28 Октябрь 2020
Protecting young children from vaccine-preventable diseases
https://www.unicef.org/eca/reports/protecting-young-children-vaccine-preventable-diseases
PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES MODULE 22 Disclaimer: The resource modules were authored by the individuals under the guidance of the UNICEF Regional Office for Europe and Central Asia. The text is presented in draft format and it is expected that it will be adapted and contextualized for use by interested countries. The material has not been edited to official publication standards. UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. Coordination and Editing: Aleksandra Jovic, UNICEF, Early Childhood Development Specialist Lead Author: Bettina Schwethelm, Young Child Health and Development Specialist, Director, MCH-ECD Co-authors: Svetlana Stefanet, UNICEF, Immunization Specialist Sergiu Tomsa, UNICEF, Communication for Development Specialist Contributors: Silvia Sanchez R., UNICEF, Knowledge Management Consultant Viviane Bianco, UNICEF, Communication for Development Consultant UNICEF/ Krepkih Andrey TABLE OF CONTENTS Key Messages Why is this Topic Important to you? ..................................................................................6 Learning Outcomes ....................................................................................................................................6 Pre-Test for this Module ...............................................................................................................................7 Glossary and Definitions ............................................................................................................................10 I. Introduction ..................................................................................................................................111. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing ................................112. Vaccination Trends Globally and in Europe ...........................................................................................................143. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary ..........................................................................................................................15 II. Immunization and Vaccine Preventable Diseases A Major Public Health Achievement ...................161. Childhood Immunization .......................................................................................................................................162. How Vaccines Work .............................................................................................................................................173. The Benefits of Vaccination to the Individual Child and Society ...........................................................................204. Vaccine Safety and Side Effects ...........................................................................................................................225. Family-Held Vaccination Records ..........................................................................................................................23 III. Understanding Barriers to Vaccination ...............................................................................................241. Caregivers Along the Continuum of Vaccine Acceptance, Hesitancy, and Rejection ...........................................242. Understanding how Individuals Make Behavioural Choices .................................................................................26 a. The Behaviour Change Journey ........................................................................................................................26b. Factors Influencing Caregiver Decisions ...........................................................................................................27c. Perception Biases, Beliefs, and Myths About Vaccines The Internet and Social Media ................................31d. The Role of Health Workers ..............................................................................................................................34 IV. Communication Skills and Tools to Support Vaccine Acceptance by Caregiver .................................371. Active Listening Skills ...........................................................................................................................................37 a. Verbal Communication ......................................................................................................................................37b. Non-Verbal Communication ..............................................................................................................................38c. Empathy ............................................................................................................................................................39 2. Working with Caregivers Along the Continuum of Vaccine Hesitancy .................................................................39a. Vaccine-Accepting Families ...............................................................................................................................40b. Vaccine-Hesitant Caregivers .............................................................................................................................41c. Vaccine Refusers and Anti-Vaccine Advocates .................................................................................................44 3. Helping Caregivers Overcome Barriers to Vaccination .........................................................................................46a. Preparing Caregivers for Vaccination and Helping Them Manage Mild Side-Effects ........................................46b. Helping Caregivers Problem-Solve ....................................................................................................................46c. Addressing Rumours in the Community ...........................................................................................................47 V. Summary of Key Points and Post-Test .................................................................................................481. Summary