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Background Over the last years, research interest in vaccine hesitancy has increased. Studies usually focus on perceptions of parents and have largely neglected the group of health care providers. However, doctors’ notions on vaccination have a major impact on the decision-making process of their patients. We were interested to understand the phenomenon of vaccine hesitancy among physicians, with a particular focus on the measles vaccine. Furthermore, we aimed to understand the underlying perceptions of measles that may be associated with vaccine hesitant decisions. Methods In order to get an in-depth view, semi-structured interviews with physicians were conducted. Doctors were eligible for the study if they articulated vaccine hesitant views and/or demonstrated vaccine hesitancy in their medical practice. Results We interviewed 12 physicians, of whom 11 had a medical practice with no contract with the Austrian social insurance (‘Wahlarzt’) and additional training in complementary and alternative medicine. We found perceptions of immunology, health and illness that were discordant with evidence-based medicine and closely related to alternative and complementary medicine. All participants argued for a delayed administration of the measles vaccine. We found a consistent inclination towards ‘individual vaccination’, which was explained as empowering parents and to strengthen their decision-making competencies. Most participants expressed doubts about the reliability of vaccine studies and were concerned with possible long-term effects. Conclusions Paying closer attention to doctors’ concerns on vaccination might help to design target-oriented interventions to specifically strengthen vaccine confidence.

Background Vaccination against SARS-CoV-2 is the most effective way to stop the pandemic and to avoid its related deaths. COVID-19 vaccine hesitancy, represent now a major hurdle to achieve herd immunity. Cancer patients constitute a prioritized group for COVID-19 vaccination as they are particularly vulnerable to severe infection and death. The aim of this study was to assess vaccine hesitancy among cancer patients of the Salah Azaiez Institute (SAI) of cancer and to identify its knowledge and attitudes associated factors. Methods A cross sectional study was conducted among all inpatients aged above 18 years old during the month of February 2021. Participants were asked according to a well-structured questionnaire about knowledge (vaccine literacy) and attitudes towards COVID-19 vaccine. Vaccine literacy was assed using two scales (functional and interactive-critical scales) for which a global score was calculated ranging from 1 to 4. A lower score corresponding to lower vaccine literacy. Chi square test and student's t test were used to identify knowledge and attitudes associated with COVID-19 vaccine hesitancy. A p value equal or less than 0.05 was considered statistically significant. Results Two hundred cancer patients were included with a mean age of 54.4±12.7 and a gender ratio equal to 0.5. Sixty-five percent reported that they would not receive the COVID-19 vaccine. Vaccine hesitancy was associated with lower interactive vaccine literacy score (1.6±0.8 vs 2.0, p = 0.002), skepticism regarding COVID-19 vaccine efficacy and safety (73.8% vs 38.5%, p < 0.001) and believing that health authorities will not be able to vaccinate the majority of the population (71,2% vs 55.7% p = 0.037). Conclusions The proportion of COVID-19 vaccine hesitancy among cancer patients is high. Mass media campaigns for vaccine promotion should be enhanced. Physicians and health care workers play a key role in increasing acceptance and uptake of COVID-19 vaccine among high risk patients. Key messages Majority of cancer patients were unwilling to receive the COVID-19 vaccine. Patient education about the benefits of vaccination against SARS-CoV-2 should be an integral part of oncology visits.

Background Several factors can determine the success of a vaccination campaign, regardless of the availability of an effective and safe vaccine. Among these, vaccine hesitancy (VH) has long represented one of the main barriers to achieving vaccination coverage goals in many countries. The aim of this systematic review was to summarize the global levels of COVID-19 VH and to identify their determinants. Methods A systematic review of the literature was carried out following the PRISMA guideline and searching on PubMed, Web of Science, Scopus and PsycINFO for observational studies published up to April 2021 in English or Italian language. Levels of hesitancy and data on determinants, according to the SAGE working group matrix of determinants, were extracted. The systematic review protocol was registered on Prospero (ID: CRD42021235328). Results Of the 5447 articles initially retrieved, 89 were included in the qualitative synthesis. The included studies investigated COVID-19 VH on 1.954.331 individuals from 68 different countries (North America 19; South America 23; Africa 3; Asia 18; Europe 55; Oceania 4) between March 2020 and January 2021. Rates of hesitancy, before to the worldwide availability of vaccinations (82 studies), ranged from 84.6% (Cameroon, May-August 2020) to 10.37% (China, March-June 2020). Studies carried out on January 2021 (N = 7) showed rates ranging from 42.8% (Turkey) to 5.3% (UK). A subgroup analysis of data referring to healthcare workers showed the highest hesitancy rates in Honk Kong (60%) and Turkey (26.6%), before and after vaccine availability, respectively. Conclusions Preliminary results confirm the wide variability of VH across the world. The ongoing quantitative synthesis on prevalence of VH and the analysis on determinants will allow to update intervention strategies to address VH, both in general population and healthcare workers, orienting public health policies. Key messages Vaccine Hesitancy continues to be one of the greatest threats to global health and, in the long term, one of the potential barriers to the success of the global COVID-19 vaccination campaign. Identifying and synthesizing the specific determinants of COVID-19 vaccine hesitancy is essential to guide intervention strategies to promote vaccine confidence and, finally, vaccine acceptance.

The European Centre for Disease Prevention and Control (ECDC) works on vaccine acceptance by searching for evidence, consulting with key stakeholders (epidemiologists, public health experts, family doctors, non-governmental organisation representatives for Roma, travellers, other under-served population groups), and identifying pilot interventions/ practices. ECDC aims to strengthen workforce capacity on vaccine acceptance by developing a training for trainers. To guide the development of this multi-annual programme ECDC organised an expert meeting in April 2019 focusing on discussing and designing main elements of the training for trainers in vaccine acceptance at the country level. Key conclusions of the meeting include: A range professionals should ideally be trained on how to communicate to increase vaccine acceptance: frontline healthcare professionals, pharmacists, gynaecologists, teachers, politicians, journalists.Investments should be made both in postgraduate professional development of frontline healthcare professionals, as well as in university curricula for medical, nursing and teachers training.Training should include both knowledge around vaccines and immunization, as well as communication skills to discuss about vaccines and motivate immunization. Possibly legal aspects at the country level should be included, too.Vaccine acceptance should be addressed throughout the life course and vaccines.Training should be delivered in a blended format, with face-to-face sessions (especially for skills building) and e-learning (especially for knowledge components).Training should include a common European-level core but be done by local trainers, in the local language and adapted to the local context.Training initiatives should be integrated into a “bigger picture”: sustainability of such an initiative should be taken into account, as well as the most efficient and interventions. Seeking synergies and partnerships are key in ensuring long-term success.

