I was in Tartu last weekend to speak at the Baltic Vaccination Day. In this small Estonian university town that has endured invasions by Germans, Poles, Swedes, Russians, Germans again and then Soviets, we discussed other smaller invaders of the respiratory and nervous systems of adults across the world: the pneumococcus, influenza virus, tuberculosis and the TBE virus which rides in on ticks in search of our brains. There was a mild sense of exasperation at the fact that we are able to make childhood vaccination programs work well – including here in the Baltic – but programs for adults continue to stumble along with coverage rates that are only a fraction of the recommended targets. In the US about 300 children die from vaccine-preventable diseases each year. As opposed to 50,000 adults. Prof Arvydas Ambrozaitis from Vilnius University noted that if this were the other way around – 50,000 deaths of children – it would be a national emergency. Yet adult immunisation seems to be caught in a fog of apathy, indecision and inaction. Prof. Stephan Gravenstein noted that in the US, the target seasonal influenza vaccination rate for high-risk adults is 90%, but the actual rates are about 30%. In Lithuania, Prof. Ambrozaitis said that the actual rates for this group hovers around 6% – a long, long way from the more modest EU target of 75%. I was however quite impressed to see that in Latvia actual coverage rates for tetanus and diphtheria (Td) vaccination of adults are between 50 – 60%. This may be below their target of 80%, but I am not sure many other countries manage to get coverage this high. Everyone seemed to agree that a major reason for this adult vaccination gap is simply that most people, including HCWs, don’t often put the words ‘adult’ and ‘immunisation’ in the same sentence. Vaccines are for kids, not grown-ups in many people’s minds. Crises of confidence in childhood vaccination in the Baltic seem to regularly come from the mass media. One headline that was recounted to me: “Vaccination is like Russian Roulette”. However, Prof. Ludmila Viksna noted that the continued widespread use of certain vaccines which have higher incidence of local complications, such as BCG which can induce pain, scarring and sometimes abscesses at the injection site, also impact the public’s perception of vaccines. When it came to solutions for this challenge of low vaccination coverage in adults, the words ‘education’, ‘information’, ‘factual’, and ‘misunderstanding’ popped up rather a lot. Read my previous blog post to see that information and education are not major drivers of behaviour. Or as Stefan rather nicely put it: We keep trying to eat soup with a fork. But there was also discussion of the access barriers that must be overcome, and the fact that opportunities to immunize adults are often missed. And interestingly, civil society organizations (CSOs) have played very positive roles in supporting vaccination in the Baltic region. Active supporters of vaccination in Latvia include religious organizations, the Latvian Red Cross, a Hepatitis Society, and a ‘Mommie’s Club’. A few years ago Vanina Laurent-Ledru and I discussed the emergence of CSOs as a key stakeholder in immunization in this paper. Most encouragingly though was Stefan’s account of the outcomes of a mindstorm (brainstorming by mind map if I understood right) by the National Adult Vaccination Program (NVAP) which aimed to build an action-plan to increase adult immunization rates in the US. They identified policy actions such as expanding policies and mandates (those may not work so well in Europe…) to require large employers to have a vaccination policy, and structural options such as centralized registries and broadening the definition of immunizers. But, of course, the stuff I liked was a call for more public engagement, and for collaboration with the social sciences (make sure you don’t miss the cognitive scientists Stefan) to help us better understand people’s concerns around vaccination. I thank all the participants because I really had a stimulating and challenging day in a beautiful part of the world. I have, however, been wondering since how it could be conducted to give more practical, concrete outcomes. Does anyone know of other vaccination days in other parts of the world, and if so, what do they do to have a lasting impact on policy or the public?