In the pre-election debate, the health of European citizens was not at the forefront of the agenda for most current policymakers or those running as candidates, with some exceptions. Paradoxically, it could almost be said that the end of the COVID-19 health emergency has created a kind of setback, as attention has shifted away from the unmet health needs of many Europeans.

At a time when European citizens have high expectations of their health systems, the complete absence of new health initiatives in the State of the Union address [1], delivered by the President of the European Commission in September 2023, drew widespread criticism.

To be fair, it must be acknowledged that the outgoing European Institutions were among the most active in addressing the health of European citizens, albeit out of necessity. No one will ever forget the extraordinary challenges faced during the pandemic, and credit must be given where it is due.

However, Civil Society Organizations (CSOs) and Patients’ Advocacy Groups (PAGs) hope that the new European Institutions will match, or even exceed, this commitment—not out of necessity but as a deliberate choice. The health of all 450 million European citizens deserves proper attention from those entrusted to make decisions on their behalf.

Figure 1: Participants to the Initiative “Active Citizens in Europe Advocate for (Adult) Vaccination” Organized In Brussels (Belgium) On 25th June, 2024.

The Vaccination Informal Platform (V.I.P.) for promoting life-course immunization, a network of leaders from patient and citizen organizations across Europe facilitated by Active Citizenship Network [2], the European arm of the Italian NGO Cittadinanzattiva [3], has come together to foster the sharing of experiences among various active citizenship groups dedicated to supporting public vaccination initiatives. The ultimate goal is to update a narrative that, when it comes to vaccination, rarely refers to the active role of Civil Society Organizations and Patient Advocacy Groups, instead focusing mainly on hesitant or even hostile attitudes toward vaccines, which, though present, do not represent the whole picture. There are many of actors from the intermediated bodies of the society that can play a constructive role with institutional and non-institutional stakeholders, as well as act as a driving force for other organizations.

To date, the V.I.P. collective has convened two in-person meetings in Brussels, supported by preparatory work and a comprehensive literature review. These gatherings have provided a valuable platform for collaborative discussions on the unmet needs of the patients they represent, while also reiterating—particularly in front of the new EU Institutions—the pivotal role of prevention in general, and routine immunization in particular. Studies indicate that every euro invested in preventive healthcare generates a 14-euro return, with adult immunization returning up to 19 times the initial investment [4].

The premises is that all the associations involved in V.I.P. strongly believe in the key role of the European Institutions for the well-being of all the population and reaffirm their commitment to supporting public policies that prioritize the health needs of European citizens. In doing so, these associations base their actions on the European Charter of Patients' Rights [5], which lists 14 fundamental patients’ rights (plus three Rights of Active Citizenship) that each EU country must protect and guarantee. Drafted in 22 languages, it has become a reference for EU citizens’ rights in healthcare and a milestone for other EU Charters [6]. All these rights, based on the Charter of Fundamental Rights of the European Union (Art. 35) [7], are crucial in matters of European citizenship and healthcare services.

An initial draft document on vaccination promotion from the citizens' perspective was prepared by Active Citizenship Network (ACN) for an extensive discussion that took place during the meeting in Brussels on June 25, 2024, titled “Active Citizens in Europe Advocate for (Adult) Vaccination”, attended by 13 leaders of civil and patients’ associations across 12 countries [8]. In particular, the leaders and representatives of the following organizations were concretely involved: Council of Representatives of Patient Organisations of Lithuania, Lithuania; Malta Health Network (MHN), Malta; CyFPA - Cyprus Federation of Patients' Associations, Cyprus; Niederösterreichische Patienten- und Pflegeanwaltschaft, Austria; My Child-My Heart Association (ACMIM) - Coalition of Chronic Diseases Patients Organizations (COPAC), Romania; Bulgarian Association for Patients' Defense, Bulgaria; Hellenic Liver Patient Association “Prometheus”, Greece; Health Diplomacy Unit, Croatia; Foundation Institute for Patients' Rights and Health Education,                Poland; Irish Patients Association, Ireland; EPECS, The Netherlands; euPrevent Foundation, The Netherlands; Cittadinanzattiva, Italy.

