According to Tallinn school nurses, the vaccination rate among children and adolescents has dropped to a critical level: while in 2019, around 10 percent of children remained unvaccinated, by 2024, more than a third of students had skipped the measles, mumps and rubella (MMR) vaccine.

Coverage for diphtheria, tetanus and pertussis (DTP) vaccinations has also declined and only 60 percent of girls and 50 percent of boys took advantage of the opportunity to receive the human papillomavirus (HPV) vaccine last year.

"There are many factors at play here," said Külli Reinsalu, head nurse at Tallinn School Health Foundation, which represents school nurses in the capital, when discussing the reasons behind the decline in vaccinations.

"First, there may be distrust and vaccine skepticism, in my opinion. Misinformation raises doubts. I've come to understand that some parents do not trust the national immunization program," Reinsalu said.

"A low perception of risk has also emerged — vaccines have been so effective in preventing these diseases that parents have never actually seen them. They have fallen into the trap of underestimating the risk. Some parents — this is just my personal opinion — are relying on herd immunity," Reinsalu added.

She explained that while school nurses have strong communication with families, the low vaccination rate is not only due to outright refusals but also parental passivity.

"School nurses put in a lot of effort: they make phone calls and send notifications. But often, parents do not respond — neither with a clear 'yes' to consent nor a 'no' to refusal," said Reinsalu.

Currently, Estonia's digital health solutions do not offer parents the option to give a one-time, blanket approval or refusal for all their child's vaccinations through the national Health Portal (formerly Digilugu).

"A default 'yes' should be set at the national level. I fully agree that consent should be given just once. That would be a major step forward," Reinsalu stated.

"As it stands, notifications about screening programs are already sent via the portal. We could have a similar solution for vaccinations, where parents could simply give their consent through the portal. This way, school nurses wouldn't have to spend their entire day contacting parents for digital signatures or paper forms. There are many things we could do differently, but this is one solution we are eagerly waiting for," Reinsalu said.

Health Insurance Fund working on a solution

Family physician Triinu-Mari Ots from the Laagri Family Medicine Center also pointed out that one possible reason for the decline in student vaccinations is that school nurses must constantly seek parental consent.

"I know from my own experience that the school nurse asks me for approval every single time before vaccinating my child. I've told her, 'Why are you asking again? I already gave permission for all the necessary shots once,'" Ots said.

According to Ots, parents should be considered to have given their default consent for all vaccinations and should only need to indicate their preference if they wish to refuse.

She does not believe that the current decline in student vaccinations is linked to the strong anti-vaccine sentiment that emerged during the COVID-19 pandemic.

"No. Skepticism exists regarding the COVID-19 vaccine, but it should not affect other vaccines. These are vaccines that have been used for a long time and have very few side effects," Ots stated.

Hanna Jäe, head of the vaccination service at the Estonian Health Insurance Fund (Tervisekassa), said that preparations have begun to introduce parental consent into the national health portal.

"A solution needs to be found for several technical issues and preparations are underway in this regard. In addition to the technical aspects, a legal analysis is also required, which is being handled by the Ministry of Social Affairs," Jäe explained.

Under Estonia's national immunization program, school nurses administer the following vaccines:

• Ages 12-18: Human papillomavirus (HPV) vaccine for both girls and boys.
• Age 13: Measles, mumps and rubella (MMR) vaccine (second dose).
• Ages 15-17: Diphtheria, tetanus and pertussis (dTpa) vaccine (sixth dose).

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