Good practices and challenges in addressing poliomyelitis and measles in the European Union
European Journal of Public Health
Good practices and challenges in addressing poliomyelitis and measles in the European Union
John Kinsman 1 3 4
Svenja Sto¨ ven 1 2 3
Fredrik Elgh 0 1 3
Pilar Murillo 1 2 3
Michael Sulzner 1 3 5
0 Department of Clinical Microbiology, Umea ̊ University , Umea ̊ , Sweden
1 Medicine, Umea ̊ University, Umea ̊ 90187, Sweden , Tel:
2 European CBRNE Centre, Umea ̊ University , Umea ̊ , Sweden
3 Present address: Department of Pharmacology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg , G o ̈teborg 40530 , Sweden
4 Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umea ̊ University , Umea ̊ , Sweden
5 Crisis Management and Preparedness in Health Unit, Public Health Directorate, Directorate-General for Health and Food Safety (DG SANTE), European Commission , Luxembourg , Luxembourg
Background: All European Union (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. However, there remain significant gaps between policy and practice in many countries. This article reports on an assessment conducted for the European Commission that aimed to support improvements in preparedness and response to poliomyelitis and measles in Europe. Methods: 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 (six each for poliomyelitis and measles). Twenty-six 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 with 22 of the interviewees and eight other experts. Results: Generic or disease-specific plans exist in the participating countries and cross-border communications during outbreaks were generally reported as satisfactory. However, surveillance systems are of uneven quality, and clinical expertise for the two diseases is limited by a lack of experience. Serious breaches of protocol have recently been reported from companies producing poliomyelitis vaccines, and vaccine coverage rates for both diseases were also sub-optimal. A set of suggested good practices to address these and other challenges is presented. Conclusions: Poliomyelitis and measles should be brought fully onto the policy agendas of all EU/EEA Member States, and adequate resources provided to address them. Each country must abide by the relevant commitments that they have already made. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
uropean Union (EU) Decision 1082/2013/EU (October 2013) on
Eserious 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.1 Among the diseases that have emerged
as being of particular importance within the context of EU Decision
1082 are poliomyelitis and measles.2 All EU and European Economic
Area (EEA) Member States have pledged to ensure political
commitment towards (i) sustaining the region’s poliomyelitis-free
status and (ii) eliminating measles, which constitute two of the six
goals of the WHO’s European Vaccine Action Plan.3
There are, however, still areas that require attention to achieve the
European goals related to these two vaccine-preventable diseases.
With regard to poliomyelitis, in spite of the considerable overall
historical success of the Global Poliomyelitis Eradication Initiative,
ongoing transmission of poliomyelitis is currently considered to be a
Public Health Emergency of International Concern,4 with particular
concerns raised in 2016 about Pakistan, Afghanistan and Nigeria.5
Europe has been poliomyelitis-free since 20026 but eight EU/EEA
countries were designated in 2015 by the WHO Regional
Certification Commission for Poliomyelitis Eradication as being at
either ‘intermediate’ or ‘high’ risk of importation and subsequent
transmission of poliomyelitis;7 and 11 EU/EEA countries were
designated as such in 2016.8 The approach to sustaining the
region’s poliomyelitis-free status is defined by the Poliomyelitis
Eradication and Endgame Strategic Plan, which, within Europe,
requires a particular focus on poliomyelitis containment alongside
continuous high vaccination coverage.9
With regard to measles, WHO calls for at least 95% coverage with
both the first and second routine doses of measles vaccine (or
measles–rubella-containing vaccine, as appropriate) in each district
and nationally, for every country in the world.10 The European
Centre for Disease Prevention and Control (ECDC) reported that,
in 2014, 16 of the 31 EU/EEA countries were above the coverage
target of 95% for the first dose and just six countries were above this
target for the second dose, indicating a significant gap that needs to
be filled.11 In addition, 21% of the measles cases in 2015 for whom
age was known in the EU/EEA were aged 15 years and older,12
suggesting that catch-up campaigns with teenagers and adults
are needed to close immunization gaps in older populations,
alongside improvements in routine vaccination coverage for
This article reports on an assessment conducted for the European
Commission 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.