Following an extensive feedback collection process conducted over the summer break and throughout September 2024, the second meeting, titled “Vaccination Informal Platform (V.I.P.) for Life-Course Immunization Promotion: Focus on VPRDs—Flu, Pneumococcal Pneumonia, RSV” [9], was held in a hybrid format. During this event, the final document was completed in the form of a Policy Brief titled “10 Policy Recommendations for Promoting Vaccination: The Citizens' Perspective for the New EU Institutions.” Leaders from the following organizations participated in person at this second meeting: Plataforma de Organizaciones de Pacientes (POP), Spain; Malta Health Network (MHN), Malta; Bulgarian Association for Patients' Defense, Bulgaria; Health Diplomacy Unit, Croatia; Foundation Institute for Patients' Rights and Health Education,                Poland; Irish Patients Association, Ireland; DKC - Kultlab Celje Society, Slovenia, Niederösterreichische Patienten- und Pflegeanwaltschaft, Austria; EPECS The Netherlands , Cittadinanzattiva, Italy. While representatives from STOMlife foundation, Poland; Association of Patients with Cardiovascular Diseases, Bulgaria; The Innovations Institute, Bulgaria; Institute of Research for Innovation and Development (IMKKA), Greece; National Patients' Organisation, Malta; euPrevent, The Netherlands; Prometheus, Greece, joined online.

Once the document was drafted, it was sent for review to a number of associations, which quickly expressed their formal endorsement of the initiative.

Figure 2: The Save the Date of the Initiative “Vaccination Informal Platform (V.I.P.) For Life-Course Immunization” Organized In Brussels (Belgium) On 15th October, 2024.

“10 Policy Recommendations for Promoting Vaccination: The Citizens' Perspective for the New EU Institutions”

Starting from the end of 2024, the following 10 Recommendations are being promoted and brought to the attention of the members of the European Commission DG Santé [10] and the European Parliament (ENVI Committee and Subcommittee SANT) [11], with the intent of presenting it as a subject for reflection and encouraging deeper involvement of CSOs and PAGs in vaccination issues at the EU level.

Figure 3: “10 Policy Recommendations to Promote Vaccination”, Edition 2024.

Promoting Life-Course Immunization Culture in the EU

Vaccination across the life course remains one of the most relevant public health inventions in history [12] and can be considered as an important patient’s right related to safety, quality, and prevention.  Boosting human papillomaviruses (HPV) and Hepatitis B virus (HBV) vaccination uptake can help prevent cancers caused by these viruses, save lives, and also reduce the pressures on health systems. Although immunization is a key action within the public health agenda of health promotion and prevention, life course immunization has not been a priority for governments around the world [13]. Ensuring EU cooperation to monitor global health threats and quickly share information, research, and solutions is a key element in preventing future pandemics and effectively managing global health threats. Through coordinated actions, information exchange, and joint research, it is possible to respond more effectively to health threats and create more effective preventive and intervention strategies.

In particular, Members of the EU Parliament (MEPs) are strongly encouraged to join the newborn informal “Interest Group on Life Course Immunisation” [14] as well as the MEPs Interest Group "European Patients' Rights & Cross-Border Healthcare" that - promoted since 2014 - has undoubtedly been the MEPs Interest Group that has been most active on vaccination policy issues within the EU Parliament [15].

Recognize and Reinforce the Involvement of Csos and Pags in Adult Vaccination

CSOs and PAGs have been continuously demonstrating that they view adult immunization as very important but are often limited by budgets and funding opportunities to further their advocacy work. CSOs and PAGs are often trusted sources of information and help to inform the decisions of their constituents and members with advocacy and policy-based strategies [16].

The concrete involvement of citizens and patients within their organizations in vaccination policies and decision-making processes is crucial also to addressing public concerns and fostering trust. This includes also non-governmental organizations (NGOs) and non-health-related CSO’s in order to reach out to marginal and vulnerable groups who would benefit from adult vaccination programmes such as migrants, persons with mental health issues, homeless or institutionalised persons, etc.

Produce and Collect Good Quality and Timely Data and Evidence for Decision-Making

Immunisation systems depend upon good quality and timely data and evidence to inform and adapt vaccination policies and programmes. As the aims and scope of National Immunisation Programs (NIPs) expand, and as new challenges emerge, demands for new data and evidence also arise. That is the case, for example, with the shift towards life-course immunisation, requiring assessment and evaluation of the impact of vaccines and vaccination on healthy ageing as well as productivity.

