France and Germany have different approaches towards childhood immunisation. The aim of this study was to determine the similarities and differences between France and Germany in terms of heath policies, vaccination rates and public opinion as far as infant vaccinations were concerned.
Study design
Literature review.
Subject and methods
We used the databases of the Robert Koch Institute (RKI) and of Santé publique France (SpF) to compare the vaccination rates of children in the year 2017. The state of public opinion was principally assessed by comparing data from SpF and the German Federal Center for Health Education (BZgA).
Results
Vaccination rates were higher in French pre-school children in 2017 for the hexavalent and anti-pneumococcal vaccines, whereas Measles–Mumps–Rubella and anti-meningococcal vaccination rates were higher in Germany. Public opinion was more favourable towards vaccines in Germany than in France. Some vaccines, especially against seasonal influenza and hepatitis B, were viewed with criticism in France, whereas German parents considered hepatitis B immunisation to be important for their children. Moreover, both countries showed higher immunisation rates in northern regions. This correlated with the state of vaccine confidence in France. In Germany, eastern regions were more favourable towards vaccines, which correlated with higher immunisation rates in these regions.
Conclusions
The state of vaccine confidence seemed to correlate with immunisation rates in both countries. The need for information about vaccines is still high in both countries and trust in the medical community as well as in the immunisation policymakers should be reinforced as a priority.
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Introduction
Vaccines are one of the safest and most efficient way to prevent infectious diseases worldwide. However, parts of the population still hesitate to vaccinate their children, so immunisation often does not reach satisfying coverage rates. Underpinning reasons for this vaccine hesitancy are quite variable and context dependent. The interindividual opinions can strongly change across time within the general population. We wanted to show this heterogeneity among European countries with the examples of France and Germany. Indeed, Larson et al. (2016) found in a worldwide survey about vaccine confidence that the French population had the highest proportion of doubts about the safety of vaccines in 2016. Furthermore, it is striking that the French population consistently had a higher proportion of vaccine hesitant responders than the European mean value, whereas neighbour countries, such as Germany, had less vaccine hesitant responders than the European mean value (Larson et al. 2016). These results were confirmed in a European survey in 2018 (Larson et al. 2018b). However, a direct comparison of both countries concerning sociological and epidemiological aspects of vaccination is missing in the literature. How could it be that these two neighbour countries, which were facing similar epidemiological situations as far as vaccine-preventable diseases (VPDs) were concerned, had such diverging opinions on vaccines?
The public health organisations ‘Santé publique France’ (SpF) and the ‘Robert Koch Institute’ (RKI) in Germany are responsible for the immunisation guidelines at a national respectively federal level and collect epidemiologic and sociologic data related to public health in both countries. Based on this data, we wanted to understand which aspects of childhood immunisation differed between France and Germany and determine the similarities between both immunisation policies and their consequences on immunisation rates and on public opinion.
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We decided to focus on three parameters to compare the state of childhood immunisation between France and Germany: the immunisation policies, the immunisation rates and the state of public opinion about vaccines in both countries.
Methods
Thus, we conducted a review of the literature to compare these three parameters. As most vaccines occur during the first two years of life in both countries, we decided to focus on the VPDs targeted by the immunisation schedules for infants. These include diphtheria, tetanus, poliomyelitis, pertussis, haemophilus influenzae b, hepatitis B, meningococcus C, pneumococcus, measles, mumps and rubella in both countries.
To evaluate the state of public opinion about infant vaccination in France and Germany, we used the results of the surveys available on the websites of the ‘Bundeszentrale für gesundheitliche Aufklärung’ (BZgA, the German federal centre for health education) and of the ‘Health Barometer’ surveys conducted by SpF in France. To complete this data, other surveys, systematic reviews, and meta-analyses, conducted for the most part in France and Germany were additionally reviewed, based on term-based research in PUBMED and in the Cochrane Library.
In addition, we wanted to display these immunisation rates in infants at a local level. Given that France and Germany have different political organisations, we had to select a dataset as representative as possible. Therefore, we decided to use the results based on the surveys of all available vaccine certificates of infants in both countries in 2017. The comparison of both datasets might be limited by the fact that the surveyed vaccine certificates were from 2-year-old children in France and 6-year-old children in Germany, but the large samples allowed to approach reliable local immunisation rates in infants in both countries in 2017.