Two complementary types of data were collected for this multi-level,
qualitative study: documentation and interviews. Material for the
documentary review was derived from government, EU and WHO
sources, supplemented as appropriate by articles in the
peerreviewed literature. Since our focus was specifically on the policy
and technical level authorities who are providing the services as
opposed to the target populations, interviews were sought with
professionals working in (i) International agencies such as WHO
(Geneva and Copenhagen), the International Office for Migration
and United Nations Children’s Fund (UNICEF); (ii) The European
Commission and ECDC and (iii) EU/EEA Member States. For
poliomyelitis, the Member States comprised the eight countries with an
‘intermediate’ or ‘high’-risk score for importation and subsequent
transmission of poliomyelitis virus as described in the 2015 report of
the WHO Europe Regional Certification Committee;7 for measles,
they comprised the seven countries with an annual measles
notification rate, as reported by ECDC, of >5 per million population
between October 2014 and September 2015.11
From each participating country, we aimed to conduct interviews
with four people, two each from the health and relevant non-health
sectors. Respondent categories included state epidemiologists,
national vaccine managers, surveillance coordinators, health
officers in the Ministries of Education and the Interior, and health
journalists. Interviewees were identified either through the European
Commission, through professional acquaintance or by following up
names identified in the literature. In total, we conducted 26
interviews for poliomyelitis (10 from the international and EU
levels and 16 from six EU/EEA Member States) and 24 interviews
for measles (six from the international/EU levels and 18 from six EU
Member States). Note that some interviewees at the international
and EU levels answered questions about both poliomyelitis and
measles. See table 1.
The interviews were conducted between April and June 2016,
mostly over the phone, but, with some of the international level
respondents, face-to-face at their offices in Geneva and
Copenhagen. The questions were sent in advance to each interviewee
to give them the opportunity to consider and prepare their answers.
The focus was on actual experiences from preparedness and response
activities against poliomyelitis and measles; challenges encountered
during these activities, and the means by which these challenges were
addressed. Interviewees also received an information sheet about the
study which stressed that their participation was voluntary, that they
would be taking part purely on the basis of their professional
experience and knowledge, and that confidentiality and anonymity
would be guaranteed. See the Supplementary data. All the interviews
were conducted by one senior expert, with extensive notes of the
conversations taken by another team member. These notes
constituted the data used in the analysis.
The data were subjected to thematic analysis, with the aim of
highlighting lessons learned as well as gaps and challenges. The
issues that emerged through this process were discussed and
further developed at a Consensus Workshop held in Luxembourg
in September 2016, with 22 of the interviewees in attendance
alongside eight other invited experts. The suggestions and points
made in this article, which has also been presented in expanded
form as a report for the European Commission, are the outcome
of the interviews and subsequent workshop discussions.
outbreak is very low: they were confident that the system would
work and that funds and vaccines would be available as needed.
Although WHO recommends that countries have a
poliomyelitisspecific plan, it was seen as one of several diseases, within a
European context, for which a generic plan would suffice. As long
as the plan is flexible, and as long as roles and responsibilities for the
different actors and sectors involved are sketched out for activities
related to mass vaccination, surveillance and containment, a generic
plan for vaccine-preventable diseases was seen as sufficient and more
cost-effective than a poliomyelitis-specific plan.
Acute Flaccid Paralysis surveillance is recognized globally as a
mainstay of poliomyelitis surveillance,13 and while five of the six
participating countries have adopted it, there were questions about
its reliability. Most doctors in Europe never have seen a case of acute
poliomyelitis, so ongoing training is needed to maintain the levels of
knowledge required to make a correct diagnosis. Environmental
surveillance13 was seen, for Europe, as a more sensitive and
costeffective method capable of confirming the poliomyelitis-free status
of a country and of detecting circulating virus. However, we were
told that care needs to be taken to align sampling schemes with
population density and mobility.
A major focus for all countries should be on poliovirus
containment and on meeting the objectives of GAP III (the current version
of the Global Action Plan on poliomyelitis containment).14 All
countries have committed through Resolution 68.3 of the World
Health Assembly,15 GAP III itself14 and EU Directive 2000/54/EC16
to produce inventories of past and present storage sites for materials
that may potentially contain poliovirus, and to destroy material that
is not considered essential. We found, however, that several
countries did not appear to be fully committed to these vital
international agreements, and serious breaches of protocol have also
recently been reported from companies producing poliomyelitis
vaccines.4,17 It was suggested that a central authority in each of
these countries should be given legal power as well as sufficient
resources to supervise the inventory and to enforce containment
All European countries currently use inactivated poliomyelitis
vaccine (IPV) in their vaccination programmes, which is highly
effective against paralysis, but which does not prevent virus
multiplication inside the intestine, potentially thereby facilitating
continued circulation in the population. By contrast, oral
poliomyelitis vaccine (OPV) does induce strong intestinal immunity and it is
therefore used in outbreak situations; however, it is not as safe as
IPV9 and it is not legally permitted in some countries. It was not
clear from the interviews how emergency mass vaccination would be
facilitated in countries where the legal framework prevents the use of
OPV even in the event of an outbreak. We were advised that
countries should review their legal framework and their
arrangements for the implementation of mass vaccination so that
immunization with OPV would be permitted.
