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Programme
04 Октябрь 2017
Immunization
https://www.unicef.org/eca/health/immunization
Immunization is a proven and cost-effective public health  intervention, saving the lives of millions of children and protecting millions more from illness and disability.  Immunization is also a wise financial investment - with every $1 invested in immunization returning an estimated $16 in health-care savings and increased economic productivity.  Most countries in Europe and Central Asia have immunization coverage of 95 percent or more for three doses of diphtheria, tetanus and pertussis (DTP), often seen as the measure of national performance on immunization. However, while most national averages for DTP vaccination may be adequate, the regional average is hovering at around 92 percent, a slight decrease from the previous year, which is not high enough to ensure immunity for everyone. Over 70 percent of the region’s unvaccinated infants are from middle income countries, with Ukraine presenting the lowest coverage rate and the greatest challenge. National averages also mask disparities, with Roma children  and those from other ethnic and vulnerable groups, including refugee and migrant children, all lagging behind. Measles outbreaks are a growing problem. Last year there were over 10,000 cases of measles in the region. Despite increased coverage of the first dose of the measles vaccine among children (up from 63 percent in 2000 to 93 percent in 2016) more work is urgently needed, as children are not fully protected against measles unless they receive two doses. Currently, second dose coverage is at 88 percent, which does not provide adequate protection.            In total, over 500,000 children in the region are still not protected against measles - a life-threatening, but easily preventable disease.   There are also concerns about ‘vaccine hesitancy’ – a growing mistrust of immunization among some parents, fuelled by myths and misinformation. Such hesitancy may stem from negative media stories linking a child’s death to immunization without the full facts. It may be influenced by the region’s anti-vaccine movements, which spread anti-immunization messages. Meanwhile, measures to counter vaccine hesitancy and build parental trust in immunization are hampered by a lack of discussion with parents about its importance and the minimal risks.  A baby girl receives her vaccination at a clinic in Serbia. A baby girl receives her vaccination at a clinic in Serbia. Donor support for immunization is falling in some countries that still require such support. Elsewhere, the concern is to ensure financial sustainability for immunization programmes once countries ‘graduate’ from the support provided by Gavi (The Vaccine Alliance). Ongoing reforms in some countries are affecting both the structure and financing of immunization programmes. Some countries, challenged by competing priorities at home and inaccessibly priced vaccines on the global market, experienced several vaccine shortages in 2015–2016, sometimes causing critical disruptions of services. These issues are particularly acute in middle-income countries, many of which self-procure vaccines and continue to face significant challenges in achieving financial sustainability of their immunization programmes. Some countries also lack adequate monitoring of vaccine coverage, which is critical to understand and address any gaps.   As a result of such challenges, the region faces outbreaks of vaccine-preventable disease, such as a polio outbreak in 2015 and an ongoing measles outbreak in Ukraine  – a country where conflict and economic recession have depleted stocks of vaccines and vaccine hesitancy is reducing immunization coverage. There is also an ongoing large measles outbreak in Romania, with over 10,000 cases of the diseases and 38 deaths. During the last five years, measles outbreaks have been registered in Georgia (2013), Kazakhstan (2014), Kyrgyzstan (2015), and Tajikistan (2017). Outbreaks in one country can spread rapidly to others, signalling the interdependence and vulnerability of all countries, whatever their stage of economic development.  
Report
17 Июль 2018
In Focus: Immunization
https://www.unicef.org/eca/reports/focus-immunization
Immunization is one of the world’s most cost-effective public health interventions, saving millions of lives each year, and protecting children from illness and disability. Vaccines have helped to halve the number of child deaths worldwide since 1990 and represent a sound financial investment: every $1 spent on childhood immunizations returns an estimated $44 in economic and social benefits. Despite the achievements of immunization programmes in the Europe and Central Asia Region in recent decades, reported immunization rates are uneven across countries — from as high as 98 percent in Albania to as low as 19 percent in Ukraine. The regional average for Eastern Europe and Central Asia stands at 92 percent, still not high enough to protect all children from preventable diseases. What’s more, there was no improvement in coverage between 2014 and 2016. At national levels, disparities can be shocking, with the most vulnerable children often missing out on immunization. Across the Region, more than half a million children have missed out on their routine measles vaccination, and many countries continue to face outbreaks of vaccine-preventable diseases that threaten the lives and well-being of children. Challenges to immunization include weak political commitment and health systems, ‘vaccine hesitancy,’ and concerns about the financial sustainability of national immunization programmes in middle-income countries. UNICEF knows that the whole Region benefits when ALL countries achieve and maintain high vaccine coverage at both national and sub-national levels. Download file (PDF, 981,23 KB) July 2018
Photo Essay
27 Апрель 2018
Saving lives one dose at a time - Immunization across Europe and Central Asia
https://www.unicef.org/eca/stories/saving-lives-one-dose-time-immunization-across-europe-and-central-asia
Vaccines protect children against disease and death, saving up to 3 million lives globally every year, and are one of the most cost-effective child survival interventions. In short, #VaccinesWork. The Europe and Central Asia Region continues to enjoy overall high childhood immunization coverage and is polio-free. The benefits of vaccines, however, are spread unevenly. Too many children are still missing the protection they deserve. A mother in Serbia holds her baby during her free vaccination as part of the Serbia's national immunization plan. A mother in Serbia holds her baby during her free vaccination as part of the Serbia's national immunization plan. Of particular concern is a rebounding of measles in the region, despite a record-low of new cases in 2016, causing over 33,000 cases and 79 deaths. The largest current outbreaks have been in Romania (12,368 cases and 49 deaths including 46 children), Ukraine (16,500 cases, 13 deaths including nine children) and Serbia.  Although Serbia has a long and successful tradition in child-health protection, it is currently facing a measles outbreak with nearly 5,000 cases (as of 24 April 2018) which have resulted in 15 fatalities. UNICEF is working with the Ministry of Health to support its response and to improve records of immunization in the future. A little boy cries as he receives a routine vaccination at a clinic in Moldova. A little boy cries as he receives a routine vaccination at a clinic in Moldova. Due to universal vaccinations of newborns in Moldova, cases of Hepatis B have dropped from 682 in 1994 to only four in 2015. However, only 89 percent of all children are immunized against all preventable diseases and UNICEF has been working with the government to precure more vaccine doses to ensure all children have access to immunizations.  A young boy puts on a brave face as he receives his second dose of the MMR vaccine in Kyiv, Ukraine. A young boy puts on a brave face as he receives his second dose of the MMR vaccine in Kyiv, Ukraine. Two-thirds of the world’s unvaccinated children live in fragile countries or countries affected by armed conflict. Between 2010 and 2016, conflict-affected eastern Ukraine had the world’s second lowest coverage rate of children fully immunized against diphtheria, pertussis, and tetanus. The country also had the third lowest coverage rate in the world for MMR vaccine in 2016. A plane with a crate of UNICEF-labelled MMR vaccines next to it. On the 26 February, 220,000 doses of the MMR vaccine arrived in Ukraine facilitated by UNICEF. UNICEF in Ukraine is helping to fast-track the delivery of MMR vaccines, assisting the Ministry of Health to respond to the recent measles outbreak in which 14,500 people have been infected – killing 13 people including nine children. Nine-month-old Sasha gets a kiss from his mother, after receiving the diphtheria, pertussis, tetanus (DTP) vaccine in Kyiv. Nine-month-old Sasha gets a kiss from his mother, after receiving the diphtheria, pertussis, tetanus (DTP) vaccine in Kyiv. Vaccine hesitancy has also become an issue in Ukraine but UNICEF is working to change attitudes and educate people on the dangers of not vaccinating their children. “Before his birth, we decided we would give our child all the necessary vaccinations,” says Sasha's father. “When my grandmother was a child, she got polio and, although she recovered from the illness, she was disabled for life. As caring parents, we want to protect Sasha from all sorts of infections.” In Turkey, a boy receives a dose of the Oral Polio Vaccine (OPV). In Turkey, a boy receives a dose of the Oral Polio Vaccine (OPV). UNICEF Turkey is supporting a vaccination program, led by the Ministry of Health. The campaign has included nine rounds of polio campaigns reaching 1.4 million refugee and migrant children and Turkish children in remote provinces between 2013-2015, and the provision of additional doses of MMR, Hepatitis B, Diphtheria, Tetanus, Pertussis, Polio and Haemophilus in 2017. A health worker vaccinates a one-year-old Syrian refugee boy at a neighbourhood health centre in Gaziantep, Turkey. A health worker vaccinates a one-year-old Syrian refugee boy at a neighbourhood health centre in Gaziantep, Turkey. UNICEF has also helped produce and disseminate information materials, in both Turkish and Arabic, to raise awareness about the importance of being immunized. A young baby receives her vaccination injection in Uzbekistan. In Uzbekistan, four-month-old Ziyoda receives a dose of the new polio vaccine - 'Inactivated Polio Vaccine’ (IPV) - which is designed to help stop polio globally. Despite Uzbekistan having an almost 99 percent coverage rate of the Polio vaccine, UNICEF continues to work with the Government to ensure that no child is left unimmunized in the future. A group of women wait for their children to be vaccinated at a village clinic in Uzbekistan. A group of women wait for their children to be vaccinated at a village clinic in Uzbekistan. Ensuring vaccination levels are high in every country across the region is essential. UNICEF is working to ensure all children are protected against the spread of vaccine-preventable childhood diseases and the best defence is a vaccine-protected population and a strong and responsive health system. The whole region benefits when ALL countries achieve and maintain high vaccine coverage at both national and subnational levels.
