15
Examination of witness
Dr Roberta Pastore.
Q173 The Chair: Welcome to today’s meeting. This is the 15th oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. Many thanks to Dr Roberta Pastore for attending as our witness today.
The session is open to the public. It is broadcast live and will subsequently be accessible via the parliamentary website. A verbatim transcript will be taken of the evidence and published on the parliamentary website. A few days after the session, our witness will be sent a copy of the transcript to check it for accuracy. It would be very helpful if you could advise us of any correction as quickly as possible, and then we can put it on the internet. If, after this evidence session, you wish to clarify or amplify any points you made during your evidence or have any additional points to make, you are very welcome to submit supplementary written evidence to us.
Let us start with the first question. What are the international trends in childhood vaccination uptake in recent years and what disparities exist, both in countries comparable to England and globally? How might these trends develop into the future?
Dr Roberta Pastore: Thank you for giving me the opportunity to participate in this session. I am a medical doctor by training, and I work in the WHO—World Health Organization—regional office for Europe. I work in the immunisation unit as a team lead for immunisation programme strengthening.
To reply to your question, I will refer mostly to the trends in the European region, which I am more familiar with, but the trends are similar globally. As a starting point to monitor the trends, we take the 2019 year, because it is the year before the Covid pandemic that brought a lot of disruption in the immunisation programmes worldwide. In most countries there was evidence of backsliding in immunisation coverage for several vaccines.
In the European region we can see that the recovery from this backsliding that was observed in 2020 and 2021 has not happened homogeneously across the countries in the region. The region as a whole includes 53 countries. We have registered a full recovery in almost a third of the countries. If we take only the high-income countries, we can see similar trends to the middle-income countries, but less acute. I will focus on the high-income countries now, because they are more comparable to England and probably more interesting for the scope of this session.
I will consult some data. Overall, if we compare the coverage level in 2019 with the coverage level in 2024, we can see that 22 countries over 36 high-income countries in the region had a decline in coverage. If we compare the most recent trend between 2023 and 2024, we can see that there was a slight further decline in 15 of these 36 high-income countries. This is using, as a tracer of vaccination coverage, the coverage for the third dose of diphtheria, tetanus and pertussis containing vaccine, which is used globally as a tracer of vaccination.
This trend is not the same if we look at vaccines such as HPV, so the vaccine against human papillomavirus. For this type of vaccine that is usually administered during adolescence, we see a different trend, with a number of countries that registered an increase in vaccination. This is probably because the starting point for the coverage of this vaccine was much lower than for traditional childhood vaccines. I will stop here, but please let me know if you want more details.
The Chair: Given what you told us about the recovery, can you predict what the trend will continue to be? Are there countries that have shown good recovery and are likely to carry on improving? Are there countries where coverage has not been so good and recovery from the pandemic has not been so good, but perhaps they are doing things that might turn that around?
Dr Roberta Pastore: It is difficult to give a yes or no answer and to predict what will happen in the future. We have preliminary data for 2025 that confirm a similar pattern as for 2024, so some recovery still has to be made. I mentioned countries that had a decrease in coverage, but there were also a number of countries that actually had an increase in coverage. This depends on several factors.
It is difficult to predict in which direction we are going, because there is a lot of variability across the countries. Last year, we did a survey across all the countries in the region to understand which actions had been put in place to counteract this declining trend and especially how to accelerate the recovery from the backsliding observed during the pandemic. Fifty-one countries that responded to the survey confirmed that they proactively implemented targeted activities for two reasons. First was to increase timely coverage, so the coverage of the target population that is eligible for vaccination every single year, but it was also to recover the vaccination for children, adolescents or the target population who had missed vaccination in the previous years.
One challenge that we have found in most of the countries in fully recovering is the dual effort that has to be made. This is the effort to catch up those who were missed during the Covid pandemic years—it is a lot of people, so it is a lot of workload—and to maintain a performance that has been declining due to several factors.
Common activities that are being implemented across the region include trying to strengthen routine vaccination through reallocating sufficient resources to reach the hard-to-reach groups, focusing on an approach that is as equitable as possible and understanding with more evidence, and not a judgment-based opinion, what the barriers and enablers to vaccination are. We have seen an increase in number of countries that are conducting what we call demand studies to understand what the underlying reasons are for having a part of the population that is under-immunised.
