How can Europe successfully navigate the transition from the Covid pandemic to an endemic situation? This is the question posed by the members of the Covid Transition Initiative (Cti), an independent and multi-stakeholder working group, which includes the main European experts (including professors Paolo Bonanni And Roberta Siliquini for Italy), established in early 2024 with the support of Novavax. First, the CTI identified the obstacles that prevented the seasonal anti-Covid vaccination campaigns from achieving adequate coverage in the various EU countries. Thus laying a basis for identifying the actions to be taken and the measures that public decision makers should adopt at national and European Union (EU) level to improve anti-Covid vaccination rates in Europe and Italy, which are currently worryingly low. Specific recommendations therefore emerged from the experts’ reflection, contained in the document “Covid Transition Initiative: a roadmap in the post-pandemic era”, published last May.
An endemic pathogen
Sars-Cov-2 broke into humans in 2019 to stay. This is confirmed by the epidemiological trend which shows that it will remain present in Europe as an endemic pathogen in the near future. In the last six months alone (data September 2023-March 2024), the World Health Organization (WHO) recorded over 3 million cases of Covid in the European area, over 100,000 hospital admissions, 3,800 admissions to intensive care and 15,000 deaths . Data probably underestimated: the former due to the decrease in access to tests and reports and the latter considering that in Italy alone the Higher Institute of Health recorded 10,000 deaths. “It is therefore very likely – according to the CTI experts – that this trend will persist over time despite the fact that it has not yet stabilized at a seasonal level. Furthermore, the hypothesis that a more aggressive future variant emerges cannot be discarded.” “Covid – they add – continues to pose a threat to public health even though the pandemic is over. Its impact and scale are comparable to that of influenza which remains a persistent public health problem.”
Poor adherence to the vaccination campaign
Among those most at risk are the immunocompromised – who are in fact strongly over-represented in epidemiological data and continue to be significantly affected – but also the elderly and chronic patients. For them – but in general for the entire population – vaccination remains an important tool to fight Covid, especially as new variants continue to emerge. But also to prevent the persistent symptoms of long Covid, a condition that affects approximately 10-20% of people affected by the infection. Vaccination against Covid also remains essential for healthcare workers, given that they are more exposed due to direct and regular contact with patients.
Despite this and despite the fact that anti-Covid vaccines have been fundamental in combating the pandemic, saving the lives of over 1.4 million people in the European WHO area, according to estimates, anti-Covid vaccination coverage in Europe has dropped drastically and has reached an average of 12% among individuals aged 60 years and older during the 2023/2024 vaccination season. A figure significantly lower than the coverage rate of flu vaccines on an annual basis which was equal to 50.8%, according to the latest data available throughout the EU from 2021. Also worrying is the data relating to the vaccination of healthcare workers which remains low, with the highest rate in Belgium (21%) and with all other reporting countries achieving less than 20%.
Barriers to adhering to the campaign
The reasons for the limited success of the campaign were summarized by the CTI experts: vaccination hesitancy, the limitations of different healthcare environments, excessive dependence on a single supplier, an uncertain strain selection process and the lack of updated data.
Hesitancy – the delay in accepting or refusing vaccines – is a complex and multifaceted problem, including factors such as trust, nonchalance and convenience, as experts explain. A study of EU countries in 2022 shows that confidence in anti-Covid vaccines is generally positive. Nonetheless, the WHO declaration declaring the pandemic over may have led one to think that the need to vaccinate groups for which there is a persistent risk has also ended. Furthermore, misinformation about the duration of protection provided by Covid vaccines may have contributed to some at-risk people, who received a course of the vaccine during the pandemic, mistakenly believing that they are still optimally protected for a period of time longer, without the need for an additional booster dose.
Another barrier is the underuse of combined Covid and influenza vaccination, an opportunity that can be exploited when data on combined administration support both safety and immunogenicity, but which has not been used enough. Whether due to the administrative burden (for example, the need to book two separate appointments, one for each vaccine), the different reimbursement and supply mechanisms of the two vaccines or simply the lack of a proactive suggestion to administer both vaccines by a healthcare worker.
Availability of vaccines and strain selection
Another limiting factor for anti-Covid vaccination campaigns is the excessive dependence on a single product in much of Europe until the end of 2026. An element which on the one hand limits the choice of people and healthcare workers, affecting trust and on the acceptability of vaccines; and on the other hand it makes the system exposed to possible critical issues deriving from supply chain problems and hinders competition. “The ECDC declared that 97% of the doses administered between 1 September 2023 and 15 January 2024 were of a single type of Covid-19 vaccine” declared Roberta Siliquini, president of the Italian Society of Hygiene, Preventive Medicine and public health (Sites). “This could expose Europe to potential supply problems and prevent individuals and healthcare workers from accessing the vaccine technology best suited to them.”
In many European countries the anti-covid vaccination campaign has a seasonal approach similar to the flu one. But unlike the latter, it is still difficult to communicate to producers in time the new Covid strains expected for the following season. “For manufacturers, it is important to make a decision on strain selection at least six months before the start of the vaccination campaign, to allow timely production, packaging and delivery of vaccines,” the document reads. “However, for Covid vaccines in 2023 the announcement was only made in May/June, while in 2024 it was made last April. This creates further tension within the system, as uncertainty persists and forces manufacturers to start production at risk. As a result, there is a greater threat of delays and shortages that can impact the timing of vaccination campaigns.”
Data is missing
Finally, data communication problems represent an additional challenge. Unlike what happened during the pandemic, timely insights into vaccination campaigns are no longer published or harmonized. The ECDC’s mid-year report, for example, did not include data from some countries, while others provided their data late (including Italy), as it was not available at the time of publication. “It is essential to measure our progress with consistent and timely data collection,” added Siliquini. “Last year alone, Italy recorded 10,000 deaths and over 80,000 hospitalizations due to Covid‐19, which almost exclusively involved vulnerable individuals, the elderly and the chronically ill. One contributing factor was a slow vaccination campaign, with only 13% of the most at-risk people having been vaccinated. Despite the effectiveness of vaccines in fighting Covid‐19 and reducing the risk of long Covid, vaccination coverage has decreased considerably, especially among risk groups. We must act urgently to improve vaccination rates this autumn and we must set a coverage target of 75%, as for seasonal flu” concluded Siliquini.
The recommendations of the CTI
To this end, the expert members of the group have drawn up a series of recommendations summarized below:
Protect people from the threat of Covid by increasing vaccine uptake
- Organize regular anti-Covid vaccination campaigns in line with national recommendations and with particular attention to the protection of risk groups.
- Communicate effectively and constantly the importance of anti-Covid vaccination for those at risk.
- Make the ways of accessing the anti-Covid vaccination more accessible and diversifying.
- Administer the Covid vaccine and the influenza vaccine together, where clinically appropriate and supported by national recommendations.
- Raise awareness and encourage healthcare workers to vaccinate against Covid.
- Ensure all available anti-Covid vaccination technologies.
Adopt an appropriate long-term framework for routine Covid vaccination
- Clarify the timing and selection process of the Covid vaccine strains.
- Ensure procurement decisions avoid over-reliance on a single Covid vaccine product.
- Encourage research and innovation of new tools against Covid.
- Update and strengthen training of health workers on vaccinations.
Promote the progress of Covid vaccination from year to year
- Periodically monitor and report key Covid indicators.
- Take proactive measures to address long Covid, protecting at-risk groups and minimizing its incidence.
- Set an anti-Covid vaccination coverage target of 75 percent.
