In April 2019, the Italian NGO Cittadinanzattiva, through its international branch Active Citizenship Network (ACN) launched, during the European immunization week, a new project called “European Active Citizens for Vaccination”. The aim was to improve the awareness on the importance of vaccination across Europe: the scientific evidence is clear; vaccination is an essential public health tool and helps to guarantee our fundamental rights as a European citizen. ACN realized a social media communication campaign supporting and spreading awareness on the topic of life-long vaccination; videos were made in all the national languages of the involved countries (Italy, Hungary, Poland, Ireland and Spain) and then produced, shared and customized for each country. Moreover, an informative leaflet in a different language has been produced.
Civic consultations on the National Immunization Plan in the countries involved were held in: Poland, Hungary and Spain. This article describes the main results of the focus group held in Poland on the topic of vaccination and its related policies. The full report has been published in the Report entitled “European Active Citizens for Vaccination: focus on -Poland (2019- 2020)” edited by Cittadinanzattiva APS                        (all rights reserved).

Life-long vaccination; Immunization; Vaccination policy; Civic activism; Poland

Quaggia D, Votta M, Decarolis G, Grzesiak I, Rzucid?o-Zaj?c P (2020) Addressing the Life-Course Approach in Vaccination Policy across Europe: The Case History of Poland. Ann Vaccines Immunization 5(1): 1018.

ACN: Active Citizenship Network.

Most vaccination programmes focus on discrete life stages such as childhood, but evidence supports a life-course approach, meaning vaccination given through all phases of life.

The life-course approach to immunization recognizes the role of immunization as a strategy to prevent disease and maximize health over one’s entire life, regardless of an individual’s age. A life-course approach requires that immunization schedules and access to vaccination respond to an individual’s stage in life.

A life-course approach has been advocated by the World Health Organization (WHO) as a model of healthcare provision that would benefit both individuals and healthcare systems. It involves looking at health as a continuum through life: a dynamic and interconnected process, as opposed to rigid life stages. It moves away from traditional approaches, where one develops and delivers vaccines in response to immediate threats for discrete age groups. Instead, investments in vaccination strategies should be based on their potential to strengthen individuals’ ability to maintain good health over the course of their lives, and their impact on the prevention of other pathogens and comorbidities over time [1].

Cittadinanzattiva-Active Citizenship Network is deeply committed to contribute to raise awareness about the importance of vaccination in Italy and across Europe [2]: immunization is vital to prevent diseases and protect life. Our commitment has been appreciated by the European Center for Disease Prevention and Control (ECDC), the Agency of the European Union aimed at strengthening Europe’s defense against infectious diseases that, in 2016, has decided to officially include Cittadinanzattiva in the ECDC Technical Advisory Group for Increasing Vaccine Coverage. As members of this Advisory Group we feel a great responsibility to commit ourselves to this issue: we believe that a widespread vaccination culture is necessary, particularly to overcome the idea that we only get vaccinated when we are young and, instead, to shift to a common knowledge linked to a life-course vaccination approach which prevents a series of diseases even during adulthood.

In April 2019, ACN launched, during the European immunization week, a new project called “European Active Citizens for Vaccination” [3]. The aim was to improve the awareness on the importance of vaccination across Europe: the scientific evidence is clear; vaccination is an essential public health tool and helps to guarantee our fundamental rights as a European citizen.

During the implementation of the above mentioned project, ACN, realized two main actions: Firstly, a social media communication campaign throughout a Video that supports and spreads this core message: “Together, as active and aware citizens, we can protect ourselves, become the champion of your future!”, sending a unified, clear and strong message on the importance of vaccination directly from citizens to citizens. Videos were made in all the national languages of the involved countries (Italy, Hungary, Poland, Ireland and Spain) and then produced, shared and customized for each country. Moreover, an informative leaflet in a different language has been produced [4] (Figure 1).

Figure 1: Images from the polish video realized for the project

Secondly, a civic evaluation of the national immunization plans throughout the realization of three focus groups (in Spain, Hungary and Poland) on the specific theme of the life-course immunization approach: thanks to the work and cooperation of our constituency of national citizens’ organizations, we brought together around the table leaders of civic and patients association, healthcare professionals, policymakers and other stakeholders involved in each country in the administration of vaccines. The aims were to find together proposals and gather impressions, suggestions, and advices and provide institutional and health care stakeholders with: the strengths/weaknesses of national policies and plans about their approach to life-course immunization approach; the common elements or specificities that affect a greater or lower success of this approach. The first countries involved were Hungary, Poland, Spain with the respective associations: Vedem Civilian for Vaccination [5], Institute of Patients’ Rights and Health Education [6], Foro Español de Pacientes [7] and the Asociación Española contra la Meningitis [8] (Figure 2).

