6th MVF Vaccination Congress “Vaccination Pact for Germany”

Brainstorming with all stakeholders

To achieve the vaccination recommendations of the WHO, STIKO, and SIKO, Germany needs the next step. It has become clear at the vaccination conferences held so far by "Monitor Versorgungsforschung": So far, the voluntary approach by healthcare stakeholders has not achieved what was hoped for. Otherwise, the actual vaccination rates would be higher. While they vary regionally, they have one thing in common: they are far too low. What needs to be done? Who is responsible? Who will assume a coordinating role? How can we do things better? This was the topic of the 6th MVF Vaccination Conference, entitled "Vaccination Pact for Germany."

"Vaccination rates are unsatisfactory for all vaccine-preventable diseases. There is even a National Vaccination Plan for influenza in Germany, according to which an influenza vaccination rate of at least 75% should be achieved." With this statement, Prof. Dr. Reinhold Roski, editor of "Monitor Versorgungsforschung" and
The moderator of the 6th MVF Vaccination Congress, entitled "Vaccination Pact for Germany," hosted the online event, for which over 100 participants had again registered. But after the coronavirus pandemic, Roski continued, too many people have developed vaccine fatigue, even with other vaccinations. Vaccination targets, vaccination agreements, and awareness campaigns would certainly help somewhat, but only relatively little. Because, according to Roski: "The population doesn't want to hear this, they tune out, and reject this information. Similar to the information about the harmful effects of smoking and alcohol." Therefore, low-threshold vaccination offers, as discussed at the last MVF Vaccination Congress in 2023, are a good step. But now Germany needs the next step. Roski: "Who is responsible for taking this step? Or better yet, who assumes the responsibility and duty to implement the sensible vaccination recommendations of the WHO, the STIKO, and the SIKO? Because relying on the voluntary participation of healthcare system stakeholders has so far failed to achieve what was desired. Otherwise, the actual vaccination rates would be higher."
Roski himself began the series of lectures by providing an overview of the five vaccination conferences organized by "Monitor Versorgungsforschung" since 2021 (1). The most important findings from these conferences were:
1. Education, knowledge transfer, and the personal commitment of healthcare professionals are crucial. Initial low-threshold vaccination offers (COVID-19/flu) are available in pharmacies, workplaces, doctors' offices, and public health centers. However, more are needed, including for other vaccine-preventable diseases.
2: We need courageous “conviction vaccinators”:
inside” to implement low-threshold vaccination offers, as there is no obligation.
3: Section 132e, Paragraph 4, has been inadequately implemented nationwide. The main reason: differing budgetary expectations between the KVs and the health insurance funds.
4: If we continue to rely solely on voluntary participation and hope that the self-governing authorities or the actors involved will reach an agreement, the recommended vaccination rates will not be achieved in the coming years either.
5: Germany needs a "vaccination push" that only politicians can initiate. Example: mandatory measles vaccination since May 2020.
After referring to the current MVF survey on the implementation of vaccination agreements according to Section 132e (2) and an MVF overview of all regional vaccination agreements (3), Roski identified the following points as effective approaches to increasing vaccination rates:
• Awareness and information campaigns to improve health literacy for insured persons in all media forms: against vaccination myths and misinformation, learning from the information campaigns on corona vaccinations
• Digital support for patients: electronic patient records, eVaccination Passport (reminder, information, monitoring and verification functions), digital platforms for scheduling appointments
• Tracking vaccination status and providing reminders
• Digital support for physicians: reminder management through better integration into the physicians’ practice management system
• Health system and health policy: Establishment of a vaccination register/vaccination system
• The financing of vaccination advice must correspond to the high expenditure required to adequately address the concerns of insured persons and patients
• Additional opportunities and increased convenience for vaccination: low-threshold offers in pharmacies, company doctors, public health services (schools), mobile vaccination teams, and pop-up clinics; the costs are covered by health insurance companies
• Better reach “difficult groups” (those uninterested in vaccination, those opposed to vaccination, refugees, socially disadvantaged): Collaboration with schools, community centers and other organizations to reach these target groups with vaccinations
• Monitoring and evaluation: regularly monitor vaccination rates and identify areas with low vaccination coverage, assess the effectiveness of vaccination interventions and make adjustments as needed.