Background Pregnancy is widely recognized as a ’teachable moment’ since attitudes and beliefs about childhood vaccines are not completely structured. Among healthcare workers (HCWs), midwives play a pivotal role in the maternal care pathway and should have a key role also in promoting opportunities of discussion and correct information about vaccinations. Methods We conducted a cross-sectional survey to assess knowledge and attitudes of a sample of Italian midwives towards vaccinations. A questionnaire was designed ad hoc and sent electronically to midwives members of the professional register of Rome. Results Preliminary results on data collected from 140 midwives (mean age 37.32, DS ± 11.61; mean years on the job: 11.94 DS ± 12.78) who completed the survey showed a heterogeneous level of knowledge: only 50% of the sample indicated the correct threshold of vaccination coverage for herd immunity, while safety of multiple shots and of the additives contained in vaccines was reported by 61% and 31% of respondents, respectively. Only 41% of midwives had identified the pertussis vaccine as one of the vaccinations recommended during pregnancy. Attitudes were generally positive: 84% of respondents recognized recommended vaccines as effective and 86% as one of the safest health interventions. However, vaccinations against MMR and Varicella were perceived as useful by 86% and 71% of the midwives, while 89% and 77%, respectively, would recommend them to parents (compared to 96% in case of hexavalent). Globally, 79% of respondents would agree with the introduction of mandatory vaccinations for HCWs in maternity wards. Conclusions Midwives show some gaps in the knowledge on vaccinations. The final results of this study will be used to build specific and tailored training programs directed to midwives involved in pregnancy management. This may help them to transfer the correct vaccination information for the empowerment and the growth of vaccine literacy. Key messages Pregnancy is a strategic teachable moment to influence attitudes regarding childhood vaccinations and healthcare professionals must be trained to be the vehicle of the most accurate information. Specific under- and post-graduate training courses on vaccinations directed to midwives are strongly needed to ensure good level of knowledge on this topic.

Background Vaccination coverage is dropping in several countries, including Slovenia. More and more people hesitate or even reject vaccinations. As the influence of the internet grows, the question becomes how to communicate about vaccination to parents in order to prevent this drop in vaccination coverage among children. Methods For the first time in Europe, the Situational Theory of Publics (STOP) has been used in the field of vaccination to segment mothers to subpublics, and to prescribe a clearly defined form of communication for each of the segmented groups. In the survey, 1704 mothers participated who gave birth in 2014 and 2015 in Slovenia. Results The study showed that mothers react passively to information on vaccination no matter whether they come across it coincidentally or intentionally. Most often, they seek information about vaccination from friends or online. The more concerned they are about the safety of vaccines, the more they search for information about vaccination, and their communication is consequently more active. The mothers that problematize the safety of vaccines more, and are afraid of their adverse events tend to be in favour of alternative options. Conclusions Our research demonstrated that the STOP can be applied to the field of vaccination. There is a huge need for intensive professional communication about vaccination on the internet and social media. The improvement of the communicational competences of doctors and healthcare workers is essential to achieve better communication with parents and the media, and needs to be focused on mothers and pregnant women.

Background Marginalization of undocumented migrants raises concerns about equitable access to COVID-19 immunization. This study describes their self-perceived accessibility of and demand for COVID-19 immunization. Methods A multi-centric cross-sectional survey was conducted in 4 health facilities providing care to undocumented immigrants in the USA, Switzerland, Italy, and France in February-April 2021. A convenience sample of minimum 100 patients per study site was recruited. Data was collected using an anonymous structured questionnaire including demographic variables, health status, and drivers/barriers for COVID-19 immunization. Descriptive statistics were used to characterize the primary and secondary outcomes: self-perceived accessibility of and demand for COVID-19 immunization. Results 812 migrants completed the survey (54.3% Geneva, 17.5% Baltimore, 15.5% Milan, and 12.7% Paris). 60.9% were women, the median age was 40 years old (range 17-76), and 19 nationalities were represented: 55.9% Latin America, 12.7% Africa, 11.2% Western Pacific, 7.9% Eastern Mediterranean, 7.6% Europe, 4.7% Asia. Among participants, 14.1% and 26.2% reported prior COVID-19 infection and fear of developing severe COVID-19, respectively. Underlying co-morbidities were common (29.5%). Self-perceived accessibility of COVID-19 immunization was high (86.4%), yet demand was low (41.1%) correlating with age, co-morbidity, and views on immunization which were better for immunization in general (77.3%) than immunization against COVID-19 (56.5%). Hesitancy was mostly due to fear of adverse reactions (39.2%). Conclusions In this multi-centric study, undocumented migrants generally believed they would access local COVID-19 immunization programs. Yet, despite positive views about immunization in general, they reported limited confidence in COVID-19 immunization and willingness to be immunized. Key messages Self-perceived accessibility of COVID-19 immunization is high, yet demand is limited. COVID-19 immunization campaigns may engage communities and leverage confidence in immunization in general to address concerns about COVID-19 immunization.

Background Migrants in Europe are at risk of under-immunisation and may also have lower COVID-19 vaccination intent and uptake. There is an urgent need to better understand the drivers of uptake in these groups to inform the development of migrant-sensitive interventions for COVID-19 vaccination and routine vaccination beyond the pandemic. Methods We did a systematic review (PROSPERO: CRD42020219214) following PRISMA guidelines to explore factors influencing vaccine uptake in migrants in the EU/EEA and identify determinants of under-immunisation. We also held 3 participatory workshops with multinational migrant community leaders (n = 23) in London, to explore solutions and approaches to strengthen COVID-19 vaccine roll-out. Results We included 66 papers reporting data on 262,761 migrants in the review. Numerous access-related factors (e.g. government policy, communication barriers) influenced uptake. Vaccine hesitancy was attributed to lack of information, concerns about side-effects, and cultural beliefs/stigma around specific vaccinations. Migrants who had recently arrived, were older, female or of African and Eastern Mediterranean origin were at risk for under-immunisation for key vaccine-preventable diseases. Migrant community leaders reported considerable hesitancy towards COVID-19 vaccination in their communities and misinformation circulating via social media. Leaders requested support in producing simple COVID-19 guidance that could be translated and adapted locally, alongside more meaningful engagement and partnership-working. Conclusions Access barriers and vaccine hesitancy may affect vaccine uptake in some migrant populations in Europe, which needs to be urgently addressed for COVID-19 vaccine roll-out but also beyond the pandemic to strengthen uptake of routine vaccinations. Actively involving migrant communities in the planning, co-production and implementation of tailored and targeted approaches will be essential. On behalf of ESGITM. Key messages Access barriers and vaccine hesitancy (from information gaps, cultural factors) contribute to low vaccine uptake in some migrant populations in the EU/EEA, with implications for COVID-19 vaccination. Meaningful engagement and co-production of tailored approaches with under-immunised migrants are urgently needed to ensure their inclusion in COVID-19 and routine vaccination programmes.