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Moreover, we decided to show immunisation rates at the second level of subdivision in both countries, i.e. the 101 departments in France and the 401 districts in Germany. On the one hand, we used the infra-national immunisation rates from 2018 publicly available on the website of Santé publique France for most departments, except for Mayotte, for which the last available data was from 2010. On the other hand, we used the local immunisation rates published on the websites of the State ministries of health for the States of Baden-Württemberg, Bavaria, Brandenburg, Lower Saxony, Mecklenburg-Vorpommern, North-Rhine-Westphalia, Rhineland-Palatinate, Saxony, Saxony-Anhalt and Schleswig-Holstein. For the States of Hessen, Saarland and Thuringia, we requested the district immunisation rates per e-mail as they were not publicly available. We also requested district immunisation rates to the public health services of Saxony for vaccines against meningococcus C and pneumococcus as these were not available on the dedicated publicly accessible domain.
All public health services responded with the corresponding immunisation rates, except for Hessen, which responded but could not provide the requested immunisation rates for Hessian districts. We therefore asked the public health services of all Hessian districts (n = 26) if they could provide immunisation rates at the district level. We included the immunisation rates of the districts who answered after one or two requests and provided valid data for immunisation rates (n = 7).
With a view to sharpening the differences between immunisation rates on a local level in France and Germany, we created maps with Adobe Illustrator and encoded the departments/districts with a colour. Each colour corresponds to a 5% interval, and the colour scale is the same for all maps showing vaccine coverage.
Results
Immunisation policies
To begin with, we shall have a look at both immunisation schedules in infants (see Fig. 1).
Fig. 1
Immunisation schedules in French and German infants in 2020. In this figure, ‘F’ stands for France and ‘G’ for Germany. 1Only for infants at risk for tuberculosis. 2Since 2017. 3Mandatory vaccinations in Germany since 2020. Sources: BZgA 2020; Ministère des solidarités et de la santé (French Ministry of Health) 2020
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At a first glance, French and German immunisation policies seem quite similar. There are, however, some small differences between both policies. First, all vaccines in France have been mandatory for children since 2018, except for the Bacillus Calmette-Guérin-vaccine (BCG) which is recommended for all infants at risk of contracting tuberculosis in France, while it is not recommended in Germany since 1998 (Ministère des solidarités et de la santé (French ministry of Health) 2020; Robert Koch-Institut 2018). Conversely, German immunisations are all recommended except for the measles vaccine, which is mandatory since 2020. To be exact, all German people born after 1970 had to prove their immunity against measles (either through vaccination or past infection) if they worked or went to a community facility (schools, nurseries, universities, etc.) starting from March 2020 (Küpke et al. 2020).
On the one hand, in France, all vaccines were mandatory for infants born after 1 January 2018. However, before 2018, the combination vaccine against diphtheria, tetanus and poliomyelitis (DTP) was already mandatory for all French infants (French ministry of Health 2020). Before that date, all other childhood vaccines were only recommended.
This coexistence of recommended and mandatory vaccinations in France had historical reasons. Vaccines against diphtheria, tetanus and poliomyelitis were respectively decreed mandatory in 1938, 1940 and 1964, i.e. at a time when the incidence of these diseases was still high (Comité technique des vaccinations 2006). After 1970, all new vaccinations were only recommended (Comité technique des vaccinations 2012). Over the years, this coexistence led to confusion: while most parents followed the immunisation recommendations, some began to think that recommended vaccines were less important than mandatory vaccines (Humez et al. 2017). As a response to this hesitancy, the French government decided to summon a civic consultation in 2016 to determine the next step that had to be made. In accordance with the overall results of the civic consultation, the government decided to implement a mandatory childhood immunisation programme (Fischer et al. 2016).
