Evolving measles status and immunization policy development in six European countries

Figures & data

Figure 1. Flow diagram for study selection.

Figure 2. Measles case numbers and vaccine coverage for first and second MCV dose in selected countries 2001–2019.

Case numbers as reported by the WHO for 2001–2019, supplemented by individual WHO-EU measles and rubella elimination country profiles.^16–21 Vaccine coverage represents official country estimates for 2001–2019 as reported by the WHO.¹⁶ The red line indicates 95% coverage in the age-eligible target populations.

Figure 3. Current measles vaccination schedule in selected countries.

Scheduled vaccinations as reported by ECDC and other sources.^21–23Cross-hatch indicates mandatory catch-up recommendation for Germany. MCV, measles-containing vaccine; MCV1, first dose of measles-containing vaccine; MCV2, second dose of measles-containing vaccine; MMR, measles-mumps-rubella-vaccine; MMRV, measles-mumps-rubella-varicella vaccine.

Table 1. Framework analysis across countries

Problem	Context	Policy implementation and required organizational mechanisms	Key observations
Decline in infant MCV coverage	Global rise of antivaccination sentiment; increasing levels of misinformation Increased politicization of immunization Decreasing trust in public health authorities, health-care systems, and governments	Stronger central coordination of immunization programs and local/regional implementation Introduction of mandatory vaccination, where appropriate Introduction of central immunization registry to monitor vaccine coverage HCW-led communication to reduce parental vaccine hesitancy Address public concerns through an ongoing informed debate and education; can involve public interest groups to reduce political aspects	Parents have unmet immunization information needs Public trust in immunization is impacted by broader institutional trust Mandatory immunization can trigger short-term negative public reaction but demonstrates a long-term political commitment to immunization
Increasing disease burden in older age groups	Most immunization programs primarily address infant immunization needs Adult immunization access may be limited	Introduction of adult catch-up campaigns (free-of-charge) Increase immunization access through engaging of additional vaccinators (e.g., community pharmacists)	Outbreaks persist despite high national coverage Increasing disease burden is in adults, ethnic and anthroposophical communities, and may not be reached by routine vaccine services Centralized immunization registries can help monitor uptake
Identify and reduce disease burden in hard-to-reach populations	Susceptible/vulnerable communities are characterized by ethnic, religious, socioeconomic, education, or migration status Identified and targeted only after outbreak Conventional outbreak responses may not address specific community needs	Address the specific needs of underserved communities; greater understanding can guide tailored responses and increase compliance Solutions involve community engagement beyond health-care systems	Outbreaks occur in populations with high nationwide coverage where immunization gaps exist in underserved populations Measles importation is important and international communities may share similar immunization attitudes; and may benefit from similar tailored strategies
Ensure agile response to changing epidemiology and outbreaks	Delays in local implementation of outbreak response measures may reduce their impact Public health decisions are not always evidence-based and may be influenced by political factors Resource constraints can reduce the capacity and ability to adapt to changing needs	Clear division of competencies and responsibilities between central and regional health-care systems and strong central coordination can improve impact of response measures Streamlining diverse stakeholder responsibilities can improve response agility	Agile adjustment of immunization policy can address changing disease burden Decentralized health-care systems require cooperation of regional authorities in implementing central strategies; local engagement is important for local public support Stronger central coordination improves the regional commitment Absence of public representation in policy-making may weaken acceptance and lead to challenges to policy decisions

Figure 4. Emergent themes.

Table 2. Key themes from semi-structured interviews

Theme	Country	Role
Centralized immunization framework and political commitment	Italy	Centralization of immunization activities allied with supportive political commitment has benefits over the previously fragmented and often unfocused approach seen with decentralized delivery Setting national immunization targets with appropriate measures for regional delivery has improved vaccine uptake Streamlined engagement of local politicians can prevent delays in outbreak response (as evident in COVID-19 responses) New policy introduction is heavily influenced by political factors; greater engagement with politicians is essential to support policy decision-making Policy decisions can seem complex; public debate on complex policy decisions (and disagreements between political and health-care stakeholders) can have a negative impact on public perception
	UK	Cost-effectiveness seems a key driver of health-care decision-making; systematic defunding of services Disconnection between the political narrative and subsequent actions; perception of competing interests Political factors can impede expert led/evidence-driven public health recommendations; greater engagement with politicians is essential to support policy decision-making Policy decisions can seem complex; public debate on complex policy decisions (and disagreements between political and health-care stakeholders) can have a negative impact on public perception
Top-down vs bottom-up implementation and equity	Italy and UK	Need for closer public/community engagement to inform and address existing trust issues; underserved communities may have specific needs Public-involvement in policy-development and implementation remains limited; public attitudes toward immunization are complex and often divisive While the antivaccine movement may seem marginal, it may represent deeper societal roots; perceived disenfranchisement contributes to mistrust and skepticism toward public health measures (including immunization)
Incentives to vaccinate and mandatory vaccination	Italy	Mandatory immunization considered a successful policy development with a positive societal impact Political commitment considered a key facilitator
	UK	Limited appetite for mandatory vaccination (political or health-care experts) Potential benefit is countered by reduced public trust in health-care system; concerns exist that policy will not address unmet needs of vulnerable populations
Vaccine hesitancy as a symptom of declining trust	Italy and UK	Vaccine hesitancy reflects broader societal views; perception of unmet needs and/or individual disenfranchisement (especially in UK) Lack of community engagement negatively impacts new policy implementation
Education	Italy and UK	Public education is the key action to improve vaccine acceptance and uptake Ideal opportunities include prenatal and school-based education to inform parents and future adults on preventive healthcare (including immunization)
Impact of COVID-19 on immunization attitudes	Italy and UK	Provides an opportunity to refocus public health activities; currently, COVID-19 has increased trust in health-care systems (in the short term) In Italy this may reinforce the top-down approach to disease prevention policies In the UK the long-term impact is uncertain; based on previous experience, positive political and public attitudes may be transient

WHO. WHO vaccine-preventable diseases: monitoring system. 2020 global summary. https://apps.who.int/immunization_monitoring/globalsummary.

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