of Key Points ......................................................................................................................................482. Post-Test with Answers ......................................................................................................................................49 VI. Websites And Video Clips .....................................................................................................................531. Websites .............................................................................................................................................................532. Relevant Video Clips ...........................................................................................................................................53 Annexes: Information Cards ........................................................................................................................55Information Card 1 - Common Vaccine-Preventable Diseases ...........................................................................................55Information Card 2 - Frequently Asked Questions (FAQS) About Childhood Vaccinations .................................................58Information Card 3 - Simple Ways to Show Empathy ........................................................................................................62Information Card 4 - Responses that Encourage Communication ......................................................................................63Information Card 5 - Roadblocks to Communication ..........................................................................................................64Information Card 6 - Practical Communication Skills Case Study ....................................................................................65Information Card 7 - The CASE Approach ...........................................................................................................................66Information Card 8 - Steps to Address Negative Rumours in the Community ...................................................................67Information Card 9 - Reducing Pain ....................................................................................................................................68Information Card 10 - What is Community or Herd Immunity and Why is it Important? ....................................................70 Worksheets................ ..................................................................................................................................71 References................. ..................................................................................................................................73 6 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES KEY MESSAGES Why is this topic important to you? Vaccination is one of the worlds safest and most cost-effective public health interventions. Yet growing distrust in science, coupled with misinformation, means that vaccination coverage rates are declining in some countries and communities, resulting in an upsurge of vaccine-preventable diseases. The routine vaccination schedule brings families into frequent contact with the healthcare system, providing opportunities to reach children with life-saving vaccines and other crucial services for children and their families. Research shows that those caring for children tend to trust the advice of their health workers when it comes to vaccination, despite conflicting and often misleading information from other sources. That is why your role is so important: poor or disrespectful responses to caregivers and their concerns, coupled with a lack of uptake of vaccines (whether at a clinic or during a home visit), can have a strong and negative impact not only on their future demand for vaccination, but also for a whole range of other health services. As a professional who is trusted by the families you serve, you have a unique opportunity to identify vaccine-hesitant caregivers; understand their fears, dilemmas and choices; provide them with relevant information; help them overcome their vaccination hesitancy; strengthen their confidence in vaccines and immunization, and, in some instances, vaccinate their children. Using your communication skills and your knowledge about how individuals make behavioural choices, you can influence and guide parents to make decisions in the best interests of their children by listening to and understanding their concerns, providing answers to their questions, and helping them make the best choice for their child and their community. LEARNING OUTCOMES Once you have completed this module you will: Have a good understanding of vaccine-preventable diseases and the importance of immunization. Understand the role of health workers particularly home visitors in guiding families in their decisions to have their children protected against vaccine-preventable illnesses. Understand the importance of checking the immunization status of the child during each relevant visit and reminding caregivers about upcoming vaccination appointments. Understand that the views of caregivers range across a continuum from vaccine acceptance, to hesitancy and rejection, and that tailored approaches and actions are required from you to ensure that as many infants and children are protected against vaccine-preventable diseases as possible. Be able to apply evidence-based techniques and approaches to address hesitancy and influence caregivers decisions and behaviours. When checking a childs records, know how to give their caregivers the space to voice concerns and ask questions so that you can provide facts about vaccination benefits and address rumours and misinformation. Know how to identify caregivers who are hesitant about vaccines and respond to their questions and concerns with facts and empathy to help them make informed decisions and move towards vaccination. Communicate with caregivers who are rejecting vaccines in a respectful and empathetic way, reminding them that vaccines are safe, advising them of the dangers and symptoms of vaccine-preventable diseases, and reinforcing their responsibilities, as caregivers, to inform health workers if their child has not been vaccinated. Show your appreciation and validation of families that have accepted vaccination and that might be willing to become vaccine advocates in your community. Be able to advise parents on how to deal with the possible common side effects of vaccination. 