Furthermore, in France, a supplementary dose of anti-meningococcal vaccine has been added to the schedule in 2017 at 5 months of age. In addition, the vaccines against rotavirus and varicella are systematically recommended for children in Germany, but not in France (BZgA 2020; French ministry of Health 2020). Finally, the fourth dose of TDaPP vaccine at 3 months of age was abandoned in France in 2014 and in Germany in 2020 (Santé publique France 2019b; Ständige Impfkommission, AG 6-fach-Impfung 2020).
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On the other hand, in Germany, mandatory immunisation was implemented in former Eastern Germany, also known as the German Democratic Republic between 1949 and 1990, i.e. in East-Berlin and the Federal States of Brandenburg, Mecklenburg-Vorpommern, Saxony, Saxony-Anhalt and Thuringia (Weigel et al. 2014). Even if immunisation became recommended again after the reunification in 1990, a gap remains between former Eastern and Western States concerning vaccine uptake and public opinion about vaccines (Horstkötter et al. 2019; Rieck et al. 2020; Robert Koch-Institut 2019a; Weigel et al. 2014).
Immunisation rates
A comparative overview of all vaccination rates between France and Germany is displayed on Fig. 2.
Fig. 2
Overview of infant immunisation rates in France and Germany in 2017. Sources: Robert Koch-Institut 2019a, b; Santé publique France 2019b, c, d, e, f, g
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Thus, in 2017, immunisation rates were higher in France for the hexavalent vaccine (TDaPP-Hib-Hepatitis B) and for the anti-pneumococcal vaccine in pre-school children. Conversely, immunisation rates against meningococcus C, measles, mumps and rubella were higher in Germany than in France.
Regional disparities
Interestingly, both countries showed higher immunisation rates in their northern regions than in their southern parts for all immunisations. For instance, for immunisation against hepatitis B in 2017, more than 60% of all French departments displayed immunisation rates above 90%, most of them located in the northern half of the country or the southwest. In south-eastern France, coverage rates are lower, and the department with the lowest coverage rate is Hautes-Alpes with 56.8% of vaccinated children (see Fig. 3).
Fig. 3
Regional disparities in HBV coverage rates in France and Germany in 2017. This map shows regional coverage rates for a complete HBV immunisation in France and Germany. In 2017, a complete HBV immunisation comprised four doses of HBV vaccine in Germany and three doses of HBV vaccine in France. The coverage rates were assessed on 2-year-old children in France and on 6-year-old children in Germany. Data for Brandenburg is from 2018. Sources: Santé publique France 2019f; STIKO 2013; Robert Koch-Institut 2019a; Federal public health departments of Baden-Württemberg, Bavaria, Brandenburg, Lower Saxony, Mecklenburg-Vorpommern, North-Rhine-Westphalia, Rhineland-Palatinate, Saarland, Saxony, Saxony-Anhalt, Schleswig-Holstein and Thuringia
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On the other hand, German districts showed very high coverage rates in Mecklenburg-Vorpommern (95.1%) and low immunisation rates in Baden-Württemberg, where the mean immunisation rate only reached 78.1%. Most districts had coverage rates between 80 and 85%, but the disparities between the district of Rastatt (90.4%) and the district of Reutlingen (56.8%) were considerable. This tends to demonstrate that immunisation rates in Germany were higher not only in the northern regions, but also in the eastern Federal States. Maps for other vaccines show a similar repartition and can be consulted in the supplementary file (Figs. 9–12).
Public opinion
Regional disparities
These regional disparities in immunisation rates also occurred to correlate with the state of public opinion about vaccines. Indeed, in 2017, on a regional level, a low vaccine adherence seemed to correlate with a low vaccine uptake for the hexavalent vaccine in France (see Fig. 4). This translates into lower immunisation rates in southern France compared with other regions (Fonteneau et al. 2019). This is consistent with other findings, such as the significant influence of the region on vaccine confidence pointed out by Gautier et al. in 2017.
