Improving Childhood Vaccination Coverage Rates in Europe

Childhood vaccination plays a critical role in reducing mortality and morbidity worldwide, lowering disease incidence, and strengthening public health protection. In short, vaccination remains one of the most effective tools for preventing infectious diseases.

Over the past several decades, childhood vaccination coverage has improved across Europe, with several countries achieving the World Health Organization’s (WHO) 95% coverage target. While this progress is significant, vaccination coverage rates declined in many European Union (EU) countries between 2010 and 2021. As a result, Europe has experienced outbreaks of vaccine-preventable diseases (VPDs), including major measles outbreaks.

These trends highlight the urgent need to strengthen resilient immunization systems across the EU. Addressing barriers to vaccine uptake is essential to protecting populations from preventable illnesses, reducing deaths linked to VPDs, and improving preparedness for future public health crises.

Researchers from the World Federation of Public Health Associations (WFPHA) and its International Immunization Policy Taskforce examined changes in childhood vaccination coverage across the EU between 2010 and 2021. Their analysis focused on WHO vaccination indicators, including:

• Diphtheria, Tetanus, and Pertussis (DTP) 1st dose
• DTP 3rd dose
• Haemophilus influenzae type b (Hib3)
• Hepatitis B 3rd dose (HepB3)
• Measles 1st dose
• Measles 2nd dose
• Polio 3rd dose

The study identified major trends, barriers, and policy recommendations for improving childhood vaccination coverage rates in Europe.

Childhood Vaccination Coverage Rates in the EU (2010–2021)

The analysis revealed several important patterns across EU member states:

• Vaccination coverage rates fluctuated significantly across countries and vaccine types.
• Most vaccines had lower coverage rates in 2019 than in 2010.
• Lower-performing countries, including Austria and Romania, experienced more severe and frequent fluctuations.
• Higher-performing countries generally maintained stable vaccination coverage rates.

These findings suggest that vaccination systems across Europe remain vulnerable to disruptions and uneven public health capacity.

Why Fluctuations in Vaccination Coverage Matter

Variations in childhood vaccination coverage are a major public health concern. Fluctuating vaccine uptake rates reveal weaknesses within national immunization systems and increase the risk of outbreaks of vaccine-preventable diseases.

Lower vaccination coverage also weakens herd immunity, leaving vulnerable populations, including immunocompromised individuals and children unable to receive vaccines, at greater risk.

To improve long-term public health resilience, EU countries need stronger vaccination infrastructure, more reliable delivery systems, and crisis preparedness strategies.

Key Factors Causing Declining Childhood Vaccination Rates in Europe

The WFPHA article identified several major barriers contributing to declining childhood vaccination coverage rates in Europe.

Structural Barriers to Vaccine Access

Practical challenges continue to limit vaccine uptake for many families. Common structural barriers include:

• Difficulty taking time off work for vaccination appointments
• Limited access to healthcare facilities
• Delays in vaccine procurement and supply chains
• Inconvenient clinic hours

Evidence suggests that improving accessibility plays a major role in increasing vaccination rates.

Vaccine Hesitancy and Misinformation

Vaccine hesitancy remains one of the leading contributors to declining vaccination coverage across Europe. The spread of misinformation (particularly online) has negatively affected public confidence in vaccine safety and effectiveness.

Research highlighted declining vaccine confidence in several EU countries, including:

• Austria
• Bulgaria
• Romania
• Germany
• France
• The Netherlands
• Sweden

Public awareness campaigns, trusted healthcare communication, and evidence-based educational initiatives have proven effective in rebuilding confidence in vaccines.

Impact of COVID-19 on Routine Immunization

The COVID-19 pandemic significantly disrupted routine childhood vaccination services across Europe.

Key pandemic-related challenges included:

• Healthcare resource diversion
• Lockdowns and restricted movement
• Reduced healthcare visits
• Supply chain interruptions
• Delayed data collection and reporting

Many countries experienced additional declines in vaccination coverage between 2020 and 2021, increasing the risk of outbreaks of measles, polio, and other vaccine-preventable diseases.

The Ukraine Crisis and Regional Vaccination Gaps

The ongoing Ukraine crisis further intensified vaccination challenges across Europe. Countries already experiencing immunity gaps, including Poland and Romania, faced additional pressure due to population displacement and disruptions to vaccination services.