In summary, I cannot predict which direction we are going in, but I can confirm that there is a significant number of countries that are proactively implementing activities to fill the immunity gaps historically accumulated and try to improve performance.
Q174 Baroness Ritchie of Downpatrick: You are very welcome, Dr Pastore. You have already referred to a decline in vaccinations globally. We know from Gavi, the global alliance, that 1.2 billion children have been prevented from getting disease due to the vaccination programme, although there have been more than 18 million deaths. In view of that, what do you see as the key drivers of international trends in childhood vaccination rates? To what extent do the same factors drive vaccination coverage in different countries?
Dr Roberta Pastore: It is very difficult to compare countries of different income levels. As you mentioned, Gavi focuses on supporting immunisation programmes in low-income or lower middle-income countries. In those countries, the barriers to achieving high coverage are mostly related to more fragile health systems overall, a health workforce that is much less developed in number and, to some extent, in capacity compared to countries with a higher income level.
Also, for example, Gavi is very active in the African region, where we also see a demographic increase, so the cohorts of children who should be vaccinated every year is increasing. There is this extra effort to reach more and more children every year in countries that have a challenging context overall.
A lot of progress has been made in the immunisation programme, so I do not want to give a very negative picture. There has been a lot of progress in terms of introducing a higher number of life-saving vaccines in the national immunisation programme. There is also a lot of nice evidence from capacity to respond to vaccine-preventable disease outbreaks using vaccination as one of the strategies to respond, or the key strategy to respond, especially in cases of outbreaks of polio and measles.
A lot of progress has been made, but there are still some structural challenges in lower-income countries that affect fast progress. There are demographic challenges and competing priorities when it comes to allocating sufficient resources. It is a complex and multifaceted topic, so it is difficult to give just one answer.
Beyond countries that are the focus of Gavi, there are also challenges related to the fact that cost of health, so supporting health interventions overall, is increasing over time. Allocating sufficient resources for vaccination beyond just buying the vaccine, so enabling activities that can be targeted, tailored and effective, becomes challenging. There is less resource available to support the efforts that are needed.
Q175 Baroness Andrews: I may have missed this, but you said that it is very difficult to compare countries. At the bottom of your list you have the fact that 55% of unvaccinated children come from just 10 countries, which I presume are the African countries and the countries where we have high levels of conflict. It is difficult to read across different cultures and situations.
I am not sure where the UK sits, and you may not want to make a judgment because it is so difficult. Could you give us a rough idea of how the UK is performing in relation to those countries that have, like us, mixed economies and mixed demographies, where we have high levels of inequality and great extremes of wealth and poverty? Is it possible to say where we fit in terms of performance?
Dr Roberta Pastore: For sure, I can comment on that. It depends on which vaccine we take as a reference. Maybe I can take as a reference DTP3, so the diphtheria, tetanus, pertussis-containing vaccine third dose. It has a coverage that is quite high, so we use it as a global target for the immunisation agenda 2030, which is the leading strategy globally. The coverage target is 90%.
Based on the data reported to the WHO, in 2024 the UK reported 92% coverage, so it is above the target that is set at the global level. In the WHO European region, because there are countries that have been historically better performing compared to the global average, we have set 95% coverage as a target, which is still considered achievable and is the target set in the European immunisation agenda 2030. The UK is currently performing a little lower than this established target.
In terms of ranking within the high-income countries in the European region, the UK is classified in the mid-tier for most of the vaccines that we use to trace coverage for vaccination across the life course. To benchmark it, instead of comparing across countries, it is better to compare to what targets are set for all the countries to achieve. The targets are set with the objective to achieve a level of coverage that can allow the control and, in some cases, elimination of vaccine-preventable diseases.
Baroness Andrews: That is very helpful. Thank you.
Q176 Baroness Hodgson of Abinger: I wondered whether you had a table that you were able to send us showing—I agree with you—the vaccination schedules and timing of other comparable countries, say in Europe, so that we could compare them to what we are doing in the UK, please.
Dr Roberta Pastore: For sure, I can send you tables, but I can also send you the link to the WHO website. We have what we call the immunisation data portal, where we publish the data reported globally to WHO by WHO member states. We use an annual data collection mechanism to collect a number of pieces of information about the vaccination schedule and vaccination coverage, as well as indicators related to the maturity and development of the immunisation programme and data on the vaccine-preventable disease epidemiology.
