The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012–2023)
Abstract
:1. Introduction
1.1. Impact of Pandemics on Immunization Programs
1.2. Declines in DTP3 Coverage During the COVID-19 Pandemic
1.3. Vaccine Hesitancy and the Role of Misinformation
1.4. DTP3 Vaccination in Europe
1.5. Challenges in Routine Vaccination Services
1.6. Research Questions and Objectives
2. Materials and Methods
2.1. Data Source and Processing
2.2. European Regions Analysis
2.3. Statistical Analysis
2.3.1. Joinpoint Regression
2.3.2. Segmented Regression
- “DTP3t” represents the DTP3 vaccination coverage in year t.
- Year is the year of the calendar.
- “Pandemic” is a dummy variable, taking 1 for the COVID-19 pandemic years (2020–2023) and 0 for pre-pandemic years.
- Interaction is the interaction between Year and Pandemic.
2.4. Software and Tools
3. Results
4. Discussion
4.1. Limitations
4.1.1. Data Quality: UNICEF and World Bank
UNICEF
The World Bank
4.1.2. Data Quality European Data
4.1.3. Intra-Country Disparities, Ethnic Minorities, and Cross-Border Mobility
- Arad, Caras,-Severin, Cluj, Timis: These counties exhibited low vaccination rates during recent measles outbreaks, with some areas reporting second-dose coverage as low as 29.7%. These coverage gaps contributed to the spread of diseases within and beyond these regions.
- Healthcare Access: Some communities in these regions face structural and logistical barriers to vaccination, such as limited healthcare services, socioeconomic challenges, and mobility.
- Mobility Patterns: The frequent movement of populations within Romania and across borders to countries such as Italy, Spain, France, Germany, and the United Kingdom can complicate vaccination efforts and disease containment strategies.
4.2. Statistical Methodology: Strengths and Limitations
4.3. Country-by-Country Contextual Insights from Available Literature
4.3.1. Albania
4.3.2. Austria
4.3.3. Belgium
4.3.4. Bosnia and Herzegovina
4.3.5. Bulgaria
4.3.6. Croatia
4.3.7. Cyprus
4.3.8. Czech Republic
4.3.9. Estonia
4.3.10. Ireland
4.3.11. Italy
4.3.12. Latvia
4.3.13. Lithuania
4.3.14. Moldova
4.3.15. Montenegro
4.3.16. The Netherlands
4.3.17. North Macedonia
4.3.18. Norway
4.3.19. Poland
4.3.20. Romania
4.3.21. Serbia
4.3.22. Slovenia
4.3.23. Spain
4.3.24. Sweden
4.3.25. Switzerland
4.3.26. Türkiye
4.3.27. Ukraine
4.3.28. United Kingdom
4.4. Strategies for Enhancing DTP3 Vaccination Coverage in Europe Amidst and Beyond COVID-19 Challenges
4.5. Strengthening DTP3 Vaccination Coverage in Europe Amidst and Beyond COVID-19
4.6. Areas for Future Research
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Region | Number of Joinpoints (Joinpoints) | APC Total Period | APC1 | APC2 | APC3 | APC4 | APC5 |
---|---|---|---|---|---|---|---|
Europe | 0 | 0.03 | - | - | - | - | - |
North | 3 (2008, 2011, 2016) | 0.11 * | 0.18 * | 0.65 * | 0.02 | −0.31 * | − |
South | 4 (2002, 2009, 2018, 2021) | −0.02 | 2.05 * | 0.12 * | −0.06 | −0.81 * | 0.50 |
East | 0 | 0.11 | − | − | − | − | − |
West | 4 (2002, 2008, 2011, 2020) | −0.12 | 1.17 * | 0.06 | 0.41 | −0.37 * | 0.03 |
Country | Number of Joinpoints (Joinpoints) | APC Total Period | APC1 | APC2 | APC3 | APC4 | APC5 |