Hubmann: Reminder systems are important and work
"Overcoming vaccine fatigue – What concrete solutions and political demands does digitalization offer?" This was the title of Dr. Michael Hubmann, President of the German Professional Association of Pediatricians (BVKJ), his presentation. He began by pointing out that pediatricians are the largest group of physicians who administer vaccinations. This is because basic immunizations, especially before school age, are closely integrated with preventive examinations and are also taken up. According to Hubmann, the vaccination rate is relatively high, especially for diseases with complicated courses, although there is still room for improvement. He highlighted how problematic the issue of vaccination is, using the example of the new vaccination recommendation for meningococcal B. Hubmann: "We doctors can explain to parents that we intend to jab their child three times, and at the same time, we must explain that there is a vaccine that we consider sensible and that, after twelve years, has also received a STIKO recommendation, but for which there is still no legal certainty that this vaccine should be used at the expense of the solidarity community." However, since there are side effects, prophylactic paracetamol administration must also be explained and ideally administered via suppository at the same time as the vaccination. Hubmann, pointing out to the health insurance representatives present the associated time and educational effort, added: "This is not comparable to a booster vaccination, where the medical assistant vaccinates against influenza as they pass by." In terms of content, the medical profession would very much welcome the vaccination. However, he hopes that it will be included in the standard care system before the end of this year.
While the almost complete utilization of U3 to U9 examinations (excluding U7a) among children born in Germany ensures high vaccination rates, the situation is different for HPV vaccination. Significantly lower vaccination rates and gender-specific differences are evident here. For example, HPV vaccination rates for girls increased from just under 30% between 2011 and 2021 to around 54% today, while for boys, the vaccination rate in 2021 is approximately 27%. The WHO has clearly set a target of a 90% vaccination rate in European countries, Hubmann continued. This makes sense because it is important to realize that the HPV vaccination is the only vaccination that can provide preventive protection against cancer. Hubmann demonstrated that it can work better than in Germany, using European HPV vaccination rates among 15-year-old girls with a complete vaccination series in 2021. All EU countries that had already met the WHO targets in 2021 rely on vaccination reminder systems.
The possibilities for increasing vaccination rates using HPV as an example are shown by an intervention study called “InveSt HPV” (4) funded by the Federal Ministry of Health, which fe-
which is being carried out primarily by the RKI and supported by the BVKJ. Initial results of the nationwide survey in pediatric practices and among parents of children aged 9 to 14 years show that
• Parents want reminders about vaccinations
• Parents indicate that they would like to be reminded of the HPV vaccination by the doctor’s office providing care
• Parents find it important or very important that the HPV vaccination reminder is personalized.
Module 1 of the project focused on the deployment and use of recall systems, which can help support timely physician contact. The effectiveness of recall systems has already been scientifically proven, yet such systems are not used widely in Germany for unexplained reasons. Module 2 (5) includes, among other things, training on innovative approaches to conversation management and addresses physicians and medical assistants (MFAs), the groups that play by far the most important role in the vaccination decision. Participating medical practices in the intervention regions of Bremen and (several districts in) Bavaria will be randomly assigned to one of the three intervention arms. While the practices in the first intervention arm will receive traditional training on HPV vaccination, the practices in the second intervention arm will be trained in conversation management (motivational interviewing) to apply this as part of HPV vaccination education. The practices in the third intervention arm will serve as a control group to compare potential increases in HPV vaccination rates between the different intervention arms during the intervention period. Initial partial results from Module 2 are expected from summer 2024.
At the end of his presentation, Hubman discussed the practice app "My Pediatric Practice," which is currently used in 1,204 practices by 2,108 pediatricians with 1,039,601 patients. In addition to a practice-specific patient information channel with push notifications and an online appointment scheduling system (OTV), the practice app also offers
For example, the option for certified video consultations and, since December 2021, a vaccination management and preventive care reminder system. This system started with the 1st and 2nd HPV vaccination (as well as the 1st and 2nd booster vaccinations for tetanus, diphtheria, and whooping cough in combination with poliomyelitis). Vaccination reminder messages were sent automatically in accordance with STIKO recommendations and on behalf of the
treating practice, which is in the
PracticeApp management can be customized. With success: Of 285,769 children and adolescents, all were reminded at least once of the four recommended vaccinations. Of these, 69,257 (24.2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 12%, 14%, 24%, 21 ...
• vaccination was fully completed at 25.4% in 2022 and increased to 28.1% in 2023,
• vaccination was partially completed at 12.7% in 2022 and increased to 13.0% in 2023,
• a date was agreed at 18.01% (year 2022), remained the same in 2023
• was reminded again at 31.7% (year 2022) and decreased to 30.2% in 2023.