All this is publicly available, so I would be happy to share the link. It is called immunizationdata.who.int, for those who are interested. There are only a few pieces of information reported to the WHO that we do not disclose because they are considered more sensitive or of lesser quality. There is a wealth of information that is publicly available.
The Chair: If you could refer us to that, that would be very helpful.
Baroness Browning: Following on from that point, the figures that Dr Pastore has been quoting are UK figures, and our committee is very much an England committee. It would be good to know how the UK figures break down between England, Wales, Scotland and Northern Ireland.
The Chair: Yes, indeed. We are in fact waiting for a response from the devolved Administrations about the differences within the United Kingdom. Thank you for reminding us of that.
Q177 Baroness Cass: It is very good to meet you online. You have spoken already about the issue of providing equitable service, and we have spoken quite a lot about the issue of variation and hard-to-reach populations compared to trust and hesitancy. I wondered how that variability in other countries compares to England. Are there any examples of good practice that the UK Government could learn from in dealing with those problems of access and equity?
Dr Roberta Pastore: Yes, there are many examples. As I mentioned, last year was the first year that the WHO monitored closely—in the European region, not globally—what countries are doing to respond to immunity gaps and equity aspects in the distribution of coverage at geographical level and across different populations. There is a variety of actions that have been reported.
Some countries focus on special populations because the immunity gap is observed in special populations, such as migrants, refugees or a population with a particular ethnic background. Interventions vary but focus on, for example, ensuring that messages about vaccination and information about how to access vaccination are translated into multiple languages and that communication about vaccination is done through the support of cultural mediators. There are some special initiatives of outreach for vaccinating special groups on the basis of geographic location.
There are also a lot of activities that were reported to support the general population, addressing, for example, issues with differential access to vaccination at geographical level. For example, some of the initiatives that have been reported are expanding the service hours, opening vaccination service during the weekends and ensuring that communication campaigns are followed by what is called periodic intensification of routine immunisation. That means, as I said, maybe different options for increasing the number of sessions for vaccination, having outreach and engaging multiple health workers beyond the immunisation programme. That might help in delivering vaccination.
There are a lot of countries that are trying to better understand the barriers and drivers to vaccination. A number of countries have reported that they are conducting what we call formative research to understand, in an evidence-based manner, the reasons for missing either special groups or people within the general population. There are a lot of findings that are being used to develop tailored intervention that addresses the challenges that have been identified.
Sometimes challenges are quite trivial. They can be, for example, that caregivers do not find the right time to bring the kids or adolescents to a vaccination appointment. Sometimes there are concerns about vaccine safety or hesitancy that is not a refusal of vaccination but more a lack of adequate information.
A number of countries are conducting a series of trainings for health workers to communicate better information about vaccination, address hesitancies and generally increase the demand and the understanding of the value of vaccination. A brief reply is that there are a lot of experiences that can be leveraged from other countries, especially those that are facing a similar challenge in seeing vaccination coverage slightly declining.
Baroness Cass: We could potentially have an offline conversation with you and with our team to check that we are across the most recent publications. That is very helpful.
You talked about that intense blast of pulling in other health workers. That is on your general programme—yes, okay, that makes sense.
The other thing we are struggling with is data systems, which are complex and certainly not as streamlined as we would like them to be. How are different countries using data systems to support uptake? Is there something we can learn from that too? I am sure that there is.
Dr Roberta Pastore: Yes, but this is not information that is systematically collected by WHO. I can provide some anecdotal information on what countries have reported in different presentations and instances. There have recently been efforts to use data to identify inequities in immunisation and immunity gaps. That is mostly based on efforts in digitalising data and developing electronic immunisation registries that perform well and have a good coverage of the programme. Based on that, in-depth analysis of the data can be conducted to understand the geographical distribution of the unvaccinated population and possible issues with not just missing vaccination but being vaccinated with some delay. Those two parameters, of course, have different underlying causes.
For countries that can do that, if they have databases that can be integrated or somehow interlinked, there is also a combined analysis of the vaccination status of the population and databases that include some social determinant information. That results in a profiling of the population to understand where immunity gaps can be more acute. This is done by countries that do not have restrictive policies on data privacy, because there is increasing reporting of challenges in doing triangulated analysis when databases are protected by data restriction policies.