The study emphasized the importance of coordinated crisis preparedness plans to prevent widening immunization gaps during humanitarian emergencies.

Strategies for Increasing Childhood Vaccination Coverage Rates

The article identified several evidence-based strategies that can improve childhood vaccination uptake across Europe.

Improve Access to Vaccination Services

Improving convenience and accessibility can significantly increase vaccine uptake. Recommended strategies include:

• Expanding the number of providers authorized to administer vaccines
• Offering vaccinations outside traditional healthcare settings
• Providing extended clinic hours
• Delivering outreach services and catch-up campaigns

Countries with accessible, community-based vaccination systems tend to achieve more stable vaccination coverage rates.

Strengthen Vaccine Communication and Education

Effective communication between healthcare professionals and families is essential for improving vaccine confidence.

Successful approaches include:

• Public awareness campaigns
• Reliable vaccine information materials
• School and community education programs
• Direct communication between patients and healthcare workers

Healthcare professionals remain one of the most trusted sources of vaccine information.

Expand the Use of Digital Technologies

Digital tools can help improve immunization tracking and reduce missed vaccinations.

Key recommendations include:

• Electronic immunization records
• Real-time surveillance systems
• Automated vaccine reminders
• Improved vaccination data collection

Countries using digital reminder systems have reported improved vaccination coverage and more accurate immunization records.

Policy Recommendations for Strengthening Childhood Vaccination Programs

Based on the WFPHA International Immunization Policy Taskforce recommendations, policymakers across the EU should focus on the following priorities.

Facilitate Easier Access to Vaccination

• Expand vaccine administration locations
• Increase provider flexibility
• Offer vaccinations outside standard working hours
• Reduce logistical barriers for families

Invest in Immunization Infrastructure

• Strengthen healthcare workforce capacity
• Improve vaccine supply systems
• Enhance outbreak preparedness plans

Improve Data Collection and Surveillance

• Develop real-time monitoring systems
• Expand electronic immunization records
• Use automated reminder technologies

Increase Public Awareness and Education

• Launch targeted vaccine education campaigns
• Combat misinformation with evidence-based communication
• Support healthcare worker engagement initiatives

The Importance of Resilient Immunization Systems in Europe

The findings demonstrate that childhood vaccination systems across Europe remain vulnerable to public health crises, misinformation, and structural barriers.

Evidence consistently shows that improving vaccine accessibility, strengthening communication, and investing in digital health infrastructure can increase vaccination coverage rates and reduce the risk of disease outbreaks.

As Europe continues to navigate the long-term effects of COVID-19 and the Ukraine crisis, resilient immunization systems will remain essential to protecting children and communities from vaccine-preventable diseases.

Maintaining strong childhood vaccination programs requires continuous investment, coordinated policy action, and sustained public trust in vaccination systems.

What Is the Intergovernmental Negotiating Body (INB)?

The COVID-19 pandemic exposed major gaps in global health preparedness, coordination, and response. In response, governments around the world began exploring stronger international cooperation to better prevent and manage future pandemics.

One of the most significant steps in this effort was the creation of the Intergovernmental Negotiating Body (INB). This body was established by the World Health Assembly to develop a global agreement to strengthen pandemic prevention, preparedness, and response.

Understanding the role of the Intergovernmental Negotiating Body helps explain how the international community is working to reduce the risks of future global health crises.

Why the Intergovernmental Negotiating Body Was Created

The COVID-19 pandemic had a profound impact on human lives, economies, and societies worldwide. The scale of disruption highlighted the need for stronger international alignment when responding to emerging health threats.

To avoid repeating the challenges experienced during COVID-19, the global community recognized the importance of building more coordinated mechanisms for pandemic preparedness.

As a result, countries agreed that a formal international framework could strengthen cooperation, information sharing, and response strategies during future pandemics.

The Historic World Health Assembly Special Session

In December 2021, the World Health Assembly Special Session (WHASS) took place in Geneva, Switzerland.

This meeting was historic: it was only the second time in the history of the World Health Organization (WHO) that the Health Assembly convened twice in the same year.