7 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES PRE-TEST FOR THIS MODULE Some of these questions may refer to topics that are unfamiliar to you at this early stage, but do not worry. The module will cover all of these issues and features a post-test (with answers) at the end so that you can assess your own progress. 1. Costing studies have shown that childhood vaccinations constitute one of the most cost-effective public health interventions. True False 2. The number of parents refusing vaccinations for their infants and young children is increasing. This group should, therefore, be the main target for education by home visitors. True False 3. Increasing herd/community immunity is not a good argument for increased support for immunization programmes. True False 4. Several countries in Europe have had a high number of measles cases. Some of the reasons for this include (please mark all answers that apply): a. Shortages of measles vaccine in these countriesb. Caregivers who are complacent, because they do not know that measles is a dangerous and very infectious diseasec. Researchers who have been unable to dis-prove the myth that measles vaccine causes autismd. Measles brought in by travellers from poor, under-developed countriese. Falling immunization coverage. 5. The reason for vaccine hesitancy is simple: caregivers just lack the evidence about the benefits of vaccines. True False 6. Some of the strategies to overcome vaccine hesitancy among parents include (please mark all answers you consider correct):a. Improving the interpersonal and communication skills of health workersb. Listening to the concerns of caregivers and showing empathyc. Understanding how behaviour change takes place and using a solid behaviour-change approachd. Ensuring that health workers welcome caregivers who may feel socially excluded and stigmatizede. Telling caregivers that health professionals know best and that they should not question immunization, as they are not expertsf. Improving the quality of health services. 7. Some of the challenges to the achievement of high immunization coverage rates for measles and rubella coverage (please circle the answers you consider correct)a. The rejection of vaccines by some families in small communities and urban areas creates pools of unprotected children, increasing the risks of the rapid spread of epidemicsb. Measles vaccine is routinely provided to children when they are one year of age: a time when some caregivers may feel that their young children have already received enough vaccines to be protected MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 8 c. Lack of trust in vaccine safetyd. Shortage of vaccines in some countries as a result of recent epidemics. 8. Home visitors should be prepared to respond flexibly to the concerns of parents about vaccinations, with brief, tailored and fact-based elevator speeches (short enough to be presented during an elevator ride of just a few floors). True False 9. Polio has been eradicated and will soon be removed from all immunization schedules. True False 10. Arrange the following stages into the correct sequence for an expanded behaviour-change model: 11. List some non-verbal communication features you can use to make caregivers feel more comfortable: 12. Giving young infants multiple vaccines at the same time can overwhelm their immune system. True False 13. Naturally acquired immunity works better and is safer than vaccine-acquired immunity. True False 14. The following approaches need to be avoided when addressing the concerns of caregivers about vaccines (mark all that apply): a. Reflective listeningb. Solving any problems the caregiver has in getting to the clinicc. Empathy for their concerns about whether they are making the best decision for their childd. Praising them by telling them that they are your best parents and that you are so proud of theme. Rebuking caregivers for missing vaccination appointmentsf. Reminding caregivers that they are not experts and should not question immunization. Stages Step Decision Advocacy Pre-contemplation Maintenance Preparation Contemplation Trigger Fine-tuning Trial 9 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 9 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 15. Caregivers who refuse vaccines are likely to include individuals with some of the following characteristics (mark all that apply)a. They are from marginalized populationsb. They question science and are often highly educated c. They come from poor and uneducated families in urban areasd. They dont trust their health care system or health workers. 16. The three Cs are (mark all that apply) Complacency Concern Convenience Confidence. 17. Vaccination programmes are expensive because of the costs of vaccines, cold-chains and the salaries needed to deliver so many vaccines to so many children. It is an important public health intervention, but not very cost-effective. True False 18. 18. Measles is so dangerous because (mark all that apply)a. The disease kills most unvaccinated children because the vaccine only starts working when a child is around two years oldb. It is so infectious that herd community cannot be achievedc. It can wipe out much of the immune memory that a young child had acquired before contracting measlesd. Survivors of measles have an increased likelihood of death in the 2-3 years after contracting the diseasee. The infection spreads rapidly when a group of unvaccinated individuals is exposed to a case of measles. 