Good Practices and Challenges in Addressing Poliomyelitis and Measles in the European Union

European Union (EU) Decision 1082/2013/EU (October 2013) on serious cross-border health threats sets out the legal basis for collaboration and information exchange between Member States of the EU, as well as between international and European-level institutions on preparedness, prevention, and mitigation in the event of a public health emergency. In keeping with that commitment, all EU and European Economic Area (EEA) Member States have pledged to ensure political commitment towards sustaining the region's poliomyelitis-free status and eliminating measles. In light of gaps perceived to exist between policy and practice in many countries, this article reports on an assessment conducted for the European Commission (EC) in 2016 that aimed to identify strengths and opportunities for EU/EEA Member States, international institutions, and EU agencies to improve preparedness and response to poliomyelitis and measles.

A documentary review was complemented by qualitative interviews with professionals working in international and EU agencies, and in at-risk or recently affected EU/EEA Member States (6 each for poliomyelitis and measles). Between April and June 2016, 26 interviews were conducted on poliomyelitis and 24 on measles; the data were subjected to thematic analysis. Preliminary findings were then discussed at a Consensus Workshop in September 2016 with 22 of the interviewees and 8 other experts.

Some of the communication-related observations and recommendations to emerge from this investigation are:

• Poliomyelitis-specific issues: There was consensus that the reason for insufficient vaccine coverage in many countries was, ultimately, inadequate political commitment at national level. There were strong calls from respondents for their governments to abide by all the agreements concerning both poliomyelitis vaccination and containment which they have signed.
• Measles-specific issues:
  • By contrast with poliomyelitis, most of the participating countries reported high levels of national level political will to eliminate measles, as per the World Health Organization (WHO)'s European Vaccine Action Plan (to which they are all signatories). However, national commitment was not translated evenly into regional and local implementation.
  • National and local measles plans - e.g., plans for the provision of public information - exist in a majority of the countries. Plans differed substantially between countries, however, and several did not cover the full spectrum of tasks needed for effective vaccination coverage and outbreak control. Further, plans were not always easy to access, and they are not always regularly updated.
  • Key areas that were highlighted as needing additional focus: (i) improving knowledge about the disease and vaccination, both for the public and for health workers; (ii) developing and instituting an electronic notification system to which health workers are obliged to notify suspected measles cases within 24 hours; and (iii) developing and communicating standard operating procedures with regard to contact tracing, ring vaccination, and post-exposure prophylaxis.
  • Low measles vaccine coverage (especially for the second dose) was ascribed in many cases to health systems issues, including a failure to inform parents of the need to vaccinate their children, as well as a failure to provide infrastructural support to health workers. Respondents indicated that policymakers need to prioritise the provision of adequate incentives and infrastructural support to health workers to ensure that measles vaccine coverage rates are optimised.
• Cross-cutting issues: In general terms, and in spite of language difficulties in some cases, cross-border communication between EU Member States was said to be good. Within the EU, the Early Warning and Response System and the Epidemic Intelligence Information System facilitate communication with neighbouring Member States in the event of an outbreak. It was suggested that mechanisms to complement the International Health Regulations could be developed to enhance and improve communications with neighbours who are not EU Member States.

Practices that were proposed as having potential to improve vaccine coverage rates include the following communication-related examples:

• Using trained health mediators to work with Roma and other under-served communities.
• Including vaccination as a topic in the school curriculum, thereby bringing about long-term benefits in coverage rates by reaching out to future parents.
• Requiring parents to provide schools with documentation to show they have been informed about vaccination recommendations for their children.
• Using smartphone apps that send parents reminders about their children's vaccinations.
• Supporting health workers, including through training and resources, to act as effective risk communicators and vaccination advocates at the community level.
• Making systematic efforts to understand the reasons for low vaccination uptake rates through WHO-EURO's Tailoring Immunization Programmes and acting on the findings.
• Improving the standard of many official public health websites and ensuring they are kept up to date.
• Making efforts to bring these official public health websites to the top of internet search lists, as a counter to anti-vaccine websites.
• Including frequently asked questions on official public health websites, with responses to issues about vaccination that are observed to be circulating online.
• Using pre-existing material from the European Centre for Disease Prevention and Control (ECDC) and from WHO-EURO as recognised means of countering vaccine hesitancy.
• Ensuring that official spokespeople during outbreaks are media-trained and trusted by the public.
• Reaching out to political leaders with comprehensive and correct information about vaccination so they do not disseminate messages that undermine vaccination campaigns.

In conclusion, advocacy is needed: "the focus now should be on ensuring that poliomyelitis and measles are brought fully onto the policy agendas of all EU/EEA Member States, and that each country abides by the relevant commitments that they have already made."