Written by Aparajeya Shanker

Worrying trends in vaccination illustrated in the “State of vaccine confidence in the EU” of 2018 conducted by the European Commission show a general decline in confidence levels in the safety and efficacy of vaccines in certain countries. These include Bulgaria, Finland, Greece, Lithuania, Poland, Slovakia, and Spain. 

Vaccination is one of the most successful programs in public health. Vaccination programs have improved life expectancy in the past century. To say that vaccination is the most important medical development in human history would be accurate and evidence supports this statement. However, the recent resurgence of vaccine-preventable illnesses such as Measles and Polio across the European Union and neighboring countries underlines a worrying state of declining vaccine confidence (WHO, 2014). The European Commission lists the decline in vaccination rates as one of its areas of priority. This is justifiable as the evidence shows a disturbing trend towards lower vaccine confidence in certain countries. In Bulgaria only 66% of the population trusts vaccines, whilst the percentages are slightly higher in Latvia (68.2%), and France (69.9%). Even though these numbers still represent more than half of the population, compared to most other European countries, such as Portugal and Austria with 95.6% of the population trusting vaccines, these levels are worrisomely low.

Vaccine confidence is defined as the trust in the effectiveness and safety of vaccines and trust in the healthcare system that delivers them (WHO, 2014). This shows that there are two important components to patients’ response to vaccines: The first is the issue of safety, and the second is the trust in the healthcare system. The European Commission’s study “State of vaccine confidence in the EU, 2018” reached a tripartite conclusion. The general trend across the European Union is that there is a direct correlation between the general public’s vaccine confidence and General Practitioners’ confidence in vaccines. Age also plays an important role in vaccine confidence as the population below 65 years of age trusts vaccines to a lesser extent than the older demographic groups. The study also concluded that education plays a crucial role in determining the general public’s vaccine confidence: Those with Primary education (five years of school education) showed lower levels of vaccine confidence as compared to those with Higher education. 

The advantage of the European Commission’s study “State of vaccine confidence in the EU, 2018” lies in its detail, and the data provides a distinct clarity in terms of what the general population across the EU thinks of vaccines. There is variation with regards to location and age group, and there is a clear distinction between concerns of vaccine safety and vaccine necessity. The correlation between General Practitioner confidence and vaccination rates underlines the importance of General Practitioners and their relationships with their patients.

However, criticism needs to be addressed. The first is that the paper is limited to two major vaccines. These are the Measles Mumps and Rubella (MMR), and the seasonal influenza vaccine. No mention is made about the twenty other vaccines currently on the vaccination schedule in EU member states. [[Note: A vaccination schedule is a series of vaccinations that are administered to infants and children over a period of time to provide immunity against a wide range of infectious diseases and to prevent certain forms of cancer. As such the HPV vaccine is administered to women to prevent cervical cancer, which is caused by the Human Papillomavirus). Vaccines are also administered in the form of boosters, which are scheduled when the initial vaccine’s effects wear off.]] In focusing solely on two vaccines the study becomes limited in its scope. Incomplete data in public health is always a burden in the policy-making process as data forms the concrete foundation upon which Public Health policy is built. 

The other major criticism, in my opinion, is the use of target populations. While it is important to focus data analyses on certain demographics such as pregnant women or infants, the use of target populations also assumes a universality in standards of health care across the EU. However, this is not given. To illustrate this, a comparison between Bulgarian and Belgian vaccination schedules is fit. In Bulgaria, the Measles Vaccine (MMR) is compulsory and is administered when an infant is 12 months of age. However, in Belgium, the measles vaccine is not compulsory and should the parents choose to vaccinate, the recommendation to vaccinate is for 13-month-old infants.

The European commission’s roadmap for vaccinations indicates that a follow-up to this paper is underway. The follow-up to this study will be conducted in 2019, and the study will be published in 2020, with a policy framed in late 2020. The European Commission wishes to implement a common vaccination schedule for the European Union and a vaccine information card by 2022 (European Commission, 2019). While this proactive policy is commendable, it does not address current and immediate concerns regarding vaccinations. 

No policy review is complete without suggestions for improvement. Recognizing the practical limitations of a more detailed study, I feel that certain improvements are prudent. I recognize the importance of a reactive policy in response to the current trends illustrated by this study. The time for action is now. It is clear that focus countries where immunization rates are falling require a more integrated approach towards increasing vaccine awareness through education about the effects of complications of major diseases and an improvement in data collection methods. Education about vaccine safety should be intensified and an awareness campaign tailored to the focus country or countries should be a matter of immediate priority. The awareness campaign should be carried out in the official language of the country and should take into account the vaccine schedule and vaccine policy of the country in question. The awareness campaign should draw from the availability of existing data and care should be given to ensure that vaccine safety data is made more accessible by the help of governmental and non-governmental institutions.

Improved data gathering should be implemented in the focus countries where vaccine confidence is low. The data should furthermore be more detailed in order to achieve a broader informational foundation. The data should include all other major childhood and adolescent vaccinations like the Bacillus Calmette–Guérin vaccine (BCG), which prevents Tuberculosis, the Poliomyelitis vaccine, and the Chickenpox vaccine. It should also include an important factor as to whether vaccine confidence trends extend to emergency use of vaccines and to the extent to which vaccine confidence is low. As such the question to ask is if the vaccine confidence is low for all vaccines or if it is low for a few vaccines only. The final approach towards increasing vaccine confidence is to actively combat vaccine misinformation. The proactive policies of data gathering and education are effective but take time to implement and often require resources and labour.

The advantage of a reactive policy towards combating vaccine misinformation lies in its swift and immediate response to known sources and mechanisms of vaccine misinformation. As such, vaccine misinformation should be combated by holding social media sites accountable for the use of their platforms for spreading misinformation. Most vaccine misinformation is relayed through social media sites and is propagated through focused groups.

In conclusion, I would like to reiterate his position that the recent study carried out by the European Commission “The State of vaccine confidence in Europe” is an invaluable starting point for identifying trends and patterns in vaccine confidence. Further, it is important to bring attention to the value of detailed data gathering and analysis, both of which are helpful instruments in Public Health. While education is an important part of combating vaccine misinformation, reactive, emergency policies targeting misinformation in focus countries should be a pan-European Union priority. To achieve the goals of public health it is important to act and to act now.

Aparajeya Shanker is a medical student, currently studying at the Medical University of Pleven, Bulgaria. He is deeply interested in the complexities of public health and its interplay with policy. It is his firm belief that health should be a priority in international policy and he hopes that his medical experience, botha s a medi cal student and as a researcher on public health, will aid him in providing an invaluable insight into the current issues surrounding public health in Europe and around the world.


European Commission (2018): State of Vaccine Confidence in the EU, 2018. A study for the European Union, https://ec.europa.eu/health/sites/health/files/vaccination/docs/2018_vaccine_confidence_en.pdf.

European Commission (2019): Roadmap for the implementation of actions by the European Commission based on the Commission Communication and the Council Recommendation in strengthening cooperation against vaccine-preventable diseases, https://ec.europa.eu/health/sites/health/files/vaccination/docs/2019-2022_roadmap_en.pdf.