We live in a time when our attention is focused on current and very pressing concerns, without realizing that other issues are quietly simmering and may soon boil over. One such predictable major problem will be the return of old and forgotten vaccine-preventable infectious diseases.

According to the World Health Organization (WHO), for effective control of infectious diseases covered by the immunization program, a vaccination coverage rate of 95 percent is required. In Estonia, the national immunization program includes vaccinations for children and adolescents against tuberculosis, hepatitis B, rotavirus, diphtheria, tetanus, pertussis (whooping cough), rubella, measles, mumps, polio, HPV and Haemophilus influenzae type b (Hib).

For example, while Estonia has consistently lagged behind Europe in voluntary flu vaccinations, and the COVID-19 vaccination campaign that began in 2021 can be seen as largely unsuccessful, the country had been doing relatively well in vaccinating children until recently. In 2014, vaccination coverage among children in Estonia exceeded the WHO-recommended 95 percent for all key vaccines in the national immunization program and remained above 90 percent until 2021.

However, last year, vaccination coverage (depending on the vaccine) fell to an average of 73-85 percent. For example, coverage for vaccines against diphtheria, tetanus, pertussis, poliomyelitis, Hib and hepatitis B has dropped to 86 percent among one-year-olds, and only two-thirds of seven-year-olds have received their second dose. Coverage for the MMR (measles, mumps and rubella) vaccine among two-year-olds has decreased to 78 percent. In Estonia, nearly 25,000 children are unprotected against dangerous infectious diseases.

Is it really a global trend which cannot be helped?

It would be easy to attribute the decline to global trends and the impact of COVID-19, as the global pandemic, with its sometimes poorly justified restrictions, provided ammunition for various hostile foreign entities.

The primary reasons for the decrease are parents' vaccine hesitancy and the spread of anti-vaccination information. Many parents have begun refusing to vaccinate their children, leading to a drop in coverage and increasing the risk of a resurgence of severe infectious diseases.

But are capitalism and the four seasons once again to blame for everything, like during the Soviet era?

Looking a bit further north to Finland, for instance, 98 percent of children born in 2021 were vaccinated against diphtheria, tetanus, pertussis, polio and Hib infections. Nearly 95 percent of the children born in 2021 received the MMR vaccine, which protects against measles, mumps and rubella.

As the Finnish Institute for Health and Welfare notes on its website, vaccine refusal remains rare in Finland: only 1.7 percent of children born in 2021 were completely unvaccinated, a slight increase from earlier cohorts – 1.4 percent of children born in 2020 remained unvaccinated by age three, and in previous age groups, the figure was around 1 percent.

Dr. Anniina Virkku, an expert at the Finnish Institute for Health and Welfare, stated in a press release that although the changes in vaccination coverage are minimal, it's important to carefully monitor whether this trend becomes more common in the coming years. "The proportion of unvaccinated children is currently higher in the age groups born during the COVID-19 pandemic, so we also need to analyze the pandemic's impact on children's vaccination rates and attitudes towards vaccines," Virkku said.

In any case, we see that Finland's setbacks (at least according to current statistics) are negligible, but we in Estonia must start preparing for the possible return of measles and polio.

What went wrong?

Vaccination, as we know, is voluntary in both Estonia and Finland. It can be likened to life insurance-+ where having a policy in place provides peace of mind, or perhaps more accurately to a seatbelt, which prevents the worst during an accident. For some reason, our northern neighbors decide to fasten their health seatbelts before the ride, while many in Estonia believe it's unnecessary.

Since we're talking about a voluntary decision the making of which should be almost self-evident, the problem might be best described as "the fish stinks from the head" – in other words, failures at the national level (read: the Ministry of Social Affairs and the Health Board). These failures have missed the mark not by mere centimeters, but by meters. The main issue is that public trust in national health institutions is significantly lower in Estonia than in Finland.

The confusion during the COVID-19 vaccination campaign certainly played a major role, including the fact that while there was initially a lack of a vaccination plan and a shortage of vaccines, an even more critical mistake soon became apparent: people had been misled. The public was told that the COVID-19 vaccine would provide immunity against the disease, which many interpreted as a guarantee of complete protection. Consequently, a large portion of the population became disillusioned with vaccines after contracting COVID-19 despite being vaccinated, albeit generally with milder symptoms.

The situation wasn't helped by the Health Board's cold storage mishap, which raised legitimate questions about whether we could trust vaccines stored in refrigerators with floor heating. Although the cold storage incident was an extraordinary blunder and more of an exception than the norm, it served as fertile ground for distrust. Our national institutions failed to meet basic expectations in both administrative functions and communication.

Moreover, the Ministry of Social Affairs' communication department deliberately linked COVID-19 vaccination with the broader national immunization program. For instance, in 2021, the previously immunization-focused website vaktsineeri.ee was temporarily revamped. As a result, parents seeking information on immunization program vaccines were instead greeted with discussions about COVID-19 vaccination, all while knowing that the COVID-19 vaccine was either unavailable or provided protection that fell short of the promised 100 percent.

Instead of boosting the popularity of the new COVID-19 vaccine, the government, through its own mismanagement, dragged into the mud the vaccines that have protected us from dangerous infectious diseases for decades.

Vaccination is necessary

As a doctor, this situation saddens me deeply. What could be a better remedy than ensuring that a dangerous disease simply passes by you and your loved ones? This is especially true as people continue to travel frequently, even to places where diseases like polio still lurk. According to the World Health Organization, the wild poliovirus is still circulating in several Asian and African countries, including Afghanistan, Pakistan, Nigeria, the Central African Republic and Chad.

Circulation of the vaccine-derived poliovirus (cVDPV) has been observed in several countries, including the Philippines, Indonesia, Syria, Iraq, Somalia, Papua New Guinea, Equatorial Guinea, Ethiopia, Nigeria, Niger, Mozambique, the Democratic Republic of the Congo, Kenya and Cameroon. While you may not travel to these countries, when you wait at major airports like Frankfurt or Amsterdam for your connecting flight to Thailand or Tenerife, you could easily find yourself sitting next to someone who has just arrived from Chad, Afghanistan or Equatorial Guinea.

Both the wild poliovirus and the vaccine-derived poliovirus have the potential to cause paralysis in unvaccinated or inadequately vaccinated individuals. The disease can manifest in varying degrees of severity. About a quarter of those with paralytic forms of the disease are left with permanent disabilities. Any muscles can be affected, though those in the legs are most commonly impacted, followed by the arms, neck and trunk muscles. Polioviruses can also invade the brainstem, leading to swallowing, breathing and speech difficulties in affected patients.

According to our immunization program statistics, as a society, we are unfortunately already exposed to several infectious diseases, including polio. It's true that our officials may often seem to be stumbling around with buckets tied to both feet, but if the Finns haven't given up on vaccination, why should Estonian parents? The vaccines in the immunization program are free – use them.

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