Figure 2: Image from the polish leaflet realized

For the success of the project, ACN established and managed a scientific committee called “Steering Committee”, composed of professionals, experts, and representatives of civic and patients’ associations to define the messages of the social media communication campaign and the main contents of the civic evaluation. The meeting of the Steering Committee of the project was realized in Brussels at the beginning of July 2019 Table 1.

Table 1: Steering Committee.

ACN worked on the creation of a questionnaire (with both closed and open questions) that was handed out to each participant in order to be used as a base of discussion during the focus group on the specific theme of life-course immunization approach in the national immunization plan; to make an exchange of information on how it is organized in that country compared with other countries: to find together proposals, suggestions, advice on that aspect.

Different people were involved, such as: leaders of civic and patient are associations, healthcare professionals, policymakers and other stakeholders implicated in the administration of vaccines. Each focus group was led by a moderator and lasted between one and a half to three hours, depending on the number of participants. The discussions were recorded in order to be better summarized. Each participant was given two sheets with the written questions that the moderator had to ask during the discussion so that they could always see them and writes down their answers in a completely anonymous way. During the debate they were given post-its of different colours to indicate their answer to the questions in a poster in the middle of the table, from which the moderator got inspiration to guide the next discussion.

The questions were divided into two blocks, A and B: in part A, the more general, all participants were asked to answer how they evaluated the awareness and support for life- course immunization approach in their Country, among different subjects, and how much vaccination plan in their country is designed to help maximize the individuals’ ability to protect themselves from infection over the course of their lives.

In part B, the questions regarded five key policy elements that characterize effective life- course immunization strategies (according to the IFPMA Report [9]): Comprehensive immunization program that supports vaccine availability, Public demand for immunization, Engaged healthcare professionals, Multidisciplinary and cross-sectoral coordination and Robust data informing policies and programs Figure 3.

Figure 3: A glimpse of the Polish Focus group at work

The Polish Focus group took place in Warsaw, in the National Aids Centre, on 12th December 2019. The meeting was organized by the Institute of Patients’ Rights and Health Education.

The participants were:

Participants to the Civic Consultation

The elements emerged from the debate showed that the vaccination system in Poland is generally evaluated as good, but not very good.

The advantages of the Polish system mentioned in the discussion, among others, were:

• The State budget covering expenses for vaccinations making them accessible independently of the patient’s financial situation;
• Mandatory vaccination for children & immunization card (increasingly required in schools) which is stored at the general practitioner’s office and used to monitor progress through the immunization schedule;
• Activities of some of the local governments, including information campaigns and financing of vaccinations that are not refunded (e.g. for children and seniors); the large Figure 4.

Figure 4: Image from IFPMA report

• and growing role of non-governmental organizations in promoting vaccination. The implemented changes have been:
• The activation of the Chief Sanitary Inspector, who more widely encourages vaccination and takes actions against anti-vaccination movements;
• Planning changes in the vaccination calendar to increase vaccine availability in other areas such as HPV;
• considering that if public funds are not enough to cover complete costs for vaccination a partial reimbursement could still be offered;
• Decisions of some local governments to give preference to vaccinated children in the recruitments to kindergartens.
• On the other hand, the challenges highlighted were:
• Vaccinations in Poland are mainly associated with the childhood period, there is no comprehensive life-long vaccinations information or programmes.
• Insufficient attention to vaccines for adults, including immunization against influenza, tetanus, tuberculosis, etc. these are not given the same focus as vaccination of children, even though, especially in seniors, infectious diseases can be life-threatening;
• too few vaccines are reimbursed, which means that, for example, recommended but not covered by the Statevaccines against rotavirus, chickenpox or HPV are only available for selected individuals and thus there is no possibility of achieving population immunity;
• defining some vaccines as recommended (meaning not reimbursed) means that patients and their relatives often misinterpret them as less needed, and therefore to be omitted;
• the lack of a comprehensive understanding by public authorities on health care expenditure and indirect costs means significant amounts spent on treating diseases that can be vaccinated against what would generate savings within few years;
• Not easy access to vaccination due to organization issues: in many cases, after qualification for vaccination, you must go to the pharmacy to get the vaccine, and then again go back to the clinic. These are difficulties that discourage vaccinations;
• Waiting lists for vaccinations appointments can be quite long;
• Lack of update knowledge on vaccinations among physicians and representatives of other medical professions. It happens that they discourage vaccinations, or they are not sure who are the addressees of vaccines and when etc.;
• Public media too little involved in the promotion of vaccinations;
• Vaccination of medical staff, among others against measles: currently, the regulations and interpretations regarding vaccinations and who should pay for them are unclear;
• availability of vaccines, since many of the recommended vaccines are not mandatory, the Polish market is not a priority for producers and vaccines production is not as fast as the production of chemical substances. In the case of vaccines against HPV, rotavirus or even measles (for adults, because for children they are guaranteed) are not easy to find.

