In the current transition to a new phase of the pandemic, it is crucial to act fast and together, and to use the summer window to prepare for possible future pandemic surges next autumn/winter and beyond.
We no longer have only the flu to consider. In fact, we have a trio of vaccine-preventable respiratory diseases (VPRDs), and we need to ensure that pneumococcal pneumonia, Covid-19 and influenza are all on the radar of health institutions.
These diseases place a burden on health systems: every year, VPRDs result in significant illnesses and high levels of hospitalisations in vulnerable populations, putting additional pressure on already strained healthcare systems[1] [2] [3].
For example, community-acquired pneumonia (CAP) is a leading cause of hospitalisation in adults, with the average estimated hospital stay due to the condition at over 12 days, according to a pre-pandemic study across 10 European countries[4].
Alongside the immediate impact on hospital bed capacity, VPRDs can cause ongoing complications: an episode of CAP has been reported by patients to worsen existing health conditions such as COPD, asthma, and high blood pressure[5], and may put patients at risk of serious cardiac events[6].
Long-term sequelae of VPRDs, including pneumonia and flu, have also become increasingly scrutinised as a result of ‘long-COVID’ symptoms following COVID-19 infection. Extra-pulmonary complications, including cardio- and cerebrovascular events, represent a potential long-term burden of disease following flu infection[7].
What do citizens know about pneumococcal vaccination?
Are we doing enough? What is the situation among the European countries? In Italy, for instance, a recent survey carried out by the Italian NGO Cittadinanzattiva revealed a low level of information and awareness of pneumococcal vaccination, territorial discrepancies in vaccination strategies, and lack of monitoring and transparency on vaccine coverage rates.
According to the survey “Pneumococcal vaccination in adults: proposals for fair and informed access”[8], in the 2021-2022 winter season, among those interviewed in Italy by Cittadinanzattiva, one in two citizens had not received pneumococcal vaccination. Among the main reasons given for this were: it was not proposed to me (62.7%), and I have no idea what it is (17.9%).
Approximately 34.5% reported having been contacted only for the flu shot and Covid-19 vaccination. Only 1.8% of those eligible for the flu vaccine received an official communication from the ASL (Italian Local Health Authority Unit) inviting them to receive pneumococcal vaccination.
The Covid-19 pandemic has seen a decline in vaccinations across all age groups; data on vaccination coverage in adults and at-risk groups are not systematically collected, unlike what happens for vaccinations in childhood and adolescence and flu shots.
General practitioners play a central role in adult vaccination. In 65% of cases, GPs were the main source of information on recommended and free vaccinations (e.g. vaccines against pneumococcal disease, flu, and shingles) — however, 27% of citizens also rely on institutional websites or specialist doctors and pharmacists (22.8%). The family doctor, in 92.7% of cases, proposes pneumococcal vaccination verbally during a visit and only 44.7% do so by phone. Flu shots and pneumococcal vaccination were not offered together in 22.5% of cases.
Recommendations at the national level
Vaccinations are not just about kids and teenagers. It is in the individual’s and community’s interests to develop concrete health policies for adults and people with preexisting conditions. For this reason, uniform and planned monitoring of pneumococcal coverage in adults is immediately necessary in Italy and across Europe.
At the same time, however, work has to be carried out on extending the access points to vaccination through the signing of a national agreement with GPs that contributes to countering territorial discrepancies.
We must also implement common intervention strategies at a national level, involving pharmacists as an additional point of pneumococcal vaccination administration; asking all specialists (pneumologists, diabetologists, oncologists and others) – to encourage patients to consider pneumococcal vaccination as a means of protecting their health; and including the pneumococcal vaccination in Italian PDTAs (Diagnostic Therapeutic Assistance Pathways) to facilitate and simplify access for chronic patients.
It is vital to recognize the role of patients’ and citizens’ associations in building confidence in vaccination and sharing accurate information. Communication campaigns can help to improve pneumococcal vaccination while greater health literacy also has a role to play.
What role will adult vaccinations play in the Council Conclusions?
The Italian experience with pneumococcal vaccination has highlighted key action areas which point the way forward in Italy as well as across the EU.