Background High rates of vaccination are worldwide required to establish a herd immunity stopping the current COVID-19 pandemic evolution. Vaccine hesitancy is a major barrier in achieving herd immunity across different populations. This study sought to conduct a systematic review of the current literature regarding attitudes and hesitancy to receiving COVID-19 vaccination worldwide. Methods A systematic literature search was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Multiple databases were searched, namely PubMed and Web of Science, on February 24th, 2021 using a set of developed keywords. Inclusion criteria included the study to be 1) conducted in English; 2) investigated attitudes, hesitancy, and/or barriers to COVID-19 vaccine acceptability among a given population; 3) utilized validated measurements techniques; 4) have the full text paper available and 5) be peer-reviewed prior to final publication. The Newcastle Ottawa (NOS) scale for cross sectional studies was used to assess the quality of the studies. Results 73 studies were included in qualitative synthesis. Overall, vaccine acceptance rates ranged from 23.6% in Kuwait to 94.3% in Malaysia and Nepal. A variety of different factors contributed to increased hesitancy, some of which included having negative perception of vaccine efficacy, safety, convenience and price. Some of the consistent socio-demographic groups that were identified to be associated with increased hesitancy included: women, younger participants, less educated, with lower income, with no insurance, living in the rural area and self-identified as a racial/ethnic minority. Conclusions Vaccine hesitancy rates against COVID-19 vaccine ranged widely among across different populations. Identifying the factors that interplay and result in high hesitancy rates among a population can allow formulating a directed intervention to increase their vaccination uptake rates. Key messages It is necessary to understand the factors that contribute to the COVID-19 vaccine hesitancy. It is important to inform policy-makers and formulate direct intervention measures that will successfully handle the pandemic.

Background Vaccine hesitancy is the reluctance or refusal to be vaccinated. While it has been widely studied for various contagious diseases, there is still a lack of knowledge about this phenomenon for COVID-19, especially if health workers' hesitancy is considered. Methods An extensive review of the literature was conducted to identify the main determinants of vaccine hesitancy in health workers, as well as to find already validated surveys to evaluate the knowledge, attitudes and behaviors (KAB) of health workers towards vaccination, both in general and with specific regard to COVID-19. Building on the available information, a new survey was developed to assess the KAB of Italian health care workers towards COVID-19 vaccination after validation with a pilot study in a diverse sample of 30 Italian health workers. Results A new survey was validated to assess the KAB of health workers towards COVID-19 vaccination in Italian health workers. The survey requires about 6 minutes to complete and is composed of 30 questions, investigating different domains: socio-demographic and professional characteristics (6); health status (2); attitudes (11); behaviors (6); knowledge (4). The survey will be administered to a representative sample of at least 385 Italian health workers through the web platform SurveyMonkey in the period June-September 2021. Preliminary results will be available by the end of October 2021. Conclusions By analyzing KAB towards COVID-19 vaccination with a new tool, the magnitude and determinants of health worker's COVID-19 vaccine hesitancy will be evaluated to understand how to improve health workers' perception towards COVID-19 vaccination and, consequently, foster their positive influence on the general population. Key messages We explore the knowledge, attitudes and behaviors towards COVID-19 vaccination in all categories of health workers operating on the Italian territory to understand the reasons of vaccine hesitancy. Understanding the determinants of COVID-19 vaccine hesitancy in Italian health workers is necessary given their influence on the perception of the general population in Italy.

Issue Despite low healthcare workers (HCWs) vaccination coverage being a risk for hospital outbreaks, vaccine hesitancy is not unusual among HCWs. In Italy vaccinations are strongly recommended for HCWs, but there are few occasions for a dedicated counseling. Aim of the study is to evaluate the effectiveness of a new vaccination service in the academic hospital of Udine (northern Italy) in tackling vaccine hesitancy among HCWs. Description of the problem Available data on HCWs specific antibody titers revealed that in high-risk units, 25% of HCWs were certainly unprotected for at least 1/6 of the vaccine preventable diseases (VPDs): measles, rubella, mumps, varicella, pertussis, hepatitis B; only varicella coverage reached the herd immunity target. Periodic occupational health visit was the only moment to screen for VPDs protection and suggest vaccination, but the following inconvenient procedure of HCWs contacting the vaccination office outside the hospital, often lead to delays or loss. In order to improve vaccination adherence, since June 2019 a dedicated clinic has been set up inside the hospital, making vaccination counseling and administration available every two weeks, with appointments directly given by the occupational doctor. Results From June 2019 to February 2020, a total of 362 appointments were booked for the dedicated vaccination clinic, 69.7% of which actually took place as 252 HCWs actually accessed the service. Hours dedicated to the service activity were 76 hours, distributed over 19 days. Administered vaccination were 322, including 107 MMR (measles, rubella, mumps), 4 MMRV (MMR+varicella), 20 varicella, 64 hepatitis B, 127 DTPa (diphtheria, tetanus, pertussis). Lessons Making the access to vaccination more convenient in term of service location within the hospital and giving the appointment when performing the occupational health visit seems to be helpful in filling the VPDs protection among HCWs gap. Key messages Monitoring immunological status of HCWs and promoting vaccination at occupational health visit would sustain herd immunity protection for susceptible individuals in healthcare settings. The dedicated hospital vaccination clinic and the effective procedure of giving the appointment during the occupational health visit could be helpful in improving HCWs vaccine adherence.

Background Vaccination has been evaluated and was found to be the most successful and cost-effective interventions to preventing illness and improve health outcomes. However, internationally, an increase in vaccine hesitancy has led to a decrease in vaccination uptake. We conducted an umbrella review to assess the factors related to under-vaccination and non-vaccination from a global perspective. Methods PubMed, EMBASE and Science Direct were searched from inception to December 2019 for systematic reviews and meta-analyses that examined the factors affecting vaccination choices. No restrictions on language, publication date, vaccination type, setting, or population were applied. Narrative and extensive reviews were excluded. A narrative synthesis was undertaken to present the results thematically. Results Twenty-two systematic reviews met the inclusion criteria. The published evidence on this topic shows that, overall, a variety of complex factors exist related to vaccine hesitancy. Across all articles included, the main areas of concern were around vaccine safety and efficacy. Mistrust towards vaccine-related bodies (e.g. pharmaceutical companies, health professionals, researchers etc.), inconvenience, cost, and overall lack of information/knowledge were also identified as major barriers to vaccine uptake. Barriers vary depending on population, place and vaccines. Conclusions Our results show a variety of complex factors influencing the decision to accept, delay or reject some or all vaccines, indicating the necessity of a multi-faceted approach to address them in order to improve vaccine coverage. Key messages The results of this review show that concerns regarding vaccine safety and efficacy were the most significant barriers. Further research, policies, programs, and community-driven initiatives are needed to enhance acceptability and uptake of vaccination.

Background Vaccine hesitancy among general population can be even greater regarding flu than other vaccine preventable diseases, as complacency towards influenza is quite high and confidence can be reduced by the confounding effect of influenza-like-illnesses. Health professionals face hesitant people alleging many different motivations against flu vaccination, some of them being susceptible to tailored one-to-one health promotion. Methods During 2019/20 flu vaccination campaign, 44 trained pharmacists of Carnia District in Friuli Venezia Giulia Region (Italy) surveyed at-risk people accessing 25 pharmacies regarding beliefs on flu vaccination and offered one-to-one advice. As stated in the Italian national vaccination plan, subjects with comorbidities or older than 65 were considered at risk. Adherence to influenza vaccination during past flu season and reasons for that choice, as well as intention to be administered flu shots after counseling were registered. Results A total of 2,748 at-risk subjects adhered to the project with a mean age of 70±12 years, 57% of them being females; 1,702 (38%) did not adhere to flu vaccination campaign last year. Most of them confirmed a low complacency level, reporting to have refused flu vaccination because of “not getting ill” (43%) believing that vaccines are dangerous (12%) or not effective (5%); some did not know they could access flu vaccination (8%). After counseling, 2196 (80%) decided to adhere to flu vaccination, in particular 83% (1284/1555) of over 65 and 84% (684/816) of at-risk subjects. Conclusions More than one third of over 65 or at-risk surveyed subjects did not receive influenza vaccination during 2018/19 flu season. One-to-one tailored counseling conducted by pharmacists resulted to be effective in tackling vaccine hesitancy among 2019/20 flu shot target population. Key messages Motivations underlying vaccine hesitancy toward flu vaccination continue to impair health outcomes of target population. A one-to-one counseling intervention conducted by pharmacists with specific targets should be useful to improve seasonal flu vaccine coverage.