Hubmann concludes: "Our descriptive in-app analyses from 2022 and 2023 show a positive trend due to vaccination reminders." Vaccination willingness (appointment made, vaccination administered) can be increased through information, reminders, and appointment management. However, ultimately, one also recognizes that while reminder systems are important and work, a legal basis and cooperation with the education system and self-government are needed for vaccination success.
Hösemann: “It is incomprehensible that we are not overrun”
At the beginning of her presentation entitled "Increasing vaccination rates for vaccinations recommended by STIKO and SIKO," Dr. Cornelia Hösemann, 3rd Chair of the Professional Association of Gynecologists and State Chair of Saxony, as well as a member of the Saxon Vaccination Commission (SIKO), pointed out that many people are unaware that "every doctor should actually vaccinate or advise on vaccination in every situation." She stated that it is true that pediatricians accompany, advise, and vaccinate children and adolescents for a long time. However, it is also important to encourage people to vaccinate in the years to come. Her credo at the beginning of her presentation: "Every doctor should acquire vaccination knowledge during their training and continuing education." This is particularly important for high-risk patients aged 18-49, for whom vaccination rates for influenza or pneumococcus – but also for pregnant women – are below 20%. The WHO recommends a vaccination rate of over 75% for influenza among seniors. At a specialist meeting at the Federal Ministry of Health, in which she participated, measures to increase vaccination rates in Germany were presented in November 2023. Among the 30 vaccine-preventable diseases, the greatest need for action was identified for HPV, pneumococcus, influenza in people over 60, and vaccinations during pregnancy (pertussis, influenza, COVID-19, RSV). There is indeed an opportunity to increase vaccination rates here. To achieve this, it is necessary that everyone visiting a medical facility always carries not only their health insurance chip card but also their vaccination certificate. According to Hösemann, this should be "common practice in every practice."
According to Hösemann, vaccination rates are generally too low, particularly for influenza and pneumococcal infections, among those over 60. This places an unnecessary burden on the healthcare system, as the subsequent costs of potential illnesses would be many times higher. Hösemann: "Therefore, one would actually hope that health insurance companies would show more commitment and also invest more money to promote vaccination, rather than hoping that hospital care costs won't be so high in the event of illness."
For example, separate reimbursement for vaccination advice, as is the case with the North Rhine Health Insurance Association, would make sense. There is a separate billing code for the sole billing of vaccination advice (4 euros). A similar practice had already taken place throughout Germany during the coronavirus pandemic, when a vaccination advice code of even 10 euros was introduced; however, this was quickly abolished afterwards. Hösemann: "We lack a uniform vaccination billing system in Germany because each of the 17 health insurance associations (KV) areas bills differently." For example, the doctor's fee for the HPV vaccination ranges between 6.90 and 9 euros, even for the same vaccination. Hösemann noted that it is strange that, while there is a uniform catalog of penalties for "traffic offenders," there is no nationwide fee catalog for vaccinations. There is also no vaccination register that would enable vaccination reminders to be issued by health insurance companies.
Like Hubmann, Hösemann addressed the potential for improvement in HPV vaccination rates. While the vaccination rate among 15-year-old girls has increased in recent years, he said it is incomprehensible that "we are not being overrun" because we have had a vaccine against cancer for over 15 years. In fact, many more parents should be vaccinating their girls and boys. The chairman of the STIKO (German Institute for Health Insurance and Prevention), Prof. Dr. med. Überla, recently advocated for a stronger role for schools in vaccination education and recommended administering HPV vaccinations in schools.
Hösemann: "If there were a vaccine against breast cancer, doctors could probably work 48 hours a day in their practice to administer vaccinations." Unfortunately, however, many people are no longer aware of the effectiveness and benefits of vaccination. This also applies to medical personnel. The vaccination rate among doctors is 8%, while in the nursing profession it is only 5%. Hösemann: "We should all take a look at ourselves, because doctors and nurses are very close to vulnerable groups."

Lämmel: a complexity that should not be underestimated
In her presentation entitled "Can and do health insurance companies take on a coordinating role in vaccination offers?" Dr. Julia Lämmel, Head of Pharmaceuticals at AOK PLUS, explicitly addressed the possibilities of the new Section 25b of the German Social Code (SGB V), which, since its inclusion in the German Health Data Use Act (GDNG), grants health and long-term care insurance funds the opportunity to conduct data-based evaluations to identify individual health risks. "We want to use this paragraph," Lämmel explained. "Because it states that health insurance and long-term care insurance funds can not only conduct data-based evaluations to protect the health of an insured person, but should also point out the results of this expansion." However, this new topic presents numerous challenges for all health insurance funds. According to Lämmel, the first step before such information is released is to inform the state supervisory authorities and the respective administrative board – all of which are not trivial. Only then must patients be informed that a health insurance fund even intends to conduct a corresponding evaluation based on the new Section 25b of the Social Code Book V. But the law doesn't specify how the information must be provided: by mail or on the website?
