Vaccination rates across Central and Eastern Europe (CEE) have declined alarmingly across age groups, falling short of the targets set by the World Health Organisation (WHO). For instance, in Romania, measles vaccination coverage fell by 14% between 2019 and 2023 [1]. Romania accounts for 12 of the 14 measles-related deaths reported in the EU, illustrating the consequences of reduced uptake [2]. Seasonal influenza coverage among older adults is also critically low, reaching only 16% in 2023–2024, far below the EU goal of 75% [3].

Across CEE, vaccination rates have fallen amid a widening crisis of public confidence. The pandemic years deepened existing mistrust, particularly among younger and more vulnerable groups, and revealed weaknesses in the way health systems communicate, engage, and deliver preventive services. A combination of misinformation, social and economic inequities, and institutional shortcomings has left many communities uncertain about the value and safety of vaccines, with consequences that extend far beyond COVID-19 to routine childhood immunisation and overall population health.

In response to these developments, this paper examines the Discussions and breakout sessions followed the Chatham House rules - insights have been captured and compiled into an outcome document to be shared with all participants, but individual contributions have not been attributed. This approach ensured full transparency of the outcomes, while creating a safe space for open exchange.

Underlying drivers of declining vaccination confidence and coverage, analyses the structural and socio-economic barriers that continue to restrict equitable access, and identifies practical, community-based strategies to rebuild trust and strengthen service delivery. The paper concludes with targeted policy recommendations for governments, healthcare professionals, civil society, and European institutions, with the overarching aim of promoting coordinated, culturally attuned, and sustainable vaccination frameworks capable of reinforcing public trust and protecting health across all stages of life.

This paper is based on a qualitative synthesis of discussions, presentations, and expert contributions gathered during the international conference bridging the Confidence Gap: Empowering CEE Communities for Vaccination, held in Bucharest in May 2025. The event brought together patient organisations, civil society groups, healthcare professionals, academics, and policymakers from across CEE and beyond. Participants were selected to ensure balanced representation of key stakeholders involved in immunisation policy, research, clinical practice, and patient advocacy. This diverse composition fostered a multidisciplinary and cross-sectoral dialogue on strengthening vaccination efforts in the region.

.Figure 1: Participants At The Conference Bridging The Confidence Gap: Empowering CEE Communities For Vaccination, Held In Bucharest In May 2025.

The methodology involved identifying barriers, collating best practices, and formulating consensus-based recommendations for policy and practice. The analysis draws on secondary evidence, stakeholder expertise, and cross-country comparisons. As part of this process, several best practice examples were identified for their potential to serve as models for replication by other organisations and relevant stakeholders across the region.

Figure 2: White Paper Titled “Bridging the Confidence Gap: Strengthening Equitable Vaccination in Central and Eastern Europe”, 2025.

Selection of Best Practices as Case Studies

The following four case studies – Greece, Italy, Romania, and a Europe-wide collaborative network – illustrate effective approaches to improving vaccine confidence, accessibility, and governance.

Greece exemplifies how coherent governance and sustained investment can secure high and stable vaccination coverage. Through close coordination among public health authorities, general practitioners, and community organisations, the country has maintained rates above 95% for most paediatric vaccines. Consistent funding, clear communication, and equitable access mechanisms have strengthened public confidence and ensured that immunisation remains a routine and trusted component of healthcare for all social groups.

The TuttoVaccini mobile campaign, coordinated by Cittadinanzattiva in Italy, exemplifies the power of community-based engagement. Implemented across ten regions, the initiative mobilised pharmacists, general practitioners, and local volunteers through information caravans that combined the distribution of educational materials with open public dialogue. Citizens were encouraged to share experiences and concerns through civic questionnaires, and the campaign promoted the Charter of Rights for Vaccination Services, helping to raise awareness of patient entitlements and reinforce vaccination as a shared societal responsibility.

Figure 3: Poster and Setting of Tuttovaccini in Italy, 2025.

In Romania, the Coalition of Patients’ Organisations with Chronic Diseases (COPAC) has emerged as a key advocate for equitable vaccine access. It was among the first NGOs to call for the inclusion of vaccines in the list of reimbursed medicines for patients with chronic conditions, a policy milestone achieved in 2023. Beyond this achievement, COPAC has led initiatives such as patient support groups where vaccination is discussed openly, health education campaigns in vulnerable communities, and ongoing advocacy with public authorities. These activities demonstrate the dual role of patient organisations as trusted community intermediaries and effective policy advocates.