Background Rotavirus vaccine efficacy is well established. However, it is important to consistently demonstrate the positive impact of vaccination programmes in order to optimize uptake rates and combat vaccine hesitancy. Methods Routine data were used to examine rotavirus vaccine effectiveness in Ireland, including changes in age-specific crude incidence rates (CIRs), hospitalizations and hospital length of stay. National intussusception incidence was interrogated. Vaccination status of vaccine-eligible cases of rotavirus infection was determined. Results Nationally, a reduction in the CIR of rotavirus infection of 77.2% [95% confidence interval (CI) 57.8–88.5%, P Conclusions Inclusion of the rotavirus vaccine in the Irish primary immunization schedule has resulted in a significant reduction in the burden of rotavirus infection. However, vaccine hesitancy remains a concern. With new vaccination programmes, risk of vaccine harms should be considered and mitigated in order to protect individuals and the integrity of the programme.

Vaccine hesitancy is considered a major global public health threat. Vaccine hesitancy stands for refusing or delaying the acceptance of vaccines, and it is influenced by matters, such as the lack confidence in the system providing the vaccines, inconvenience of vaccination services and individual risk perceptions. In a European context, the lack of confidence is often put forth as major reason behind low vaccine uptake. However, it is equally important to address matters relating to the accessibility and convenience of vaccination services. The European Council and the European Commission have made several decisions aiming to strengthen vaccine confidence and uptake in Europe. The ongoing EU Joint Action on Vaccination (EU-JAV) is delivering a number of these. As a work package leader for the actions related to vaccine hesitancy and uptake, Jonas Sivelä will talk about the importance of capitalizing on existing knowledge and practices within Europe - and the potential we have in increased cooperation between countries, regions and actors. The EU-JAV develops a systematic overview and analysis of best practices, lessons learned and experiences from vaccine hesitancy and uptake related work. Such work can encompass different types of interventions and practices, for example, training of health care workers, communication policies, or initiatives aiming to increase the accessibility of vaccination services. The EU-JAV creates mechanisms and practical tools for disseminating the knowledge about this work for actors in the public health sector in order to strengthen their possibilities to encounter vaccine hesitancy.

Background Vaccination is the main tool for primary prevention of disease and one of the most cost-effective public health measures available. Immunisation through vaccination is the best defence we have against serious, preventable, and sometimes deadly, contagious diseases. Thanks to widespread vaccination, smallpox has been eradicated, Europe made polio-free, and many other diseases almost eliminated. Methods This presentation provides an overview of recent European Union (EU) initiatives to support national vaccination efforts. Results The EU has launched a number of initiatives to strengthen national vaccination efforts. In December 2018 the European Council adopted a Recommendation to strengthen the EU cooperation on vaccine-preventable diseases. The initiative aims to tackle vaccine hesitancy, improve coordination on vaccine procurement, support research and innovation, and strengthen EU cooperation on vaccine-preventable diseases. EU countries are encouraged to develop and implement national vaccination plans with initiatives to improve coverage, and to introduce routine vaccination status checks. The European Commission is also reinforcing its support to national vaccination efforts to increase coverage, including through the preparation of a Joint Action on vaccination co-funded by the Health Programme. Launching in 2018, the Joint Action will address vaccine hesitancy and seek to increase vaccination coverage in the EU. It is coordinated by INSERM (France) and involves 23 countries (among them 20 EU countries). Conclusions Vaccination policy is a competence of national authorities, but the European Commission assists EU countries in coordinating their policies and programmes.

Background Covid-19 vaccines have been anticipated throughout the year 2020. These are envisaged by many as the way forward to beat the pandemic. However, vaccination hesitancy among the population is a public health concern. The aim was to explore the intend to take the Covid-19 vaccine among the adult residents of Malta. The vaccination roll-out in Malta started on 27th December 2020. Methods An anonymous survey was distributed through social media platforms during February 2021, targeting adults residing in Malta. Socio-economic data along with the intention to take the Covid-19 vaccine was gathered. Quantitative and qualitative analyses were performed. Results A total of 1,034 participants responded, with the majority showing intend to take the Covid-19 vaccine (75.44% CI95%:72.72-77.96). While 13.06% (CI95%:11.13-15.25) reported having already taken the vaccine. The majority of those not intending (n = 119) to take the vaccine were female (77.31% CI95%:68.95-83.96); between 30 to 39 years (42.02% CI95%:33.53-51.00), employed (76.47% CI95%:68.05-83.23) and with a post-graduate degree (36.97% CI95%:28.83-45.94). The commonest reasons for unintentional vaccine uptake were due to concern for its safety and long side effects as well as concerned if it is effective. Notably, 15.22% (CI95%:9.16-24.06) of the females reporting not intending to take the vaccine were concerned about the effect of the vaccine on their pregnancy or else were planning to become pregnant. Conclusions A high acceptance rate for the Covid-19 vaccine was observed among the Malta adults. However, an element of hesitancy was evident including among this study's high socioeconomic status group. The unknown future and long-term effects of the vaccine appear to be the main contributors to hesitancy. Key messages Covid-19 vaccine is well accepted in Malta, potentially reflecting the population’s desire to protect themselves and their families. Vaccine hesitancy is still evident even in the midst of the pandemic among high socio-economic group, reflecting the need for vaccine transparency.

Issue/problem In an unprecedented effort to end the pandemic, national mitigations strategies have been implemented and highly effective vaccines have been developed and rolled out in record time. Success of many of these public health endeavors is contingent upon people being willing to engage in proposed behaviours. Description of the problem The key to slowing the spread of COVID-19 and ending the pandemic, is public adherence to the rapidly evolving behaviour-based government policies. However, adherence to these policies involves implementing behaviour changes that may come with significant personal, social and economic costs. In addition, public health vaccination campaigns are widely available, and the success of these initiatives is dependent on the behaviour of people getting the vaccine. Understanding the determinants of adherence at each phase of the infection curve around the world is critical for effective policy planning and communication. Results The results of the global iCARE study demonstrated a substantial level of national variations, when it comes to engaging in preventive behaviours (social distancing, mask-wearing, hand-washing, self-isolating). Moreover, we observed increasing levels of COVID-19 vaccine hesitancy across several countries. Adherence to these behaviours seems to be driven by socio-demographic (e.g., age, sex, gender, ethnicity, parental status, employment/ student status, built environment, healthcare system factors), psychological (e.g., COVID-19 attitudes, beliefs and concerns), behavioural, physical/mental health, and economic factors. Lessons iCARE study offers deeper understanding and continuous assessment of the predictors of behavioural adherence globally. To this end, the study identified possible communication targets, and proposes tailoring the format and the content of the communication, which should be consistent, prioritize equity, foster transparency and trust-building in different communities.