During this session, Member States agreed to establish the Intergovernmental Negotiating Body (INB).

The mandate of the INB is to draft and negotiate a convention, agreement, or other international instrument under the Constitution of the World Health Organization. The goal of this instrument is to strengthen global systems for pandemic prevention, preparedness, and response.

The Core Mandate of the Intergovernmental Negotiating Body

The Intergovernmental Negotiating Body is responsible for developing a global framework that helps countries work together more effectively during health emergencies.

Its work focuses on creating an international instrument that supports:

• Stronger pandemic prevention strategies
• Improved preparedness for emerging health threats
• More coordinated global response mechanisms
• Greater cooperation among countries and health systems

The INB’s work is guided by several core principles:

• Inclusiveness
• Transparency
• Efficiency
• Member State leadership
• Consensus-based decision making

These principles ensure that negotiations reflect broad international participation and collaboration.

Timeline for the Pandemic Agreement Negotiations

The Intergovernmental Negotiating Body was tasked with progressing negotiations within a clear timeline.

Key milestones include:

• Progress reporting to the 76th World Health Assembly in 2023
• Target adoption of the international instrument by 2024

These milestones allow Member States to evaluate progress and ensure that negotiations continue to move forward.

How the INB Process Includes Global Stakeholders

Although the INB is led by Member States, the process also involves participation from a wide range of stakeholders.

The decision establishing the INB requested that the WHO Director-General convene meetings and support the negotiation process. This includes organizing public hearings to gather perspectives from organizations and experts.

Participants in the process may include:

• United Nations system bodies
• Non-state actors
• Civil society organizations
• Global health stakeholders

This inclusive approach ensures that negotiations consider diverse expertise and perspectives from across the global health community.

Public Health Organizations Contributing to the INB Process

Public health organizations have played an active role in the consultation process surrounding the Intergovernmental Negotiating Body.

During INB public hearings, several organizations submitted statements to contribute to the discussions, including:

• The World Federation of Public Health Associations (WFPHA)
• The International Federation of Social Workers (IFSW)
• The International Hospital Federation (IHF)
• The World Organization of Family Doctors (WONCA)

These contributions help ensure that public health expertise informs the development of the international pandemic instrument.

Why the Intergovernmental Negotiating Body Matters for Future Pandemics

The creation of the Intergovernmental Negotiating Body reflects a global recognition that stronger international cooperation is essential to address future health threats.

By working toward a shared framework for pandemic preparedness and response, the INB aims to help countries:

• Strengthen health system resilience
• Improve coordination during emergencies
• Reduce global health inequalities
• Respond more rapidly to emerging threats

Ultimately, the work of the Intergovernmental Negotiating Body represents an important step toward building a more coordinated and effective global system for pandemic preparedness.

Protecting Ecosystems Through Nature-based Solutions for Improved Public Health

The relationship between the natural world and human health is foundational. From the food we eat and the water we drink to the air we breathe and the environments where we live, human survival depends on the health of ecosystems.

This reality underpins the growing global focus on nature-based solutions for improved public health. Protecting biodiversity and restoring ecosystem functions are environmental priorities and public health imperatives.

The World Federation of Public Health Associations (WFPHA) highlighted this urgency in its official statement during the 27th Conference of the Parties to the UN Framework Convention on Climate Change (COP27), calling for a stronger global commitment to ecosystem protection and nature-positive climate strategies.

The Invisible Infrastructure Supporting Human Health

The interconnectedness between natural and human systems is well-documented and observable in the sheer breadth of our interactions with nature. Ecosystems provide food, water, shelter, and virtually every critical resource needed for human survival and prosperity.

The health benefits derived from ecosystems are delivered through biodiversity, species composition, and complex ecological processes performed by natural systems.

These processes enable ecosystems to deliver what are commonly known as ecosystem services, typically grouped into four categories:

• Provisioning services: such as food, freshwater, and medicinal resources

• Regulating services: including climate regulation, flood control, and disease regulation

• Supporting services: such as nutrient cycling and soil formation

• Cultural services: including recreation, mental wellbeing, and social connection

More recently, these benefits have also been described as nature’s contributions to people, emphasizing how ecosystem health directly influences human well-being.

