The Lancet: Ukraine at risk of polio outbreakBy Ed Holt
A combination of public mistrust in vaccinations, poor vaccine supply, and corruption in the health system has left Ukraine with worryingly low rates of immunisation.
Fear and mistrust among Ukrainians towards vaccinations must change if the country is to avoid outbreaks of polio and other potentially lethal diseases, international health officials have warned.
The country has seen a surge of recorded cases of measles, rubella, and mumps in recent years—measles cases were up from less than 100 in 2010 to more than 12 700 last year—as vaccination coverage fell to a 20-year low.
© UNICEF/UKRA00502/GIACOMO PIROZZI
WHO and UNICEF have also recently said that an outbreak of polio is a real danger. The disease is rarely seen in Europe today but Ukraine is particularly vulnerable to an outbreak, experts say, with only 74% of the population immunised against it. This compares to average coverage in Europe and the USA of more than 90%. The chances of an outbreak are so great that Ukraine last month hosted a WHO-led polio simulation exercise.
Concerns are rooted in low coverage for vaccinations, brought about because of not only supply problems but also the fact that a large minority of parents refuse to have their children vaccinated. “Public trust in vaccinations has been eroded in recent years and this has to be changed. People's confidence in vaccinations has to be won back”, Dorit Nitzan, head of WHO's Ukrainian branch, tells The Lancet.
A survey by UNICEF last year showed that as many as a third of Ukrainian parents are against vaccinations. Only around 50% of children in the Ukraine are fully immunised against polio, measles, rubella, and other diseases.
Vaccinations are free under state health care and national health guidelines say children should be vaccinated against ten infectious diseases. But compliance is poor and has been falling for the past 5 years—from around 80% in 2008 to just 50% in 2012, according to UNICEF.
The drop-off followed a high-profile case in 2008, when a boy died following a measles and rubella vaccination. His death was unrelated to the vaccination but incorrect media reporting of the case and a confused government response created a deep-seated mistrust of vaccinations among the public, which continues today.
Many parents speak privately of being aware of the risks of not having their child immunised but say they are preferable to the dangers of vaccines. Olena Merkulova, a 34-year-old mother in Kiev, tells The Lancet that she had her 12-year-old daughter vaccinated but could understand why other parents rejected vaccination for their children. “It concerns me greatly. The public doesn't have enough information about the content of vaccines and possible risks, and you hear so many stories about vaccines being unsafe. There is definitely something very wrong with the vaccination process if a mother needs to be worried”, she says.
By law parents are supposed to produce a certificate of immunisation before their children can start school but they often get round this by obtaining fakes. WHO, UNICEF, and some prominent Ukrainian doctors have been at pains in recent years to publicly stress the safety and efficacy of vaccines. However, not all parents who do want to get their children vaccinated can. Although vaccines are free through the state health-care system, hospitals often run short of them. Parents then face a choice of waiting, potentially for many months, until the vaccine becomes available again, or paying out of their own pockets at a pharmacy. In a country where the average monthly wage is around €300, this cost is sometimes prohibitively expensive.
The state budget is under pressure as Ukraine struggles with a recession and the government has said that it has enough to finance about 65% of the country's vaccination needs. But this is only one of the apparent reasons for short supply. Allegations of corruption in vaccine tenders, which ultimately leads to problems with their supply, are made regularly. Meanwhile, vaccine procurement mechanisms have come in for criticism for poor forecasting leading to shortages or wasted vaccines.
But there is another substantial hurdle to raising vaccination rates—health-care workers themselves. Some doctors speak openly against vaccination and WHO says it has identified apathy among many medical workers towards promoting immunisation—something rooted again in the 2008 scandal. Nitzan explains to The Lancet: “Many health-care workers are not actively promoting vaccinations. They are afraid that, just like in 2008, that if they vaccinate someone and they get sick then they will get the blame for it.”
This situation, and the other problems leading to poor vaccination coverage, must be dealt with soon, though, she says. “Until vaccination coverage is improved we can expect to see more outbreaks of diseases with polio a very real threat.”
The full text of The Lancet article by Ed Holt is available here