There are countries that in their reporting rely on use of data that comes from outbreak investigations or vaccine-preventable disease surveillance. Outbreaks or cases of vaccine-preventable diseases are always an indicator that there is some immunity gap, especially when it is an outbreak. Isolated cases are not very informative. In case of outbreaks, several countries have reported that they conducted an in-depth analysis of data to understand who is affected by vaccine-preventable diseases, the underlying vaccination status and possible information on non-compliance with the recommended vaccination schedule.
There are countries that are conducting special studies that collect information on immunisation coverage independently from registries that are available. That might be affected by data quality issues. There are a variety of examples from countries on how to use information to guide interventions.
Baroness Cass: That is really helpful. We might learn something, because our data lacks granularity and something on the social determinants and racial backgrounds. It would be interesting to see some of that better data.
The Chair: Are there any countries that you know of whose Parliaments are so concerned about the situation, such as ours, that they are setting up committees of inquiry, such as ours?
Dr Roberta Pastore: I am not aware. There might be, but I do not have this information.
Q178 Baroness Neuberger: Thank you very much for joining us. If you hear of any other countries where the Parliament is doing an investigation, please let us know. We would love to know. I want to ask you about trust and how different countries build up trust in childhood vaccinations. Are there examples that we could learn from here in the UK?
You will know better than all of us about how social media spreads disinformation. Professor Sander van der Linden sent us evidence that made it very clear—an article in Nature—that anti-vaccination networks across 3 billion Facebook users showed how anti-vaccination clusters grew more rapidly than pro-vaccination clusters. There is an issue here with how social media is used. We would like to know from you what you know and are seeing about tackling the spread of misinformation about vaccines, including across borders. Anything you can tell us would be really helpful.
Dr Roberta Pastore: This is definitely an issue. The issue of misinformation and social media amplifying misinformation or disinformation is definitely there, but, with the support of the WHO, we have been collecting information from countries that conduct studies on reasons for non-vaccination. The issue of misinformation is certainly there. It is a reason for people not being vaccinated, but it is often not the main reason. There is a little bit of a tendency to over-exaggerate and over-amplify the role that misinformation and social media play.
It has been observed that the health workers in high-income countries in the European region—so this cannot be generalised globally, but at least in contexts that are comparable to the UK and England—are still the most trusted source of information. Some activities that have been effective have focused on training health workers to equip them with the needed information about vaccines and some skills to communicate about vaccines in order to maintain the trust in and demand for vaccines.
That said, of course there are also efforts to counteract the misinformation that is spread through social media and multiple platforms. Examples from Denmark or other countries show that reinforcing correct, fact-based information on vaccination is more effective than trying to run after each myth and piece of disinformation that is spread on social media. Misinformation can be presented in many ways and every day there is something new coming up. If you want to be factual in responding to every single piece of misinformation, it takes time, so the spread of misinformation will always be faster than the spread of a fact-check.
Being consistent through official channels and trusted informers, such as health workers, or people trusted in the community, such as religious leaders, is more effective than trying to run after every single piece of misinformation. There are several studies being conducted to understand the best strategy to move forward. There is growing evidence that it is important to respond to misinformation, but not one by one and more by continuing to give a consistent, fact-based message on vaccination.
Baroness Neuberger: Can you give us some examples of countries that do it particularly well that we could learn from?
Dr Roberta Pastore: I do not have the complete review of countries that have done that, but Denmark is a very good example of how it responded to misinformation about HPV vaccination. Its experience has been published and it is considered one very good example in the European region. I do not want to single it out, because there are other countries that have done a very good job, but this is an example that comes to my mind right now. I can check and maybe send you some other examples in writing later.
Baroness Neuberger: That would be really useful. Thank you very much indeed.
Q179 Baroness Andrews: Thank you very much for being with us this afternoon. I wanted to ask you a rather general question about the relative merits of mandating vaccination in relation to those countries that have done it and the other countries, such as ours, that have never contemplated it. Do you see that there are real benefits from requiring people to do this and on what evidence would you base that?