When Ecosystems Fail, Public Health Suffers

When ecosystems cannot function optimally, the consequences are immediate and far-reaching for human health.

Examples illustrate how ecological degradation directly undermines well-being:

• Soil microbial depletion reduces the nutritional quality and yield of agricultural crops.

• Pollinator decline disrupts plant reproduction, threatening food production and medicinal resources.

• Deforestation destroys habitats needed to maintain biodiversity and ecological balance.

• Ocean pollution damages marine ecosystems and diminishes cultural, recreational, and psychological benefits associated with coastal environments.

Each of these disruptions weakens the ecological systems that support human life.

Environmental Degradation Is Reversing Public Health Gains

Over the past 70 years, economic and technological growth, often described as the “great acceleration,” has lifted millions from poverty and extended life expectancy worldwide. Yet these gains have come at a profound environmental cost.

Because public health is fundamentally intertwined with ecosystem health, environmental degradation threatens to reverse decades of progress.

Research shows that ecological breakdown can:

• Reduce the nutrient content and productivity of food systems

• Harm agriculture-based livelihoods

• Trigger severe mental health consequences, particularly among Indigenous communities

• Disrupt planetary systems necessary for climate stability

These intersecting pressures illustrate how environmental damage represents a systemic threat to human survival and well-being.

Biodiversity Loss and the Rising Burden of Disease

Even when examined individually, ecological disruptions can have enormous public health consequences.

For example:

• Pollinator loss could place 71 million people at risk of vitamin A deficiency and 173 million people at risk of folate deficiency, contributing to 1.42 million additional deaths annually from malnutrition and non-communicable diseases.

• Urban areas without adequate green space experience higher air pollution, more frequent heat waves, elevated stress levels, and increased rates of non-communicable diseases.

• Deforestation has been linked to increased waterborne diseases due to reduced flood control and contamination of surface water sources.

• Tropical forest loss increases interactions between humans and wildlife, raising the risk of emerging infectious diseases that could trigger epidemics or pandemics.

These examples demonstrate how ecosystem health functions as a protective barrier for global public health.

Climate Change Is Intensifying Ecosystem and Health Risks

At COP27, global discussions emphasized the accelerating impacts of climate change on ecosystems and human wellbeing.

The IPCC Sixth Assessment Report highlights that climate change is already affecting:

• Marine and coastal ecosystems

• Terrestrial and freshwater ecosystems

• Global food production systems

These changes are expected to produce cascading public health impacts.

For example:

• Climate change could increase the number of people at risk of hunger by 8 to 80 million by mid-century, with the highest impacts in Sub-Saharan Africa, South Asia, and Central America.

• Extreme temperature, rainfall variability, droughts, flooding, and sea-level rise will likely increase outbreaks of aquatic pathogens in coastal populations.

• Shifts in ecosystem conditions and vector ranges are expected to significantly increase the global burden of vector-borne diseases.

In many regions, these combined pressures may ultimately render areas increasingly difficult or impossible to inhabit.

Environmental and Social Determinants of Health Are Interconnected

The forces driving environmental degradation are closely tied to the same social and economic factors that shape health outcomes.

As a result, the current socio-ecological crisis is also a crisis of inequality. Communities that contribute the least to environmental damage often face the greatest health consequences.

This dynamic places particular burdens on:

• Vulnerable populations

• Indigenous communities

• Low-income regions

• Future generations

Delaying action is therefore not an option. Protecting biodiversity and restoring ecosystem functions are essential to safeguarding public health worldwide.

Why Nature-based Solutions for Improved Public Health Matter

A biosensitive approach to development recognizes that human wellbeing depends on living in balance with natural systems.

Transitioning toward a nature-positive economic framework can simultaneously strengthen ecosystems and support economic development. The World Economic Forum estimates that such a transition could generate $10.1 trillion in annual business value and create 395 million jobs by 2030.

Nature-based solutions for improved public health include strategies such as:

• Reforestation and afforestation

• Habitat protection and ecosystem restoration

• Regenerative and restorative agricultural practices

• Mangrove conservation

• Expansion of urban green spaces

• Protection of natural carbon sinks such as forests, oceans, wetlands, and peatlands

These approaches strengthen ecosystem resilience while reducing climate and health risks.