Press release
24 Октябрь 2016
Increasing immunization coverage is priority for Ukrainian Government – Vice Prime Minister of Ukraine
https://www.unicef.org/eca/press-releases/increasing-immunization-coverage-priority-ukraine
KYIV, 24 October 2016 – Ukrainian Vice Prime Minister Pavlo Rozenko, representatives of the Ukrainian Government and the Presidential Administration have expressed their commitment to restore the routine immunization programme in Ukraine. Speaking at a high-level roundtable on immunization, organized by the Ministry of Health of Ukraine and UNICEF on the occasion of World Polio Day, Vice Prime Minister Rozenko said: “Evidence-based medicine confirms the effectiveness of vaccines to prevent diseases such as polio, tetanus or whooping cough. Increasing the rates of immunization coverage is an important task and a priority of the government and a matter of national security.” Ukraine currently has the lowest routine immunization rates in the world. According to the Ministry of Health data, only 30 percent of children in Ukraine were fully immunized against measles, only 10 percent against hepatitis B, and only 3 percent against diphtheria, pertussis and tetanus, as of August 2016. Moreover, only 44 percent of children under 18 months of age were fully immunized against polio. Shortage of vaccine supplies has been one of the main reasons behind the critically low immunization rates in the past years. To address this, at the request of the Ministry of Health of Ukraine, UNICEF has procured a number of high quality certified vaccines to protect children against dangerous vaccine-preventable diseases, namely  tuberculosis (BCG), measles, mumps and rubella (MMR), hepatitis B, diphtheria, tetanus and pertussis (DTP), tetanus and diphtheria vaccine for adults (Td), paediatric diphtheria and tetanus (DT), rabies, and bivalent oral polio vaccine (bOPV). The vaccines are now available in health facilities across the country. “This time last year, Ukraine was dealing with a polio outbreak. The comprehensive outbreak response was successfully implemented with the help of international partners, but this success is still fragile”, said Marie-Pierre Poirier, UNICEF Regional Director for Europe and Central Asia. “With such low routine immunization coverage, Ukraine is still at risk of outbreaks of long-forgotten diseases. Today, with millions of doses of vaccines available across the country, there is no reason to delay vaccination. Being vaccinated is fundamental to guarantee child’s right to health and now more than ever, it is important for Ukraine to put in place a strong and effective immunization programme,” she added. Speaking at the event, Professor David Salisbury, Chairman of the European Regional Certification Commission for Poliomyelitis Eradication said: “The polio cases in 2015 in Ukraine happened as a direct consequence of failings in the provision of vaccines for children. Efforts have been made to redress these problems but there is still more that needs to be done to give the children of Ukraine protection from vaccine preventable diseases. I am greatly encouraged by the commitments that have been made today and I look forward to being able to remove Ukraine from our list of polio high-risk countries.” Representatives of the Governments of Canada and the United States of America, who provided funding for the polio outbreak response last year, reaffirmed their support for restoring the routine immunization programme in Ukraine. “Canada worked hard last year with Ukraine’s Health Ministry to get nationwide polio vaccination restarted. We are grateful to the thousands of doctors who helped vaccinate millions of children. This year, we are happy to see that the UN has made more vaccines available. But still, far too many children are not routinely fully vaccinated. I urge Ukrainian parents to take advantage of these free vaccines and protect their children from completely unnecessary illnesses,” said H.E. Roman Waschuk, Ambassador of Canada to Ukraine, speaking at the Roundtable today. "Ukraine must continue to build on the great progress that has been made globally to eradicate polio," explained USAID Ukraine Director Susan Fritz. "These positive developments will only have the necessary impact if there is strong and visible political support from leadership at all levels of the Ukrainian Government." “Myths about vaccination that have been spread in recent years are not rooted in evidence-based medicine. As a result, Ukraine has been dealing with cases of diseases that have been long-forgotten in the rest of the world. It is important that the Vice Prime Minister of Ukraine, the Government and our international partners recognize the problem and are willing to work together with the Ministry of Health of Ukraine to resolve it. Increasing vaccination coverage rates in the country is our priority. This is not only a question of health and life of the citizens of Ukraine. This is a national security issue,” said Dr Ulana Suprun, Acting Minister of Health of Ukraine. “Necessary vaccines are available in all regions of the country. I appeal to all citizens who care about their life and health: get vaccinated and vaccinate your children,” added Dr Suprun. Nurse Ivana Knysh administers Maksym, 5, with a Hepatitis B vaccine as he holds his mother's hand, at Novoselytsi Family Medical Facility, Chernivtsi Oblast, Ukraine. UNICEF/UN060132/Oleksii Nurse Ivana Knysh administers Maksym, 5, with a Hepatitis B vaccine as he holds his mother's hand, at Novoselytsi Family Medical Facility, Chernivtsi Oblast, Ukraine.
Press release
25 Апрель 2017
UNICEF reaches almost half of the world’s children with life-saving vaccines
https://www.unicef.org/eca/press-releases/half-children-life-saving-vaccines
  NEW YORK, 26 April 2017 – UNICEF procured 2.5 billion doses of vaccines to children in nearly 100 countries in 2016, reaching almost half of the world’s children under the age of five. The figures, released during World Immunization Week, make UNICEF the largest buyer of vaccines for children in the world.  Nigeria, Pakistan and Afghanistan, the three remaining polio-endemic countries, each received more doses of vaccines than any other country, with almost 450 million doses of vaccines procured to children in Nigeria, 395 million in Pakistan and over 150 million in Afghanistan. UNICEF is the lead procurement agency for the Global Polio Eradication Initiative. Access to immunization has led to a dramatic decrease in deaths of children under five from vaccine-preventable diseases, and has brought the world closer to eradicating polio. Between 2000 and 2015, under five deaths due to measles declined by 85 per cent and those due to neonatal tetanus by 83 per cent. A proportion of the 47 per cent reduction in pneumonia deaths and 57 per cent reduction in diarrhea deaths in this time is also attributed to vaccines. Yet an estimated 19.4 million children around the world still miss out on full vaccinations every year. Around two thirds of all unvaccinated children live in conflict-affected countries. Weak health systems, poverty and social inequities also mean that 1 in 5 children under five is still not reached with life-saving vaccines. “All children, no matter where they live or what their circumstances are, have the right to survive and thrive, safe from deadly diseases,” said Dr. Robin Nandy, Chief of Immunization at UNICEF. “Since 1990, immunization has been a major reason for the substantial drop in child mortality, but despite this progress, 1.5 million children still die from vaccine preventable diseases every year.” Inequalities persist between rich and poor children. In countries where 80 per cent of the world’s under-five child deaths occur, over half of the poorest children are not fully vaccinated. Globally, the poorest children are nearly twice as likely to die before the age of five as the richest. “In addition to children living in rural communities where access to services is limited, more and more children living in overcrowded cities and slum dwellings are also missing out on vital vaccinations,” said Nandy. “Overcrowding, poverty, poor hygiene and sanitation as well as inadequate nutrition and health care increase the risk of diseases such as pneumonia, diarrhea and measles in these communities; diseases that are easily preventable with vaccines.” By 2030, an estimated 1 in 4 people will live in urban poor communities, mainly in Africa and Asia, meaning the focus and investment of immunization services must be tailored to the specific needs of these communities and children, UNICEF said.     NOTES TO EDITORS: UNICEF works with World Health Organization (WHO), Gavi, the Vaccine Alliance, the Bill & Melinda Gates Foundation and others to ensure that vaccines protect all children – especially those who are the hardest to reach and the most vulnerable. World Immunization Week runs from 24 – 28 April 2017. For more information visit: www.unicef.org/immunization Immunisation session at Family Medicine Center #1 of Osh city, Kyrgyzstan UNICEF/UN041255/Pirozzi
Statement
24 Апрель 2017
Governments must invest in immunizing the most vulnerable children and addressing vaccine hesitancy
https://www.unicef.org/eca/governments-immunization-statement
GENEVA, 24 April 2017 - “UNICEF is urging governments in Europe and Central Asia to invest in health systems that prioritize reaching the most vulnerable children with life-saving immunizations alongside national campaigns to address the concerning trend of growing vaccine hesitancy.”   “Immunization is one of the most significant and cost-effective public health achievements in modern times. Vaccines save children’s lives and stop the spread of diseases.   “Sustainable immunization coverage is only possible through well-functioning health systems that reach all children, including children from minority communities, those living in poverty or children uprooted from their homes. Coverage must be monitored so breakdowns in availability and services are rapidly identified and addressed.  “Demand from caregivers and communities equipped with the knowledge to overcome misconceptions and protect their children is equally critical. Misinformation on vaccines has grave implications. Governments must closely monitor public perceptions, counteract misinformation and promote the benefits of immunization. “Measles outbreaks and pockets of unacceptably low vaccination rates are stark reminders that achieving universal routine immunization coverage must be a priority for governments, communities and caregivers.    