---|---|---|---|---|---|---|---|
Albania | 2 (2011, 2019) | 0.04 | 0.18 * | −0.01 | −0.50 * | ||
Andorra | 0 | 0.06 | |||||
Austria | 3 (2009, 2014, 2017) | 0.19 | 0.1 | 3.0 * | −3.8 * | −0.5 | |
Belarus | 2 (2003, 2006) | 0.50 | −13.3 * | 11.6 * | −0.2 | ||
Belgium | 4 (2003, 2006, 2014, 2019) | 0.12 | −0.15 | 1.12 * | 0.14 * | −0.37 * | 0.24 * |
Bosnia | 4 (2005, 2010, 2017, 2021) | 0.96 | −0.74 | 4.30 * | 0.34 | −2.41 * | 3.87 * |
Bulgaria | 1 | −0.21 * | 0.76 | −0.31 * | |||
Croatia | 1 (2008) | −0.12 | 0.41 * | −0.34 * | |||
Cyprus | 1 (2011) | −0.10 | −0.14 | 0.31 * | |||
Czechia | 1 (2011) | −0.15 | 0.14 | −0.41 * | |||
Denmark | 3 (2004, 2007, 2018) | 0.13 | −0.38 | −2.88 * | 0.91 * | −0.06 | |
Estonia | 1 (2007) | −0.21 * | 0.33 * | −0.37 * | |||
Finland | 2 (2014, 2017) | −0.46 * | 0.06 | −3.11 * | 0.17 | ||
France | 4 (2003, 2006, 2013, 2016) | −0.09 * | 0.04 | 0.58 | 0.02 | −1.00 | −0.00 |
Germany | 3 (2003, 2010, 2017) | −0.21 * | 2.18 * | −0.05 | −0.76 * | 0.02 | |
Greece | 2 (2003, 2007) | 0.33 | 1.71 * | 1.36 | −0.00 | ||
Hungary | 0 | 0.00 | 0.27 | −2.55 * | 0.18 | ||
Iceland | 2 (2009, 2012) | −0.30 * | 0.27 | −2.55 * | 0.18 | ||
Ireland | 4 (2002, 2005, 2013, 2021) | 0.40 * | −1.49 * | 2.95 * | 0.69 * | −0.28 * | |
Italy | 1 (2003) | 0.09 | 2.85 * | −0.08 | |||
Latvia | 1 (2011) | −0.01 | −0.55 * | 0.46 * | |||
Lithuania | 1 (2009) | −0.21 * | 0.14 | −0.40 * | |||
Luxembourg | 0 | 0.01 | |||||
Malta | 3 (2005, 2008, 2012) | 0.60 | −0.77 | −9.17 * | 9.46 * | −0.06 | |
Monaco | 0 | 0.00 | |||||
Montenegro | 1 (2011) | −0.91 * | 0.94 * | −1.43 * | |||
Netherlands | 0 | 0.29 | |||||
North Macedonia | 1 (2013) | −0.48 * | 0.21 | −1.47 * | |||
Norway | 0 | 0.29 | |||||
Poland | 2 (2013, 2020) | −0.23 * | 0.06 | −0.76 * | −0.03 | ||
Portugal | 0 | 0.14 | |||||
Republic of Moldova | 0 | −0.50 | |||||
Romania | 0 | −0.83 | |||||
Russian Federation | 2 (2007, 2011) | 0.01 | 0.36 * | −0.32 * | 0.00 | ||
San Marino | 1 (2015) | −0.40 * | −0.92 * | 0.90 * | |||
Serbia | 0 | −0.02 | |||||
Slovakia | 3 (2012, 2015, 2021) | −0.15 | 0.00 | −1.10 * | 0.23 * | −0.50 * | |
Slovenia | 1 (2008) | −0.16 | 0.86 * | −0.57 * | |||
Spain | 1 (2012, 2016) | −0.16 * | 1.24 | −0.07 | −0.61 | ||
Sweden | 1 (2021) | −0.14 * | −0.09 * | −1.94 * | |||
Switzerland | 3 (2003, 2012, 2021) | 0.16 * | −0.01 | 0.36 * | 0.00 | −0.45 * | |
Türkiye | 2 (2003, 2006) | 0.89 * | −6.17 * | 9.35 * | 0.18 | ||
Ukraine | 3 (2012, 2015, 2018) | −2.63 | −3.75 | −35.32 * | 56.47 * | ||
United Kingdom | 2 (2008, 2012) | 0.11 * | 0.18 | 0.91 * | −0.34 * |
2019 | 2023 | |||||
---|---|---|---|---|---|---|
Country | DTP3 (%) | Births (n) | DTP3 (%) | Births (n) | Change in DTP3 (%) | p † |
Albania | 99 | 29,773 | 97 | 28,538 | −2 | <0.001 |
Andorra | 99 | 590 | 98 | 569 | −1 | ns |
Austria | 85 | 84,744 | 84 | 84,132 | −1 | <0.001 |
Belarus | 98 | 93,218 | 98 | 86,154 | 0 | ns |
Belgium | 97 | 116,136 | 98 | 116,823 | 1 | <0.001 |
Bosnia and Herzegovina | 73 | 29,754 | 73 | 26,279 | 0 | ns |
Bulgaria | 93 | 61,637 | 92 | 55,495 | −1 | <0.001 |
Croatia | 94 | 36,700 | 93 | 33,537 | −1 | <0.001 |
Cyprus | 95 | 13,237 | 95 | 12,348 | 0 | ns |
