covered by the national immunisation program.

OBJECTIVE

To assess the coverage and influencing determinants of HBV vaccination among adult patients attending GP clinics as well as to establish serological status in terms of HBV infection.

METHODS

Patients who were seen consecutively in March 2013 at four randomly selected GP practices located in Zgorzelec county, in south-western part of Poland, were invited to participate and complete questionnaires on socio-demographic data and other factors related to vaccination. A pilot study was done in one urban GP practice in the city of Gryfino (Gryfino county), the results have been included in the study. Patients' immunisation status was assessed basing on vaccination cards and anti-HBs titer with the use of third-generation testing methods. In addition, serum samples were assayed for anti-HBc total.

RESULTS

Response rate: 99.3 %. Of 410 participants (66.1 % females, median age 56 years), 55.4 % (95%CI:50.5-60.1 %) were previously vaccinated; in those 11.5 % took 2 doses, 66.1 % - 3 doses,18.1 % - 4 doses. Elective surgery was the main reason (57.7 %) for HBV immunization, 4.8 % - were vaccinated due to recommendations by GPs. The multivariable logistic regression model revealed that living in a city (OR 2.11), and having a surgery in the past (OR 2.73) were each associated with greater odds of being vaccinated. Anti-HBc total prevalence among those unvaccinated was 13.6 % (95%CI:9.3 %-19,5 %), and 7.2 % (95%CI:4.4-11.8 %) among those vaccinated.

CONCLUSIONS

Low HBV immunization coverage among adult patients from GP clinics and the presence of serological markers of HBV infection among both - those unvaccinated and vaccinated call for comprehensive preventative measures against infection, including greater involvement of family doctors. Although interventions should cover the whole population, inhabitants living in the rural areas should be a group of special interest. Preoperative immunization for HBV seems to be an efficient public health tool to increase the vaccination uptake.

[Influenza, tetanus, and pertussis vaccination coverage among adults in Germany]

In order to be adequately protected throughout life and to protect specific risk groups from particular diseases, regular booster or specific indicator vaccinations are also recommended during adulthood. Adults should be vaccinated against seasonal influenza (annually, e.g., persons with underlying chronic diseases and persons aged ≥ 60 years), tetanus (every 10 years), and pertussis (as a one-time vaccination with the next due tetanus vaccine and, e.g., when people have close contact to newborn babies). The aim of this study was to provide an overview of the current status of vaccination uptake among adults living in Germany, focusing on these three vaccines. In line with nationwide continuous health monitoring, the Robert Koch Institute conducted the representative study "German Health Update" (GEDA 2012) between 2012 and 2013. The survey is conducted regularly and adults are asked questions relating to their vaccination status through computer-assisted telephone interviews. Overall, 19,294 interviews were held. In 2010/2011 and 2011/2012, seasonal influenza uptake among persons aged ≥ 60 years was 54.3 and 52.6 % and among individuals with underlying chronic diseases 46.2 and 42.9 %. 7.6 and 75.6 % of participants reported up-to-date pertussis and tetanus vaccination, respectively. 22 % of people living with a baby in one household were vaccinated against pertussis. In general, vaccination rates against seasonal influenza, pertussis, and tetanus among adults are still low, but differ depending on the specific vaccination. The required aim of the European Commission to reach influenza vaccination coverage by the 2014/2015 winter season of 75 % of higher age groups has not yet been reached. The low pertussis vaccination coverage among persons in close household contact to infants poses a big challenge to the implementation of the cocooning strategy to protect the very vulnerable newborns. To emphasize the importance of a complete vaccination schedule and to increase vaccination uptake, tailored interventions should be provided for both physicians and adults.

Missed opportunities for Hepatitis B vaccination among diabetic patients

Many infectious diseases in adults can be prevented by a 'life-long vaccination strategy'. Hepatitis B disease burden was shown to be higher in diabetic patients. American Advisory Committee on Immunization Practices recommends to vaccinate diabetic patients against hepatitis B since 2011. In this study, we aimed to determine hepatitis B virus serology status to determine the rates of diabetic patients who have indications for hepatitis B vaccination. The electronic database of the hospital was searched to identify adult patients aged above 18 years and with hemoglobin A1C levels of 6.5% or above, who have been seen at General Medicine Outpatient Clinics of a university hospital during a 3-year period. A total of 5187 patients were included in the study. After exclusion of patients with an incomplete serological panel, 1358 patients were included for further analyses. Twenty-nine percent of the patients had indication for hepatitis B vaccination, whereas only 8% were vaccinated. This study showed that nearly one third of patients who had hepatitis B serological data had an indication for hepatitis B vaccination and this is a clear reflection of the need to keep a lifelong vaccination log and inquire vaccination data.

Adult vaccination: Now is the time to realize an unfulfilled potential

Each year, vaccine-preventable diseases kill thousands of adults, both in the United States and across the planet, causing a significant human toll and severe economic burden on the world's healthcare systems. In the United States, while immunization is recognized as one of the most effective primary prevention services that improves health and well-being, adult immunization rates remain low and large gaps exist between national adult immunization goals and actual adult immunization rates. Closing these gaps requires a commitment by national leaders to a multifaceted national strategy to: (1) establish the value of adult vaccines in the eyes of the public, payers, policy makers, and health care professionals; (2) improve access to recommended adult vaccinations by improving the adult vaccine infrastructure in the United States and developing public-private partnerships to facilitate effective immunization behaviors; and (3) ensure fair and appropriate payment for adult immunization. Many of the situations that result in low adult immunizations rates in the United States also exist in many other countries around the world. Successful strategies to improve adult immunization coverage rates will result in reductions in morbidity, mortality, and healthcare costs. All medical and public health stakeholders must now collaborate to realize the significant health benefits that come with a strong adult immunization program.