Press release
10 Ноябрь 2016
Measles jab saves over 20 million young lives in 15 years, but hundreds of children still die of the disease every day
https://www.unicef.org/eca/press-releases/measles-jab-saves-million-young-lives
NEW YORK/ATLANTA/GENEVA, 10 November 2016 – Despite a 79 per cent worldwide decrease in measles deaths between 2000 and 2015, nearly 400 children still die from the disease every day, leading health organizations said in a report released today.   “Making measles history is not mission impossible,” said Robin Nandy, UNICEF Immunization Chief. “We have the tools and the knowledge to do it; what we lack is the political will to reach every single child, no matter how far. Without this commitment, children will continue to die from a disease that is easy and cheap to prevent.”   Mass measles vaccination campaigns and a global increase in routine measles vaccination coverage saved an estimated 20.3 million young lives between 2000 and 2015, according to UNICEF, the World Health Organization (WHO), Gavi, the Vaccine Alliance, and the Centers for Disease Control and Prevention (CDC).   But progress has been uneven. In 2015, about 20 million infants missed their measles shots and an estimated 134,000 children died from the disease. The Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria and Pakistan account for half of the unvaccinated infants and 75 per cent of the measles deaths.   “It is not acceptable that millions of children miss their vaccines every year. We have a safe and highly effective vaccine to stop the spread of measles and save lives,” said Dr. Jean-Marie Okwo-Bele, Director of WHO’s Department of Immunization, Vaccines and Biologicals. “This year, the Region of the Americas was declared free of measles – proof that elimination is possible. Now, we must stop measles in the rest of the world. It starts with vaccination.”   “Measles is a key indicator of the strength of a country’s immunization systems and, all too often, it ends up being the canary in the coalmine with outbreaks acting as the first warning of deeper problems,” said Dr. Seth Berkley, CEO of Gavi, the Vaccine Alliance. “To address one of the world’s most deadly vaccine-preventable childhood killers we need strong commitments from countries and partners to boost routine immunization coverage and to strengthen surveillance systems.”   Measles, a highly contagious viral disease that spreads through direct contact and through the air, is one of the leading causes of death among young children globally. It can be prevented with two doses of a safe and effective vaccine.   Measles outbreaks in numerous countries – caused by gaps in routine immunization and in mass vaccination campaigns – continue to be a serious challenge. In 2015, large outbreaks were reported in Egypt, Ethiopia, Germany, Kyrgyzstan and Mongolia. The outbreaks in Germany and Mongolia affected older persons, highlighting the need to vaccinate adolescents and young adults who have no protection against measles.   Measles also tends to flare up in countries in conflict or humanitarian emergencies due to the challenges of vaccinating every child. Last year, outbreaks were reported in Nigeria, Somalia and South Sudan.   Measles elimination in four of six WHO regions is the global target at the midpoint of the Global Vaccine Action Plan implementation. “The world has missed this target, but we can achieve measles elimination as we have seen in the Region of the Americas,” said Dr. Rebecca Martin, director of CDC’s Center for Global Health. “As the African adage goes, ‘it takes a village to raise a child’ and it takes the same local and global villages to protect children against measles. We can eliminate measles from countries and everyone needs to play a role. This year’s report shows that the 2015 WHO regional measles elimination goals were not met because not every child has been reached – gaps exist. We need to close these gaps, ensure that commitments for adequate human and financial resources are kept and used well to reach every child, detect and respond to every case of measles, and prevent further spread. These efforts will protect all children so that they can become the next generation of leaders. This will also ensure that every country has a strong safety net to stop disease threats where they occur and protect the world from global health threats.”   Note to editors: The Global Vaccine Action Plan adopted by the World Health Assembly in 2012 set a goal of eliminating measles in four regions by 2015. Failure to close immunization coverage gaps has resulted in a failure to meet the goal.   Since 2000, some 1.8 billion children have received measles vaccination through mass measles vaccination campaigns with support from UNICEF, a founding member of the Measles & Rubella Initiative, launched in 2001 with the American Red Cross, the UN Foundation, U.S. Centers for Disease Control and Prevention and the World Health Organization.   Gavi, the Vaccine Alliance, has programmed close to US$1 billion over the period 2016-2020 to help developing countries approach measles in a comprehensive manner that will contribute towards saving more than a million lives. The latest measles mortality data is published in WHO’s Weekly Epidemiological Report and CDC’s Morbidity and Mortality Weekly Report . A mother watches Dr. Nataliya Seredyuk checking her five-month-old baby prior to administering him immunizations at the General Practice Clinic in Bohorodchany, Ivano-Frankivsk Oblast, Ukraine. UNICEF/UN060130/Zmey A mother watches Dr. Nataliya Seredyuk checking her five-month-old baby prior to administering him immunizations at the General Practice Clinic in Bohorodchany, Ivano-Frankivsk Oblast, Ukraine.
