The increase of life expectancy in Europe renders older people an important proportion of the general population and healthy aging is being increasingly incorporated into modern healthcare systems.
In 2019 persons ≥65 years old accounted for approximately 20% of the European population, and this is expected to increase to approximately 30% by 2050. The region has had a comprehensive adult immunization schedule, which is likely related to lesser vaccine hesitancy as well as larger acceptance for adult immunization.
A 2019 analysis of vaccination policies for adults in 42 European countries revealed that adult immunization programs for adults were in place in all countries.
However, there were considerable differences between countries in terms of number of vaccinations, target populations, etc. Despite the long-standing vaccination programs, large epidemics of measles, mumps, rubella, pertussis and hepatitis A occurred in Europe in the past decade, disproportionately affecting vulnerable communities like the elderly, asylum seekers, refugees and immigrants.
In Denmark’s universal, decentralized health system, Danes are entitled to publicly financed care.
Pneumococcal (PPSV23) and seasonal influenza vaccines are free and recommended for adults over age 65. No other adult vaccines are currently recommended for other adults, with the exception of COVID-19 and catch-up measles vaccine for those born outside Denmark and previously unvaccinated.
On 31 March 2020, the Danish government offered free Pneumococcal(PPSV23) vaccination to all persons aged 65 and above, aiming for a vaccine coverage rate of 75%. By November 2020, less than eight months after the introduction of the universal age-based vaccination program, they had achieved coverage of 59%.
Since 2002, seasonal influenza vaccination has been free to all adults aged 65 and older. In the 2019/2020 season, influenza vaccine coverage among those ≥65 years was only 52%. The coverage still lags far behind the 75% coverage target recommended by the World Health Organization(WHO), which is also the vaccination target in Denmark.
Like other European Welfare States, France has a system of universal health care. This is largely financed by the government through a system of national health insurance.
In France, about 13.4 million individuals over the age of 65 years are considered at risk for adult Vaccine Preventable Diseases(VPDs) – a figure predicted to rise to 20 million by 2050. Despite recommended schedules and evidence on protective effects of vaccination, uptake rates are decreasing in France.
Health insurance is mandatory in Germany. Approximately 86% of the population is enrolled in statutory health insurance, which provides inpatient, outpatient, mental health, and prescription drug coverage.
In Germany, the Standing Vaccination Committee at the Robert Koch Institute (Ständige Impfkommission, STIKO) issues recommendations on vaccination to prevent the occurrence and spread of infectious diseases in the nation’s population. The annually updated vaccination calendar currently includes recommendations for vaccination against diphtheria, tetanus, pertussis, type b Haemophilus, influenza, hepatitisB, poliomyelitis, and pneumococci. Adults should have their Tetanus and Diphtheria(Td) vaccinations refreshed regularly and their pertussis vaccination refreshed once; from age 60 onward, they should be vaccinated against pneumococcal and influenza.
Germany has adopted a risk-based influenza vaccination policy to recommend influenza vaccination in most at-risk groups, including citizens over the age of 60 years, pregnant women, healthcare workers and people with chronic medical conditions such as diabetes, asthma, or cardiovascular disease.
Italy’s National Health Service (Servizio Sanitario Nazionale, or SSN) automatically covers all citizens and legal foreign residents.
In 2017, 10 vaccinations were made compulsory and free of charge for all infants and children up to age 16, though immunization remains voluntary for adults. The Italian National Immunization Plan is considered among the most advanced adult vaccination plans in Europe. However, available data indicate low adherence to vaccination recommendations.
The Italian National Immunization Plan target for influenza vaccination is 75% at minimum and optimally 95%.
Romania has a highly centralized health care system, covering nearly 89% of the population in 2017. Reform in the Romanian health system has been both constant and yet frequently ineffective, due in part to the high degree of political instability. The Romanian population has seen increasing life expectancy and declining mortality rates, but both remain among the worst in the European Union. Public sources account for over 80% of total health financing. In Romania, only one vaccine is currently recommended for adults 65 and older: influenza.
Spain has a strong primary care, which acts as the gatekeeper of the health system. The universal national health system (Sistema Nacional de Salud, SNS) operates in 17 regions and is responsible for care provision.
In 2018, an expert group on adult immunization noted that there is low health care workers and public understanding of the subject, resulting in low coverage. Diphtheria, Tetanus and Pertussis are recommended for citizens over 65 years of age.
This health system overview includes only England, omitting the three other countries that, together with England, form the United Kingdom(UK) of Great Britain and Northern Ireland: Scotland, Wales, and Northern Ireland.
All English residents are entitled to free public health care through the National Health Service(NHS). The NHS is funded primarily through general taxation.
The UK Green Book – the national immunization guide – includes just three routine adult vaccines: pneumococcal polysaccharide vaccine (PPV) at 65 years of age; inactivated influenza vaccine at 65 and older (and for pregnant women and others based on risk); and shingles vaccine at 70.
Influenza immunization has been recommended in the UK since the late 1960s. In 2010, pregnancy was added as a clinical risk category, and in October 2014 the Joint Committee on Vaccination and Immunisation (JCVI) advised that morbid obesity (defined as BMI 40+) should be considered a risk factor for seasonal influenza vaccination. More than 136.39 million doses had been administered, accounting for 76.4% and plus of the population; 47.91 million and plus are fully vaccinated.
Pneumococcal Polysaccharide vaccine(PPV) vaccination is recommended for adults aged 65 and over. Pneumococcal vaccines (PPV and PCV) are also recommended for people of all ages with some health conditions who are at greater risk of complications from pneumococcal disease. Zoster vaccination is recommended and offered free of charge for all people in their 70s. Adults aged 80 or over are not offered the shingles vaccine.