Of those countries that have mandated compulsory vaccination, is there a political universality about them? Does it represent a political choice that you can see as, in a way, typical of other political choices they make, or is there something separate from that? When they have chosen to use a mandatory system, have they done so from the beginning of the introduction of vaccination, or in response to crisis or some form of fundamental change that they felt required a compulsory approach?
Dr Roberta Pastore: I do not have the full information to respond to this question, because WHO does not monitor whether vaccination is mandatory. However, we can refer to a policy brief that was published by WHO on ethical considerations of mandatory vaccination during the Covid pandemic. That is the only written policy brief on this topic from WHO. WHO does not take a position on whether vaccination should be mandatory but provides some considerations for countries to consider before making such a decision.
The definition of mandatory vaccination can change. Countries might make vaccination mandatory, in that there being fines if someone is not vaccinated, or there could be restriction in access to schools or kindergartens. In case of vaccination of special professional categories, such as health workers, there could be some limitation in renewal of contracts or accreditation. It takes different forms and those different forms should be taken into consideration when evaluating the impact of a mandatory vaccination.
Another aspect to consider is, as you mentioned, why countries make vaccination mandatory. Some countries have a legacy mandatory vaccination because it was implemented at the very inception of the vaccination programmes. As a legacy issue, it is usually not strongly enforced. Even if some vaccines are mandatory, there is no strong enforcement of these mandatory aspects. Some countries have made some vaccines mandatory because of declining coverage and failure of the impact of other measures that were adopted to increase vaccination.
Based on what has been published in the literature, there are mixed reviews of what the impact of making vaccination mandatory is. It is country context specific. It is very much linked to the reason for making vaccination mandatory and the specific culture and context of each country. There is really no one answer about mandatory vaccination.
Countries have also been recommended to carefully consider the possible rebound effect or opposite effect of making vaccination mandatory, because that could make trust in vaccines weaker. That is something that has been observed in a few instances. It could be not a very effective intervention if there was no consideration for the impact on broader trust in vaccination, the health system and, to some extent, Governments and policy decision‑makers. There is a very mixed experience and there are several considerations that should be considered carefully in each country context.
WHO in general recommends to all countries that have reached out to understand what to do with mandating, or not, vaccines to first try to build trust in vaccines by any other means and really understand the underlying causes for seeing decline in vaccination. Mandatory vaccination is considered as a possible solution as a last resort where everything else has failed. Experience from countries indicates that it could be a double-edged sword, so it is really important to use it carefully.
Baroness Andrews: That is very interesting. To recap, the WHO advises that it is a last-resort choice. You said that countries that have from the beginning introduced mandatory vaccination as a legacy have actually slightly declined, or it has tailed off. Is that what I understood you to say? Countries that have introduced it as a response to a decline have had variable experiences. We know, for example, that France did very well. Do you know of countries where they introduced it as a result of lower take-up post Covid and have not maintained coverage? Are there countries that you could tell us about in that category?
Dr Roberta Pastore: In this moment I cannot name specific countries because I do not recall. I recall reading literature and experience about that, but I do not recall specifically, so I prefer not to give a name.
Baroness Andrews: That is fine. You are telling us that this is very variable and we have to be very careful in our judgment, because there are different types of coverage, different types of motivation and so on. One country that seems to do very well without mandatory vaccination, except for diphtheria and tetanus, is Portugal. Why is Portugal so successful without general mandation?
Dr Roberta Pastore: Portugal has been consistently reporting high coverage for almost all the vaccines and it also reports a very limited occurrence of vaccine-preventable disease cases, which is a very important tracer to understand if coverage data are reliable. It has multiple ways of keeping vaccination coverage high.
One is definitely working on trust in vaccination. For example, it has excellent monitoring of adverse events following immunisation that is used to build trust in vaccination. It uses very effectively what it calls micro-influencers. It identifies in the population, at different levels, people who are trusted by their community and can provide good advice on vaccination. It did it in a very excellent way during the Covid pandemic to motivate people to get vaccinated against Covid. This is a strategy that is also used for other vaccines included in its routine vaccination schedule.
It always performs monitoring of vaccination. As soon as there is a drop in vaccination detected at a sub-national level or in any population, it immediately acts. It is a well-structured system. It is well resourced, with sufficient staff allocated, or at least this is based on what has been reported in the past. I trust that that is still valid. There are multiple factors that contribute to maintaining high coverage.