Press release
13 Декабрь 2017
New funding will allow countries to secure sustainable vaccine supplies and reach children more quickly
https://www.unicef.org/eca/press-releases/new-funding-will-allow-countries-secure-sustainable-vaccine-supplies-and-reach
COPENHAGEN, 13 December 2017 – UNICEF announced today that funding for its Vaccine Independence Initiative (VII), a mechanism to help countries secure a sustainable supply of life-saving vaccines, has more than doubled in the past year, increasing from $15 million to $35 million.  The increase was made possible especially by a $15 million financial guarantee from the Bill & Melinda Gates Foundation, adding to a VII capital base that also includes recent contributions from Gavi, the Vaccine Alliance, and the United States Fund for UNICEF.  Over 60 low-income countries currently benefit from Gavi support to purchase life-saving vaccines. As countries’ economies grow and transition away from Gavi support, the VII gives them access to short-term bridge “loans” so that they can purchase vaccines while waiting for the release of national budget funds. In addition, it provides countries assistance to strengthen the planning and budgeting processes to manage their essential supplies procurement moving forward.  VII is one tool to help countries minimize vaccine stock-outs and ensure more children receive vaccines on time. Since 2016, it has helped provide an estimated 91 million doses to children in 23 countries faster than would have otherwise been possible. “Financing mechanisms such as the VII are an essential part of a vaccine supply financing toolkit to improve financial sustainability and ensure supplies are reaching children when they are most needed,” Shanelle Hall, UNICEF Deputy Executive Director for Field Results, explained. “We look forward to continuing our work supporting countries, together with the Foundation and other donors and partners. It is especially critical now, in light of many countries graduating from donor support, inequities in Middle Income Countries and the broader Sustainable Development Goals agenda.” “We know from speaking with government leaders around the world that countries transitioning from Gavi support can face some significant short-term budget and technical difficulties securing their own vaccines,” said Dr. Orin Levine, director of Vaccine Delivery at the Bill & Melinda Gates Foundation. “The foundation, along other partners in the Gavi Alliance, are committed to helping countries address these challenges, and the VII is one tool that we have to make sure that children, no matter where they live, are protected against vaccine-preventable diseases.” Vaccines are one of the most effective health interventions in history, and have helped reduce the number of child deaths by more than half since 1990. For every dollar spent on childhood immunizations, countries yield $44 in economic and social benefits.  Global immunization coverage for the basic package of vaccines stood at 86 percent in 2016, the highest on record. However, much remains to be done to ensure the sustainability of national vaccination systems and funding, and make essential supplies for children available. “Tools like the Vaccine Independence Initiative are becoming increasingly important as developing countries invest more and more of their own resources in their vaccine programmes, in this case by creating a stable, predicable vaccine supply,” said Dr Seth Berkley, CEO of Gavi. “This new investment will therefore give a welcome boost to countries moving towards self-sufficiency, helping to ensure children don’t go without life-saving vaccines.” Recent contributions to the VII have been key to support countries who are expanding their national budgets to purchase vaccines, such as Kenya and Chad. Additionally, the recently increased size of VII has allowed the new countries such as Uzbekistan, Cote d’Ivoire, and most recently Tajikistan to sign-up to the mechanism. More countries are in active discussions for new subscriptions. These efforts contribute to providing sustained immunization supplies to an increasing number of newborns in these countries.  Note to editors The Vaccine Independence Initiative Launched in 1991, the Vaccine Independence Initiative (VII) is a financial mechanism that enables governments to manage temporary budget shortfalls and facilitate timely procurement of essential supplies. The VII offers flexible credit terms to countries, allowing them to pay after critical supplies are delivered, reducing stock-outs and ensuring a systematic and sustainable provision of goods. In 2015, in order to respond to the increasing use of domestic budgets to fund essential commodities, the UNICEF Executive Board approved the expansion of the capital base from $10 million to $100 million, subject to donor contributions, and authorized the broadening of the fund applicability beyond immunization supplies. Since then, UNICEF has increased its resource mobilization efforts to encourage contributions from government donors and the private sector to expand the capital base of the fund. At the end of 2017, the capital base had increased to $35 million following support from the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance and the United States Fund for UNICEF.   A girl gets her oral polio vaccine in a children’s municipal polio clinic in Chernomorsk, Ukraine. UNICEF/UN09083/Bershadskiy
Press release
19 Октябрь 2016
Supply of children’s five-in-one vaccine secured
https://www.unicef.org/eca/press-releases/supply-childrens-five-one-vaccine-secured
GENEVA, 19 October 2016 – Breakthrough prices have been achieved with six vaccine suppliers who offered to price pentavalent vaccine at an 84 cents a dose average – half the price that the UN children’s agency currently pays.   In the next three years, UNICEF will buy 450 million doses to send to 80 countries. Four hundred million doses will be allocated to Gavi-supported and transitioning countries. The vaccine will protect tens of millions of children from potentially deadly infections caused by diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type b.   Since 2001, strong collaboration on market shaping across Gavi Alliance partners, including the Bill & Melinda Gates Foundation, WHO and UNICEF, has achieved an affordable and sustainable pentavalent vaccine supply for children in the world’s poorest countries.   The new pricing can also be accessed by governments who self-finance procurement of this cost-effective vaccine. It will generate over $366 million in savings for donors and for governments.   “Ninety per cent of the world’s children under five who die from vaccine-preventable diseases live in countries whose vaccine supply is no longer fully funded by donors,” said Shanelle Hall, Director of UNICEF’s supply and procurement headquarters. “For the most vulnerable children in the world, pricing can make a difference between life and death,” Hall added.   “Gavi estimates that 5.7 million deaths will be averted thanks to pentavalent vaccination in Gavi-supported countries between 2011 and 2020,” said Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance. “The market for five-in-one vaccines is now a lot healthier than it was just a few years ago thanks to our collective efforts to grow a base of vaccine suppliers. We remain committed to making vaccine markets work better for the world’s poorest countries to ensure immunization investments and efforts are sustainable for all.”   Achieving milestones in making vaccines more affordable illustrates how collaborative engagement, including with vaccine suppliers, can result in vaccine markets that put children’s health first.   Careful monitoring of supply and demand in vaccine markets and consultations with vaccine manufacturers have helped determine the most effective actions to secure sufficient production levels and efficiencies of scale. Between 2001 and 2015, UNICEF’s pentavalent vaccine procurement jumped from 14.5 million to more than 235 million doses, mainly driven by the increase in demand in countries supported by Gavi.   Broadening the supplier base reduces the risk of supply shortages and other serious market constraints that could negatively impact children. Collaboration between Gavi, the Gates Foundation and UNICEF leveraged the significant donor funding and through multi-year supplier contracts, improved demand forecasts and special contracting terms, helped grow the pentavalent vaccine supplier base from one in 2001 to six by 2016, and reduce prices.   As additional manufacturers become interested in supplying vaccines to UNICEF, competition between them intensifies. Since 2011, UNICEF publishes the prices of all vaccines it procures, giving manufacturers the advantage of seeing what their competitors charge – and this had led to better offers. By 2016, the price for donor-funded and government self-funded pentavalent vaccines was an average of $1.65 a dose.   In 2016, a competitive pentavalent vaccine market and excess supply capacity represented ideal conditions to launch a new phased approach to tendering.   In the first phase, UNICEF invited interested suppliers to submit a proposed price. After making awards to the most competitive bids, UNICEF published prices and launched a second request for proposals, which gave time for suppliers to sharpen their initial offers. The final awards achieved lowest ever pricing while sustaining a healthy supply market for the longer-term.   “Today’s announcement demonstrates that partnerships can bring affordability and price sustainability to the table in supplier discussions, and this is transforming health outcomes for children,” said Hall. ## Pricing information on UNICEF’s 2017-19 pentavalent vaccine supply can be downloaded from: http://www.unicef.org/supply/index_57476.html .    A 2 year-old gets her dose of oral polio vaccine in the children’s polio clinic in Ukraine. UNICEF/UN09097/Krepkih
Press release
16 Июль 2018
Record number of infants vaccinated in 2017
https://www.unicef.org/eca/press-releases/record-number-infants-vaccinated-2017
  New York, 16 July 2018: A record 123 million infants were immunized globally in 2017, according to data released today by the World Health Organization and UNICEF.  The data shows that: 9 out of every 10 infants received at least one dose of diphtheria-tetanus-pertussis (DTP) vaccine in 2017, gaining protection against these deadly diseases.   An additional 4.6 million infants were vaccinated globally with three doses of the diphtheria-tetanus-pertussis vaccine in 2017 compared to 2010, due to global population growth. 167 countries included a second dose of measles vaccine as part of their routine vaccination schedule and 162 countries now use rubella vaccines. As a result, global coverage against rubella increased from 35 per cent in 2010 to 52 per cent.   The human papillomavirus (HPV) vaccine was introduced in 80 countries to help protect women against cervical cancer.  Newly available vaccines are being added as part of the life-saving vaccination package – such as those to protect against meningitis, malaria and even Ebola. Despite these successes, almost 20 million children did not receive the benefits of full immunization in 2017. Of these, almost 8 million (40 per cent) live in fragile or humanitarian settings, including countries affected by conflict. In addition, a growing share are from middle-income countries, where inequity and marginalization, particularly among the urban poor, prevent many from getting immunized.  As populations grow, more countries need to increase their investments in immunization programmes. To reach all children with much-needed vaccines, the world will need to vaccinate an estimated 20 million additional children every year with three doses of the diphtheria-tetanus-pertussis vaccine (DTP3); 45 million with a second dose of measles vaccine; and 76 million children with 3 doses of pneumococcal conjugate vaccine.  In support of these efforts, WHO and UNICEF are working to expand access to immunization by:  Strengthening the quality, availability and use of vaccine coverage data.  Better targeting resources. Planning actions at sub-national levels and Ensuring that vulnerable people can access vaccination services.    Notes to Editors Since 2000, WHO and UNICEF have jointly produced national immunization coverage estimates for each of the 194 WHO Member States on an annual basis. In addition to producing the immunization coverage estimates for 2017, the WHO and UNICEF estimation process revises the entire historical series of immunization data with the latest available information. The 2017 revision covers 37 years of coverage estimates, from 1980 to 2017.  Related links WHO/UNICEF 2017 country and regional immunization coverage data  Global Vaccine Action Plan 2012-2020   A baby girl receives her vaccination at a clinic in Serbia. UNICEF/UN040869/Bicanski A baby girl receives her vaccination at a clinic in Serbia.