19. There are no good sources of credible information about vaccines and vaccine safety. True False 20. Vaccine rejectors have a responsibility to inform health workers that their child has not been protected against vaccine-preventable diseases and should know about the signs and symptoms of these diseases. True False 21. While vaccination contributes primarily to Sustainable Development Goal 3 (SDG 3) on good health and wellbeing by reducing the number of vaccine-preventable deaths, it also contributes indirectly to many other SDGs. True False 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 10 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES GLOSSARY AND DEFINITIONS Caregiver. The parent or primary guardian of the child. This module uses the terms parent and caregiver interchangeably, recognizing that while most children are cared for by their parents, this is not always the case. For the purposes of this module, the terms parent or caregiver refer to the adults responsible for children and who make critical decisions on their behalf around immunization. Closed questions. Questions that are generally answered with a simple yes or no, in contrast to open-ended questions that encourage the other person to elaborate on their answer and encourage a genuine, two-way dialogue. Empathy. The capacity to understand or feel what another person is experiencing from their point of view, i.e. putting yourself in their shoes. This contrasts with sympathy, which often conveys pity for someone else, but not necessarily an understanding of their situation. European Centre for Disease Prevention and Control (ECDC). EU agency aimed at strengthening Europes defenses against infectious diseases. The core functions cover a wide spectrum of activities: surveillance, epidemic intelligence, response, scientific advice, microbiology, preparedness, public health training, international relations, health communication, and the scientific journal Eurosurveillance.1 Herd/community immunity. It is achieved when the vast majority of a population (at least 95% of children for childhood vaccination) is vaccinated, ensuring the protection of the whole community, including individuals who have not been vaccinated. Immunization. The process by which a person develops resistance to an infectious illness, usually through the application of a vaccine. Interpersonal communication. The exchange of information, thoughts, and feelings both verbal and non-verbal between two or more people that leads to dialogue, mutual understanding, respect for different perspectives and positions and immediate feedback. It can take place in a face-to-face setting or via video or audio settings by phone or Internet. MMR. Measles-mumps-rubella vaccine. Vaccination. Act of introducing a vaccine into the body to produce immunity to a disease. Vaccine hesitancy (WHO, 2019). The reluctance or refusal to vaccinate despite the availability of vaccines. Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines, and is influenced by multiple factors, such as complacency, convenience and confidence. 1 European Centre for Disease Prevention and Control. https://www.ecdc.europa.eu/en/about-ecdc https://www.ecdc.europa.eu/en/about-ecdc 11 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IINTRODUCTION 1. Nurturing Care A Holistic Approach to Young Child Health, Development and Wellbeing Recent decades have seen a surge of research on neuroscience and child development that has identified what newborns and young children need to survive, thrive, and lead healthy and productive lives. In May 2018, this critical body of scientific knowledge was brought together and used to create the Nurturing Care Framework by the World Health Organization (WHO), UNICEF, the World Bank and other partners. Compelling and robust scientific evidence was translated into five easily understandable and mutually supporting components that are essential for children to thrive (also shown in Figure 1): Good health Adequate nutrition Opportunities for early learning Responsive caregiving, and Security and safety. G OOD HEAL TH ADEQUATE NUTRITION G O PP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y R ESPO NSIV E C AR EG IVIN G Components of nurturing care Figure 1. The Nurturing Care: five interconnected components UNICEF/Kudravtsev 12 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES To survive, thrive and reach their full developmental potential, infants and young children need all five components of the Nurturing Care wheel. The components are not stand-alone, nor do they work as additions to each other: they are indivisible and synergistic. Responsive caregiving, for example, creates an enabling environment that can safeguard the other components: that is, a caregiver who is responsive to a child will be able to detect early signs that the child is feeling ill, tired, overwhelmed, anxious or threatened and will be able to respond in a way that protects the childs wellbeing. Similarly, a responsive caregiver is sensitive to the signs that a child is feeling well, alert, and ready to play and explore, and will be able to respond with appropriate activities. While parenting is perhaps the most challenging task for any adult, measures and support to prepare people for parenthood and education in parenting are more often available in high-and middle-income countries. Where such support is available in low-income countries, it tends to be accessed most frequently by high- and middle-income families. Families in many countries in the Europe and Central Asia region are fortunate to benefit from universal health care and home-visiting services provided by the public sector during the critical times of pregnancy and the first few years of a childs life. While the number of visits provided to all families is often limited, home visiting can be an effective entry point and opportunity to provide reliable and valid information and advice on child development, child rearing and parenting. Universal home-visiting services can also be used to identify families that are vulnerable or that need additional and targeted services. Providing all families with trusted and evidence-based information and advice and identifying the families with additional needs require knowledge and special skills in working with families from all walks of life to build a genuine and supportive partnership. About the resource package for home visitors and its modules The resource package for home visitors Supporting Families for Nurturing Care is a growing set of training modules (see Figure 2). It aims