Background the world is facing a novel coronavirus pandemic, and the role of vaccination and vaccination acceptance is playing an important role under current vaccination deployment. Japan's vaccination system has progressed these days greatly; however, the non-mandatory vaccination rate for children such as mumps, influenza is still low due to mothers' hesitancy. Given this circumstance, we conducted a qualitative analysis using text analysis methods for Japanese mothers with children about their hesitancy to vaccinate their children in Japan. Methods We used the data of a questionnaire survey first conducted in 2012, where two hundred and twenty-six mothers participated with an average age of 44.7 years (SD ± 5.02). The questionnaire included open-ended questions, where mothers wrote their opinion freely about vaccination about their children. We conducted text analysis focusing on the keywords of ‘hesitancy' (IBM SPSS Text Analytics for Surveys 4.0). Results The keywords that extracted frequently included; vaccination (n = 160), hesitancy (n = 66), difficulty in access to vaccination (n = 57), knowledge/information scarcity (n = 31), fear for side effect (n = 30), complexity of vaccination schedule (n = 23) and government subsidies (n = 20). The most related keyword with hesitancy was; side effect (n = 20), expensive cost (n = 12), and non-mandatory (n = 10). A keyword of having natural immunity was also closely connected (n = 8). Discussion and Conclusions To ameliorate hesitancy among mothers against vaccination of their children, local government notification and subsidy as mandatory vaccination, providing the correct information about diseases and side effects of vaccinations would work as plus factors. Key messages For pandemic preparedness, it is necessary to research vaccine acceptance among children. This research is to explore vaccine hesitancy among mothers and factors related to their unwillingness.

The digital age we currently live in is characterized by an overwhelming production of information by multiple users. This is particularly relevant in public health areas, where inaccurate information can be a threat to populations' wellbeing. The internet became a field where anyone can produce non validated health information and spread rumors that can drive vaccine hesitancy, non compliance with public health measures and use of ineffective treatments, among other consequences highlighted by the COVID-19 pandemic. Public health professionals must be aware of such relevant concepts, the cognitive theories that support them and the strategies that can be used to monitor, identify, prevent and tackle the spread of health misinformation. However, such an approach should involve not only public health professionals but also journalists, data scientists, social marketeers and behavioural change experts involved in different organizations. Infodemic management is a recent area of research and practice that requires a comprehensive, multidisciplinary capacity building approach focusing behavioural change theories, digital technologies and social media, and community engagement strategies among others. This presentation will provide a brief introduction on main infodemic concepts and cognitive theories, show how infodemic management can overlap common epidemic management and highlight monitoring and social listening strategies and relevant interventions to prevent and tackle misinformation.

Background In 2019, WHO classified vaccine hesitancy as one of the top 10 threats to global health. Vaccination is an area of excellence in nursing that has gained a new focus and has become a challenge in the provision of care and in the management field. Vaccine hesitation raises questions about mandatory vaccination, individual versus collective freedom that are highlighted in the current context due to the emergence of new vaccines. In this paper, we want to analyze and update knowledge about vaccines hesitancy from an ethical and bioethical perspective. Methods A combination of literature reviews on vaccine refusal/hesitancy, ethics and COVID-19 vaccine confidence, accessed on SciELO and PubMed databases and analysis of documents from General Directorate of Health and Ordem dos Enfermeiros (National Nurses Association). Results Vaccination programs aim is a collective protection. The desirable effects at individual level do not have the same ethical value at collective level, leading to cost-benefit imbalances. Moral conflicts between the individual and the collective, cost-benefit imbalances and the insufficiency of bioethics principles, lead us to the use of other moral values and principles, such as responsibility, solidarity and social justice, as a tool for ethical reflection problems related to COVID-19 vaccines. Conclusions There are no perfect solutions to ethical dilemmas and some optimal solutions could depend the context. In a pandemic situation, one of the most relevant ethical issues is the herd immunity since it leaves public health at risk. Equity and the principle of justice in vaccination campaign are shown daily in the nursing profession.

Introduction In a recent estimation, time spent engaging with smartphones is 3h43m in 2019 in US population, surpassing conventional media such as TV. However, smartphones are not just a distraction from everyday life, but also a powerful tool by which to search for information and interface with institutions and services providers. National Healthcare Systems are not an exception, in particular for tackling vaccine hesitancy and fake news: in this frame, we have focused our research on mobile apps for vaccination. Methods We scanned Apple App Store through an API (Application Programming Interface) made available from Apple Inc. itself searching single words related to vaccination (no Boolean operators available) from both Italian and English-speaking markets, then exporting and merging the results. The univocal 121 apps obtained were then classified according by category, description, target population, informative materials and n° of reviews. Results The majority of apps falls under the “organizer” category (49 apps, 40.5%) with almost half of them (22) with vaccination as main topic (vaccine reminders and recorders), the others as part of a health management tool, mostly designed for parents. Just 32% of these apps give information regarding vaccines or preventable diseases. The second one is medical education apps (26.4%) focused on healthcare workers with guidelines and updates, mainly in English, then games (11.6%), Local Healthcare Service booking services (9.1%) of which only 4 from Italy, and lastly travel management apps (2.5%). Conclusions Organizers and reminders are a recognised tool to increase vaccine adhesion, but a complete plain-language information should be provided together with the service, to answer the most frequently asked questions from parents and dispel their doubts. In the meanwhile, Italian NHS results rarely adequate in providing a fully digital experience, from planning shots to registration of vaccine status. Key messages Mobile vaccination organizers are a helpful tool for parents, but they are undervalued as a first-hand source of knowledge about vaccination programs. Italian NHS should develop a modern mobile interface in order to book vaccination services as a big nudge towards the increase of vaccine adherence.

Vaccination is one of the most powerful and cost-effective public health measures developed in the 20th century, and remains the main tool for primary prevention of communicable diseases. Yet, in spite of the overall benefits of vaccination, a number of key challenges still remain to ensure sustainable, equitable and effective vaccination programmes in all EU Member States, and to secure that the added benefits of vaccinations are not lost. The overall purpose of the research programme presented is to facilitate and execute research on vaccine confidence, identifying behavioural determinants of vaccine hesitancy across different subgroups of the population (including disadvantaged and socially excluded groups) and healthcare workers, for specific categories of vaccines in a number of Member States of the European Union (MS of EU). The research group has facilitated and executed a preliminary research (consisting of a set of focus groups and an experimental survey) on vaccine confidence, for specific categories of vaccines in a number of MS of EU (Spain, Portugal, Romania, Italy, Poland, French). The outcome of the preliminary study will support the identification of the most promising areas of implementation of behavioural insights to improve vaccine confidence. At the time of writing of this abstract, the results are under collection, and will be ready by the end of June 2020. During the policy design and preparation phase, supported by a behavioural mixed methodology study, a number of behavioural determinants of vaccination demand and acceptance have been identified. This is crucial for policy making at the EU level, especially since the principle of subsidiary limits the possibilities for direct EU action over choice architecture. This requires further coordination with national health authorities Key messages During the policy design and preparation phase, supported by a behavioural mixed methodology study, a number of behavioural determinants of vaccination demand and acceptance have been identified. In the policymaking at EU level, including behavioural insight at the design and preparation stage is crucial for effective delivery of policy objectives.