Fig. 4
Regional disparities in vaccination adherence and immunisation rates for the hexavalent vaccine in France. This figure compares the regional distribution of vaccinal adherence (proportion of people being favourable towards immunisation) and the regional immunisation rates for the hexavalent vaccine (=TDaPP, Hib and VHB vaccine) in France. Two three-colour scales have been used to encode the data. Vaccine adherence data for the oversea departments marked with an asterisk is from 2014. Data for Mayotte is not available. Sources: Fonteneau et al. 2019; Gautier et al. 2017; Richard 2015
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French Guyana, however, displays low immunisation rates for the hexavalent vaccine in 2017 despite a very large majority of people being favourable towards immunisation in 2014 (Richard 2015). This may be due to geographical and financial obstacles which makes it difficult for infants to benefit from immunisation in time (Parez et al. 2019).
In Germany, regionality also has an influence on vaccine uptake and public opinion. A study by Goffrier et al. (2017) showed that some districts in southern Bavaria and Baden-Württemberg were correlated with a significantly lower vaccine uptake for measles and meningococcal C vaccines (see Fig. 5).
Fig. 5
Regional disparities in vaccine uptake against measles and meningococcus C in Germany (after Goffrier et al. 2017). Source: Goffrier et al. 2017
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Additionally, in 2018, the general population of former Eastern States was significantly more favourable towards vaccines than the population from former Western States. Respondents from Eastern States were also significantly more inclined to have been vaccinated in the past 5 years, to consider vaccines as (very) important, to trust in vaccines’ safety and to be correctly informed about some vaccine indications (Horstkötter et al. 2019).
Furthermore, Weigel et al. (2014) found a relationship between German physicians’ attitudes towards vaccination and immunisation rate (p < 0.0001), as well as a relationship between immunisation rates and the geographic location. Thus, the attitudes of both surveyed physician groups (paediatricians and general practitioners) were significantly more positive towards vaccination in former Eastern States compared with former Western States and the physicians from former Eastern States were more compliant with federal immunisation guidelines than those from former Western States (Weigel et al. 2014).
The evolution of vaccine confidence
In 2018, according to Larson et al. the attitude of the general population was overall positive towards vaccination in both countries, but the French respondents were less inclined to agree that vaccines were important, safe and effective than Germans. In addition, the proportion of French respondents strongly agreeing to all four propositions was always smaller than the proportion of German respondents strongly agreeing.
In addition, 69.9% of French respondents agreed or tended to agree that vaccines were safe. This was the third lowest score for vaccine safety among all EU-countries, just behind Bulgaria and Latvia. As a comparison, 83.6% of German respondents agreed that vaccines were safe (Larson et al. 2018a, b).
According to the results of countrywide surveys, the state of vaccine confidence seemed to improve between 2010 and 2016 in both countries (Gautier et al. 2017; Horstkötter et al. 2017, 2019; Ommen et al. 2014; Reckendrees et al. 2013; see Figs. 6 and 7)
Fig. 6
Evolution of vaccination adherence in the French general population from 2000 to 2017. Sources: Gautier et al. 2017; Santé publique France 2018
Fig. 7
Evolution of vaccination adherence in the German general population from 2012 to 2018. Sources: Horstkötter et al. 2019, 2017; Ommen et al. 2014; Reckendrees et al. 2013
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Reasons underpinning vaccine hesitancy
In addition, a systematic review by Karafillakis and Larson in 2017 found that even if the different reasons underpinning vaccine hesitancy depend on factors such as the country, the vaccination or the target group, three of the five most common reasons for vaccine hesitancy were found in both France and Germany: concerns about vaccine safety, a risk of contracting VPDs perceived as low and the impression of a low effectiveness of vaccines (see Fig. 8). In France, other reasons included the lack of recommendations (due to the coexistence of mandatory and recommended vaccines until 2018) and claims that the vaccine was too new, while in Germany, other reasons were the perceived low severity of VPDs and the impression that the vaccine was not needed (Karafillakis and Larson 2017).
Fig. 8
Five most common reasons underpinning vaccine hesitancy in France and Germany (after Karafillakis and Larson 2017) Source: Karafillakis and Larson 2017
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The country-related history of some vaccines also had an impact on vaccine hesitancy for a specific vaccine. In France, for instance, vaccines against hepatitis B suffered from the interrupted vaccination campaign in 1998, and has therefore become the second most rejected vaccine in the general population (13.0%), just after seasonal influenza vaccine (15.4%) in 2016 (Gautier et al. 2017). As a comparison, in Germany, hepatitis B was considered the third most important disease against which adults should be vaccinated (84%), just behind tetanus (95%) and poliomyelitis (88%) (Horstkötter et al. 2019).