Facilitate Citizens’ Access to Vaccines

Increasing citizens’ access to vaccines in a timely manner in relation to the availability of vaccines, the accessibility of vaccination services, and vaccination equity is of extreme importance (such as equal access to healthcare through free vaccinations). A policy action is needed to: (a) enable faster population access to vaccination by improving the timeliness of decision-making; (b) widen the provision of vaccination services beyond traditional healthcare settings – for example, in schools, workplaces, and community pharmacies; (c) develop and implement strategies to improve access to vaccination for disadvantaged groups [17].  Work on the development of effective reminder systems that inform vaccinated individuals about the need to complete vaccinations or receive a booster dose.

An example on how to use digitalization to facilitate access: a simple and comprehensive portal where you can find the vaccination centres that best suit your needs, updates on vaccination campaigns in your region, and all the useful information on vaccinations [18].

Increase the Role of Community Pharmacies in Vaccine Delivery

Pharmacies are often more accessible than doctors’ surgeries, and can play an active role in delivering vaccinations and to shorten the vaccination process. Governments and healthcare organisations must increase the role of pharmacies in vaccine delivery to ensure that vaccinations are “easy to reach”, and accessible to populations that are affected by poverty and social exclusion [19].

Advance Vaccination Equity in Europe

Despite being a “high-income” region globally, Europe has large pockets of health disparity and inequity, particularly in urban and suburban populations experiencing poverty, and in remote/inner/rural areas.

Given the challenges faced also by the population in border regions, we are in favour of coordinated actions among neigh boring regions and countries. An EU-wide coordinated vaccination registration system is suggested, respecting the subsidiarity principles of the EU, which at the same time by using the same system, facilitates infectious disease control among e.g. cross-border workers, and immigrants.

In line with the European Immunisation Agenda 2030 [20], it is important to improve attention to vaccination equity as part of EU-funded programs. The European Union should, via its different funding programs, better integrate equity considerations as part of current and future initiatives on vaccination, either as specific programs or as new features within on-going ones. The intersections between poverty, social exclusion and vaccination must be better mapped at the EU level [21].

Support the Efforts to Prevent Cancer through Vaccination

European institutions are called upon to support the recent recommendation by the European Commission aimed at assisting Member States in their efforts to prevent cancer through vaccination [22].

The recommendation focuses particularly on promoting adherence to two key vaccinations capable of preventing viral infections that can cause cancer - Human Papillomavirus (HPV) and Hepatitis B Virus (HBV) - and on improving the monitoring of vaccination coverage rates. The recommendation is part of the European Cancer Plan [23], a fundamental pillar of the European Health Union. It is estimated that around 40% of cancer cases in the EU are preventable. However, according to a new report [24], in 2021 EU Member States allocated only about 5% of total health expenditure to prevention.

Strength Fight against Dis- & Mis-Information

The Covid-19 pandemic demonstrated the threats and challenges of mis- and disinformation for society. To counter the ensuing risks to human health, health systems, and effective crisis management, the 2022 “Council Conclusions on vaccination as one of the most effective tools for preventing disease and improving public health” [25] invite, amongst others:

To strengthen the coordination between EU policies on vaccination and on fighting disinformation

Develop training opportunities for health professionals to become more versed in techniques and tools for countering vaccine mis- and disinformation (in particular GPs and midwives should be helped to address vaccination adequately in the interaction with their patients.)

To establish an expert forum on vaccine hesitancy (in which, CSOs & PAGs request that the representation of civil and patient associations, as well as civil society in general, be guaranteed).

In addition to what is already included in the aforementioned Council Conclusions, the following should be added:

Increase training for those (like CSOs & PAGs) who advocate for vaccinations and interact directly with citizens on how to address people who are hesitant, with a focus on negotiation and moderation skills for conversations about vaccines.

The provision of information (f.e. an establishment of publicly accessible documentation) about all the benefits and possible side effects of vaccinations as well as about complications of a disease and sequelae occurring in persons who are not vaccinated is a prerequisite so that each citizen can make a free and self-determined decision.

Improve the Health Literacy & Competence of the Public…

Health inequality is also a reluctance to vaccinate and a misunderstanding of the role of vaccination. Health education from an early age give us hope that future generations will take far more rational care of their health. The process of building social responsibility for the most valuable of capitals - health - will take time and a patient and consistent approach. Governments and healthcare organizations need to introduce lessons on health into the education system, increase the role of this subject, and monitor the program on an ongoing basis, adapting it to the latest medical discoveries/advances.