Background In June 2017 the Italian government made childhood vaccination mandatory following a drop in immunization rates. In the years preceding, two court judgments affirmed a causal link between vaccines and autism. Studies have linked these decisions to internet searches about vaccine-autism, the popularity of 'no-vax' theories, and drops in immunization rates. This paper provides an in-depth case study of both decisions and their impact. Methods We use a synthetic research design reliant on: (i) a systematic collection of primary sources (publicly available and obtained via official access to information requests); (ii) interviews with key actors prominently involved in the two cases or privy to the Italian vaccine-injury compensation regime (iii) a systematic analysis of media coverage. Results Circumstantial and systemic flaws enabled these decisions. Poor trial strategies, insufficient resources and laborious communication practices between arms of government were facilitators. Lack of awareness of the social sensitivity of vaccine issues, underestimation of the phenomenon of vaccine hesitancy, and a tendency to 'think in silos' informed the lack of attention dedicated to the cases. The decisions created false expectations of economic benefits and vindication for families with autistic children, resulting in increased litigation. Systemic flaws exist in the process of appointment of expert consultants acting for the court leading to judicial reliance on false data. Conclusions Lessons learned include greater levels of attention to vaccine cases by the administration and a matured attitude of adjudicating bodies. Two issues remain: (i) the inability of government lawyers to disseminate positive results to counteract unfounded narratives; (ii) flaws in the process of appointing expert consultants advising courts, which remains focused on the fiduciary nature of the relationship, rather than scientific authority. Key messages The Milan and Rimini decisions that directly affected vaccine governance stemmed from a combination of circumstantial decision-making and systemic flaws that still lurk in public health governance. Strategic decision-making that overlooks lower levels of the adjudicative system can lead to significant public health consequences as courts of law and courts of public opinion obey different logics.

In this talk, EdV will discuss barriers and facilitators to vaccination uptake in a range of diverse migrant groups in Europe, explore the role of vaccine hesitancy in vaccine uptake in migrant populations, and define effective and cost-effective strategies to improve coverage.

Background Infectious diseases are more common and severe in patients with HIV, which show different response to vaccines and a diminished protection. It is therefore very important to assess knowledge and attitudes towards vaccination in people with HIV, since precise vaccination coverage and vaccine hesitancy are not well established in this subgroup of patients. Methods A sample of 119 patients with HIV completed a cross-sectional survey. Patients were recruited during their routine medical examination at the infectious diseases clinic in Turin. The survey explored these main areas: demographics and history of HIV infection, vaccination history, attitudes towards vaccination, confidence in the public health system, contagion risk and disease seriousness perception. In this preliminary phase descriptive analysis were conducted. Results Preliminary data show that mean age of the participants was 49.51 years, 80% were males. The median of HIV infection duration was 10 years, while the median of the lymphocyte count was 762.50 cells/mm3. The disease with the highest vaccination coverage was tetanus (88.7%), considered a serious or very serious disease by 85.6% of the participants, despite low or very low contagion risk perception (84.1%). The disease with the lowest vaccination coverage was Herpes Zoster (7.3%), despite high or very high seriousness perception (70%). Furthermore, 99.1% of the participants showed high or very high confidence toward public health system professionals, and the majority of them (59.5%) stated that vaccines are more useful for the community than for the single person. Conclusions Vaccination coverage is still not fully satisfactory regarding diseases considered infrequent or mild. Considering the high level of confidence toward the public health system that has emerged, it is necessary to implement informative and operative strategies about vaccination for European HIV patients, which are particularly at risk regarding infectious diseases. Key messages Vaccination coverage and risk perception in HIV patients is not satisfactory for many diseases and an effort to implement informative strategies in Europe is needed. The role of vaccination in preventing infectious diseases in HIV patients should be recognized and strengthened by relying on the high level of confidence toward European public health systems.

Background Even though vaccinations are referred to as one of the greatest achievements of modern medicine, they are constantly associated with the mood present in part of society denying their sense and effectiveness. The development of technology has moved discussions about vaccinations to the space of the internet. The study aims to analyze the arguments of vaccine-deniers of children use in social media. Methods All public comments from the leading Facebook page of opponents of vaccination on Facebook were collected, which were available there between 01/05/2019 and 31/07/2019. Then the comments were stored on a Google spreadsheet and analyzed quantitatively in terms of the content according to the modified method developed by Kata (Kata, 2010). Results 18685 comments were analyzed, of which 4042 contained content within the adopted criteria: 28.2% concerned conspiracy theories, 19.9% covered misinformation and based on unreliable premises, 14.0% related to the safety and effectiveness of vaccinations, 13.2% to non-compliance with civil rights, 10.9% own experience, 8.5% of morality, religion, and belief, and 5.4% of alternative medicine. There were also 1223 pro-vaccine comments, of which 15.2% were offensive, mocking or non-substantive. Conclusions A relatively large amount of content concentrated in terms of conspiracy theories and disinformation may indicate that this is a community characterized by a lack of trust in the scientific achievements of medicine. Surprisingly many comments related to one's own negative experiences with vaccinations, which contrasts with official statistics about side-effects. Vaccination promotion should refer to the arguments of vaccination opponents. Key messages The tendency of vaccine-hesitancy is strengthened by 'anti-vaccine' content in social media. To understand the individuals we need to understand what information he daily learns from the internet. It can be hard to maintain herd immunity, due to the prevailing misinformation on vaccination. To overcome this phenomenon, information campaigns must be dependent on the content in social media.

Introduction 'No Jab, No Play' and 'No Jab, No Pay' mandatory immunisation policies were introduced in the state of Victoria and Australia nationally in January 2016. They restrict access to childcare/kindergarten and family assistance payments respectively, for under-vaccinated children. We aimed to describe the proportion of attendees to immunisation services of a tertiary hospital, the Royal Children's Hospital Melbourne (RCH), who were motivated by the policies to discuss or catch up vaccination. We also explored the association between policy motivation, vaccine hesitancy (VH) and intent to seek medical exemption, with vaccine-uptake. Referrals to the Specialist Immunisation Clinic (SIC) were also reviewed. Methods Parents/Guardians and clinicians completed surveys October 2016-May 2017 from the nurse-led immunisation Drop in Centre (DIC) or physician-led SIC. Vaccine-uptake was measured using the Australian Immunisation Register at baseline, 1 and 7 months post-attendance. The association between vaccine-uptake, policy motivation and VH was explored by logistic regression. Results Of 607 children included, 393 (65%) were from the DIC and 214 (35%) SIC. 74 (12%) of parents were motivated by the policies to attend immunisation services and 19% were VH. Only 50% of VH parents planned to catch-up vaccination for enrolment to childcare/kindergarten. Fewer children were fully immunised at 7 months if their parents were VH (difference 18%; OR 0.24, CI 0.1-0.54,p Conclusions The 'No Jab' policies motivated attendance to a tertiary immunisation service but children of vaccine hesitant parents and those seeking medical exemption to immunisation were less likely to be fully immunised post attendance, compared to baseline. These data will be used to inform a comprehensive evaluation of the impact of the policies, particularly the educational impact from loss of early childhood education.