Age-specific differences in influenza virus type and subtype distribution in the 2012/2013 season in 12 European countries

The epidemiology of seasonal influenza is influenced by age. During the influenza season, the European Influenza Surveillance Network (EISN) reports weekly virological and syndromic surveillance data [mostly influenza-like illness (ILI)] based on national networks of sentinel primary-care providers. Aggregated numbers by age group are available for ILI, but not linked to the virological data. At the end of the influenza season 2012/2013, all EISN laboratories were invited to submit a subset of their virological data for this season, including information on age. The analysis by age group suggests that the overall distribution of circulating (sub)types may mask substantial differences between age groups. Thus, in cases aged 5–14 years, 75% tested positive for influenza B virus whereas all other age groups had an even distribution of influenza A and B viruses. This means that the intepretation of syndromic surveillance data without age group-specific virological data may be misleading. Surveillance at the European level would benefit from the reporting of age-specific influenza data.

Adult vaccination

Vaccination of children has had a major impact on the morbidity and mortality of many infectious diseases globally. However, with age, immune responses to vaccines can be less robust, which can be further enhanced by underlying diseases that are common in the older adult. In many countries around the globe booster vaccinations against diphtheria, tetanus, and pertussis are recommended for adults. For the older adult, vaccination against pneumococcal diseases, influenza and herpes zoster are also recommended. Despite these recommendations, the widespread use of these vaccines in the adult population clearly lags behind the vaccine uptake and successes documented for pediatric vaccination programs. Furthermore, extensive and sometimes inappropriate use of antibiotics have fostered the emergence of antibiotic-resistant bacteria (e.g., methicillin resistant Staphylococcus aureus (MRSA)) as well as increased susceptibility in the elderly to bacterial species such as Clostridium difficile. Infectious diseases remain an important unmet medical need and new concepts to successfully implement vaccination of adults are urgently needed.

Vaccine-preventable diseases: from paediatric to adult targets

The morbidity and mortality related to many communicable infectious diseases have significantly decreased in Western countries largely because of the use of antibiotics, and the implementation of well-planned vaccination strategies and national immunisation schedules specifically aimed at infants and children. However, although immunisation has proved to be highly effective for public health, more effort is needed to improve the currently sub-optimal rates of vaccination against various diseases among adults who may be at risk because of their age, medical condition or occupation. The vaccines currently licenced in Western countries are safe, immunogenic and effective against many infectious diseases and their complications, but the availability of newer vaccines or vaccines with new indications, the evolving ecology and epidemiology of many infections, population ageing, and other demographic changes (i.e. the increasing prevalence of chronic comorbidities and immunodeficiencies, mass migration, new working relationships, and widespread international tourism) require changes in the approach to immunisation. There is now a need for appropriate preventive measures for adults and the elderly aimed at protecting people at risk by using every possible catch-up opportunity and recommending specific age-related schedules on the basis of local epidemiology.

Adult immunization policies in advanced economies: vaccination recommendations, financing, and vaccination coverage

OBJECTIVES

While many countries have robust child immunization programs and high child vaccination coverage, vaccination of adults has received less attention. The objective of this study was to describe the adult vaccination policies in developed countries.

METHODS

From 2010 to 2011, we conducted a survey of 33 advanced economies as defined by the International Monetary Fund. The survey asked about national recommendations for adults for 16 vaccines or vaccine components, funding mechanisms for recommended adult vaccines, and the availability of adult vaccination coverage estimates.

RESULTS

Thirty-one of 33 (93.9 %) advanced economies responded to the survey. Twelve of 31 (38.7 %) reported having a comprehensive adult immunization schedule. The total number of vaccines or vaccine components recommended for adults ranged from one to 15 with a median of 10. Seasonal influenza (n = 30), tetanus (n = 28), pneumococcal polysaccharide (n = 27), and hepatitis B (n = 27) were the most frequently recommended vaccines or components.

CONCLUSIONS

Approximately two-thirds of survey respondents do not have a comprehensive adult vaccine schedule, and most do not measure vaccination coverage. We found that a funding mechanism is available for most recommended adult vaccines.

Medical and economic burden of influenza in the elderly population in central and eastern European countries

Influenza affects 5-15% of the population during an epidemic. In Western Europe, vaccination of at-risk groups forms the cornerstone of influenza prevention. However, vaccination coverage of the elderly (> 65 y) is often low in Central and Eastern Europe (CEE); potentially because a paucity of country-specific data limits evidence-based policy making. Therefore the medical and economic burden of influenza were estimated in elderly populations in the Czech Republic, Hungary, Kazakhstan, Poland, Romania, and Ukraine. Data covering national influenza vaccination policies, surveillance and reporting, healthcare costs, populations, and epidemiology were obtained via literature review, open-access websites and databases, and interviews with experts. A simplified model of patient treatment flow incorporating cost, population, and incidence/prevalence data was used to calculate the influenza burden per country. In the elderly, influenza represented a large burden on the assessed healthcare systems, with yearly excess hospitalization rates of ~30/100,000. Burden varied between countries and was likely influenced by population size, surveillance system, healthcare provision, and vaccine coverage. The greatest burden was found in Poland, where direct costs were over EUR 5 million. Substantial differences in data availability and quality were identified, and to fully quantify the burden of influenza in CEE, influenza reporting systems should be standardized. This study most probably underestimates the real burden of influenza, however the public health problem is recognized worldwide, and will further increase with population aging. Extending influenza vaccination of the elderly may be a cost-effective way to reduce the burden of influenza in CEE.