Baroness Andrews: It would be worth us looking at Portugal as a really interesting and positive model in a way. Can I ask you one more question about Australia? Australia has a different approach again. Australia has compulsory voting. I do not know whether there is any relationship at all with the way Australians approach public policy, because it is on a federal basis anyway. They have this “no jab, no pay” law, which means that children have to receive routine vaccinations for the family to receive family assistance programmes. Is that unique to Australia? Do you know of any other country that does that and how effective that might be?
Dr Roberta Pastore: I do not know of any other country. I know that it is quite unique, but there are countries that are considering this type of indirect mandate of vaccination, so linking vaccination to access to certain services or social insurance. As far as I know, Australia is the only country that has implemented that, but I do not have a comprehensive overview of all the countries in the world, so I cannot tell you for sure. This is an indirect way of mandating vaccines. In the case of Australia, it has been considered effective, but there were also some objections to this approach, because it might decrease access to rights that the population might have regardless of the position on vaccination.
Baroness Andrews: It is interesting that trust in vaccines has gone down. Certain age groups in Australia may or may not be related at all to that, but there has been quite a significant drop over the past few years. That is worth exploring too.
Q180 Lord Dholakia: I wanted to follow up the question that Baroness Andrews asked about Portugal. You mentioned two similar countries in the report. One is Denmark and the other is Germany. Vaccination rates are very high in these countries compared to what we have in the United Kingdom. Do you have a breakdown of different variations of different groups as to how they feature in terms of vaccination in these countries?
What are the factors that make them go for vaccination, as against in this country? Is it one of the elements that, in Germany, for example, you are going to find a lot of migrant workers coming from Europe, as against people in this country who come to settle? If you are a migrant worker and you want a job you must have a health provision that provides for vaccination and other things. That tends to make the proportion very high, compared to what we have in this country. Do you have this breakdown of figures that can give some idea of what sort of progress we have to make in the United Kingdom?
Dr Roberta Pastore: I do not have this level of detail. I do not have data on specific population groups in Germany or Portugal. I am not privy to how these countries act with specific population groups. I prefer to refrain from providing information that I might know only very incorrectly.
Lord Dholakia: Are there any studies being done about countries, other than Europe, that seem to be identifying a high rate of vaccination compared to people in other parts of the world coming into western countries? Are any studies being done on those communities?
Dr Roberta Pastore: There are several studies being done. I do not have a list available right now, but there are several studies that look at vaccination coverage in specific population groups and vulnerable populations. They look at possible reasons for achieving a certain level of coverage. The literature is very rich in terms of country experiences that are related to how to ensure that coverage is high in specific population groups.
It is difficult to understand what types of experiences can be transferable and applicable to other contexts. Sometimes the experiences that are published are very valuable for general knowledge, but are not always easily transferable to contexts that are dissimilar from several points of view, such as the legal set-up of a country, the overall organisation of service delivery and the capacity to monitor specific populations. The literature can be very rich, but it is not always possible, from good and successful experience, to take that and transfer it to contexts that are quite different.
Q181 Baroness Hodgson of Abinger: Picking up on what you are saying, some of the countries being mentioned have a much lower population than we do and therefore it may be easier to deal with these kinds of things. Also, density of population may come into it. I do not know whether you have had any thoughts about that. When you have a large number of people, it may be harder to get these messages across.
Dr Roberta Pastore: Absolutely, the density of population, the internal mobility of the population, the level of migration and cultural differences within the population who live in the same country are all aspects that create what we call the country context. That needs to be understood before understanding how experiences from other contexts can be implemented in that context. We cannot compare.
For example, I mentioned that I was checking data from high-income countries in the European region to benchmark the UK or England, but, among the high-income countries in the European region, there are countries, such as San Marino, that are extremely small, or countries, such as Russia, that have a completely different health system set-up. It is very difficult to compare and make inferences that one approach can fit all.
Q182 The Chair: Thinking about opportunities to remind parents that it is a good idea to vaccinate their children, do you know of any countries where they do not mandate vaccination for attending any particular educational institution but do seek to know what the vaccination status of the children is before they go into the school, college or nursery? Is that helpful? Does it work as a nudge to parents, especially if you then give them an opportunity for catching up on something that has not been received?