The primary issue of concern for poliomyelitis was to ensure high
levels of population immunity. 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 our respondents for their
governments to abide by all the agreements concerning both poliomyelitis
vaccination and containment which they have signed—including
Resolution 68.3 of the World Health Assembly,15 WHO’s
European Vaccine Action Plan,3 the Poliomyelitis Eradication
Endgame Strategic Plan9 and the Conclusions of the EU on the
role of vaccination for public health.18
No major problems were anticipated by the national level
interviewees in the event of a poliomyelitis event or outbreak in their
countries. Although individual cases may conceivably emerge due to
travel from endemic areas, it was felt that the chance of a sustained
By contrast with poliomyelitis, most of the participating countries
reported high levels of national level political will to eliminate
measles, as per WHO’s European Vaccine Action Plan (to which,
as indicated earlier, they are all signatories).3 However, national
commitment was not translated evenly into regional and local
implementation. Factors such as political, financial and operational
structures shaped regional responses, as evidenced by differences
in the incidence of measles in various regions of these countries.11
National and local measles plans exist in a majority of the
countries. These include strategic plans, as well as procedures for
vaccination campaigns, the provision of public information about
measles, and conducting outreach missions to at-risk communities
such as migrants and Roma people. 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. An additional, major
concern is that although plans exist for some countries, it is not
always possible to fully implement them due to financial and/or
Delays in response were observed at the start of some outbreaks
due to a combination of: delayed diagnosis, caused by low clinical
awareness of measles; inefficiencies in notification systems that are
paper-based rather than computer-based; and insufficient laboratory
capacity. These collectively allowed outbreaks to spread rapidly
before effective control measures were put in place. Key areas that
were highlighted as needing additional focus included (i) improving
knowledge about the disease and vaccination, both for the public
and for health workers; (ii) the development and institution of an
electronic notification system connected to all levels of the health
system, to which health workers are obliged to notify suspected
measles cases within 24 h; and (iii) standard operating procedures
for measles with regard to contact tracing, ring vaccination and
Although the administration of two measles vaccine doses is
universally required by national vaccination programmes, measles
vaccination is not mandatory in all the participating countries. Where
vaccinations are covered by health insurance, not everyone is
covered, so children may go unvaccinated because of parents’
financial constraints. Many adults are also not protected from
measles. 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 to provide vaccinations. We were informed that
policy makers need to prioritize the provision of adequate
incentives and infrastructural support to health workers to ensure
that measles vaccine coverage rates are optimized.
The 2008 economic crisis had a great impact on health systems in
many European countries, including on their capacity to implement
vaccination programmes and to support polio containment
activities. However, reductions in funding and staffing levels were
seen as due not only to the economic crisis but, in at least some
cases, also to a lack of meaningful political commitment to allocate
adequate financial resources to the public health system.
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 System19 and the Epidemic Intelligence Information
System20 provide easily utilized and effective means of
communicating with neighbouring Member States in the event of
an outbreak. It was suggested that mechanisms to complement the
International Health Regulations21 could be developed to enhance
and improve communications with neighbours who are not EU
Efforts to improve vaccine coverage rates should, we were
informed, focus both on the health system and on the community.
Practices that were proposed as having potential to improve vaccine
coverage rates included the following (note that these are not
presented in any order of perceived importance):
) Ensuring that vaccines and vaccination services are easily
accessible, such as through user-friendly, ‘one-stop shops’.
(2) Enacting legislation to ensure that vaccination is free of charge
to all, including asylum seekers, migrants, refugees, people who
are uninsured, and potentially high-risk employees (health
workers, migration, police, border control, etc.).
(3) Using trained health mediators to work with Roma and other
) Inclusion of 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 that they have been informed about vaccination
recommendations for their children.
) Reviewing children’s vaccination status at school on a regular
basis, as a means of identifying at-risk children and encouraging
their parents to have them vaccinated.
) Enacting legislation to prohibit unvaccinated children from
attending school during a measles outbreak.
) Use of smartphone apps that send parents reminders about their
) Supporting health workers, including through training and
resources, to act as effective risk communicators and vaccination
advocates at community level.