Czechia | 97 | 109,738 | 94 | 99,736 | −3 | <0.001 |
Denmark | 97 | 60,455 | 97 | 65,003 | 0 | ns |
Estonia | 91 | 14,158 | 90 | 13,102 | −1 | 0.005 |
Finland | 91 | 45,790 | 91 | 47,143 | 0 | ns |
France | 96 | 701,300 | 96 | 671,363 | 0 | ns |
Germany | 91 | 771,867 | 91 | 755,129 | 0 | ns |
Greece | 99 | 81,148 | 99 | 76,080 | 0 | ns |
Hungary | 99 | 92,375 | 99 | 104,762 | 0 | ns |
Iceland | 92 | 4402 | 92 | 4553 | 0 | ns |
Ireland | 94 | 60,463 | 89 | 56,728 | −5 | <0.001 |
Italy | 96 | 418,113 | 95 | 406,243 | −1 | <0.001 |
Latvia | 99 | 18,693 | 98 | 15,996 | −1 | <0.001 |
Lithuania | 92 | 28,075 | 90 | 25,605 | −1 | <0.001 |
Luxembourg | 99 | 6167 | 99 | 6724 | −2 | ns |
Malta | 98 | 4318 | 98 | 4863 | 0 | ns |
Monaco | 99 | 331 | 99 | 323 | 0 | ns |
Montenegro | 85 | 7429 | 81 | 6773 | 0 | <0.001 |
Netherlands (Kingdom of the) | 94 | 169,827 | 92 | 182,435 | −2 | <0.001 |
North Macedonia | 92 | 20,447 | 86 | 19,769 | −6 | <0.001 |
Norway | 97 | 54,384 | 96 | 54,464 | −1 | <0.001 |
Poland | 95 | 382,527 | 94 | 423,741 | −1 | <0.001 |
Portugal | 99 | 85,439 | 99 | 79,465 | 0 | ns |
Republic of Moldova | 91 | 40,266 | 87 | 49,667 | −4 | <0.001 |
Romania | 88 | 203,903 | 78 | 214,232 | −10 | <0.001 |
Russian Federation | 97 | 1,486,730 | 97 | 1,375,609 | 0 | ns |
San Marino | 88 | 209 | 91 | 199 | 3 | ns |
Serbia | 97 | 69,672 | 93 | 65,195 | −4 | <0.001 |
Slovakia | 97 | 57,020 | 96 | 62,451 | −1 | <0.001 |
Slovenia | 95 | 19,865 | 89 | 18,520 | −6 | <0.001 |
Spain | 95 | 354,681 | 93 | 351,908 | −2 | <0.001 |
Sweden | 98 | 114,109 | 94 | 113,685 | −4 | <0.001 |
Switzerland | 96 | 85,930 | 95 | 86,100 | −1 | <0.001 |
Türkiye | 99 | 1,303,201 | 99 | 1,214,053 | 0 | ns |
Ukraine | 80 | 353,538 | 83 | 184,455 | 3 | <0.001 |
United Kingdom | 93 | 709,079 | 92 | 677,708 | −1 | <0.001 |
Region | Intercept | Year | Pandemic |
---|---|---|---|
Europe | 26.77 | 0.0336 | −0.1530 |
Northern Europe | −252.76 | 0.1724 *** | −2.2187 *** |
Southern Europe | −84.61 | 0.0896 * | −2.6746 *** |
Eastern Europe | −65.71 | 0.0791 | 0.5507 |
Western Europe | 59.61 | 0.0179 | −1.8149 * |
Nation | Intercept | Year | Pandemic | Interaction |
---|---|---|---|---|
Albania | −31.2673 | 0.0645 | −1.6521 ** | N/A |
Andorra | −252.7788 | 0.1742 | −0.8535 | N/A− |
Austria | −677.9055 | 0.3806 | −6.8187 | N/A− |
Belarus | −23.6828 | 0.0602 | −0.2919 | N/A− |
Belgium | 145.8932 | −0.0237 | −0.3228 | N/A− |
Croatia | 687.9301 | −0.2946 *** | 0.4016 | N/A− |
Cyprus | 270.5469 | −0.0860 | −1.6544 † | N/A− |
Czechia | 569.6045 | −0.2344 *** | −0.9975 | N/A− |
Denmark | −1253.2089 | 0.6688 *** | −1.8051 | N/A− |
Estonia | 634.5661 | −0.2688 *** | −0.9021 * | N/A− |
Finland | 1455.1928 | −0.6753 *** | 0.1131 | N/A− |
France | 643.1797 | −0.2710 *** | 0.5816 | N/A |
Germany | 1058.9201 | −0.4796 *** | 1.5304 * | N/A− |
Greece | 42.6651 | 0.0280 † | −0.1802 | N/A− |
Hungary | 99.0000 | 0.0000 *** | 0.0000 | N/A− |
Iceland | 1317.9547 | −0.6086 *** | 4.5846 ** | N/A− |
Ireland | −247.6943 | 0.1699 | −3.2433 * | −1.8087 ** |
Italy | 355.2488 | −0.1290 * | 0.0899 | N/A |
Latvia | −494.0307 | 0.2925 † | −0.7037 | N/A− |
Lithuania | 591.5722 | −0.2473 ** | −1.3813 | N/A− |