Figure 4: Information Guide for the Vaccination of Chronic Patients (Children and Adults) Created by COPAC, 2019 & David’s Journey in Vaccination World (Guide for Vaccination of Children), 2022.

Moreover, the case of COPAC demonstrates that consolidation into broader coalitions can markedly improve the effectiveness of patient advocacy. Through uniting individual patient associations and integrating into European-level bodies like the European Patients’ Forum and the EU Working Group on Respiratory Care, such structures amplify representation, facilitate knowledge exchange, and increase policy influence.

The Vaccination Informal Platform (V.I.P.) for life-course immunisation promotion, a collective of leaders of patient and citizen organisations across Europe promoted by Active Citizenship Network, the EU branch of Cittadinanzattiva, has united to strengthen the exchange of experiences among the many expressions of active citizenship working to support public vaccination policies. The platform – a collaborative network of NGOs from more than ten EU countries – facilitates the identification of shared challenges, the development of joint advocacy tools, and the promotion of EU-level policies supporting life-course immunisation. Through cross-border cooperation, V.I.P. enhances the collective influence of civil society and strengthens its contribution to shaping inclusive vaccination policies across Europe. The ultimate goal is to update a narrative that, when it comes to vaccination, almost never refers to the active role of civil society organisations and patient advocacy groups, instead focusing mainly on hesitant or even hostile attitudes toward vaccines, which, though present, do not represent the whole picture. Many intermediary civil society actors can play a constructive role with institutional and non-institutional stakeholders, as well as act as a driving force for other organisations.

Vaccine Confidence and Barriers to Vaccination in CEE

Across CEE, confidence in vaccination has been steadily eroding, most notably among adults under 35. This generational shift, accelerated by the COVID-19 pandemic, has revealed structural and communicative weaknesses across health systems and left space for misinformation to flourish. As trust in public institutions waned, routine childhood immunisation rates declined sharply. What began as a communication challenge has become a complex, systemic threat to public health.

Individual and Social Drivers of Vaccine Hesitancy

Vaccine confidence in CEE is shaped by a combination of historical, cultural, and informational dynamics. Public health communication is often inconsistent, overly technical, or detached from local realities, leaving citizens without clear, relatable messages. This vacuum has been filled by misinformation and conspiracy narratives circulating rapidly through social media ecosystems where low media literacy limits critical evaluation.

Empirical evidence illustrates the scale of the challenge. In Poland, 85% of Facebook comments on vaccination expressed opposition, most citing distrust in government and concerns about side effects [4]. Studies confirm that individuals relying mainly on social media are nearly twice as likely to exhibit vaccine hesitancy as those using verified information sources [5], and exposure to sceptical content can suppress vaccination intent forty-six times more effectively than fact-checked materials. A single misleading headline suggesting a doctor’s death after vaccination had over 55 million views [6].

Generational differences further complicate the picture. According to The State of Vaccine Confidence in the EU 2022, overall confidence has returned to pre-pandemic levels, but the gap between younger and older adults has widened [7]. Younger cohorts, the most active online, are more exposed to conflicting or polarised narratives and increasingly view vaccination through a lens of institutional distrust. Low health literacy, limited access to comprehensible information, and a longstanding scepticism toward government, rooted in inconsistent policy and underfunded health systems, further undermine trust.

Social influences reinforce these behavioural patterns. In many communities, vaccination decisions are guided more by family beliefs and social norms than by medical evidence. Persistent anxieties regarding vaccine safety, particularly around novel technologies, continue to deter uptake. A widespread misconception that vaccination in childhood ensures lifelong protection contributes to the neglect of adult immunisation across the region.

Systemic and Structural Barriers to Immunisation

Even when vaccines are available, multiple structural, organisational, and socioeconomic barriers limit access. Health system fragmentation impedes efficient delivery, especially in rural and underserved areas, while stockouts, inadequate cold-chain capacity, and inflexible service hours restrict continuity. Out-of-pocket costs and the absence of universal reimbursement discourage uptake, particularly among low-income families. Weak integration with primary care and underdeveloped digital infrastructure hinder outreach, follow-up, and real-time data collection.

The WHO Tailoring Immunisation Programmes (TIP) framework [8] and Kaufman et al. [9] identify six main categories of barriers, each clearly visible in the CEE context:

Access Barriers

Geographic isolation, financial limitations, and structural inequality restrict service availability.

