Vaccination in Europe – the crucial role of the health care provider

By Pierre Van Damme , MD, PhD, vice-dean faculty of Medicine and Health Sciences, director Centre for the Evaluation of Vaccination, University of Antwerp, Belgium.


Immunization has been a great health success story. Consistent widespread use of vaccines has proven successful in controlling or even eliminating disease.

Indeed, diseases that commonly killed infants, children, adolescents and adults only decades ago are now virtually unknown in many countries. However, many young people and even health care providers (HCPs) are not aware of these diseases that have been eliminated and others may not fully comprehend the value of vaccines and the importance of herd immunity. Moreover, no matter how strong the science may be and how large and uniform the expert consensus, young adults and adolescents are far more likely to be influenced by the opinions and actions of a friend or peer, or a message on twitter or facebook, particularly in the digital age.

Over the past decade, an increasing number of studies have documented a rising amount of people in both high–income and low-income countries who are losing confidence in vaccines, to the point of choosing not to vaccinate their children ( According to organizations such as the WHO and UNICEF, gains in the world’s fight against vaccine-preventable diseases are at risk.

The WHO has specifically identified vaccine hesitancy – which the organization defines as ‘the delay in acceptance or refusal of vaccines despite the availability of vaccination services’ – as one of the top ten health threats to the world in 2019.

Therefore recognizing and identifying champions who can inform, communicate and encourage confidence in immunization is key. Partnering with future and current HCPs is a good opportunity to promote the importance of vaccination.

Health care providers in Europe

HCPs are among the most trusted sources of immunisation information, and therefore are a core group to address low or declining public confidence in vaccination. However, reliance on HCP to provide optimal guidance to target population may be jeopardised if HCP, themselves, have doubts about vaccines or if they do not communicate effectively with their clientele.

A qualitative study among HCP from four different European countries (Croatia, France, Greece and Romania (Karafillakis et al, 2016) showed that, in general, while the benefits of vaccination were appreciated there were also risks considered to be important such as the  fear of side-effects, especially for new vaccines, and the HCP’s responsibility for these side-effects if they should occur in their patients. While some HCP see it as their role to respond to hesitancy and have impact one their patients’ decision, others feel they should remain neutral, and leave it to the patients to decide.

In general, it was felt that vaccine confidence could be improved by more information (e.g. on side-effects) and training (e.g. communication skills), as well as stricter legislation.

Larson et al (2018) showed in a large-scale survey that there is a positive correlation between the GPs believes about vaccines and the public confidence.  This recent study assessed the overall state of confidence in vaccines among the public in all 28 EU member states and among general practitioners (GP) in ten EU member states. The survey found that overall GPs are confident in the safety, importance and effectiveness of vaccination and have higher levels of confidence than the general population (except for 1 country). While these results are re-assuring and confirm results from other studies that only a minority of health care providers have concerns about vaccines (Karafillakis et al, 2016; Paterson et al, 2016), confidence of GPs in MMR vaccination is lower in certain countries in the survey.

Overall this illustrates that HCPs can play a crucial role in addressing vaccine hesitancy and in communicating with vaccinees or their parents. Paterson et al (2016) reviewed a number of studies from which it is clear that a good knowledge is related to a better confidence and improved recommendations. Evidence suggests that improved knowledge through training also improves vaccine confidence in HCPs. In addition, HCPs who are vaccinated themselves are more likely to recommend vaccines to others; they also lead by example or role model (Maltezou et al, 2019). In agreement with these findings Paterson et al (2016) report that a lack of preparedness for advising patients about vaccination and a lack of training act as inhibiting factors for recommending the vaccine.

Unfortunately a lot of work remains to be done in Europe to well educate and train our future HCP, nurse, pharmacist and midwife.

In order to estimate the current basic knowledge of EU medical students towards vaccines and vaccination policy in Europe, a large web-based survey was performed among the students of the European Medical Student Association (2018): overall, 73% indicated to have courses in vaccinology in their curriculum, ranging from 1-2hours up to several courses.  Up to 20% of last year medical students never had had vaccinology teaching in their curriculum!

To assist HCPs in obtaining up-to-date knowledge and information on vaccines and vaccination programmes, increasingly post-graduate courses and in-service trainings are being organized at a national, regional and international level. In an attempt to list all available courses on vaccinology worldwide, a global vaccinology e-portal was set up recently ( (Duclos et al, 2019).


HCPs serve as the most trusted advisors and influencers of vaccination decisions. A lack of knowledge among HCPs is considered one of the most important factors for vaccine hesitancy. Major efforts are needed to prepare and assist our EU HCP through pre- and in-service training.


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Karafillakis E, Dinca I, Apfel F, Cecconi S, Wurz A, Takacs J, et al. Vaccine hesitancy among healthcare workers in Europe: A qualitative study. Vaccine. 2016;34:5013-20.

Larson H, de Figueiredo A, Karafillakis E, Rawal M. State of Vaccine Confidence in the EU 2018 – Report 77p.  ISBN 978-92-79-96560-9 doi:10.2875/241099 – Publlication office of the European Union, 2018.

Maltezou HC, Poland GA. Vaccination policies for healthcare workers in Europe. Vaccine. 2014;32:4876-80.

Maltezou HC, Botelho-Nevers E, Brantsæter AB, Carlsson RM, Heininger U, Hübschen JM, Josefsdottir KS, Kassianos G, Kyncl J, Ledda C, Medić S, Nitsch-Osuch A, de Lejarazu RO, Theodoridou M, Van Damme P, van Essen GA, Wicker S, Wiedermann U, Poland GA; Vaccination Policies for HCP in Europe Study Group. Vaccination of healthcare personnel in Europe: Update to current policies.

Vaccine. 2019 Oct 14. pii: S0264-410X(19)31285-X

Paterson P, Meurice F, Stanberry LR, Glismann S, Rosenthal SL, Larson HJ. Vaccine hesitancy and healthcare providers.

Vaccine. 2016 Dec 20;34(52):6700-6706