Article
25 Апрель 2018
#VaccinesWork to protect children in Ukraine, amid measles outbreak
https://www.unicef.org/eca/stories/vaccineswork-protect-children-ukraine-amid-measles-outbreak
As a mother of two young children, Natalia was once told by her doctor that vaccinations were unnecessary. Now – with a measles outbreak gripping Ukraine –Natalia is glad she chose to ignore the doctor’s advice and instead vaccinate her children. This recent national outbreak has affected 16,500 people and killed 13, including nine children. According to a UNICEF poll taken in 2016, 16 percent of parents in Ukraine have refused vaccinations for their children.  Natalia with her two children in a park in Kyiv. Natalia, with her two young children in a park in Kyiv. “Many parents I know still refuse to vaccinate their children,” says Natalia, whose children received the MMR vaccine against measles, mumps and rubella. “They say the vaccines are bad, that they have adverse effects. My children are fine and I think their health is more important.” Ukraine’s Ministry of Health has been leading the outbreak response since 2017 with support from UNICEF and other partners. While less than half of all children in the country were vaccinated against measles as part of routine immunization in 2016 (via the MMR vaccine), the number more than doubled in 2017 to over 90 percent, according to the Ministry. Valentyna Ginzburg, a doctor who heads Kyiv’s state healthcare department, says she and her team have been working to combat the measles outbreak since first being alerted to a rise in infections following the New Year and Orthodox Christmas celebrations in 2018. “We received information on the incidence rates of measles in Kyiv,” Dr. Ginzburg says. “We knew we needed to take rapid action to prevent a situation similar to other regions, such as Odesa, where there had already been fatalities amongst both adults and children from the illness.” Measles is one of the most contagious diseases around and we understood that if we were not proactive and did not control it, it would have not been long before we had the same situation as in other regions. Dr. Ginzburg Dr. Ginzburg explains how she and her colleagues had to act quickly to stop the spread of the disease in Kyiv. UNICEF/2018/Krepkih Dr. Ginzburg explains how she and her colleagues had to act quickly to stop the spread of the disease in Kyiv. In the four days that followed, 11,000 children were vaccinated in Kyiv. Around 48,000 children were immunized from January to March, a tally that would normally take 12 months to reach. Following national recommendations on outbreak response, authorities in Kyiv launched a ‘situation room’ to collect the latest information and coordinate response actions. Being vaccinated was also made a pre-condition for children attending schools and preschools to help stop the spread. The city administration also encouraged medical specialists to visit schools and raise awareness of vaccination among both teachers and parents.  Maryna Stefanenko, a pediatrician at a clinic on the left bank of Kyiv, gives more details. “We had a lot of people coming in, even those who normally go to private clinics,” she says. Dr Stefanenko’s clinic usually administers around 80 vaccines per day, but during the outbreak they were immunizing around 1,200 people each day.   On the other side of the city, in Obolon district, another clinic rushed to meet demand. A pediatrician there, Dr Natalia Yatsenko, explained that as part of her job, she must sign the paperwork for parents who refuse to vaccinate their children. She says she spends a lot of time explaining the benefits of vaccination, as well as the risks for children who do not receive their shot. Before the measles outbreak, she managed to talk some 10 per cent of objectors into changing their mind. However, during the outbreak, she did not even have to persuade them – many parents who were once against vaccinations were very keen to bring their children to the clinic. A young boy receives several vaccines at a time at Dr Natalia Yatsenko clinic in Kyiv. A young boy receives several vaccines at a time at Dr Natalia Yatsenko clinic in Kyiv. Another factor in the response? The effects of armed conflict in eastern Ukraine. “We had some internally displaced people from the eastern regions who came to our clinic,” says Yatsenko. “They told us that their children’s vaccination records had been falsified, and now they wanted to vaccinate them for real. So we vaccinated them.” “We also vaccinated some parents,” adds Stefanenko. “The parents bought the vaccines for themselves from the pharmacy then brought them to us and we administered the shots.” Dr. Ginzburg also advocated with the Kyiv authorities to address one of the biggest issues the country is struggling with - access to vaccines for adults and health workers. “All health workers had to be checked and those who required vaccination had to be immunized,” she says. “Then we were sure that, no matter what, the doctors wouldn’t be incapacitated.” The city administration also made sure the municipal pharmacy chain had measles vaccines available for adults. Artem, six, receives his second dose of the MMR (mumps, measles, rubella) vaccine in Kyiv. Artem, six, receives his second dose of the MMR (mumps, measles, rubella) vaccine in Kyiv. Although vaccines for children were available in 2017, increased demand had depleted stocks in some regions. To help replenish stocks, a new expedited supply of MMR vaccines was delivered by UNICEF at the request of the Ministry of Health at the end of February 2018, and another 800,000 doses are due this month, to ensure sufficient vaccines for both routine immunization of children and those who may have missed their immunizations in previous years. Significant progress has been made in reaching more children with vaccines, yet still an estimated 1.5 million children die globally from vaccine preventable diseases every year and an estimated half a million children in the region are still not immunized. Millions of lives can be saved by extending basic health services like routine immunization to the most vulnerable and disadvantaged, and UNICEF is on the ground immunizing millions of children each year . Vaccines protect children against disease and death, saving up to three million lives every year. In short, #VaccinesWork. 
Report
01 Апрель 2013
Tracking anti-vaccination sentiment in Eastern European social media networks
https://www.unicef.org/eca/reports/tracking-anti-vaccination-sentiment-eastern-european-social-media-networks
Page 1 Page 2 A lie can travel halfway around the world while the truth is putting on its shoes. Mark Twains quote is more relevant than ever in times of online communication, where information or misinformation, bundled in bits and bytes, streams around the earth within seconds. SUMMARY DISCLAIMERUNICEF working papers aim to facilitate greater exchange of knowledge and stimulate analytical discussion on an issue. This text has not been edited to official publications standards. Extracts from this paper may be freely reproduced with due acknowledgement. For the purposes of this research, no personal data has been extracted and stored for data collection and analysis. This UNICEF working paper aims to track and analyse online anti-vaccination sentiment in social media networks by examining conversations across social media in English, Russian, Romanian and Polish. The findings support the assumption that parents actively use social networks and blogs to inform their decisions on vaccinating their children. The paper proposes a research model that detects and clusters commonly-used keywords and intensity of user interaction. The end goal is the development of targeted and efficient engagement strategies for health and communication experts in the field as well as for partner organisations. Page 3 CONTENT1. Rationale 2. Introduction 2.1 Social Media: the conversation shift 2.2 Social Media: Fertile ground for anti- vaccination sentiment 2.3 Social Media Monitoring 2.4 Influencers 3. Research Objectives 4. Methodology 4.1 Descriptive and Explorative Research Design 4.2 Data Collection 4.3 Limitations 4.4 Ethical Considerations 5. Empirical Findings 5.1 Networks: Volume and Engagement 5.2 Common Arguments 5.2.1 Religious and Ethical Beliefs 5.2.2 Side Effects 5.2.3 Development Disabilities 5.2.4 Chemicals, Toxins and Unnecessary 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest 5.3 Influencers 6. Discussion and Recommendations 6.1 Discussion 6.2 Recommendation Acknowledgements Literature Appendix 4 555 78 9 1111121313 1414191920212222 23 252527 313134 Page 4 Over the past few years, the region of Central and Eastern Europe and the Commonwealth of Independent States has been troubled by the rise of a strong anti-vaccine sentiment, particularly via the internet. Wide ranging in origin, motive, source, and specific objectives, this online sentiment has succeeded in influencing the vaccination decisions of young parents, in many instances negatively. A number of factors are at play in this online anti-vaccine sentiment. First, vaccination coverage in this region is generally high. As a result, vaccine-preventable childhood diseases like polio and measles have been absent in most countries for the past few decades. This has led to complacency toward the diseases and has unfortunately made vaccines, rather than the diseases, the focus of debate and discussion. Meanwhile, poorly-managed immunization campaigns in some countries have caused widespread mistrust of vaccines and government vaccination programs. Most countries have run sluggish, high-handed public communication campaigns while avoiding transparent dialogue with the public on possible side effects, coincidental adverse events and other safety issues. Moreover, when new vaccines have been introduced, they have often just exacerbated the publics existing doubts, hesitations or outright resistance. Into this mix, rapid penetration of the internet in the region has provided a powerful, pervasive platform for anti-vaccine messages to be disseminated. Rooted in scientific and pseudo-scientific online sources of information, messages are often manipulated and misinterpreted, undermining the confidence of parents and causing them to question the need for, and efficiency of, vaccines. The result is hesitation towards vaccination, which in large numbers poses a serious threat to the health and rights of children.This paper aims to examine this rapidly growing phenomenon and its global lessons. Depending on the nature of the problem, special strategies need to be developed to tactically address and counter, diffuse or mitigate its impact on ordinary parents. The prevailing approach of most governments in largely ignoring these forces is unlikely to address this growing phenomenon. Governments, international agencies and other partners - in particular the medical community - need to combine forces to identify the source and arguments of these online influences, map the extent to which they control negative decisions, develop more effective communication strategies and ultimately reverse this counterproductive trend. RATIONALE Page 5 The first part of this paper describes how anti-vaccination groups communicate and how social networks connect concerned parents in new ways. The second part emphasizes the role of social media monitoring in strategic communication, based on understanding audience needs. 