to strengthen the knowledge of home visitors on the key components of Nurturing Care, and enhance their skills in working with families to enable and empower them to provide the best start to their children. While targeting home visitors, many of these modules are also suitable for other health and non-health professionals who interact with pregnant women and the families of young children. Each of the modules responds to one or more components of Nurturing Care and builds capacity and skills needed by the home visitor to provide supportive home visits. In addition, each module aims to help home visitors reflect on professional attitudes and strengthen practices to engage inclusively and respectfully families that are diverse and face different needs and challenges. The modules have been developed by well-known experts and can be translated and adapted to different country contexts. In some countries, the modules have already become a mainstay of lifelong learning and continuing professional development for health workers and social-service providers engaged in promoting the comprehensive wellbeing of young children and their families. You can find hard copies of all modules on the International Step by Step Association (ISSA) website at https://www.issa.nl/modules_home_visitors and on UNICEF Agora. UNICEF/Voronin https://www.issa.nl/modules_home_visitors 13 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Knowledge Module 1: The Early Childhood Years - A Time of Endless Opportunities Module 7: Parental Wellbeing Module 11: Working against Stigma and Discrimination - Promoting Equity, Inclusion and Respect for Diversity Module 12: Children Who Develop Differently - Children with Disabilities or Developmental Difficulties Module 18: Gender Socialisation and Gender Dynamics in Families - The New Role of the Home Visitor Skills Module 2: The New Role of the Home Visitor Module 10: Caring and Empowering - Enhancing Communication Skills for Home Visitors Module 13: Developmental Monitoring and Screening Module 15: Working with Other Services Module 17: Supervision - Supporting Professionals and Enhancing Service Quality Module 22: Protecting Young Children from Vaccine-Preventable Diseases Figure 2. The Supporting Families for Nurturing Care resource package and its modules (asterisks indicate complementary pre-existing training packages) Components of nurturing care Thinking Healthy*Care for Child Development*Module 4: Falling in Love - Promoting Parent-Child AttachmentModule 5: Engaging Fathers Module 8: Common Parenting Concerns Integrated Management of Childhood Illnesses (IMCI)*Module 20: Healthy Weight, Physical Activity, Sleep and Sedentary TimeModule 21: The Care of Small and Sick NewbornsModule 22: Protecting Young Children from Vaccine-Preventable Diseases Module 6: The Art of Parenting - Love, Talk, Play, ReadModule 19: Early Childhood Education Programmmes Module 9: Home Environment and SafetyModule 14: Keeping Young Children Free from Violence, Abuse and Neglect Infant and Young Child Feeding (IYCF)*Baby-friendly Hospital Initiative (BFHI)Module 16: Responsive Feeding G OOD HEALT H ADEQUATE NUTRITIO NG OPP UR TU NIT IES FO R E ARLY LEARN ING SECURITY AND SAFET Y RE SPO NS IVE C AR EG IVIN G 14 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. Vaccination Trends Globally and in EuropeSince the development of the first vaccination against smallpox more than a century ago, vaccine programmes for children have become an integral component of preventive primary health care in every country on earth. Vaccination programmes prevent between 2 and 3 million deaths globally each year (WHO, 6.12.2019). In 2019, about 86 per cent of infants worldwide (116.3 million infants) received 3 doses of diphtheria- tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness, disability or death. Individuals and governments benefit from vast cost-savings as a result of the prevention of illness (EU and WHO, 2019). Based on the costs of illnesses, including treatment costs and productivity losses, that have been averted, every dollar invested in vaccines during the Decade of Vaccines (2011-2020) is estimated to have yielded a net return of about $16 (Ozawa et al., 2020). Two of the three strains of wild polio virus strains have been eradicated. A growing number of countries have achieved disease-free certifications (i.e. the European region has sustained its polio free status since 2002). The growing number of combination vaccines (i.e. the child is vaccinated against several diseases with one injection) is reducing the number of injections needed. In recent years, however, vaccination programmes have become victims of their own hard-earned success: few caregivers remember epidemics of polio, measles, pertussis or chickenpox that took the lives of many children, left many more with disabilities, and undermined their health and development. They may be unaware that measles is one of the worlds most contagious diseases, and that its transmission can only be halted if at least 95 per cent of the population is protected by immunization. In addition, misinformation that links vaccines to autism is easy to find and continues to circulate through social media and on websites, despite being discredited repeatedly, including by large-scale population studies (Hviid et al., 2019). Misinformation is sometimes disseminated deliberately to contradict (and appear alongside) evidence-based information about the benefits of vaccination. As a result of such challenges, countries around the world, and particularly in the Europe and Central Asia Region, have seen a resurgence of measles as the number of unprotected children and adults has grown. Measles cases have reached their highest level in Europe in 20 years (The Guardian, 21.12.2018). In total, 49 of the 53 countries in WHO European Region reported more than 192,943 measles cases and more than 100 measles-related deaths between 1 January 2018 and 31 December 2019, with a regional coverage with 2 doses of measles vaccination of only 91 per cent for the two doses of measles vaccination, which is too low to ensure herd immunity. Large disparities at the local level persist: some communities report over 