During the debate some other considerations emerged such as the importance of health education from an early age through a lifetime.

Another important point regarded designing and implementing pharmaceutical care, which would include performing at least some of the vaccinations at the pharmacy, without the necessity to visit a doctor: access to pharmacies is much simpler. This direction is being developed in other countries, in Poland it has been discussed, but the ministerial project on pharmaceutical care does not contain this element. It was included, though, in the National Drug Policy for the years 2018-2022.

A wider involvement, and financial incentives, to, first of all, nurses, that now can perform vaccinations, but cannot qualify or prescribe them and other different heath care professionals, such as midwives, would make access to vaccines and information much easier, also lightening the heavy workload, and the lack, of doctors.

In addition, considerations and advices about funds and economic incentives such as:

• Adopting an adequate resolution of the Council of Ministers, the National Program for Preventing Infectious Diseases, which would ensure a stable funding and expand the scope of free vaccinations, were given. In fact, according to the recommendations of the European Commission, mechanisms should be introduced to ensure that the expenditure on vaccines amounts at least to 0.5% of public expenditure on health care because vaccinations are an investment.
• Changes in vaccines funding have been proposed: now vaccinations are carried out as part of primary healthcare. Primary healthcare physicians are remunerated with a capitalization rate, a specific amount for the entire year, independently of the number of services performed or the cost of medical exams, one action that could increase the vaccination rate, especially for adults, is to separate vaccinations funding from the service rendered.
• Moreover, suggestions for incentives for employers to invest in employees who get vaccinated and additionally, who vaccinate family members as well (i.e. cost deductions) were discussed.
• Lower health premium for people who take care of their health, including those who get vaccinated.
• The creation of a special fund, that has been discussed and announced a long time ago, would be used to finance assistance for people who had a vaccine adverse reaction (patients would benefit from this, and furthermore offering help and admitting that vaccine adverse reactions, though very rarely, but do occur could increase confidence in vaccines, combating conspiracy theories about them).

Finally, other options discussed were about development of vaccines that do not require injection (now available against rotaviruses and for children against influenza), as less anxious for patients due to less invasiveness and therefore potentially feasible, for example, by the patients themselves. In conclusion a wide campaign on vaccinations that involves celebrities, using social media was suggested.

The experience and the main outputs of the project suggest how relevant it is, in the field of vaccination, to develop a policy on lifelong vaccinations rather than only focus on child vaccination only because it is mandatory. The initiative testifies the positive role played by health professionals as well as private and public actors involved in the policymaking. Despite their tendency to criticize the failures and weaknesses existing within the system, they have demonstrated their contribution by giving plenty of advice and suggestions on how to improve the actual vaccination system in Poland.

Moreover, the project shows that the role of these focus groups is that of identifying not only emerging problems but also possible solutions to denounce what doesn’t work properly and to appreciate what proves to be successful. As for us, we have been committed to this topic and we will work hard to reinforce vaccination policies all around Europe.

This initiative, in Poland, was possible thanks to Fundacja Instytut Praw Pacjenta i Edukacji Zdrowotnej (IPPEZ) / Institute of Patients’ Rights and Health Education [10].

1. “Implementing a Life-Course Approach to Immunization” IFPMA.

2. http://www.activecitizenship.net/patients-rights/projects/278-theengagement-ofcittadinanzattiva.

3. on-vaccination.html

4. http://www.activecitizenship.net/patients-rights/projects/294- european-active-citizens-forvaccination

5. 2019.html

6. All the materials are available on www.activecitizenship.net/patientsrights/projects/294-

7. european-active-citizens-for-vaccination-2019.html

8. https://vedem.hu/

9. http://ippez.pl/

10. https://forodepacientes.org/

11. https://www.contralameningitis.org/la-asociacion/

12. https://www.ifpma.org/wpcontent/uploads/2019/08/IFPMA_HPP_ Life_Course_Immunization_Full_Report.pdf

13. http://ippez.pl/