To reinforce these recommendations, the survey was also presented at the European level in July at an event hosted by Active Citizenship Network, the EU branch of Cittadinanzattiva. The meeting, entitled ‘Towards the next Council conclusions: which role of adult vaccination?’ is part of the VaccinAction2022 project and featured contributions from the European Commission as well as representatives of health professionals, patients and citizens.
EU health ministers will meet later this year, under the Czech Republic’s Presidency of the European Council, to discuss EU Institutions’ commitment to vaccination. Participants highlighted the need to consider life-course vaccination in these policy discussions. Panellists called on governments to prioritise immunisation for all vaccine-preventable diseases to help ensure protection of the most vulnerable and reduce the burden to healthcare systems.
To achieve this, we urge governments to:
- Commit to maintaining and evolving National Immunisation Plans by improving uptake of existing vaccines and the incorporation of novel ones
- Review, protect and expand budgets for ongoing and novel immunisation programmes, especially for diseases where current recommended targets are not being met
- Build processes into ongoing mass vaccination against Covid-19 to check the broader vaccination status of adults, particularly against VPRD
- In line with calls by the International Pharmaceutical Federation (FIP)[9] to expand pharmacists’ scope of practice[10], we urgently request that governments update legal and regulatory requirements to enable pharmacists to vaccinate eligible patients against all vaccine-preventable respiratory diseases, to protect vulnerable populations and strengthen health system capacity
- To support accessibility and uptake, governments and healthcare professionals should seek to improve communication on immunisation, providing clear and targeted communications that respond to local contexts.
Our shared hope is to not waste the window of opportunity of the summer to take urgent action ahead of winter 2022/23 to invest in healthcare infrastructure and strengthen immunisation programmes. If we take the right action now, we can protect populations and healthcare systems in future.
Mariano Votta, Director, Active Citizenship Network
[1] Morbey RA, Elliot AJ, Harcourt S, et al. Estimating the burden on general practitioner services in England from increases in respiratory disease associated with seasonal respiratory pathogen activity. Epidemiol Infect. 2018;146(11):1389-1396.
[2] Choe YJ, Smit MA, Memel LA. Seasonality of respiratory viruses and bacterial pathogens. Antimicrob Resist Infect Control. 2019;8:125.
[3] Smith S, Morbey R, Pebody RG, et al. Retrospective observational study of atypical winter respiratory illness season using real-time syndromic surveillance, England, 2014-15. Emerg Infect Dis. 2017;23(11):1834-1842.
[4] Ostermann H, Garau J, Medina J, Pascual E, McBride K, Blasi F; REACH study group. Resource use by patients hospitalized with community-acquired pneumonia in Europe: analysis of the REACH study. BMC Pulm Med. 2014;14:36.
[5] Wyrwich KW, Yu H, Sato R, Strutton D, Powers JH. Community-acquired pneumonia: symptoms and burden of illness at diagnosis among US adults aged 50 years and older. Patient. [2013] ;6(2):125-134.
[6] Musher DM, Rueda AM, Kaka AS, Mapara SM. The association between pneumococcal pneumonia and acute cardiac events. Clin Infect Dis. [2007];45(2):158-165
[7] Sellers, Subhashini A., et al. “The hidden burden of influenza: a review of the extra-pulmonary complications of influenza infection.” Influenza and other respiratory viruses 11.5 (2017): 372-393.
[8] The survey “Pneumococcal Vaccination in adults: proposals for fair and informed access. Focus on adults ≥ 65 years and subjects with pathologies or predisposing conditions” was conducted by Cittadinanzattiva with the unconditional contribution of Pfizer and presented last 27 May 2022 in Rome. www.cittadinanzattiva.it/multimedia/files/Report_vac_antipneumo_final_25_maggio.pdf
[9] FIP (2020). Intervention on provisional agenda item 3. Address by Dr Tedros Adhanom Ghebreyesus, Director-General, 73rd WORLD HEALTH ASSEMBLY, Speaker: Ms Zuzana Kusynová, from the International Pharmaceutical Federation (FIP). www.fip.org/files/content/publications/2020/FIP_ intervention_on_3_Address_by_WHO_DG_final.pdf Accessed 02 03, 2022.
[10] FIP (2020). FIP calls for governments to support pharmacists and pharmacy workers on COVID-19 front line. https://www.fip.org/press-releases? press=item&press-item=66 Accessed 02 03, 2022.