95% coverage, and others below 70%. Several countries in the region Albania, the Czech Republic, Greece and the UK have recently lost their measles free certification. In the absence of disease, fear of disease has been replaced by fear of vaccines for some people (WHO, 2017). UNICEF/Bershadskyy Yuriy Immunization is one of the most cost-effective ways to save lives and promote good health and well-being. Every year, vaccines save 2-3 million lives, and millions more are protected from disease and disability. It routinely reaches more households than any other health service and brings communities into regular contact with the health system. This provides an effective platform to deliver other primary health care services and upon which to build universal health coverage. (Gavi The Vaccine Alliance, 2019) 15 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. Working with Families to Protect Young Children from Vaccine-Preventable Diseases Module Overview and Summary UNICEF/ Krepkih Andrey Because of the frequency of the contact required with families, especially during the early months of a childs life, the quality of immunization services can either enhance or endanger the trust families place in health care services and professionals. As a health visitor for families with young children, you are in a unique position to educate the families you meet on the importance of vaccines and the vaccination schedule and identify caregivers who have some concerns or who may even reject vaccines. In their own home, and when talking to someone the family trusts their home visitor caregivers may feel more comfortable asking questions and voicing fears that have not been addressed during crowded vaccination sessions or in a busy doctors office. Your knowledge of the benefits and safety of vaccines, your communication skills and empathy for families, and your understanding of their concerns are your major tools for the promotion of this crucial health intervention. Once you have completed this module, you will be able to answer questions and provide practical tips to caregivers on how to support their child while they are being vaccinated and help them deal with common side effects. You will also be able to provide evidence-based information to counter any misinformation that might be spreading through the caregivers network or social media. Because you have the information about the childs vaccination status, you can tailor your response and refer families to other experts and specialists where necessary. The quality of your support is vital. It may influence whether caregivers complete the vaccination schedule for their children, and the way in which they engage with health services in the future. You may never know for sure, but you may have saved a childs life, while protecting other young children who cannot be vaccinated because of counter-indications, as well as infants who have not yet received their first vaccines! MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 16 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES IIIMMUNIZATION AND VACCINE PREVENTABLE DISEASES A MAJOR PUBLIC HEALTH ACHIEVEMENT 1. Childhood Immunization In its listing of 100 objects that have shaped public health, Global Health NOW of the Johns Hopkins Bloomberg School of Public Health called immunization one of the most important public health achievements in human history.2 The development of vaccines has accelerated since the first use of a smallpox vaccine in 1798, and particularly since the middle of the 20th century. Today more than 30 infectious diseases can be prevented with vaccines (see Information Card 1 in annexes for information about common vaccine-preventable childhood diseases). Even though the worlds population has grown by almost 70 per cent, Gavi The Vaccine Alliance reports that cases of common vaccine preventable diseases have fallen by around 90 per cent (Gavi, 29.01.2019). Smallpox has been eradicated, as well as two of the three wild polio strains (WHO, 24.10.2019), and a number of countries have achieved measles-free status. Today, WHO recommends 10 vaccines during infancy and the early childhood years, plus one (for HPV) during adolescence recommendations that apply to every country (WHO, April 2019). Bacillus Calmette Guerin (BCG) (1 dose protects against tuberculosis) DTP-containing vaccine (3 doses protects against Diphtheria, Tetanus, and Pertussis Td (Tetanus and Diphtheria) booster at 9-15 yrs Hepatitis B (34 doses - protects against hepatitis type B) Hib (3 doses - prevents Haemophilus influenzae type b) Pneumococcal (3 doses - protects against pneumococcal disease) Polio (OPV and/or IPV, 34 doses - protects against poliomyelites) Rotavirus (23 doses - protects against rotavirus disease) Measles (2 doses - protects against measles) Rubella (1 dose - protects against rubella) HPV (2 doses - protects against human papilloma virus that can cause cervical and other types of cancer) (adolescent girls) Most of the countries in the ECA region use the MMR vaccine, a combined vaccine against measles, mumps and rubella. WHO recommends vaccination against mumps in high performing immunization programmes with the capacity to maintain coverage over 80% and where mumps reduction is a public health priority. Unfortunately, there has been a 30 per cent increase in cases of measles globally, and many countries in Europe and Central Asia have reported falling immunization coverage: half of the countries in the Region have DTP3 and MCV1 coverage below the 95 per cent minimum needed to ensure herd immunity. In 2019 WHO declared vaccine hesitancy as one out of 10 threats to global health. As we will discuss in more detail below, the WHO Vaccines Advisory Group has attributed this to the three Cs: Complacency, in-Convenience, and lack of Confidence, which contribute to vaccine hesitancy among parents and caregivers. Health workers, especially home visitors who work closely with their communities, have a critical role to play, as their advice is trusted by parents and can influence decisions around vaccination. To fulfil this role, however, home visitors need clear, factual information on vaccines, as well as communication tools to tackle the global threat to health posed by vaccine hesitancy (WHO, 2019). 