2.1 Social media: The conversation shifts The rise of social networks has changed both the way we communicate and the way we consume information. Even within the relatively recent internet era, a major evolution has occurred: In the initial phase known as Web 1.0, users by-and-large consumed online information passively. Now, in the age of social media and Web 2.0, the internet is increasingly used for participation, interaction, conversation and community building1. At the same time, conversations or social interactions that used to occur in community centres, streets, markets and households have partly shifted to social media2. Parents, for instance, suddenly have an array of collaborative social media tools with which to create, edit, upload and share opinions with their friends, peers and the wider community. These conversations are recorded, archived and publicly available. 2.2 Social media: Fertile ground for anti-vaccination sentiment In todays information age, anyone with access to the internet can publish their thoughts and opinions. On health matters in particular, the public increasingly searches online for information to support or counter specialised, expert knowledge in medicine3. Due to the open nature of user participation, health messages, concerns and misinformation can spread across the globe in a rapid, efficient manner4. In this way, social media may influence vaccination decisions by delivering both scientific and pseudo-scientific information that alters the perceived personal risk of both vaccine-preventable diseases and vaccination side effects. INTRODUCTION 1 Constantinides et al, 2007 2 Phillips et al, 2009; Brown, 2009 3 Kata, 2012 4 Betsch et al, 2012 Page 6 In addition to this accelerated flow of information (whether accurate or not), social media messages tend to resonate particularly well among users who read or post personal stories that contain high emotional appeal. This holds true for anti-vaccination messages too. In other words, both logistically and qualitatively, social media is intensifying the reach and power of anti-vaccination messages. Negative reactions to vaccines are increasingly being shared across online platforms. All of this leads to a frustrating predicament and critical challenge: Immunizations protect people from deadly, contagious diseases such as measles, whooping cough and polio. But parents influenced by anti-vaccination sentiment often believe vaccines cause autism, brain damage, HIV and other conditions, and have begun refusing them for their children. As a consequence, health workers face misinformed, angry parents, and countries face outbreaks of out-dated diseases and preventable childhood deaths5. Why do anti-vaccination messages resonate with so many parents in the first place? Parental hesitation regarding vaccinations is thought to stem from two key emotions: fear and distrust: Vaccination is a scary act for many children and parents. A biological agent is injected into the child. The way the biological agent works in the childs body is for most people unclear, which appeals to parents fears. The high level of distrust stems from the intersection of government, medicine and pharmaceutical industry. The nature of its act and the fact that vaccinations are mostly compulsory leads to worries among citizens. (Seth Mnookin, 2011) This distrust, along with the interactive nature of social media, suggests an urgent need for health workers to become attuned to arguments and concerns of parents in different locations and of various cultural backgrounds. To achieve more synergistic relationships with an audience, organisations need to shift their communications strategy from getting attention to giving attention6. Compounding this challenge is the fact that some anti-vaccination groups are not merely sceptics or devils advocates, but operate in an organized, deliberate and even ideological manner. These anti-vaccination groups often employ heavy-handed 5 Melnick, 20116 Chaffrey et al, 2008 Page 7 communication tactics when dealing with opponents: they delete critical comments on controlled media channels, such as blogs7 ; they mobilize to complain about scientists and writers critical of their cause; sometimes they go going as far as to take legal action to prohibit the publishing of pro-vaccine material. Governments and organisations aim to keep parents accurately informed about vaccinating their children. As more of the public conversation indeed battle takes place across social media, there is an urgent need to understand this online landscape. This, in turn, requires the use of effective monitoring tools. 2.3 Social media monitoring Social media analysis plays an important strategic role in understanding new forms of user-generated content8 . Indeed, this type of monitoring has become a leading trend in Marketing, PR, political campaigns, financial markets and other sectors. As demand for this kind of data increases, more monitoring tools are becoming available. These tools search social networks for relevant content, and archive the publicly available conversation in a database. Researchers conduct their internet analysis primarily by formulating combinations of keywords that can be placed in relation and weighted for importance. There are four different types of social media monitoring: Monitoring by volume looks at the amount of mentions, views and posts a topic, organization or user receives. Monitoring by channels maps and examines the various networks that users use to exchange content. Monitoring by engagement seeks deeper insight into how many users actually respond, like, share and participate with the content. Monitoring by sentiment analysis is a qualitative approach that uses word libraries to detect positive or negative attitudes by users towards an issue9. The first phase in social media monitoring is listening to what users say, because in order, for instance, to engage effectively with parents on social networks, it is important to know what they are talking about10. 7 Kata, 2012 8 Cooke et al, 2008 9 The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. 10 Kotler et al, 2007 Page 8 Social media monitoring is a young discipline that began just a few years ago, and in its initial phase the practice faced a number of challenges. Data was very complex, so first generation monitoring tools produced results that were unstructured and generally overwhelming11. Even when that data was sorted and structured, organizations struggled to generate actionable management recommendations from it12. Since that time, however, social media professionals and research communities have made steady progress in overcoming the early challenges. 2.4 Influencers Recent studies on social media networks emphasize the central role played by influential individuals in shaping attitudes and disseminating information13. Indeed, it is argued that a group of such influencers is responsible for driving trends, influencing public opinion and recommending products14. One study found that 78% of consumers trusted social peer recommendations, while just 14% trusted advertisements15. Intensive interaction and content sharing through social media means that an audience instinctively determines its own opinion leaders. What makes opinion leaders particularly interesting and important from our perspective is that they add their personal interpretation to the media content and pass it on to their audience. Depending on whether these influencers speak responsibly or not, this can have positive or negative impact on the goal of disseminating accurate information. In his book The Panic Virus, journalist Seth Mnookin offers some examples of controversial influencers: A British gastroenterologist, Andrew Wakefield, entered into the vaccine discourse and alleged that the measles-mumps-rubella vaccine might cause autism. The medical community eventually dispelled his arguments and he lost his medical license. For a decade Wakefield - though not a public health specialist - very successfully disseminated misleading information and garnered a significant social media following. Meanwhile, actress and model Jenny McCarthy has become another self-proclaimed expert on vaccine safety. Through frequent public appearances she has positioned herself as an 11 Wiesenfeld et al, 201012 Owyang et al, 201013 Tsang et al, 2005; Kiss et al, 2008; Bodendorf et al, 201014 Keller and Berry, 200315 Qualman, 2010 Page 9 educated, internet-savvy mother set on challenging the medical establishments information about vaccinations. This, too, has helped fuel the recent growth in anti-vaccination sentiments. The public following and authority gained by Wakefield and McCarthy demonstrate how with the proliferation of online channels and the user as the centre of attention, it becomes difficult for information seekers to differentiate between professional and amateur content16. By the time the record is set straight, trust in immunization is been partly destroyed. Fostering the positive opinion of influencers in communities can have a disproportionately large impact in terms of online reputation17. Though they may not know each other in the real world, and despite ever-expanding advertisement platforms and sources, consumers around the world still place their greatest trust in other consumers18. Audiences listen to opinion leaders because they are known to be independent, credible and loyal to their peers19. Identifying and influencing the influencers of the social media conversation in the region should therefore be part of any effective strategy to reinforce positive messages in the vaccination debate. Though the internet is increasingly used to search for health information, a number of questions about social media and vaccination decisions are still unanswered: Which channels are used by anti-vaccination groups? What are the key arguments and conversation themes? What makes anti-vaccination messages appealing to parents? Who are the opinion leaders in online discussions? What are the best strategies to respond to anti-vaccination arguments? This paper seeks to understand the internal dynamics of anti-vaccination sentiment in social media networks in Eastern RESEARCHOBJECTIVES 16 Cooke et al, 200817 Ryan et al, 200918 Nielsen, 200919 Weiman, 1994 Page 10 Europe20. These insights are expected to help health workers, partners and national governments to develop appropriate response strategies in order to convince the public of the value, effectiveness and safety of vaccinations. The objectives of this research are: 1. To monitor social media networks, consolidate existing data and information from partners. 