The Belgian health system covers almost the entire population with a large range of services. The provision of care is from independent medical practice, with free choice of physician and care facility, and predominantly fee-for-service payment. Health insurance is compulsory.
Belgium’s approach to vaccination is among the few to evolve a focus on adults. Influenza vaccination coverage in eligible persons is 59.1% and plus. Pertussis vaccine is also recommended for specific high-risk groups in Belgium. Vaccines for Diphtheria, Tetanus, Pertussis, influenza and pneumococcal diseases are recommended for adults.
The Eastern Mediterranean Region(EMR) has seen a remarkable increase in the number of people receiving vaccines in recent years, with more vaccines introduced and more countries eliminating diseases through immunization. More than 470 million children have been vaccinated against measles through supplementary immunization activities, and several countries are making progress toward eliminating measles. The region includes a number of countries wracked by war and conflict, including Afghanistan, Sudan, Somalia, the Occupied Palestine Territory and Yemen.
Vaccine deployment in the Region has reflected regional differences in capacities and resources. High-income countries are quick to vaccinate and have better immunization infrastructures, while low-income countries are slow on the uptake. Having said that, national immunization programs in the Region have achieved some success over the last decade. By the end of 2019, three Eastern Mediterranean Region(EMR) countries (Bahrain, Iran, and Oman) had achieved measles elimination. As many as 3.1 million and plus children remain unvaccinated or under-vaccinated in the Region, and outbreaks of measles and diphtheria have been reported in some countries.
There is limited knowledge about adult vaccinations and the limited data reveals high vaccine hesitancy among adults. Researchers in UAE found that for all the vaccines except pneumococcal and zoster, the recommendation rate (from physicians) decreased as the age increased.
According to WHO, only five of the 22 member states have met the global goal of vaccinating 70% of their populations. The vaccination rates vary hugely from 99% in the United Arab Emirates all the way down to around 2.1% in Yemen.
To establish life-course immunization, policy frameworks need to be adapted, systems to monitor immunization in older age groups expanded, and collaborations to integrate age-appropriate vaccination into public and private health services strengthened.
The South-East Asia WHO region is a region of enormous social, economic, and political diversity, both across and within nations. The through-line between these nations is that it is witnessing dramatic demographic transition, affecting the population growth rate, deaths and births. By 2050, the number of people over 65 years in South-East Asia is expected to double to over 110 million seniors.
Keeping this in mind, in 2020, India launched the National Programme for the Health Care for the Elderly (NPHCE) aimed at delivering affordable and quality geriatric care at primary and secondary levels.
From a public health perspective, it is a challenge to improve elder care-the fastest growing demographic segment-and promote a Life Cycle Inventory(LCI) but the region is well-poised to build on its significant achievements in controlling and eliminating paediatric vaccine-preventable diseases. The region was declared ‘polio-free’ in 2014 and achieved Medical Nutrition Therapy(MNT) elimination in 2016.
Immunization has been a priority for all nations in the South-East Asia region, and political commitment at the highest level has led to great progress over the past decade. The South-East Asia Regional Vaccine Action Plan (SEARVAP) was developed in line with Global Vaccine Action plan(GVAP) to expand region wide access to vaccines. National routine immunization coverage data show that six countries I.e. Bangladesh, Bhutan, Democratic People’s Republic of Korea, Maldives, Sri Lanka, Thailand have achieved and sustained ≥90% Diphtheria Tetanus Toxoid and Pertussis(DTP3) coverage since 2012.
All Thai citizens have access to comprehensive health services under public health insurance schemes. Thailand’s health expenditure as a share of GDP fluctuated in recent years.
The National Immunization Program(NIP) was introduced in 1977, and since 2005 it has consistently achieved around 96–99% immunization coverage among Thai children. Schools provide routine immunization for Human Papilloma Vaccine(HPV) for girls in Grade 5 (11 years of age) and Tetanus and Diphtheria(Td) for both boys and girls in Grade 6 (12 years of age).
Besides paediatric and maternal immunizations, seasonal influenza for pregnant women and older citizens, the Royal College of Physicians of Thailand recommend Pneumococcal vaccine, Hepatitis B and Human Papilloma Vaccine(HPV).
Free influenza vaccination is provided annually to high-risk populations, including persons ≥65 years, persons with chronic illness, pregnant women, persons with obesity and children 6 months to 2 years old. The total number of people eligible for free influenza vaccination is estimated at >20 million, approximately 30% of the population.
Thailand has 76 provinces, with 9,770 primary health centers and 771 community hospitals providing secondary health services and the Bangkok Metropolitan Area, which has 68 public health centers responsible for primary care similar: 39 public hospitals and 92 private hospitals in Bangkok. Immunization is integrated in the primary care units of all public health facilities in Thailand.
Indonesia, a middle-income country, is also witnessing demographic and epidemiological transitions. While maternal and child health and communicable diseases persist, noncommunicable and chronic diseases are emerging as new priorities.
Health indicators in Indonesia have improved significantly over the last 30 years, but spending as a proportion of GDP remains at around 3.3%. The country faces a dual burden of its incidence of Non-Communicable Diseases (NCDs) and communicable diseases and the health system is made up of a mixture of public, private and not-for-profit providers.
The National Immunization Program(NIP) is limited to basic immunization for children: hepatitis B, BCG, polio, diphtheria, pertussis, tetanus, measles, Hib, PCV and uses the pentavalent vaccine distributed by Bio Farma, the national vaccine supplier. Recommendations for adult immunization are limited to Tetanus and Diphtheria(Td) in women of childbearing age.