2 Global Health NOW. One hundred objects that shaped public health. Retrieved from https://www.globalhealthnow.org/object/vaccines https://www.globalhealthnow.org/object/vaccines 17 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 17 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 2. How Vaccines WorkAs a home visitor, you often have very little time to cover a large range of relevant topics with the families you visit. That is why you need to be able to explain, in concise and understandable terms, how vaccines work and why it is important to vaccinate all children. To be efficient, apply the Elevator speech approach (Karam et al., 2019a, b) to make your most important points in the time that it would take for a ride in an elevator. It is important to tailor your messages to each family, taking into account their existing level of knowledge, as well as their concerns and attitudes around vaccination. Visuals can often be very powerful, helping you to make a point quickly and convincingly. Reflection and discussion There are many reasons why children are not vaccinated or vaccinated incompletely, but the following four steps can help you prepare short, clear responses to families that have concerns. First write down some of the questions and concerns you and your colleagues have heard from the caregivers you visit. Then choose several questions related to how vaccines work and develop brief elevator speeches with your colleagues or on your own. For your responses, use simple language, avoid jargon and technical terms; use analogies or simple examples and comparisons. Then try out your elevator speeches on others (family, caregivers, etc.) Finally, compare your responses to those provided by experts from WHO and the European Centre for Disease Prevention and Control (ECDC) and modify your elevator speeches as needed. Here are your practice questions: the kind of questions you may well be asked by the families you visit. Look through them and prepare some answers. When you have finished, compare your answers to the information provided in Box 1 below: How do vaccines work? Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Can vaccines cause the infection they are supposed to prevent? What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? I have heard that vaccinating my child also protects other children. What is community/ herd immunity and why is it important? UNICEF/Krepkih Andrey MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 18 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES How do vaccines work? Vaccines contain either a much-weakened form of the virus or bacterium that causes a disease, or a small part of it. When the body detects the contents of the vaccine, its immune system will produce the antibodies required to fight off infection and eliminate the disease-causing virus or bacterium. When a person later comes into contact with the virus or bacterium, the immune system will recognize it and protect the person by producing the right antibodies before any disease can be caused. (ECDC, Questions and answers about childhood vaccinations) Why it is better to be vaccinated than to acquire natural immunity (have the child fight the disease on his/her own)? Infants and young children are vaccinated in controlled settings (doctors offices or clinics), and parents are informed about possible side effects, how to manage these, and when to seek additional advice. With vaccines, the immune system is stimulated to develop protection without infection, hence it is more effective (WHO, 2017). The only way a child can acquire natural immunity is to become sick with the disease itself. Even when the impact on the child is mild, it may mean additional caregiving and expenses for some families. But the disease could also result in complications, long-term illness, disability and even death, and many other children may become exposed in the process. For measles, the Center for Disease Control and Prevention (CDC) has reported complications with 30 per cent of measles cases, most commonly diarrhoea, ear infections and pneumonia. For every 1,000 cases of measles, one child may also be affected by encephalitis and two may die. Whats more, the measles infection can destroy much of the wider immunity a child has built up, increasing their risk of contracting other diseases. Are the vaccines, especially multiple doses, too strong for a small fragile baby to handle? Newborns commonly manage many challenges to their immune systems at the same time. The mothers womb is free from bacteria and viruses, so newborns immediately face a host of different challenges to their immune systems. From the moment of birth, thousands of different bacteria start to live on the surface of the intestines. By quickly making immune responses to these bacteria, babies keep them from invading the bloodstream and causing serious diseases. In fact, babies are capable of responding to millions of different viruses and bacteria because they have billions of immunological cells circulating in their bodies. Therefore, vaccines given in the first two years of life are a drop in the ocean of what an infants immune system successfully encounters and manages every day. (ECDC. Questions and answers about childhood vaccinations) Can vaccines cause the infection they are supposed to prevent? Inactivated vaccines do not have live germs and cannot cause infections. Live vaccines have weakened germs that are unable to cause disease in healthy people. Rarely a mild form of infection may occur. (WHO, 2017) What happens when a child has been sick with a vaccine-preventable disease? Doesnt this make them more resistant and stronger in fighting new diseases? The defences of children who have survived a vaccine preventable-disease are not necessarily stronger. On the contrary, the disease tends to make the child weaker and more vulnerable. Recent research on measles has shown that having suffered and survived this deadly disease may make it harder for a child to fight other infections for years to come. It has been known for some time that children who had measles were 2-3 times more likely to