Publication Date
June 8, 2016

On June 8 2016, a high-level technical roundtable on immunisation and polio eradication in Ukraine was held in Washington DC, United States (US). It was convened by the US-Ukraine Foundation and hosted by Representative Mary Kaptur, (D) Ohio 9th Congressional District and co-chair of the Congressional Ukrainian Caucus with technical support from The Communication Initiative. It was chaired by Dr. Boris Lushniak, Chair, Department of Preventive Medicine and Biostatistics at the Uniformed Services University of the Health Sciences (USU) F. Edward Hébert School of Medicine and former acting Surgeon General of the United States. Other presenters included: Dr. Patrick O’Connor, team lead (accelerated disease control, vaccine preventable diseases, and immunisation) at the World Health Organization (WHO)'s Regional Office for Europe; Dr. Kateryna Bulavinova, senior health and communication advisor at the United Nations Children's Fund (UNICEF) Ukraine; and (via video) Judyth Twigg, professor of political science at Virginia Commonwealth University and author of the March 2016 Centre for Strategic and International Studies (CSIS) Global Health Policy Center report "Polio in Ukraine: Crisis, Challenge and Opportunity." A statement addressed to the meeting from Dr. David Salisbury, Chairman of the European Regional Certification Commission for Poliomyelitis Eradication, was also read to the roundtable.

The event brought together senior polio and technical experts centrally involved in immunisation activities in Ukraine, people from within the North American Ukrainian diaspora with knowledge of and interest in immunisation, and global public health technical experts on communication, immunisation, and polio eradication. Its purpose was to engage in open and free dialogue and analysis of the status of immunisation and the response to the polio outbreak in Ukraine, as well as to identify on strategic steps to address the core issues, and to share these with relevant decision-makers.

Background
Wide-scale immunisation and vaccine coverage in almost all countries of the world has led to significant, in some cases dramatic, decreases in child and infant mortality and morbidity. This coverage is the key factor in the elimination of smallpox from the globe and the very near eradication of polio. Vaccination is regarded as one of the 10 major public health achievements of the 20th century.

Ukraine has amongst the very lowest immunisation rates in the world. Rates dipped to 14% in mid-2015 for polio. There are as many as 3.5-million children un- or under-vaccinated in Ukraine. Important antigens such as DTP (diphtheria, pertussis and tetanus) have rates as low as under 5% in 2016. There have been pertussis (whooping cough) outbreaks. Most economically poor countries have markedly better coverage rates. The recent polio concerns in Ukraine are also a strong pointer to very poor immunisation coverage; however, a nationwide polio campaign in 2015-2016 helped boost coverage.

Analysis
The participants identified a number of factors that contribute to Ukraine's dangerously low immunisation coverage rates, which are listed in the final statement. In brief, they are:

  • Vaccine supply is inadequate.
  • Many medical personnel and scientists/academicians do not have up-to-date knowledge on vaccines and immunisation.
  • Public misperceptions exist about vaccines, many of which have no basis in science.
  • Government investment is low compared with almost every other country in the world.
  • Vaccine costs are high due to the influence of the pharmaceutical industry.
  • The conflict in Eastern Ukraine has left areas where there is little or no information on child immunisation.
  • Mobile populations of internally displaced people (IDPs) and migrant groups have limited access to health care.
  • There is considerable corruption within the health system.
  • Different levels of government are not clear about their roles and responsibilities for delivering health services.
  • Health workers and policymakers (Ministry of Health - MoH) face unacceptable legal risks and can easily become a subject to legal action in cases of alleged adverse events following immunisation (AEFIs).
  • Widely used social media platforms are often used as mass forums for the communication of erroneous information.
  • The MoH has major capacity gaps such as the absence of a significant communication section and a chronically understaffed Expanded Program on Immunization (EPI) department.

More positively, it was noted that the recent polio outbreak campaigns carried out using global standards have improved population immunity, indicating that rapid increases in coverage are possible.

Ways Forward
In a statement issued after the roundtable, the following initiatives were identified that could greatly expand routine immunisation and polio vaccination coverage:

  • A clear official Government statement that full immunisation coverage for all children under 5 years of age.
  • Immediate re-stocking of the required vaccines for all routine immunisations recommended for children under 5 years of age in Ukraine. (Use support of international organisations to establish national regulatory and procurement mechanisms able to gradually take over vaccine procurement in an effective and transparent way.)
  • Government adoption of a target of at least 95% coverage for all routine immunisation antigens for all children under 5 years of age in Ukraine within 2 years.
  • Increasing support for vaccinators by providing much stronger legal protection for health care workers and policymakers.
  • Increased public financial investment in immunisation by Government, Oblasts, and Cities.
  • A major and immediate training programme for all medical personnel on the most recent science related to immunisation and vaccines and the demonstrated epidemiological impact they have for major child and adult diseases.
  • An enhanced social media initiative to engage parents, communities, the medical community, the private sector, and government representatives and officials with accurate knowledge about vaccines and immunisation, from polio to HepB.
  • A review of current global standards for policy and practice on immunisation and vaccines by countries, with the assessment of the Ukrainian status as compared to those global standards.
  • Organisation of a subsequent high-level roundtable on this topic to be held in Ukraine as soon as possible. (The purpose would be to help address immediate concerns, support reform, and share lessons learned and recommendations with government and non-governmental stakeholders. The meeting could also serve as a review mechanism for progress achieved since the 2015 polio outbreak.)
  • The convening and facilitating of Oblast-level dialogues, in person and through local media, on child health issues and risk.
  • Efforts to ensure that both sides of the conflict in the East are prepared to honour days of tranquility, monitored by the Organization for Security and Co‑operation in Europe (OSCE), which would allow vaccinators into areas along the contact line that are cut off.