Dr Roberta Pastore: Checking vaccination records at school entry is a recommendation from WHO, especially when it comes to, for example, strategies to achieve measles elimination. That is one of the recommended strategies, because it is a very effective strategy for understanding who has not been vaccinated and having an opportunity for catching up vaccination. The majority of countries in the European region do checks of vaccination records at entry to kindergarten or school or both. This is a very common practice.
What changes is whether the vaccine records are only checked and then, if a vaccination is missing, parents are referred to vaccination services or whether vaccination can be directly provided from school health services. That is something that makes a difference in terms of how much of the immunisation gap can be filled through this strategy. Nudging parents in general is a strategy that proved to be useful, but the impact of this strategy is also linked to how easy it is to get access to vaccination.
Studies have been conducted on how to best leverage the check of vaccination records in schools, for sure, and in kindergartens, but also in any contact that parents might have with the health sector for children. There are guidelines, for example, on the so-called missed opportunities when vaccination records could be checked if a child is in contact with the health system or sectors that care about the well-being of the child overall.
The Chair: That relies on having the correct information as to whether there are any gaps in the vaccination record for that child. We worry about that in this country. Are we unique in that?
Dr Roberta Pastore: The individual vaccination records and the records kept by the health system are not of the same quality across different countries. The retention of individual vaccine records tends to be low in certain settings and countries. The fact that caregivers are not always informed about the vaccination status of children and do not have records is not, unfortunately, a rare occurrence. There are a number of coverage surveys conducted in several countries that show what the retention of vaccination cards is. In some contexts it can be quite low.
Also, if records at service delivery level are kept only locally, it might be difficult to retrieve what is available on the history of vaccination of every child or individual. It is a common problem. Having a well-performing electronic immunisation registry that is accessible nationwide can provide much higher-quality information on the record of vaccination. This is what several countries are striving towards.
Q183 Lord Randall of Uxbridge: You have provided us with lots of information and things about the different countries and the differences. As this committee, we will be providing recommendations to our Government about how we may reduce the disparities and improve vaccination rates in England. Bearing in mind the differences in countries, is there anything you would particularly put forward from your international experience that we should be suggesting to the Government that would help in those regards?
Dr Roberta Pastore: We have published some guidelines on how to investigate and address inequities in immunisation. Inequities does not mean that it is an intentional inequity. It is just that some people might not be vaccinated. We recommend using a structured, phased approach to allow the identification of whether there are immunity gaps and to have an understanding, from the available data and information, of where the immunity gaps might be and who might be affected by them.
Based on that, do some targeted investigation to understand the underlying reasons for not being vaccinated, because they can be very context and population specific. Based on that, have tailored strategies that are informed by evidence and not general opinion to understand what can work in every context, based on the available evidence. Then, implement an assessment or evaluation of the strategies to understand whether they worked and, if they worked, to understand whether they can be expanded, maybe to other contexts, or further strengthened, and, if they did not, to understand why they did not.
This is a structured approach that can help in devising strategies that are locally relevant and can be locally impactful. This requires resources. Resources to have this type of tailored intervention should be allocated in terms of human resources and financial resources. This is what we suggest and recommend to all the countries to follow. It is a structured approach that can be based on an understanding of the real reasons for under-vaccination in specific populations or locations.
Lord Randall of Uxbridge: I do not suppose you have any relative information about the different countries and how much resource they are putting in, presumably as a percentage rather than actual figures. Do you have any information on that? If so, could you possibly send it to us?
Dr Roberta Pastore: WHO collects information on the financing of the immunisation programme. Information on how much is spent on vaccine procurement can be quite accurate. Information on how much is spent on the immunisation programme to allow the delivery of vaccines, to inform about vaccination and to maintain and monitor the immunisation programme is not very reliable. Several countries report having challenges in quantifying that, because often immunisation is not a vertical programme. For example, human resources that work in delivering vaccines also work across other health services.
It is very challenging to disentangle exactly what the cost of an immunisation programme is. Based on what is routinely reported to WHO, I would refrain from sharing the information with you because it could be misleading. There are some cost-benefit analyses and cost estimation studies that may be more telling about what resources should be allocated to the immunisation programme.
The Chair: Thank you very much indeed. You have given us a lot of information today based on your international experience. We are very grateful. As you mentioned, there are a number of things that you are going to refer us to, and our secretariat team will follow those up. I am very grateful to you.