Health System Barriers

Fragmented delivery, vaccine stockouts, and inconvenient operating hours reduce efficiency.

Concerns and Beliefs

Cultural mistrust, fear of side effects, and exposure to misinformation weaken confidence.

Perceptions and Experiences

Negative encounters with healthcare providers discourage future engagement.

Knowledge and Information Gaps

Low health literacy and scarce exposure to accurate sources hinder informed decision-making.

Social and Familial Influence

Peer pressure, religious norms, and community narratives shape vaccination behaviour.

These factors interact dynamically, often reinforcing one another. Limited data systems obscure gaps, preventing timely intervention, while the lack of routine adult vaccination policies impedes the transition toward a life-course immunisation model.

Marginalised and minority communities face additional, intersecting barriers. Roma populations, for example, continue to experience discrimination, exclusion, and deep-rooted distrust toward institutions. Poverty, housing insecurity, and low educational attainment intersect with language and cultural barriers to limit access and engagement. Health literacy gaps heighten susceptibility to misinformation, while the absence of culturally adapted materials alienates entire communities. The result is persistently lower vaccination coverage and higher disease incidence among populations already burdened by poor health outcomes.

The COVID-19 Pandemic as an Accelerator

The pandemic acted as a catalyst for many of these pre-existing vulnerabilities. Social media platforms such as Facebook and Twitter amplified emotionally charged content that frequently overshadowed scientific communication [10]. Reactive measures like “debunking” and “prebunking” proved insufficient, particularly in a highly politicised and emotionally polarised environment [10]. Inconsistent or politically influenced messaging further weakened institutional credibility, enabling anti-vaccination sentiment to spill over into routine immunisations, including influenza and childhood vaccines, and jeopardizing broader public health objectives [11].

Consequences for Health Systems and Equity

Declining confidence and systemic barriers now threaten both public health outcomes and health system resilience. As vaccination rates fall, preventable diseases resurface, placing additional strain on already stretched healthcare infrastructure. Outbreaks divert resources from other priorities and widen inequalities between urban and rural or privileged and marginalised populations. In the long term, the erosion of vaccine confidence threatens herd immunity and risks reversing decades of progress in disease prevention and population health across CEE.

Local Level: Implementation and Community Engagement

Healthcare Professionals

Vaccine-related communication should be integrated into routine medical practice, supported by continuous professional training in empathetic dialogue and strategies for addressing sensitive questions. Healthcare professionals who are themselves hesitant require targeted support through educational materials, mentoring, and opportunities for exchange with experts. Specialist physicians also have a critical role to play by actively promoting and recommending vaccination within their fields. Beyond the clinic, healthcare providers should be engaged in community campaigns in collaboration with NGOs and local authorities, reinforcing their position as trusted advocates for immunisation. Coordinated partnerships between providers and community organisations can ensure consistent messages and better reach.

Civil Society and NGOs

Strengthening community engagement requires the creation of local networks of vaccination ambassadors composed of patients, community leaders, and healthcare professionals who can act as trusted messengers. Health literacy initiatives should be developed in ways that are culturally and linguistically adapted to the needs of diverse populations. Monitoring vaccination services from the patient’s perspective is also vital, enabling the identification and reporting of inequities in access and delivery. In addition, cross-border collaboration with similar organisations across CEE can facilitate the exchange of best practices and support regional solidarity in addressing shared challenges.

While community-level initiatives are critical for restoring trust, their long-term sustainability depends on coherent national policies and adequate resourcing.

National Level: Policy, Financing and Governance

Strategic Policy Design

National immunisation strategies must be updated and expanded to place stronger emphasis on paediatric vaccination as a cornerstone of public health, while embedding childhood immunisation within a broader life-course framework that ensures continuity into adolescence and adulthood. Governments should align education, digital, and health policies to integrate vaccination into schools, digital health records, and family care planning. Achieving this requires stronger interministerial coordination, particularly between health, education, and digitalisation ministries, to ensure effective rollout and long-term sustainability.

Financing and Infrastructure

Significant and sustained investment in cold chain logistics, data systems, and vaccine procurement is essential to guarantee reliable access across CEE. Funding should prioritise equity-based approaches, directing resources toward rural and vulnerable populations most affected by gaps in coverage. Strengthening primary care services through increased staffing, infrastructure, and outreach capacity is critical to sustaining routine immunisation. Public financing must also support culturally competent outreach programs, communication campaigns, and provider training, addressing vaccine confidence issues as a systemic challenge rather than a series of isolated interventions.