…Including AI and New Media Literacy

As we are in a “digital era also for vaccination", to effectively improve health literacy, it's essential to integrate artificial intelligence (AI) and new media literacy into our efforts. We should create digital literacy programs aimed at educating the public on how to critically evaluate online information. Promoting awareness of reliable sources of health information and teaching individuals how to identify credible information online can significantly enhance their ability to make informed health decisions.

Prioritize Vaccination Efforts for Minorities and Refugees

To effectively increase vaccination rates among minorities and refugees, it is essential to incorporate cultural competency and sensitivity. This involves developing tailored communication materials in multiple languages that are culturally relevant. Utilizing community leaders and organizations can create a dialogue around vaccinations, fostering trust. Healthcare providers should receive cultural training to better understand and address the specific concerns of these populations. Accessibility and convenience are crucial (mobile vaccination clinics, offering vaccinations at flexible hours, free or low-cost, etc..).

Overcoming barriers is another important aspect. Assisting refugees and minorities with legal and documentation issues can help them access healthcare services. Employing community health workers or navigators can support individuals in understanding and accessing vaccination services, thereby improving overall health outcomes.

List of Associations

The Policy brief “10 Policy recommendations for promoting vaccination: the citizens' perspective for the new EU institutions” is a political initiative promoted by Active Citizenship Network with the support of the following national civil society organizations (CSOs) and patient advocacy groups (PAGs):

1. Lower Austrian Patient and Nursing Advocacy - NÖ PPA (Austria)
2. Patients' Organizations With you (Bulgaria)
3. Association of Reproductive Health, Pregnancy and Childcare "Smile" (Bulgaria)
4. Alliance of Transplanted and Operated ATO "Future for All" (Bulgaria)
5. Association of Patients with Cardiovascular Diseases (Bulgaria)
6. The Innovations Institute Founders (Bulgaria)
7. Bulgarian Association for Patients' Defence (Bulgaria)
8. Cyprus Federation of Patient Associations - CyFPA – OSAK (Cyprus)
9. Croatian Association for Patients' rights - CAPR (Croatia)
10. International Council of The Patient Ombudsman (Croatia)
11. Prometheus - Hellenic Liver Patient Association (Greece)
12. Irish Patients' Association (Ireland)
13. Cittadinanzattiva-Tribunale per i diritti del malato (Italy)
14. IMPACT 2040 (Latvia)
15. Talented Borders (Latvia)
16. Council of Representatives of Patient Organisations of Lithuania (Lithuania)
17. National Patients' Organisation – NPO (Malta)
18. Malta Health Network -MHN (Malta)
19. EPECS (the Netherlands)
20. Foundation euPrevent (Netherlands)
21. Institute for Patients' Rights and Health Education - IPPEZ (Poland)
22. The alliance for combating infectious respiratory diseases. poland breathes healthily (Poland)
23. Forum for HPV elimination (Poland)
24. Azorian Association of Chronic Pain Patients - ADDCA (Portugal)
25. Portuguese Health Literacy Association - SPLS (Portugal)
26. Coalition of Patients Organisation With Chronic Disease - COPAC (Romania)
27. My Child My Heart Association (Romania)
28. Kultlab Celje Society – DKC (Slovenia)
29. The Slovenian foodbank - SIBAHE (Slovenia)
30. Association for Justice and Control (Slovenia)
31. Universidad del Paciente y de la Familia (Spain)
32. Asociación Española contra la meningitis (Spain)
33. Spanish Patients Forum (Spain)
34. Greek patients association (Greece)
35. ZD Patient- Zadarski pacijent (Croatia)

    Figure 4: EU Project Logo #Vaccinaction, Edition 2024.

The WHO defines community engagement as a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes. It also highlights community and civil society engagement as a cornerstone of its global Action Plan for Healthy Lives and Well-being for All.

On December 5, 2023, the European Commissioner for Health and Food Safety, while presenting the EU4Health 2024 work program, emphasized that civil society has a crucial role to play in reaching out to European citizens. This is more important than ever, particularly in affirming the culture of life-course immunization and addressing the ongoing consequences of the Covid-19 outbreak.