Discussion
Evolution of vaccine confidence and vaccination rates
Between 2012 and 2018, vaccine confidence overall has improved in both countries (Gautier et al. 2017; Santé publique France 2018; Horstkötter et al. 2017, 2019; Ommen et al. 2014; Reckendrees et al. 2013). Simultaneously, immunisation rates against HBV, meningococcus C and MMR (second dose) have increased in France, while the immunisation rates against pneumococcus increased in Germany. In addition, immunisation rates for the TDaPP, Hib and the first dose of MMR vaccines in France, as well as the MMR vaccines in Germany have been stable over that period. As for TDaPP, Hib and HBV vaccines in Germany, the slightly decreasing immunisation rates might be explained by the fact that more and more children were getting three doses of vaccines instead of four over the years.
Moreover, the decrease in the incidence of some VPDs such as invasive pneumococcal and meningococcal infections, including meningitis, as well as Hib infections correlates with higher immunisation rates on a national level in both countries (Georges et al. 2013; Réseau Epibac 2019; Robert Koch-Institut 2019b; Santé publique France 2019j; Weinberger et al. 2018).
Public opinion
In countries where vaccines are predominantly recommended, the success of immunisation relies mostly on the compliance of the general population with immunisation policies. If most of the general population have a positive opinion about immunisation in France and Germany, the proportion of vaccine hesitant people is higher than 20% in both countries (Horstkötter et al. 2019; Santé publique France 2018).
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To address this vaccine hesitancy, France decided to establish generalised mandatory immunisation for pre-school children born after 2018. In the following year, this measure had a positive impact on vaccine uptake and on public opinion (Fonteneau et al. 2019). However, information gaps still need to be filled, as parents still did not feel informed enough about immunisation in 2019 (Fonteneau et al. 2019).
This need for ‘information’ can, however, obscure the problem of trust. According to Peretti-Watel et al. (2015), trust is one of the two main factors influencing vaccine hesitancy. To accept a vaccine, a person needs to trust the vaccine itself (i.e. its efficiency, its harmlessness), but also the vaccine providers (i.e. the vaccinating physician, the pharmaceutical industry) and the immunisation policymakers, i.e. the public health authorities such as SpF and the RKI (MacDonald and the SAGE Working Group 2015).
A recent systematic review also suggested that parents found it difficult to know which source of information was the most trustworthy and to find information that seemed balanced and unbiased (Ames et al. 2017). Being part of an ethnic minority and having a low income were also associated with lower trust towards the health system or healthcare professionals (Larson et al. 2018a).
Consequently, strategies to address vaccine hesitancy should be easily understandable and try to rebuild trust between patients, policymakers and health professionals. Additionally, mandatory immunisation can be a double-edged sword, resulting either in greater acceptance or refusal through reactance, as in a psychological experiment by Betsch and Böhm in 2016 (Betsch and Böhm 2016). Its effects in France and Germany should therefore be monitored in the future. Moreover, the regional disparities in both countries could be modelled and the correlation between vaccine confidence and other factors such as regionality further investigated. As a complement, qualitative studies of representative samples of the population could help understand the underpinning reasons for vaccine hesitancy as shown in the work of Humez et al. (2017).
In other words, the need for information about vaccines remains immense, and trust needs to be rebuilt with transparency and tailored communication. The relationship between patients and physicians should be built on mutual trust and make the patients/parents aware of their own responsibilities as individuals, but also as part of a community. In a context of waning trust towards immunisation policymakers, vaccines, and science in general, perhaps it is time for the benefits of vaccination to become visible again.
Declarations
Ethics approval
As this is a literature review, no ethical approval or review is needed.
Consent to participate
Not applicable.
Consent for publication
The authors have consented to the publication of this review in the Journal of Public Health. The authors confirm that this work is original and has not been published previously nor is it currently under consideration for publication elsewhere.
Competing interests
The authors have no competing interests to declare that are relevant to the content of this article.
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