Lessons Learned from SIAs:

1
Lessons Learned from SIAs

• Magnification of the opportunities and risks to
  routine immunization programmes

Rebecca Martin Communicable Diseases Unit, WHO
Regional Office for Europe
2
Objectives

• To share lessons learned from measles and rubella
  SIAs in the WHO European Region in 2008
• To demonstrate that opportunities and risks to
  routine immunization programmes, including the
  introduction of new vaccines, are magnified
  during SIAs

3
SIAs conducted in the context of strengthening
health systems

• Stewardship
• High-level political commitment
• Health service delivery
• Creation of demand for services
• Deliver safe, effective vaccines
• Health finances
• Funding
• Government supported
• Creation of resources
• Capacity building of health care workforce
• Training in programmatic issues and vaccinology

4
Why is it important to monitor safety during SIAs?

• Immunizing a large population in a short period
• Vaccines can be given outside of routine health
  care setting
• Increased potential for programme errors
• Perception of increased rate of adverse events
  following immunization (AEFI)

Source Dina Pfeifer WHO/HQ
5
UKRAINE

• Second largest country in Eastern Europe with
  largest pool of MR viruses in circulation in
  Region from 2005-2007
• MR SIA to start 26 May 2008 to vaccinate 7.5
  million people aged 16-29 years

6
Anti-vaccination atmosphere prior to SIA

• Known anti-vaccination groups active in Ukraine
• CD-ROMs and booklets
• Lack of evidence
• MR vaccine is an attack on the genetic fund of
  Ukraine
• MOH participated in discussion with
  anti-vaccination groups in November 2007
• Negative press generated

7
Communications activities to address SIA issues
conducted and planned

• Focus groups conducted among students and health
  care professionals
• FAQs developed to address concerns of health care
  professionals and students
• Trainings planned for journalists, educators, and
  health care professionals
• Radio programmes planned ask the experts
• Press conference planned for launch with
  partners to give positive message

8
Events aligning
Death of a 17 year-old within 15 hours of
receiving MR vaccine in advance to the SIA
State prosecutor takes case Multiple
commissions Legal aspects of vaccine
May 26
May 17
May 13
May 14
May 16
Incomplete case investigation, prophylactic
hospitalisation of 156 children from the same
school, media outburst

• Campaign suspended
• 116,000 immunized
• (6-16 May)

9
Consequences of events

• Increase in negative, misinformation from media
  towards immunization, MOH, SII, WHO and UNICEF
• Generated mistrust
• SIA, death and vaccine become prominent public
  issue
• Detention and questioning of 1st Deputy Minister
  of Health and Chief Sanitary Physician
• Order to quarantine vaccine

10
Extremely Hostile Media Response
Unscheduled Vaccination GENIE SET FREE
Vaccination 2008 Gain Freedom From All Ills MR
Vaccine You can Trust
Deadly Vaccine MOH playing Indian Roulette
11
Media coverage in Ukraine on MR SIA and AEFI, 12
May 2 June 2008
May
June
12
What was themedical community doing?

• Widespread confusion
• Lack of information
• General mistrust
• Anti-vaccine position held by several high level
  persons in academia
• Pseudo-experts threatened to sue MOH, WHO, UNICEF
• Pro-vaccination voice barely heard

13
MOH response to crisis

• Limited attempts to state vaccine was safe
• Suspension/firing of staff
• 1st Deputy Minister
• head of communicable diseases
• heads of the two institutions involved in
  vaccine importation
• Lack of communication with the public
• Mixed messages

14
Partners support Ukraine MOH

• International technical experts
• Technical advice on death/hospitalized cases
• Vaccine storage
• Pro-immunization media messages
• High level meetings
• Geneva WHO Director General, Ukraine Minister of
  Health, India Minister of Health
• Ukraine RD of WHO/EURO and UNICEF RO

15
Risks to routineimmunization programme

• Temporary gains made by anti-vaccination movement
• Public belief in vaccination as an effective
  public heath intervention was lost
• Negative shift in risk perception affecting
  health-seeking behaviours
• Threat of measles and rubella outbreak exists

16
Strategies to rebuild trust in immunization in
Ukraine

• Conducted KAPB surveys
• Maintain high level of political advocacy
• Develop and implement long-term strategy to
  restore public trust in immunization
• Scenarios to immunize susceptible population
• Provide competent and independent sources to
  media, public and different Government bodies
• Reinforce technical and communication capacity
• Build pro-vaccine coalition

17
Georgia

• MR SIA conducted 20 October 12 December
• Targeted 980,136 persons aged 6-29 years

18
Events aligning

• AEFIs reported
• majority in adolescents, predominantly in females
• the most frequent clinical manifestations
  fainting and other symptoms related to emotional
  reaction (psychogenic) after vaccination
• AEFIs identified during the SIA do not differ
  from those of MR campaigns conducted in the
  European region in 2000-2007

19
Rustavi 2 broadcast22 October 2008

• The Indian medicine used for the injections of
  measles and rubella is not registered in
  Georgia...
• Twelve teenagers were taken to the resuscitation
  department of the first clinical hospital due to
  extreme worsening of their health conditions in
  sequence of the injections. .

Measles and rubella virus vaccination started in
Georgia
20
Immunization coverage by region 20-31 October
2008, Republic of Georgia
Rustavi 2 story on vaccine from India
21
Alia Kronika28 October 2008
Fatal experiments with measles-rubella
vaccine carried out on Georgian children
Note that Big Scale is the name of the
experiment initially determined for the Ukrainian
population. As the experiment failed in Ukraine,
it was introduced in Georgia.
22
MOH response to AEFIs

• Intense monitoring and analysis of AEFI
• National Committee of Experts on AEFI review
  reports
• Feedback to sub-national level
• Frequent positive press releases by MOH and NCDC
• Extended SIA through 12 Dec 2008
• 50.3 national coverage achieved

23
Magnification of the opportunities and risks to
routine immunization programmes
24
Lessons learned from SIAs

• Political commitment and trust are key
• Conduct a situational analysis
• Knowledge, attitudes, practices, and beliefs of
  health care professionals and general population
• Anti-vaccine movement
• AEFI surveillance must be operational and risk
  management strategy developed prior to SIA or
  introduction of new vaccine
• Develop a preventive communication plan
• Educate and work with the media
• Document and share experiences among countries
  and Regions

25
Source Dina Pfeifer WHO/HQ
26
Acknowledgements

• Ministries of Health
• Ukraine
• Georgia
• WHO Country Offices
• UNICEF Country Offices
• WHO Regional Office
• UNICEF Regional Office
• UNICEF Supply Division
• Yalda Momeni

• WHO Headquarters
• Dina Pfeifer
• Peter Strebel
• Nora Dellapiane de Rey
• Patrick Zuber
• UNICEF Headquarters
• Dragoslav Popovic
• Edward Hoekstra
• US CDC
• Steve Wassilak
• Nino Khetsuriani
• Amra Uzicanin

27
Thank you
28
Focus groups conducted

• Health care professionals
• Why vaccinate 2 years after the epidemic?
• Did the vaccine pass clinical trials?
• Where has it been used?
• What complications occurred afterwards?
• High school and university students
• Why vaccinate when there was a large outbreak?
• Is there any risk of mutations for me or my
  children if I get vaccinated?
• Where has vaccine been used before are we going
  to serve as lab animals?
• Can we refuse vaccination?