2. To categorize and analyse conversation themes, based on volume of discussion, influence, engagement and audience demographic as appropriate. 3. To identify influencers in the different language groups and platforms. 4. To contribute to a set of recommended strategies to address specific anti-vaccine sentiment around the various conversation themes. This content analysis is expected to help us understand the motivations and mind sets behind the sentiment, and offer clues that can inform the development of a strategy to effectively address the phenomenon. The research is also expected to help drawing comparisons between the anti-vaccination sentiment phenomenon and similar sentiments expressed against interventions in nutrition, child protection and other areas of UNICEF practice. This paper is supported by UNICEF Department of Communication in New York and UNICEF Regional Office for Central and Eastern Europe and the Commonwealth of Independent States. The region covers 22 countries and territories: Albania, Armenia, Azer-baijan, Belarus, Bosnia & Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kosovo (UN Administered region), Kyrgyzstan, TFYR Macedonia, Moldova, Montenegro, Roma-nia, The Russian Federation, Serbia, Tajikistan, Turkey, Turkmenistan, Ukraine, Uzbekistan. UNICEF does not have a country programme in the Russia Federation but is in discussions to develop a new mode of engagement. Page 11 In order to assess the dynamics of the anti-vaccination sentiments in the four languages, a systematic mapping and content analysis via social media monitoring is proposed. For the purpose of stakeholder monitoring in social media, a combination of descriptive and exploratory methods in form of quantitative and qualitative observation is proposed. According Wiesenfeld, Bush and Skidar (2010) it is reasonable to combine both methods because social media monitoring offers the richness of qualitative research, with the sample sizes of quantitative research. It may also give the opportunity to overcome problems associated with each research method in order to understand stakeholders dynamics in social media. 4.1 Descriptive and Explorative Research Design The descriptive methodology involves recording the activities of users and events in a systematic manner. Information is recorded as events occur and archived. Descriptive research in this case involves: Figure 1: Research Process for data gathering and analysis. METHODOLOGY 12 Aggregating text from public accessible social networks in in English, Russian, Polish and Romanian language. Cleaning and categorizing the data over time. The data is categorized and analysed into reoccurring conversation themes, based on volume of posts, engagement and audience demographic as appropriate. The exploratory methodology follows the descriptive research to allow for the interpretation of patterns and to provide background understanding of sentiment and attitudes of users. The results of the structured observation will be put into context by the human judgement of the researcher through the participant observation. In this research, the researcher will be a complete observer and will not interact with the users during the participant observation (Saunders et al, 2009). 4.2 Data Collection Traditional sampling techniques such as random, convenience or judgemental sampling are difficult to apply to a fluid social media environment. On top of the social media measurement process, the selected social media channels feed into the sample set. The posts are further categorized into different issue arenas that will be associated with relevant stakeholders. Figure 1 presents the data collection process for monitoring stakeholders in social media.The process contains the following six steps: 1. Channels: The first step of the data collection process involved the selection of relevant social media channels. Social media monitoring is instead generally considered to provide a complete set of all contributors, because tools like Radian6 or Sysomos are designed to capture a wide range of social media channels, such as blogs, forums, Twitter, Tumblr, Youtube and Facebook. 2. Demographics: The software gathered relevant posts that were posted in English, Russian, Polish and Romanian language3 during the period of 1 May and 30 July 2012. Posts could be submitted from all regions worldwide. 3. Context: The quality of data collection is determined by how well the collected data is gathered with regards to formulated searches. Keyword logic and search profiles were employed to filter the data. The full list of keyword combination can be found in Appendix A. 3The approach must employ qualitative analysis as machines are not able to track sarcasm or slang. Page 13 4. Data Collection: Relevant social media mentions that contained an issue-related keyword in relation to a stakeholder-related keyword was archived in the database. The list of relevant mentions was stored chronologically and assigned an ID. The full list of exported information about each mention was stored in a separate EXCEL file. 5. Data Analysis: The empirical application and content analysis of the relevant posts can be found in Chapter 6. 4.3 Limitations There are limitations in terms of reliability and validity of the recorded data. The data collection covers a three-months period. There is a need for caution when generalizing the data because events and evolution of discussions may alter the findings in other time periods. Therefore, limitations in reliability refer to reproducibility of research results. Reliability in the extent to which measures are free from error and therefore provide consistent results, such as the consistency of data availability in social media monitoring, is the second limitations. Quantitative observation has relatively high reliability because it reduces the potential for observer bias and enhances the reliability of data (Malhorta et al, 2007). However, social media monitoring might carry the risk of monitoring bias, as the relevant posts are extracted through keyword logic that is developed by the researcher. The collected data cannot be regarded as complete. For example, the share of Russian-speaking discussions seems to be fairly low compared to the amount of users accessing social media. Governmental control and censorship might also be contributing for lower volumes.The external validity, which is defined as the extent to which the research results are applicable to other research settings (Malhotra et al, 2007), is relatively low. Because of the richness of data, the sampling needs to be based on the experience of the researcher. As a disadvantage, the lack of established sampling technique in social media limits the ability to generalize the findings to other relevant issue arenas or stakeholders in the population. However, the ability to generalize the results was enhanced by careful use of the theoretical terms and relationships in the stakeholder literature (especially Freeman, 1984; Mitchell et al, 1997; Luoma-aho et al, 2010; Owyang et al, 2010). 4.4 Ethical Considerations Monitoring social media conversations raises two important questions about a) the protection of privacy, and b) ethical concerns. The growth of interest in social media monitoring has Page 14 triggered a new debate about ethics, which centers on what is in the public domain and what is not (Poynter, 2010). Privacy is a big issue, and social networking sites are under public criticism for lax attitudes regarding the security and respect of users privacy (Wakefield, 2011). It is the responsibility of the market researcher to protect a respondents identity and not disclose it to external audiences (Malhotra et al, 2007). Social media monitoring offers a rich volume of data, however the Internet is largely unregulated. The data of users around the world is stored on servers in the US and completely available to the US authorities. What might seem legal to the researcher may not necessarily be deemed morally right by society. Public interactions in social media are available for anyone and can be assigned to a personal IP address, geographic location, language, date and even specific computer. For the purposes of this research, no personal data has been extracted. The IP addresses and geographic locations have not been stored in the excel exports as it is not necessary for the purpose of the research. A unique post ID identifies each post. The following findings start with an overview of the networks used by the anti-vaccination community. Trends in volume and engagement are outlined in 5.1. In 5.2, clusters of common belief of the anti-vaccination sentiment are categorized and explained. The importance of influence in the anti-vaccination discussion is illustrated 5.3 because it is critical to understand that communication needs require adjustment to each country or region, which itself can present a challenge. 