A similar principle was recently reinforced at the global level during the G7 Health Ministers' Meeting held in Ancona (Italy) on October 10-11, 2024, under the Italian Presidency. Here, it was reaffirmed that “vaccination is an essential preventive measure and reiterate[s] the crucial role of routine immunisation and campaigns.” Here, it was reaffirmed that vaccination is an essential preventive measure and reiterates the crucial role of routine immunisation and campaigns. The meeting also stressed the need to enhance public awareness by sharing evidence-based information through initiatives designed to empower citizens and improve health literacy in areas such as prevention, research, and care. These guidelines call for serious attention from the new EU Institutions as a foundation for strengthening the protection of patients' rights across Europe.

The post-election period offers a unique opportunity to request concrete commitments from the new EU Institutions on health issues. However, it also compels us to acknowledge that health concerns for European citizens were almost entirely absent from the pre-election debate.

Civil Society Organizations (CSOs) and Patient Advocacy Groups (PAGs), through a series of recommendations, aim to expose the current challenges and barriers to promoting vaccination policy from a citizens' perspective. They also seek to pave the way for improved immunization pathways for citizens and patients alike. About it, it is extremely grateful the official endorsement of the Italian Member of the European Parliament (MEP) Ignazio Marino, as follows: "The 10 Policy Recommendations to Promote Vaccination”, developed by Active Citizenship Network in the context of the EU project VaccinAction together with 35 civil society organisations from 16 EU countries, represent a concrete call to action for European institutions. Grounded in the European Charter of Patients’ Rights, the recommendations highlight the importance of transparency, equity, and patient participation. Now is the time to put health back at the centre of the political agenda by strengthening healthcare systems, tackling preventable diseases and ensuring access to vaccines for all ages. As a surgeon and Member of the European Parliament, I support this Manifesto because I believe that prevention is fundamental to building a healthier, fairer and more resilient Europe”.

Figure 5: Video Message of the Italian MEP Ignazio Marino (Group of the Greens/European Free Alliance) .

The Policy Brief “10 Policy Recommendations for Promoting Vaccination: The Citizens' Perspective for the New EU Institutions” is designed to support EU policymakers in prioritizing and actively implementing comprehensive vaccination strategies across the life course. These strategies should ensure equitable access, accurate data collection, and robust public health education. By recognizing the critical role of civil society and addressing the unique needs of vulnerable groups, CSOs and PAGs aim to foster trust and improve vaccination uptake. Collaborative efforts, including combating misinformation and enhancing digital literacy, are essential for solidifying the EU's leadership in global health and preventive care. Most importantly, all recommendations should be considered within a framework that shifts the paradigm: public expenditure on immunization and preventive care is not a cost-it is an investment.

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.

Acknowledgements

The Policy Brief “10 Policy recommendations for promoting vaccination: the citizens' perspective for the new EU institutions” is part of a broader EU project carried out in 2024 by Cittadinanzattiva-Active Citizenship Network and titled “#VaccinAction2024, which has received the unconditional support from GSK, MSD, Pfizer, Sanofi.

Special thanks for their comments and additions to Christine Baluci & Gertrude Buttigieg from Malta Health Network (MHN); Andreas Christodoulou from the CyFPA - Cyprus Federation of Patients' Associations; Christine Frühling from the Niederösterreichische Patienten- und Pflegeanwaltschaft,

Reneta Ilieva from the Bulgarian Association for Patients' Defense; Marta Kulpa from the Foundation Institute for Patients' Rights and Health Education, Stephen MacMahon from the Irish Patients Association; Marleen Struss from the EPECS; Hui Wang from the euPrevent Foundation.

1. “State of the Union address”. 2023.
2. Active Citizenship Network (ACN) is one of the most widespread and flexible European network. Established in 2001, it is coordinated by Cittadinanzattiva, the Italian non-profit organization founded in 1978, independent from any political affiliation, trade unions, private companies and public institutions.
3. Cittadinanzattiva APS is an organization, founded in Italy in 1978, which promotes citizens' activism for the protection of rights, the care of common goods, the support for people in conditions of weakness in Italy and abroad.
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10. This Commission department is responsible for EU policy on food safety and health and for monitoring the implementation of related laws.
11. ENVI is the EU Parliement Committee on Environment, Public Health and Food Safety, while SANT is the Subcommittee on Public Health.
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25. Read more and watch the video message (in Italian language) by MEP Ignazio Marino (Group of the Greens/European Free Alliance).