How to tackle inequitable access, vaccine hesitancy, and other barriers to achieve high vaccine uptake

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World Immunisation Week is an opportune moment to reflect on the importance of vaccination as one of the foundations of a functioning public health system. This year presents a unique set of challenges for the European Region, as several European countries begin settling nearly five million refugees from Ukraine, while countries also plan their next steps to control the covid-19 pandemic.

Interest in covid-19 vaccination is faltering in the WHO European Region; the proportion of the region’s population that is fully vaccinated has only increased by 5% so far in 2022: from 58% in January 2022 to 63% in April 2022.1 The disparity in vaccination uptake between countries in the WHO European Region is glaring: 73% of the total population in high income countries have received their complete dose series while only 37% of the total population in low middle income countries have received the same.1 WHO’s target of 70% uptake in all countries by mid-2022 remains an important aspiration, but it will be almost impossible for several countries in the WHO European Region in view of the current pace of vaccination uptake.

Large scale rollout of covid-19 vaccines in the WHO European Region since December 2020, coupled with the restrictive public health and social measures put in place to contain the pandemic since early 2020, have impacted on routine vaccination coverage in many countries. Eleven countries reported a drop of more than 5% in national coverage either with the third dose of diphtheria-tetanus-pertussis vaccine or the first dose of measles-containing vaccine in 2020. Nine countries in the Region reported national coverage with the third dose of diphtheria-tetanus-pertussis vaccine below 90% in 2020, compared to four in 2019. Vaccine disparity within countries has also increased. Approximately 1/5 of countries in the Region experienced a substantial increase in disparity between highest and lowest coverage areas.2 The pandemic has also led to increased politicization of vaccines, which could potentially spillover into routine childhood vaccinations.3

It is imperative that we systematically identify and consider all the factors that hinder uptake of routine and covid-19 vaccinations in every community and address them holistically and effectively—with the ultimate goal of preventing any outbreak of vaccine-preventable diseases, including measles, polio, diphtheria, and pertussis.

The challenges of 2022 and their impact on immunisation systems, if not addressed comprehensively, will be felt beyond this year. Addressing these challenges will be critical and will require both immediate actions and a longterm, integrated approach. National immunisation programmes must simultaneously maintain high uptake of routine immunisation services and facilitate catch-up for children who missed doses in the past two years. At the same time, they must offer the same vital immunisation services to millions of refugees from Ukraine. Leaving no one behind is not an empty promise, but a necessity to control disease and provide the opportunity for everyone to live a long and healthy life.

The European Immunisation Agenda 2030 (EIA2030), adopted in September 2021 by all Member States of the WHO European Region, is intended to lead the way to ensure everyone everywhere reaps the benefits of the available vaccines.4 It offers a comprehensive pathway and robust strategy for controlling vaccine-preventable diseases during this decade that pivot away from the traditional approaches and are designed appropriately to address current challenges:

For example, vaccine inequity and vaccine hesitancy are among the primary barriers to high uptake of vaccines in many countries. However, these factors are often perceived and discussed as separate issues, with the former usually addressed to marginalised or low-income populations, and the latter concerning higher-income groups. In reality these two issues are often entangled—part of a complex matrix of social norms, economic concerns, historical factors, discrimination, issues with service delivery, and personal experiences with medical care that influence how likely people are to get themselves or their children vaccinated. As well, these challenges are often amplified and reflected in our online, interconnected world, resulting in a so-called infodemic of disinformation.

To succeed, collaboration across the health sector, with other sectors (e.g., private, education) and with civil society and community-based organizations is needed to increase engagement, trust and public support in vaccines and the authorities that provide them.

As a starting point and matter of urgency, WHO/Europe invites countries in the Region to focus on the following, as laid out in recent guidance, as they translate EIA2030 into national action plans5:

Ensuring the health and wellbeing of all people lies at the core of WHO’s mandate and commitments in all situations, including humanitarian crises and conflicts. Leaving no one behind does not only mean providing needed services like immunisation to all—but also working to remove all barriers to ensure full utilisation of these services. Thoughtful, holistic vaccination programming is essential to maintain public health in the weeks, months and years to come.