Governance and Accountability

National authorities should introduce performance-based indicators and accountability frameworks for local health authorities and service providers to strengthen responsibility for vaccination outcomes. Incentive structures, whether financial or reputational, can encourage higher-performing providers and motivate improvements in areas with persistently low coverage. Accountability must also be tied to routine public reporting, enabling stakeholders to track progress and advocate for corrective measures where needed. Civil society organisations have an important role to play in this process by monitoring implementation, highlighting equity gaps, and co-creating solutions together with policymakers.

European and Regional Level: Coordination and Support

Regional coordination and EU-level action are essential to sustain national reforms and address shared challenges across borders. Policy action should include financial support for pilot projects that focus on community mobilisation within the CEE region, enabling innovative approaches to be tested and scaled. An early warning mechanism is also needed to detect and counter disinformation campaigns before they erode public trust. In parallel, a common culture of vaccination should be promoted through educational platforms and legislative initiatives that emphasise prevention as a shared societal value.

The decline in vaccination confidence and access across CEE is a complex and urgent public health challenge. Driven by widespread misinformation, institutional distrust, and systemic barriers in healthcare delivery, this erosion of trust threatens to reverse decades of immunisation progress and expose communities to resurgent disease outbreaks. Younger generations are increasingly disengaged from vaccination narratives, while vulnerable populations face persistent access inequities due to financial, geographic, and cultural barriers. In parallel, health systems in the region remain under-resourced and unevenly equipped to deliver routine immunisations at scale.

Addressing this crisis requires more than isolated interventions. It demands a coordinated, multistakeholder approach that mobilises national authorities, healthcare professionals, civil society, European institutions, and actors alike. Solutions must be community-centred, culturally informed, and sustained over the long term, including harmonizing data, policy changes, and civil society initiatives. Failure to act will result in deeper trust deficits, lower immunisation rates, and preventable suffering, particularly among children. Strengthening vaccine confidence and ensuring equitable access must become top priorities for public health policy across the CEE region to safeguard population health and restore public trust. Rebuilding vaccine confidence across CEE is not only a matter of communication, but a fundamental investment in public resilience and equity.

Declarations

Each of the authors confirms that this manuscript has not been previously published by another international peer-review journal and is not under consideration by any other journal. Additionally, all the authors have approved the contents of this paper and have agreed to the submission policies of the journal.

Authors’ Contribution and Conflict Of Interest

Each named author has substantially contributed to drafting this manuscript. Additionally, to the best of our knowledge, the named authors have no conflict of interest, financial or otherwise.

Acknowledgments

The authors would like to thank all the following organisations and experts who contributed to the May 25, 2025 Bucharest event, and to the development of this paper. Their insights and experiences were invaluable in shaping the recommendations.

List of Organisations

• Aristotle University of Thessaloniki, Greece
• Cittadinanzattiva, Italy
• Clinical Emergency Hospital “Prof. Dr. Agrippa Ionescu”, Romania
• Faculty of Medicine of University of Belgrad, Serbia
• Family Physicians Association Bucharest, Romania
• International Longevity Centre, UK
• Medical University of Warsaw, Poland
• National Institute of Paediatrics “Heim Pal” Budapest, Hungary
• National Institute of Public Health, Romania
• National Society of Family Physicians, Romania
• Romanian Society of Paediatrics
• Romanian Society of Pneumology
• Jude Children's Research Hospital, Memphis, USA
• University of Medicine and Pharmacy “Carol Davila”, Romania
• World Health Organisation-Romanian Office

List of Experts

Dr. ALEXIU Sandra, Prof. Dr. ANTACHOPOULOS Charalampos, Dr. BERBECEL Cosmina, Dr. CLARINVAL Caroline, Prof. Dr. FURTUNESCU Florentina, Prof. Dr. GHEORGHI?? Valeriu, Prof. Dr. MARKOVIC Milos, MATEESCU Barbu, Prof. Dr. MESZNER Zsofi a, Prof. Dr. MIH?L?AN Florin, Lecturer Dr. MITRAN Mihai, Associate Prof. Dr. NITSCH OSUCH Aneta, Dr. PÂRVU Simona, Prof. Dr. PLE?CA Doina, Dr. RAMILO Octavio, SINCLAIR David.

Funding Information

The conference and the development of this paper have been unconditionally supported by a financial grant from Pfizer.

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