The world is facing multiple health challenges, among those the outbreaks of vaccine-preventable diseases and the rise of anti-vaccination groups. Vaccination is one of the most cost-effective ways of avoiding disease; it currently prevents 2-3 million deaths a year and a further 1.5 million could be avoided if global coverage is improved. Moreover, global immunization will contribute towards achieving broader global health goals under the UHC and SDG initiatives. Barriers to immunization may vary according to the country and specific context ranging from hesitancy, inappropriate communication, lack of resources, access, individual belief, management of adverse events following immunization etc. Vaccine hesitancy threatens to reverse progress made in tackling vaccine-preventable diseases and is listed by WHO in the 10 threats to global health in 2019. Access to vaccinations is sometimes difficult especially in rural areas affecting most vulnerable populations. Immunization history is not always well managed thus affecting the proper vaccination for all ages. Immunization is one of the best uses of limited public funds for health; however, financing for immunizations are often not covering in a sustainable matter the needs. The World Federation of Public Health Associations has developed a high-level “International Immunization Policy Taskforce” on vaccination policies to engage with public health associations, international organizations and like-minded partners to sustain the development, adoption and implementations of key vaccination policies at country level. The taskforce has developed a position paper that will be launched during the workshop to debate about role and responsibilities as well effective approaches to be applied both in developed and developing. The position paper has its roots in vaccination as human right and as a key component of UHC and SGD initiatives. Global immunization is crucial for every individual and the broader community to prevent diseases, promote health and wellbeing and protect the global population as highlighted in WFPHA Global Charter for the Public's Health. Key experts from different parts of the world will discuss strategies and synergies to create a global coordinated advocacy movement to foster engagement for equitable and effective global immunisation by governments and society at large. Key messages Vaccination challenges may vary from developed & developing countries. Responsibility for immunization uptake lies at different levels. Analyses, advocacy, action are key to prevent & face epidemics. Vaccination is not a personal choice rather a political choice. A strong advocacy movement by PHW is key to guarantee the best equitable and sustainable immunization worldwide.

Background and Objectives Migrants are thought to be one of several under-immunised groups in Europe, and involved in outbreaks of vaccine preventable diseases - including the recent large pan-European outbreak of measles. They may be under-immunised because of poor functioning of the health systems in countries they come from, because of barriers to catch-up vaccination and health services on arrival to Europe, and vaccine hesitancy may play a role. Amid substantial migration to Europe in recent years, ECDC public health guidelines for newly arrived migrants to EU/EEA countries have defined new recommendations, including focusing on catch-up vaccination in adult migrants. Yet there is an urgent need to better define what strategies work to improve vaccine coverage and to better understand the views of migrant communities, which will be the focus of this workshop. In this workshop we will explore various facets of migration and vaccination in the European context, and seek audience participation in better defining innovative implementation models and models of best practice to improve vaccine coverage in migrant populations residing in the region. Workshop plan The workshop will start with 15-minute presentations by each of the 4 speakers (to include a short Q&A after each talk). This will then move into a 30-minute audience discussion centred around seeking specific feedback on examples of innovation, good practice, and lessons learned across EU/EEA countries in engaging migrants and improving vaccine coverage in this group. Speakers and topics Sally Hargreaves (St George's, University of London): Are migrants to Europe an under-immunised group and involved in outbreaks? implications for health systems, policy, and practice. Elizabeth de Vito (Università degli Studi Di Cassino e del Lazio Meridionale, Italy) Barriers and facilitators to catch-up vaccination in migrant populations: defining effective and cost-effective implementation strategies. Ines Campos-Matos (Public Health England, UK) Vaccination on the move for asylum seekers and refugees: evidence, policies and practicalities. Christina Louka (University of Groningen, The Netherlands) Perspectives of asylum seekers, refugees, and other migrant groups on approaches to catch-up vaccination on arrival to Europe. Key messages Migrants are likely to be an under-immunised group in Europe, with new ECDC guidelines outlining key recommendations for catch-up vaccination on arrival. There is a need to better define more effective strategies to improve vaccine coverage in migrant populations in Europe.

Background The French National Cancer Control Plan (NCCP) launched in 2014 set the objective to improve human papillomavirus (HPV) vaccination coverage (VC). The NCCP included a measure to integrate a VC indicator in the pay for performance (P4P) scheme for general practitioners (GPs), which was not implemented. The objective of the study was to analyse the reasons for non-implementation of this measure, using the health policy analysis framework. Methods The policy from proposal to non-implementation of the HPV VC indicator into the P4P scheme was analysed through the actors involved, the content of the measure, the contextual factors and the processes of policy-making. Results The actors were the Ministry of Health (MOH) and National Cancer Institute as policy-makers, the public health insurance as an indirect target, and GPs as direct targets. The content of the policy was not evidence-informed and was not included into the NCCP preparation report. The context included vaccine hesitancy and ethical concerns from GPs in opposition with MOH. The process involved a diversity of stakeholders with a complex governance and no strict monitoring of the measure. Conclusions Complex vaccination policy governance associated with a non-evidence-informed policy content and an unfavourable context may have been the reasons for the policy failure.

Digital health has revolutionised healthcare, with implications for understanding public reaction to health emergencies and interventions. Social media provides a space where like-minded people can share interests and concerns in real-time, regardless of their location. This can be a force for good, as platforms like Twitter can spread correct information about outbreaks, for example in the 2009 swine flu pandemic. However, social media can also disseminate incorrect information or deliberately spread misinformation leading to adverse public health sentiment and outcomes. The current issues around trust in vaccines is the best-known example. Vaccine hesitancy, traditionally linked to issues of trust, misinformation and prior beliefs, has been increasingly fueled by influential groups on social media and the Internet. Ultimately, anti-vaccination movements have the potential to lead to outbreaks of vaccine-preventable diseases, especially if refusal is concentrated locally, creating vulnerable populations. For example, 2018-19 saw a large increase in incidence of measles in the US and Europe (where cases tripled from 2017), two regions where the disease was already or almost eliminated. In 2019, the World Health Organisation listed anti-vaccination movements as one of the top 10 threats to global public health. HPV vaccination is another example of the impact of anti-vaccination movements. As viral videos originating on YouTube spread across social networks, uptake has tumbled in a number of countries, with Japan, Denmark, Colombia and Ireland being badly hit. In Japan, the government came under sufficient pressure that they de-recommended HPV vaccine, seeing an 80% uptake rate fall below 1% in 2014. There have been reports of successful interventions by national governments. A recent campaign run by the HPV Alliance (a coalition of some 35 private companies, charities and public institutions) in Ireland has seen rates below 40% back up to a national average of 75%. A combination of hard-hitting personal testimonials, social media and traditional media promoted the HPV vaccine. Despite this, systematic engagement and supranational strategies are still in the early stages of being formulated. As misleading information spread through social media and digital networks has undesirable impact on attitudes to vaccination (and uptake rates), urgent actions are required. Analysis and visualisation techniques mining data streams from social media platforms, such as Twitter, Youtube enable real-time understanding of vaccine sentiments and information flows. Through identification of key influencers and flashpoints in articles about vaccination going viral, targeted public health responses could be developed. This roundtable discussion will showcase different ways in which media and social networks, accessible in real-time provide an opportunity for detecting a change in public confidence in vaccines, for identifying users and rumors and for assessing potential impact in order to know how to best respond. Key messages Social media has significantly enhanced our understanding of anti-vaccination movements and potential impact on public health attitudes and behaviors regarding vaccination. Innovative methods of analysing social media data, from digital health, data science and computer science, have an important role in developing health promotions to counter anti-vaccination movements.