die from pneumonia, diarrhoea or other conditions in subsequent years. Now, we have learned that the measles virus infects and destroys memory B-cells. These are the cells where the immune system stores information about past Box 1. How vaccines work https://www.cdc.gov/vaccines/pubs/pinkbook/meas.html https://www.ecdc.europa.eu/en/immunisation-vaccines/childhood-vaccination/faq?pdf=yes&preview=yes 19 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 19 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES infections that can help it in fighting new infections. In addition, the measles virus also reduces the ability of the immune system to respond to new and dangerous pathogens. It now seems possible that there could be actually five times more indirect deaths from immune amnesia (caused by the measles virus) than the initial infection caused. (Gallagher, 2019) I have heard that vaccinating my child also protects other children. What is community/herd immunity and why is it important? Vaccination protects you and your family, and it also helps protect others. It contributes to community immunity. This is achieved when enough people in a population are immune to an infectious disease (through vaccination and/or prior illness) so that it is unlikely to spread from person to person. Even those who cannot be vaccinated because they are too young, are allergic to vaccine components, or vaccination is contraindicated for them, are offered some protection because the disease cannot spread in the community and infect them. This is also known as herd or community immunity. When more than 95% of population is (blue dots) in a community they can protect those who are not yet vaccinated (yellow dots) from those who are infectious (red dots) When groups of unvaccinated people build up and are in close proximity, community immunity doesnt work and the disease spreads. For additional brief answers to common questions and concerns (developed by WHO and ECDC communication experts), check Information Card 2 Frequently Asked Questions (FAQs) about Childhood Vaccinations (in annexes), which also includes links to additional information. However, keep in mind that you will have to tailor your answers to the needs of individual families, their attitudes towards vaccination, and level of knowledge, so just learning some standardized answers by heart is not enough. 20 MODULE 22 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 20 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES 3. The Benefits of Vaccination to the Individual Child and Society NOPOVERTY AFFORDABLE ANDCLEAN ENERGY CLIMATEACTION LIFE BELOWWATER LIFE ON LAND PARTNERSHIPSFOR THE GOALS DECENT WORK ANDECONOMIC GROWTH SUSTAINABLE CITIESAND COMMUNITIES ZEROHUNGER EDUCATIONQUALITY EQUALITYGENDER AND SANITATIONCLEAN WATER PEACE, JUSTICEAnd STRONG INSTITUTIONS RESPONSIBLECONSUMPTIONAND PRODUCTION GOOD HEALTHAND WELL-BEING INDUSTRY, INNOVATIONAND INFRASTRUCTURE REDUCED INEQUALITIES GLO BA L S TRA TEGY FOR WOME NS, CHILDRENS AND ADO LESCEN TS HEA LTH SU RVIV E TH RIV E TRANSFORM Figure 3. Sustainable Development Goals (SDGs) Reflection and discussion Immunization for vaccine-preventable diseases provides one of the strongest financial returns of any public health intervention, but its benefits go far beyond the health sector alone. Take a look at Figure 3, which sets out all of the Sustainable Development Goals. Can you list ways in which the benefits of immunization can be felt across all of these goals? To help you, the potential links between immunization and the SDGs are set out in Table 1: perhaps you can think of others! When you see how vaccination supports the achievement of the SDGs, you can feel confident and proud in promoting such a cost-effective and safe service to your community and to the families you serve. Immunizing children is one of public healths best buys. Vaccines are relatively easy to deliver and, in most cases, provide lifelong protection. They boost development both through direct medical savings and indirect economic benefits such as cognitive development, educational attainment, labour productivity, income, savings and investment (Gavi The Vaccine Alliance, 2019) https://www.gavi.org/vaccineswork/value-vaccination https://www.gavi.org/vaccineswork/value-vaccination 21 MODULE 21 PROTECTING YOUNG CHILDREN FROM VACCINE-PREVENTABLE DISEASES Sustainable Development Goal Vaccination programmes 1. No povertyPrevent expensive illnesses and associated health-care costs, reducing the number of people forced into poverty. 2. Zero hungerProtect childrens nutritional status, because illness impairs absorption of essential nutrients. Malnourished children are also at a higher risk of death from vaccine-preventable diseases. 3. Good health and wellbeing Reduce mortality and morbidity and provide the platform for the delivery of other health services. 4. Quality educationVaccinated children have better nutrition and health status, and have, therefore, better chances to learn and achieve. 5. Gender equalityGlobally, this is a gender-equal intervention, with similar rates of vaccination for girls and boys 6. Clean water and sanitation (WASH) Prevent diarrhoeal diseases, alongside WASH programming. 8. Decent work and economic growth Contribute to the growth of healthy children who attain education and become a productive workforce. Caregivers are more likely to be able to work when children are not affected by vaccine-preventable diseases. 10. Reduce inequalityProtect all communities and children, including the most marginalized, those living in rural areas and in conflict zones, which can be further devastated by epidemics of infectious disease. 11. Healthy citiesProtect children from increased risk of exposure to vaccine-preventable diseases in cities where infections are more able to spread quickly. 16. Peace, justice and strong institution Contribute to equity and strong health services. Table 1. Vaccination and the achievement of the Sustainable Development Goals (SDGs) Source: Gavi, 2019 UNICEF/ Krepkih Andrey 4. Vaccine Safety and Side Effects Before you respond to concerns about the safety of vaccines in general
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