In Conclusion
In the final statement, the participants noted that there are clear and indisputable returns on investment from vaccination. In the US, for each birth cohort, the adoption of routine immunisation schedules has reduced direct health care costs by US$9.9 billion, reduced indirect costs by US$33.4 billion, and prevented 14 million cases of disease.

Unfortunately, few of the elements of Ukraine's immunisation program are at the standard expected or required to protect public health. Experts agree that a major overhaul of all elements from procurement through to policy and implementation and political will is urgently required.

While external goodwill still exists, the country is urged to work together with international partners to increase vaccination coverage. Government leaders must not wait for outbreaks of vaccine-preventable diseases to repair the serious gaps in the health care system. Inaction could bring consequences - including further outbreaks that increase a population's morbidly and mortality, national health care burden, travel restrictions, lost productivity, and diplomatic isolation.

Presenter Perspectives
The Chair and each of the presenters, including Dr. Salisbury (whose statement was read to the meeting), were interviewed by Michael Bokiurkiw as a way of adding further background and insight to the discussions. Below are quick introductions to each of the presenters with a link to their video interviews.

Boris Lushniak, Professor and Chair, Department of Preventive Medicine and Biostatistics at the Uniformed Services University of the Health Sciences (USU) F. Edward Hébert School of Medicine in Bethesda, MD, US. Dr. Lushniak also chaired the roundtable, which he describes as critical but notes that most of the people in the room were diaspora and technical experts. Ultimately, it will be the MoH who needs to take a close look at the recommendations and apply the ones they think need to be implemented. View English and Ukrainian language interviews at this link.

Judyth Twigg, professor of political science at Virginia Commonwealth University and author of the March 2016 Centre for Strategic and International Studies (CSIS) Global Health Policy Center report "Polio in Ukraine: Crisis, Challenge and Opportunity". Professor Twigg's analysis paper explores the aftermath of a polio outbreak: 2 children contracted polio in the Transcarpathian region in western Ukraine in August 2015 after a 19-year absence of the disease in that country. Twigg argues that "[t]he proper reaction from the global health community is a sober, realistic admission: we will almost certainly see a proliferation of infectious outbreaks in Ukraine and the Balkans, especially as some governments struggle with a continued massive influx of refugees." She contends that the international community can take advantage of Ukraine's membership in Western institutions as a pressure point. This is also a key moment, she suggests, to demonstrate the utility and potency of the Global Health Security Agenda (GHSA), as Ukraine is one of 30 US partner countries designated in November 2015 for priority achievement of GHSA targets. In the interview conducted for the June 8 roundtable (click here to view it), Professor Twigg is asked to discuss some of the key findings from her paper. Twigg states that it would be difficult to imagine a more rapid and efficient on-the-ground response than there was to the 2015 polio outbreak in the Ukraine. Where there is room for improvement is the imposition of high-level political pressure. We need to take advantage of Ukraine's aspiration toward membership in Western institutions. View the interview at this link.

David Salisbury CB, Associate Fellow, Centre on Global Health Security at the Chatham House in the United Kingdom (UK). He here presents his perspective on the poor state of the immunisation programme in Ukraine, arguing that the entire programme needs to be "picked up and shaken and almost started afresh". One of his suggestions is that the government programme design communication materials and ensure they disseminated through the whole system as part of a well-constructed communication strategy that starts at the top and goes down to the very bottom of the programme. To ensure that all health workers are "speaking from the same song sheet", they need to all be given the same information. In the UK, when there was an issue with public trust of the measles, mumps, and rubella (MMR) vaccine, the solution was to work from the point of local health care providers. As members of community, these providers are trusted even if the government might not be. They can speak sincerely to parents, saying "I vaccinated my children", and this can be taken seriously. View the interview at this link.

Patrick M. O'Connor, team lead (accelerated disease control, vaccine preventable diseases, and immunisation) at the WHO's Regional Office for Europe, opines events of 2015 had the effect of helping make the health system in Ukraine more resilient. For example, the communication of activities that needed to happen - e.g., supplementary immunisation activities (SIAs) - in the aftermath of the outbreak proved confidence-building for parents in that they saw that the outbreak was controlled. Dr. O'Connor suggests that we need to capitalise on this momentum on for routine immunisation (RI) so that long-term gains are sustained. View the interview at this link.

Source: 

Interviews with presenters; Statement on the Roundtable on Immunization for Vaccine-Preventable Disease and Polio in Ukraine [PDF]; and "Ukraine's immunization challenges discussed at Capitol Hill roundtable", by the U.S.-Ukraine Foundation, June 24 2016 - accessed on September 12 2016. Image credit: Adrian Karmazyn