Indigenous Knowledge Is Essential for Sustainable Ecosystem Management

Effective environmental stewardship also requires recognizing the leadership and knowledge of Indigenous communities.

Indigenous groups have long practiced forms of land stewardship that promote biodiversity, ecosystem restoration, and sustainable environmental management.

Supporting Indigenous leadership in conservation efforts ensures that community-based solutions remain central to long-term environmental resilience.

A Global Call to Protect Nature for Public Health

The WFPHA supports the United Nations’ warning that humanity is “losing our suicidal war against nature” and emphasizes that the world faces a stark choice: collective action or collective suicide.

In response, the organization affirms the human right to a clean, healthy, and sustainable environment and calls for global commitment to nature-based climate solutions and ecosystem protection.

This call to action aligns with the principles of One Health, which recognizes the deep interdependence between human, animal, and environmental health, an interconnection highlighted clearly by the COVID-19 pandemic.

The Path Forward

Protecting ecosystems is not solely an environmental responsibility; it is one of the most powerful public health interventions available.

Nature-based solutions for improved public health offer a pathway to:

• Reduce climate risks

• Prevent emerging diseases

• Strengthen food and water security

• Improve mental and physical well-being

• Protect the health of future generations

The global public health community now faces a decisive moment. Acting to protect biodiversity and restore ecosystems is essential to ensuring a healthy and sustainable future for humanity.

Big Tobacco’s Dirty Tricks

Since its inception, the tobacco industry has been at the forefront of influencing public opinion and disrupting health policy through various sophisticated and deceptive methods. As evidence has mounted supporting the undisputed deadly effects of tobacco products, the industry has found ways to adapt and thrive. They have succeeded in attracting enough new smokers to support industry growth despite losing eight million of their consumers annually to tobacco-related deaths. The sphere of influence of multi-billion dollar tobacco companies extends to the fields of scientific research, politics, law, education, and the media.

The WFPHA Tobacco Control Working Group has published a casebook entitled Big Tobacco’s Dirty Tricks: A Casebook of Seven Key Tactics Used by the Tobacco Industry which contains seven articles discussing key tactics used by tobacco corporations to improve their brand, hinder their opponents, and undermine tobacco control measures globally. The cases provide insights into the industry’s methods as they trick, manipulate, bribe, and threaten in the eternal quest for profit. Each article outlines a particular tactic, demonstrates examples where it has occurred, and offers recommendations for how individuals, professionals, organizations and governments can recognize and counteract them.

To evaluate readers’ feedback on the articles and investigate attitudes toward the tobacco industry tactics, a brief survey is provided. The quick anonymous survey can be accessed with the link below.

The more informed our society is about the tactics used by Big Tobacco, the better chance we have of effectively imposing tobacco control measures, reducing consumption globally and preventing tobacco-related illness and death.

Primary Dental Care During COVID-19: Global Guidance for Safe Oral Health Services

Oral health is an integral part of primary care. While oral diseases pose a major health and financial burden globally, oral health is widely neglected and considered optional or specialty care. Recognizing the global public health importance of major oral disease, the World Health Organization’s governing body adopted resolution WHA74.5 on Oral Health in 2021, affirming that oral health is an integral part of the health and healthcare system.

The COVID-19 pandemic has infected almost 400 million people worldwide and caused approximately 6 million deaths, fundamentally changing daily life and healthcare delivery. Oral health practitioners are among the professionals most at risk of infection due to exposure to airborne droplets and aerosols generated during dental procedures.

In response to inconsistent dental practice guidelines during the pandemic, the World Federation of Public Health Associations (WFPHA) Oral Health Working Group recognized the need for clear global guidance on the delivery of dental care during pandemics and future airborne disease outbreaks. A group of 24 public health–focused dental professionals from 13 countries collaborated to publish a resolution titled “Urgent, Essential and Primary Dental Care during COVID-19 and Future Airborne Pandemics.”

The resolution outlines core elements for the safe delivery of dental care during pandemics and proposes a working definition of urgent, essential, and primary dental care during COVID-19. It was accepted and approved by the WFPHA General Council in May 2022.