) Guaranteeing that health workers have legal protection in the
event that a patient suffers from adverse effects following
) Making systematic efforts to understand the reasons for low
vaccination uptake rates through WHO-EURO’s Tailoring
Immunization Programmes,22 and acting on the findings.
) Using vaccination coverage surveys to identify potential
geographical and demographic immunity gaps, thereby providing a
strong evidence base for where catch-up vaccination
programmes may be needed.
) Evaluating vaccination campaigns as a means of maximizing
effectiveness and cost-effectiveness in future.
) Significantly improving the standard of many official public
health websites, and ensuring that they are kept up to date.
Criteria for quality public health websites are available at
WHO’s Vaccine Safety Net project.23
) Making serious efforts to bring these high quality official public
health websites to the top of internet search lists, as a counter to
) 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 ECDC [‘Let’s talk about
hesitancy’24 and ‘Let’s talk about protection’25] and from
WHOEURO [‘How to respond to concerns about vaccination’26] as
recognized means of countering vaccine hesitancy.
Political and public health authorities
) Ensuring that official spokespeople during outbreaks are
mediatrained and trusted by the public.
) Targeting political leaders with comprehensive and correct
information about vaccination so that they do not disseminate
messages that undermine vaccination campaigns.
The methodology adopted for this study into good practices and
challenges faced in addressing poliomyelitis and measles in the
EU/EEA has facilitated an unusually broad analysis of current
thinking about these two vaccine-preventable diseases. The
findings presented in this article can be seen as reflecting the
majority of the core issues that technical experts face across
Europe, as well as a range of good practices that they themselves
have identified as means of addressing the various challenges
inherent in their work.
In general terms, we found that poliomyelitis was not prioritized
by national level decision makers as much as measles, perhaps
because Europe has now been polio-free for 15 years, and it simply
is not seen as a major problem. In spite of this difference, however,
unacceptable immunity gaps remain the norm for both measles and
poliomyelitis in many populations.7,11 Further, lax safety standards
by poliomyelitis vaccine producers have recently led to dangerous
releases of live poliovirus.4,17 Together, these points suggest that in
spite of the high-level agreements made by all EU/EEA Member
States to prioritize poliomyelitis and measles control,1,3,9,14–16,18
there remains a significant gap between vaccination and
containment policy and practice in settings across Europe.
New legislation at European level to bring about effective
poliomyelitis containment and to close existing immunity gaps in the
population for both measles and poliomyelitis was not seen by our
respondents as either necessary or viable. Rather, 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
Supplementary data are available at EURPUB online.
The authors gratefully acknowledge the input provided by all the
experts who took part in this study, both through interview and
through participation in the Luxembourg Consensus Workshop.
They also thank John Angre´n, Daniel Stro¨mberg, Lia Olsson and
Nada Amroussia for their assistance during the interviews and in
This work was funded through a contract signed between the
Consumers, Health, Agriculture and Food Executive Agency
(Chafea), under powers delegated by the European Commission
and the Case studies, Exercises, Learning, Surveys and Training
across Europe (CELESTE) Consortium. The CELESTE Consortium
comprises Public Health England, the Swedish Defence Research
Agency, Istituto Superiore di Sanita and Umea˚ University. Specific
Contract Number 2015 72 02; Framework Contract Number EAHC/
This article was produced under the Health Programme (2014–
2020) in the frame of a specific contract with the Consumer,
Health, Agriculture and Food Executive Agency (Chafea) acting on
the mandate from the European Commission. The content of this
report represents the views of the contractor and is its sole
responsibility; it can in no way be taken to reflect the views of the European
Commission and/or Chafea or any other body of the European
Union. The European Commission and/or Chafea do not
guarantee the accuracy of the data included in this report, nor do
they accept responsibility for any use made by third parties thereof.
Conflicts of interest: None declared.
There remains a significant gap between vaccination and
containment policy and practice in settings across Europe.
Reductions in funding and staffing levels for the health
systems in some countries were due not only to the 2008
economic crisis and subsequent austerity measures, but, in
at least some cases, also to a lack of meaningful political
commitment to allocate adequate financial resources to the
public health system.
EU/EEA Member States should abide by the various
commitments that they have already made for measles and
poliomyelitis vaccination and for poliomyelitis containment.
Mechanisms need to be developed to ensure that national
vaccination policies and programmes are fully implemented
at regional and local levels.
Cross-border communication regarding health threats
between EU Member States was reported to be good;
systems to complement the International Health Regulations
could be developed to enhance and improve communications
with neighbours who are not EU Member States.
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