Or by mail to the insured persons concerned? The procedure is currently being reviewed, but she is confident that a solution will be found. With this initial information, every insured person must be given the opportunity to object. This could include the level of detail of a data analysis or a general objection to any data analysis. For example, an insured person could declare that they do not want to be informed about individual cancer risks, but agree to be informed about missing vaccinations. There is also a right to information about the data basis to be used. Lämmel: "This overall situation harbors a complexity that should not be underestimated, which we are approaching and for which we will also find solutions, but the new Section 25b of the Social Code Book V is not as trivial as it appears at first glance."
Once the initial information has been sent and consent has been received by the health insurance company and entered into the ePA, the evaluation can begin. If the data analysis yields results, this results in mandatory information about – using vaccination as an example – the relevant vaccination indications and their status. According to Lämmel, this information must then be communicated to the insured person in an understandable manner and with a comprehensible justification for the associated vaccination recommendation through appropriate channels. For example, the approach to promoting an HPV vaccination must be different than that for an influenza vaccination for people over 60.
If all of this has happened and the insured person is willing to be vaccinated and goes to the doctor (or in the case of influenza also to the pharmacist), the regional vaccination agreements of the respective KV and the health insurance funds form the basis. These, in turn, are based on the recommendations of the STIKO and SIKO as well as the vaccination guidelines of the G-BA.
According to Lämmel, the problem here is that, although there are nationwide documentation codes, the vaccine to be used is not documented. Furthermore, everyone faces the challenge that the billing systems result in a six- to nine-month delay between the service provided and the transmission of the billing codes. Lämmel's conclusion: "AOK Plus policyholders should and will be informed about the benefits of vaccinations in the future based on the new Section 25b of the German Social Code (SGB V). We want AOK Plus policyholders to take advantage of the offer of comprehensive vaccination protection from our healthcare partners."

Dolfen: Brainstorming with all stakeholders
Susanne Dolfen, Head of the Pharmaceuticals Department at AOK Sachsen-Anhalt, took a different stance. She began her keynote speech not from the perspective of a health insurance manager, but from that of an insured person, which she is. "As a vaccine recipient, it's really important to me that I have easy access to my vaccination," Dolfen explained. It's equally important to her that there is truly digital documentation of her vaccinations, which she can access at the touch of a button and share with anyone receiving the vaccination.
After this very personal statement, Dolfen addressed Section 132e SGB V, Paragraph 4. Statutory health insurance associations (KVs) and health insurance funds are called upon to work together to find means and methods for increasing vaccination rates, but the "how" remains open. Dolfen's questions: "Are we, as participants in this supply chain, doing ourselves any good if we only ever discuss money?" And: "Is more money really the solution to the problem?" All currently existing vaccination agreements are based on Section 132e SGB V, but for the most part do not contain an agreement regarding Paragraph 4. With these words, Dolfen did not want to cast doubt on the contractual basis itself, but merely on Paragraph 4, particularly if implementation only takes place between vaccinating physicians and health insurance funds if a flow of money is necessary. In particular, a flow of money for advice without a vaccination is not desirable, Dolfen added.
Saxony-Anhalt has long been the "vaccination champion." Nevertheless, the somewhat higher vaccination rates cannot be rested on their laurels. These are the result of hard work dating back to shortly after reunification, when health goals were formulated for the state of Saxony-Anhalt. Since then, the state of Saxony-Anhalt has maintained regular exchanges with all stakeholders on the topic of vaccination. In addition, the state has sent a very clear message to the medical profession and health insurance companies to work intensively together on the issue of vaccination rates. Therefore, in her opinion, a passage from paragraph 4 of Section 132e of the Social Code Book V is not absolutely necessary in Saxony-Anhalt's vaccination agreement. Dolfen added: "There are other means and ways to sensitize the population to the topic of vaccination and to seek appropriate advice from doctors." Her suggestion: "I don't have a recipe for how to boost certain vaccinations. But we should openly engage in a brainstorming session with representatives of all stakeholders involved in vaccination, including the pharmaceutical industry, to work out how vaccination recommendations and marketing should be designed to generate the greatest possible benefit for the population as early as possible."