Luxembourg | 99.0000 | 0.0000 | 0.0000 | N/A− |
Malta | −3965.2956 | 2.0150 *** | −9.8854 | N/A− |
Monaco | 99.0000 | 0.0000 | 0.0000 | N/A− |
Montenegro | 1272.4608 | −0.5871 ** | −3.6447 † | N/A− |
Netherlands (Kingdom of the) | 667.1475 | −0.2839 *** | 0.1977 | N/A− |
North Macedonia | 527.0100 | −0.2151 *** | −8.5288 *** | N/A− |
Norway | −368.5200 | 0.2301 *** | 0.1076 | N/A− |
Poland | 695.2581 | −0.2968 *** | −1.3290 † | N/A− |
Portugal | −222.5545 | 0.1591 *** | −0.1465 | N/A |
Republic of Moldova | 432.4086 | −0.1699 | −1.9710 | N/A− |
Romania | 1960.9631 | −0.9290 *** | 1.0756 | N/A− |
Russian Federation | 270.4040 | −0.0860 *** | 0.4885 * | N/A− |
San Marino | 789.8433 | −0.3484* | 4.9212 * | N/A− |
Serbia | 179.9877 | −0.0430 | −0.0415 | N/A− |
Slovakia | 669.0760 | −0.2839 *** | 1.5191 * | N/A− |
Slovenia | 679.7028 | −0.2903 * | −3.0657 * | N/A− |
Spain | 321.4823 | −0.1118 * | −2.4221 ** | N/A− |
Sweden | 253.5922 | −0.0774 † | −1.3389 † | −1.2494 *** |
Switzerland | −190.1452 | 0.1419 *** | −1.0274 ** | −0.4516 * |
Türkiye | −587.3172 | 0.3398 ** | −1.8081 | N/A |
Ukraine | 6563.0914 | −3.2301 * | 45.3210 * | N/A− |
United Kingdom | −170.2197 | 0.1312† | −2.4664 ** | N/A− |
Country | Segmented | Chi-Square | Joinpoint |
---|---|---|---|
Albania | − | − | − |
Austria | − | − | |
Belgium | + | + | |
Bosnia | + | ||
Bulgaria | − | ||
Croatia | − | ||
Cyprus | − | ||
Czechia | − | ||
Estonia | − | − | |
Ireland | − | − | − |
Italy | − | ||
Latvia | |||
Lithuania | − | − | |
Moldavia | − | − | |
Montenegro | − | − | |
Netherland | − | ||
North Macedonia | − | − | |
Norway | − | ||
Poland | − | − | − |
Romania | − | ||
Serbia | − | ||
Slovakia | − | − | |
Slovenia | − | − | |
Spain | − | − | |
Sweden | − | − | − |
Switzerland | − | − | − |
Türkiye | − | ||
Ukraine | + | ||
United Kingdom | − | − |
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Aguinaga-Ontoso, I.; Guillen-Aguinaga, S.; Guillen-Aguinaga, L.; Alas-Brun, R.; Guillen-Aguinaga, M.; Onambele, L.; Aguinaga-Ontoso, E.; Rayón-Valpuesta, E.; Guillen-Grima, F. The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012–2023). Vaccines 2025, 13, 6. https://doi.org/10.3390/vaccines13010006
Aguinaga-Ontoso I, Guillen-Aguinaga S, Guillen-Aguinaga L, Alas-Brun R, Guillen-Aguinaga M, Onambele L, Aguinaga-Ontoso E, Rayón-Valpuesta E, Guillen-Grima F. The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012–2023). Vaccines. 2025; 13(1):6. https://doi.org/10.3390/vaccines13010006
Chicago/Turabian StyleAguinaga-Ontoso, Ines, Sara Guillen-Aguinaga, Laura Guillen-Aguinaga, Rosa Alas-Brun, Miriam Guillen-Aguinaga, Luc Onambele, Enrique Aguinaga-Ontoso, Esperanza Rayón-Valpuesta, and Francisco Guillen-Grima. 2025. "The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012–2023)" Vaccines 13, no. 1: 6. https://doi.org/10.3390/vaccines13010006
APA StyleAguinaga-Ontoso, I., Guillen-Aguinaga, S., Guillen-Aguinaga, L., Alas-Brun, R., Guillen-Aguinaga, M., Onambele, L., Aguinaga-Ontoso, E., Rayón-Valpuesta, E., & Guillen-Grima, F. (2025). The Impact of COVID-19 on DTP3 Vaccination Coverage in Europe (2012–2023). Vaccines, 13(1), 6. https://doi.org/10.3390/vaccines13010006