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Editor,—Gershon summarised the rationale for universal varicella immunisation and strongly advocated its implementation in developed countries.1 While the reduction of varicella associated morbidity is indeed an important public health goal, it seems warranted to draw attention to epidemiological, political, economic, and cultural characteristics of Europe that may affect the success of a universal varicella vaccination programme.
Recent epidemiological data indicate that severe complications of varicella are uncommon in Europe.2 3 Persuading primary care physicians of the need for universal varicella vaccination will face obstacles similar to those reported from the state of Washington,4 where fewer than 50% of physicians surveyed followed the policy of universal varicella vaccination. One of the main reasons for non-adherence was the impression that varicella is a benign illness. While ongoing monitoring of severe complications is crucial, it is clear that an appreciable burden of the illness must be obvious to those in charge of administering the vaccine.
The demise of the East–West divide, the Balkan war, and the free employment market in the European Union contribute to an accelerated migration of people across national boundaries, the directions and flow of which are poorly predictable. Unless a multinational varicella vaccination programme can be implemented, such migration will dilute immunisation rates, and the emergence of populations of susceptible adults becomes a realistic scenario.
The cost effectiveness of the varicella vaccine relies heavily on indirect savings resulting from the prevention of parental work loss. In many European countries, most children are cared for by a housekeeping family member. Overall cost effectiveness in this socioeconomic environment is unclear.
A considerable proportion of parents object to immunisations against common childhood illnesses. A recent survey5 of vaccine coverage at the age of 36 months among Swiss children found immunisation rates for diphtheria–tetanus, pertussis, and poliomyelitis of 98%, 90%, and 98%, respectively, while the rate for measles–mumps–rubella (MMR) was as low as 76%. The last rate does not reflect the lack of opportunity, but the lower acceptance of the MMR vaccine. The varicella vaccine is likely to fall into the same category.
Both the safety and efficacy of the varicella vaccine are undisputed, and the prospect of preventing herpes zoster may become a powerful argument supporting its use. However, strategies for overcoming the issues described must be available before universal vaccination should be recommended. Equally important, new vaccines of high priority, such as the pneumococcal conjugate vaccine, will soon be available. It seems prudent not to waste the cooperation of both paediatricians and parents with a vaccine of lower priority.