The WFPHA Oral Health Working Group calls for coordinated oral health action during pandemics to protect oral and overall health for all. The following recommendations outline how dental services can be safely maintained.

Strategic Planning and Clear Communication in Dental Care

All oral health programs should establish clear plans and communication strategies to screen for or identify confirmed cases and potential exposures, in line with national and regional public health guidelines.

Oral health professionals should also be recognized as an essential part of the broader public health workforce. This includes supporting public health initiatives and maintaining preparedness during pandemics and other public health emergencies.

PPE and Facility Measures to Reduce Airborne Transmission

Personal protective equipment (PPE) and facility design play a critical role in infection prevention during pandemics.

All healthcare facility personnel should wear well-fitting surgical masks that cover the mouth and nose to reduce the spread of respiratory droplets. Dental practitioners and care staff should use face masks or respirators approved by national guidelines.

These protective measures help reduce transmission risks while maintaining safe dental services.

Urgent Dental Care During COVID-19

Urgent dental care refers to medically necessary treatment that addresses:

• Acute oral infections
• Severe pain that cannot be controlled with analgesia
• Dental or orofacial trauma

Urgent care and associated diagnostic examinations should be provided for all patients.

Aerosol-generating procedures (AGPs) should be avoided or minimized whenever possible. Instead, atraumatic restorative treatments (ART) using hand instruments should be prioritized to reduce aerosol production while ensuring necessary care.

Essential Dental Care and Preventive Treatments

In 2021, the World Health Organization defined essential dental care as the use of:

• Fluoride toothpaste
• Glass ionomer cement
• Silver diamine fluoride

These materials allow preventive and restorative care with minimal or no aerosol generation. Treatments such as ART using glass ionomer cement and the use of silver diamine fluoride are also recognized in basic dental care packages by the FDI World Dental Federation.

Essential dental care, including fluoride application, should be provided for all patients, including those with confirmed infection, if the treatment falls under urgent care.

What Primary Dental Care Includes During a Pandemic

Primary dental care during COVID-19 includes a wide range of routine dental services, such as:

• Routine dental examinations
• Professional cleaning
• Radiographs
• Permanent restorations
• Periodontal treatment
• Endodontic treatment

These services are provided in addition to urgent and essential dental care.

Providing primary dental care with minimal risk during pandemics is recommended. However, for patients with COVID-19 or other highly infectious airborne diseases, only urgent and essential dental care should be delivered on an emergency basis.

When aerosol-generating procedures are necessary for low-risk patients, mitigation strategies should be used, including:

• Four-handed dentistry
• High-volume evacuation suction
• Isolation devices to reduce droplets and aerosols

Providers may also consider oral antiseptic rinses based on scientific evidence.

Protecting Oral Health in Hospitals and Long-Term Care Facilities

Hospitalized patients and individuals living in long-term care facilities are particularly vulnerable to oral health deterioration during pandemics.

Daily oral hygiene practices should be maintained, with assistance from nurses or caregivers when necessary. Consistent oral care helps reduce infection risks and supports overall health outcomes for these populations.

Oral Health Education for Mothers, Children, and Caregivers

Oral health should be integrated into primary and prenatal care for mothers, children, and individuals with special needs.

Preventive strategies should emphasize:

• Dental caries prevention
• Proper home oral hygiene practices
• Low-cariogenic diets

Education for mothers is particularly important because it helps establish lifelong healthy habits and dietary practices for children.

Oral health education should also be provided to caregivers of people with disabilities to support consistent oral hygiene and preventive care.

Integrating Dental Care into the Broader Health System

Oral health services should continue even during global health crises. Dental care must be recognized as a fundamental component of primary care and integrated into broader health systems, including:

• Primary health care
• Perinatal health care
• Long-term care facilities
• Schools
• Nutrition programs

Ensuring access to oral health services strengthens both individual health outcomes and public health resilience during pandemics.

A Call for Global Collaboration on Oral Health

The WFPHA Oral Health Working Group invites collaboration with dental and non-dental health organizations to advance these goals and improve oral health globally.

For collaboration inquiries, please contact the former Chair of the Oral Health Working Group, Dr. Hyewon Lee, at hyewon@idasociety.org

By Hyewon Lee & the WFPHA Oral Health Working Group Members