Background The diffusion of false myths and vaccine hesitancy are alarming phenomena in European countries and leads to decreasing trends in infant vaccine coverages. Aim of the study was to analyse the level of confidence and correct awareness about immunization, which are crucial for the success of vaccination programs. Methods As part of the NAVIDAD multicentre study, we examined vaccination confidence and complacency, among a sample of 1820 pregnant women from 14 Italian cities. The questionnaire assessed the interviewee’s knowledge, beliefs and misconceptions, as well as their socioeconomic status, sources of information about vaccines and confidence in the Italian National Healthcare Service. Results Of the participants, only 9% of women completely believed to efficacy, necessity and safety of vaccinations. Almost 20% of them had misconceptions on the majority of the themes. There was a significant difference in level of knowledge considering educational level: women with a high educational level have less probability to obtain a low knowledge score (OR 0.43 [95%CI 0.34-0.54]). The level of knowledge was influenced also by the sources of information: women who got information from General Practitioner and from Institutional Web sites have significantly less chance to have misconceptions (OR 0.74 [95%CI 0.58-0.96]; OR 0.59 [95%CI 0.46-0.74]). Finally, results underlined the influence of trust in healthcare professional information on likelihood of having misconceptions (OR 0.49 [95%CI 0.27-0.89]). Conclusions Data suggest the efficacy of healthcare professionals and Institutional Web sites as source of information to contrast misconceptions and underline the importance of confidence in the healthcare system to increase complacency and confidence on vaccines. Key messages There is a general lack of knowledge about vaccinations among future mothers. Most of misconceptions regarding vaccinations are related to their safety: this could affect confidence and complacency. To increase vaccine confidence, there is a strong need to inform future mothers: our data show the importance and efficacy of Health Professionals and Institutional Web sites as information sources.

Background South-eastern France is marked by insufficient vaccination coverage for several vaccines and some mistrust of its population towards vaccination. In this context and given the application of new vaccination obligations for early childhood, we carried out a qualitative survey to study opinions of parents and health professionals (HPs) on information tools on vaccination (ITV). Methods An inventory of French existing ITV was conducted to select a diverse set of 17 ITV for our qualitative evaluation. In 2018, we carried out 26 individual interviews with parents of young children (recruited in nurseries and kindergartens) and 5 focus groups with HPs (nurses, general practitioners, midwives and pediatricians; n = 33). Results Most parents appreciated videos for their convenience: they used them to discover new/complex subjects in an entertaining way. Paper ITV remained essential mostly among parents with high socio-economic status (SES) or marked vaccine hesitancy, who also requested detailed information and scientific sources. Some parents of low SES considered ITV difficult to understand because of their length, quantity of information and scientific language. For HPs, giving their patients a paper ITV is a way to show the importance they attach to their patient’s questions. HPs reported reluctance using videos during consultations. Some HPs stated their need for guidance on two aspects: 1) key discussion points to use when giving an ITV to parents and 2) most appropriate timing to give ITVs: prescription, injection… Conclusions In the pool of tested ITV, articulation and formatting of arguments are not always optimal for HP and parents use. Tailored ITV should be available for the different needs of HP and parents, especially, for the latter, according to their SES and hesitancy profiles. ITV adapted to use during consultation are necessary. Key messages Information tools on vaccination (ITV) are not always optimal for HP and parents use. ITV should be tested and better adapted to the patient profile and consultation context.

Background Flu vaccination rates among health workers remain low and very variable between European countries despite the recommendations. Medical schools could be the best phase to educate health workers toward flu vaccine. This study aims to evaluate flu vaccine “prejudice” and vaccine hesitancy in medical students (MSs). Methods In 2018/19 flu season a cohort study was conducted at the School of Medicine of Turin, parallel to the flu vaccination campaign. Students were surveyed for sociodemographic variables, knowledge, attitudes and practices toward vaccination, adverse reactions, overall satisfaction toward received vaccination. Data was collected from 377 students. Multivariable logistic regressions were performed. The significance level was p ≤ 0.05. Results Females were 70% and median age was 24 (IQR 22.5-25). The 73.2% of the sample was vaccinated in the campaign, although the 60% of this had never been vaccinated before. Poor knowledge on flu vaccine, both self- and objectively assessed, was associated with lower vaccination rate (OR 0.23, p = 0.006; OR 0.15, p < 0.001 respectively). Vaccination was more likely in those who had been vaccinated in the last 3 years (OR 9.14, p < 0.001). Among non-vaccinated students, most frequent reasons to not undergo vaccination was not feeling at risk of contagion (48%). Vaccine decreased flu prevalence (OR 0.33, p = 0.039). Among vaccinated students, the persuasion that vaccination should be mandatory for health workers (OR 5.91, p = 0.039) was associated with higher vaccine satisfaction score while self-diagnosis of flu was associated with a lower score (OR 0.009, p < 0.001). Conclusions Lack of flu vaccination among health workers increases flu prevalence and multiplies possible carriers in health facilities. European Medical Schools should start yearly vaccination campaigns to promote good habits in MSs. In parallel, more must be done to teach MSs the benefits of flu vaccination and thus increasing willingness to being vaccinated. Key messages Feeling poorly informed and being poorly informed about influenza vaccine significatively decrease likeliness of vaccination in medical students. Students do not feel at risk of contagion. Influenza vaccine uptake is a habitual behavior that should be promoted as early as possible among European health workers, possibly during Medical School.

Background Given geographical disparities in vaccination coverage (VC) and the crucial role general practitioners (GPs) play in vaccination in France, we sought to: 1) determine the existence of geographical variations in GPs' perceptions of vaccines, their trust in information sources, and the frequency of their recommendations to patients by comparing data from southeast (SE), central-west (CW), northwest (NW), and the rest of France; and 2) identify individual and contextual factors associated with regional variations in GPs' recommendations. Methods This cross-sectional observational study in 2014 collected data from a panel of 2586 French GPs in private practice: 3 specific regional samples and a fourth sample for the rest of France. We calculated a composite score summarizing GPs' vaccine recommendation frequency for 6 vaccine situations and used a five-step hierarchical linear regression to study the score's links with practice location and individual and contextual factors. Results GPs' vaccine recommendation frequency score was highest in NW France and lowest in the SE. The low SE score was explained by GPs' greater doubts about vaccine utility and risks and lower trust in information sources. The high NW score was partially explained by greater adherence to guidelines by GPs there. The contextual factors studied did not explain regional differences. Conclusion The geographical variations in GPs' vaccination-related attitudes and practices suggest that vaccine hesitancy among GPs differs in prevalence between regions. These variations coincide with north/south trends in population VC. Intervention strategies to restore confidence in vaccines should target GPs and must be adapted to each regional context.