Portugal in focus: public trust drives vaccine uptake at all ages

Portugal must be doing something right: more than 95% of children have their recommended vaccines, with measles vaccination among the highest in the world at 99%. Its COVID vaccination drive was a source of national pride in 2021, and a 2022 report for the European Commission showed that the Portuguese public was the most pro-vaccination in the EU. 

• Vaccination rates in Portugal are among the highest in Europe
• Flu vaccination rates are close to 75% target & COVID-19 rollout was a success
• Awareness of recommended shingles and pneumococcal vaccines is low
• Experts remain concerned about false information, especially online 
• A new initiative, +Longevidade, aims to increase uptake of vaccines for people of all ages – by focusing on healthy ageing

‘Portuguese citizens really believe in the benefits of vaccination and take a proactive approach to vaccination,’ says Dr Diana Costa. ‘We have a vaccination culture.’ 

Dr Costa was part of the coordination of Portugal’s COVID-19 vaccination campaign and coordinated the national vaccination centre for two years. She said the instinct among the public, health professionals and policymakers is to go beyond the targets and reach the highest possible level of coverage. ‘For example, with COVID-19 vaccination, there was 99% coverage of adults with their first dose, and 95% for people aged over 60.’

Read more: COVID-19 vaccine uptake protecting Portugal against wave of deaths

The steep decline in hospitalisation, intensive care unit admissions and mortality – and high public awareness of these achievements – reinforced the view that vaccination pays off. This success was also driven by close cooperation between institutions and individuals throughout the immunisation service, Dr Costa adds. 

‘The Directorate-General for Health was supported by a COVID-19 NITAG [National Immunisation Technical Advisory Group] that assured high vaccination quality and safety through rapidly evolving evidence-based strategies and recommendations,’ says explains. Other key factors included: public campaigns calling for vaccination, effective mass vaccination centres, appointment scheduling systems, a centralised vaccination registry and a management platform called Vacinas.

‘But, in my opinion, the success of the COVID-19 vaccination campaign is the result of a legacy left over from several years of the National Vaccination Programme,’ Dr Costa says. 

While most vaccines are well accepted, some adult vaccines are less well known. Uptake of shingles and pneumococcal vaccines in older people is generally lower than the stellar vaccination rates consistently seen in the childhood programme. The public continues to view vaccination as part of infant healthcare.  

Dr Costa said education and public health campaigns are crucial to shifting this perception and emphasising ‘the need for life-course immunisation to prevent diseases and maintain health throughout adulthood’.

‘I believe we face various challenges with adult vaccination: some older adults may hold misconceptions about vaccination, leading them to underestimate its importance, while others might have concerns about vaccine safety, efficacy, or side effects,’ she explains. 

‘Elderly individuals, especially those with reduced mobility such as wheelchair users or those who have difficulty walking, face additional [practical] challenges. Some older adults lack personal transportation or have difficulties using public transport. Many older adults live in rural areas or places with limited access to health centres.’

Read more: Portuguese pharmacists on the front line against flu

For the Seasonal Vaccination Campaign in 2023-2024 which ran from September to April, the nationwide mobilisation of pharmacists played a key role in addressing access to vaccination. Portugal has a long history as an early adopter of pharmacy-based vaccination, with 95% of the public supportive of flu and COVID-19 vaccination in local pharmacies. Last winter, a record 2,491 pharmacies took part in the flu/COVID vaccination campaign, administering 2.5 million doses of flu in six months.  

Driving action through data

As the focus of preventative health widens to include healthy ageing, Portugal aims to build on high levels of public trust, good vaccination infrastructure and the lessons of recent campaigns. 

Dr Filipe Froes, Consultant in Respiratory Medicine and Intensive Care at Pulido Valente Hospital, Lisbon, says convenient access to free vaccines and proactive engagement with the public are vital if people of all ages are to have their recommended vaccines. 

‘Flu vaccines are recommended; you don’t need an appointment or prescription, you just go to any pharmacy’ he notes. ‘We have strong communication campaigns to give advice on the advantages of vaccines and answer questions people may have.’ 

The example of flu vaccination campaigns shows what can be achieved by engaging a range of healthcare organisations and advocates. Six scientific societies, including experts in pulmonology, diabetology, cardiology, gerontology, internal medicines and infectious diseases, developed a position paper on the impact of flu prevention. The pioneering paper, for which Dr Froes is the lead author, reviews the evidence on the impact of flu, the safety and effectiveness of flu vaccines, and makes strong recommendations for vaccination. 

Achieving the same success with pneumococcal, shingles and RSV in adults will take time and the generation of robust evidence. Awareness of the impact and burden of disease, and knowledge of some adult vaccines, is low. ‘For shingles, there is enough evidence, in my opinion, to include it in the National Immunisation Programme, but we need more data to convince decision-makers.’ 

Dr Froes is coordinating studies on the burden of infectious diseases in Portugal, including research on hospital admissions related to community acquired pneumococcal. Preliminary findings show that after the introduction of a pneumococcal vaccine for all children born after 2015, there was a decrease in the incidence of hospitalisation and a decrease in mortality. ‘It’s very easy to see,’ Dr Froes says. ‘We will present this data to authorities to reinforce the importance of vaccination in children and to go further and increase vaccination.’

In 2012, the Ministry of Health in Portugal decided, after reviewing the burden of disease and vaccine cost-effectiveness, to make vaccination free to all people over 65. ‘Things don’t happen by chance. We are now benefiting from the things we did starting ten years ago,’ he says. ‘Vaccination rates have increased since then, but results don’t come immediately. It takes planning and organisation.’

Dr Froes, who has served as an advisor to the Department of Health and on the technical advisory group that shapes vaccination decisions, says health professionals should set an example by having their own vaccines and sharing this information with patients. ‘By vaccinating ourselves we protect ourselves, set an example for patients and avoid transmitting viruses to our most fragile patients and our families.’

Living well for longer

A new multi stakeholder initiative, known as +Longevidade, has been launched to support healthy ageing. Vaccination is a central part of living longer and staying well. 

The project aims to develop local evidence on the burden of disease and impact of adult vaccination, boost awareness and health literacy, and support planning and policymaking. A series of meetings was held in April and May, before moving to a public-facing campaign. 

Dr Froes, an Ambassador for +Longevidade, says the shift from childhood vaccination to life-long immunisation is vital in the context of ageing societies. ‘This is a problem in Portugal and elsewhere,’ he notes. ‘We are working together to change this paradigm and increase awareness so that the value of prevention is better understood by the public and by politicians.’

In the meantime, Portugal remains vigilant against rising cases of measles and pertussis in Europe. In January, officials reported an imported case of measles in an infant who was hospitalised in Lisbon. A timely reminder to guard against complacency, even in a country with strong community protection against most vaccine-preventable diseases.