5.1 Networks: Volume and Engagement During May to July 2012, the researchers recorded messages with anti-vaccination sentiment from 22,349 participants. The majority of participants spoke English, followed by Polish, Russian and Romanian. EMPIRICALFINDINGS Page 15 Figure 2: Participants of anti-vaccination discussions per language. Across all four researched languages, blogs are the most frequently used channel for posting anti-vaccination content in social media. Blog is short for weblog, which is a website normally maintained by an individual (or group of individuals) and updated with regular entries. Entries are typically displayed in chronological order and tagged with relevant keywords and phrases. Blog visitors usually have the opportunity comment and share the content on blogs. Blogs are by far the most important channel in terms of volume of posts in Romanian (86% of all posts) and Polish (85% of all posts). In Russian discussions, 65% of all posts are submitted on blogs and in English nearly half of the anti-vaccination content (47%) is posted on blogs. Facebook is the second largest channel in terms of volume of posts. The social network has a share of 25% in English speaking networks, 13% in Polish, 8% in Romanian, and 5% in Russian channels. Facebook allows users to build personal profiles accessible to other users for exchange of personal content and communication via the Facebook. Twitter, which allows users to send brief (<140 character-long) updates, is the second largest channel in Russian-speaking (24% of the total volume) and fourth with 5% in English-speaking anti-vaccination communities. Other channels to consider are News websites and Forums in which users post comments to engage in discussions about specific topics. Since 68% of all participants in the anti-vaccination discussions during the observed time-period speak English, the dataset is able to reveal more accurate insights into demographics compared to the other languages. Insights in all languages can be found in Appendix 4, while the following analysis focuses on the English Page 16 data set. The English dataset also reveals that blogs have generally the highest rates of mentions (61%), conversations (67%), posts (67%) and interactions (43%). Based on the volume of posts, it is a logical consequence that most engagement takes place on blogs. Engagement is defined as followed: Post: An initial message submitted to a social networking site, i.e. a blog post, Facebook status, tweet, video, etc. Interaction: Any activity created as a direct response to an initial post, i.e. comments, likes, retweets, @replies, etc. Conversation: The sum of a post and all its related interactions. Note: a post with at least one interaction is considered as conversation. Mention: An appearance of search terms in a public social media space. Figure 3: Distribution by channel for Romanian, Russian, English and Polish networks Page 17 Blogs, forums, and Facebook are the leading networks for anti-vaccination discussions in English during the observed time-period. In other words, the anti-vaccination sentiments are expressed on those platforms through posting user-generated content. However, while conversations on forums only makeup 2% of total conversations, they account for 25% of all interactions among users. This indicates a heavily engaged audience. It can Figure 4: Mentions, Conversations, Posts and Interactions per channel. Page 18 be argued that opinions are formed during interactions among users and therefore, it is vital to add pro-vaccination content to the discussions on forums. Similarly, Facebook only contains 9% of conversations, but 21% of interactions. Both channels are important to consider for interactions with the anti-vaccination sentiment even if more posts occur on blogs. Similar findings occur in Forums. Forums are designed to be interactive conversation, where topics are discussed in greater depth. The English dataset is a reflection of this distinguish feature 16% of all posts and 25% of all interaction occur on Forums. The figures show that while the volume of content on Forums is relatively low, the engagement is an important strength that shaped the opinion in the anti-vaccination community. Figure 5 indicates that the data skews towards female audiences when issues such as developmental disabilities (59%), chemicals and toxins (56%) and side effects (54%) are discussed within the anti-vaccination sentiment, whereas men focus on arguments around conspiracy theory (63%) and religious/ethical beliefs (58%). Anti-vaccination social media participants are approximately 56% female and 44% male. Figure 5: Gender comparison in English per argument. Page 19 5.2 Common Arguments The amount of argument-mentions in anti-vaccination sentiment changes significantly by language during the observed time-period. Figure 6 illustrates that conspiracy theory and religious/ethical beliefs are the main topic trends in English, while religious/ethical beliefs drive the majority of discussions in Russian speaking anti-vaccination discussions. Polish anti-vaccination discussions are driven by arguments about side effects and chemicals and toxins in vaccines. The issue of chemicals and toxins is the major driver in Romanian discussions during the observed time-period. The arguments are described in detail in the following sections. The categories are based on keyword strings that were narrowed down over time. Issues should not be regarded in a static way, they might overlap and are interconnected. 5.2.1 Religious and Ethical Beliefs Religious and ethical discussions are especially active in discussion in Russian, with 96% of all anti-vaccination discussions focused on that issue. In English discussions, 32% of all anti-vaccination discussion use religious and ethical arguments. The arguments are less relevant in Polish (5%) and Romanian (0%) speaking anti-vaccination discussions. The main train of thought derives from Figure 6: Allocation of arguments by language for the anti-vaccination sentiment. Page 20 the belief that humans are created just as they should be and external interference is not required. My body was designed by God to be self healing and self regulating and no man will be able to do better than God is a quote by a female blog commentator from the US. Another user states, anything that involves substances that should never belong in a humans body, should not be injected or consumed without that individuals consent. Anti-vaccination advocates believe in homeopathy and alternative medicine. My BodyMy Decision writes a community member from Australia. A broad sentiment that mandatory vaccination is a violation of human rights can also be detected. From an ethical standpoint, the anti-vaccination community claims that it is a basic human right to be free from unwanted medical interventions, like vaccine injections. The same kind of argumentation can be recorded in all four languages. On June 15th 2012, the Polish Parliament voted to change the existing laws on vaccinations. The Act on Preventing and Fighting Infections and Infectious Diseases in Humans and in The Act on National Sanitary Inspection has created controversy among social media users because of it makes vaccination mandatory. The anti-vaccination advocates were sending petitions to the Polish President demanding him to stop the act. The petition received support from some representatives of the Catholic Church, but not an official support from the church as whole. Radio Maryja, the most powerful independent catholic media in the country, also critiqued the act based upon: The argument that vaccines are made based on cell lines derived from the bodies of babies killed by abortion. The notion of unethical activities by campaigning teenagers and women to be vaccinated against HPV infection and it is promoting immoral, and disorderly behaviour in the area of sexuality. 5.2.2 Safety and efficacy Side effects are the most common anti-vaccination theme in Polish networks (28%), but they also play a role in English networks (9%) and Romanian (5%). The argument is mentioned in less than 1% of all anti-vaccination discussions in Russian language. Typically, parents who reach out to online communities because they are unsure about vaccines trigger the discussions about side effects. Individual stories from parents are powerful because they humanize the discussion. One user writes, My baby is 5 months old, not vaccinated and he is going through pertussis right now! Its very scary! I HATE it! I have 3 children, the other 2 were vaccinated but Im scared to vaccinate my baby! Any other mommys new at Page 21 this? This quote reflects a level of fear and uncertainty about the right thing to do, even though the mother has experienced both the effect of vaccines and vaccine-preventable diseases. Another parent writes: My brother, sister in law, and all three kids under the age 5 were vaccinated for whooping cough and they all got it! An argument in a Russian network claims that live vaccines can mutate in the organism and create deadly strains. The fear of side effects leads to discussion about vaccines causing diseases and death. A user from the UK argues, The only way you can get this virus is if it is injected into you. Besides individual stories, argumentation backed by figures without context or sources are equally powerful in fostering fear of vaccines. For example, a member in one English network posts: Vaccinated children have up to 500% more diseases than unvaccinated children. Community members in Russia postulate that vaccinated children get sick 2-5 times more often than non-vaccinated children. For example in Romania, school nurses perform the mandatory vaccination during class, which is seen as a human rights violation and a safety issue. Parents are sceptical about the skills of the school nurses and feel surpassed by authorities in its decision to have children vaccinated. A user in a Polish anti-vaccination community states: I am a mother of two disabled children. When my daughter was five months old, she had a negative reaction to the vaccine, now she has been diagnosed with autism and mental retardation. For 10 years, I did not vaccinate my children and I would not want the right to decide on this matter taken away from me. I am an educated person, and have researched the subject and do not believe in the efficacy or safety of vaccinations. 5.2.3 Developmental Disabilities Another reoccurring argument in the anti-vaccination sentiment claims that vaccines contain toxins and harmful ingredients. Injecting vaccines into the body of a child leads to brain injury and developmental disabilities. This theme is discussed in 15% of all English and Polish speaking anti-vaccination discussions. Development Disabilities was in less than 1% of anti-vaccination discussions mentioned in Russian or Romanian networks. The arguments evolve from sentiment surrounding vaccines posing challenges to the immune system and producing antibodies that may cause autoimmune diseases. Another notable argument is that vaccines are not able to fight off the mutant viruses that develop over time. Across communities, anti-vaccination advocates link vaccines to Page 22 epilepsy, autism and neurodegenerative diseases (Parkinson and Alzheimer). A member of the Polish community writes: Mercury causes developmental disorders in children (including epilepsy and autism), in adults, neurodegenerative diseases (Parkinsons and Alzheimers), and degenerative changes in the reproductive systems of men and women, impairing their ability to reproduce offspring. It is notable that figures are used based on estimates by the author without links to sources. A Russian speaking user notes that vaccinations against pandemic influenza H1N1, also known as swine, can lead to the development of Guillain-Barr syndrome, acute poliradikulita in adults, according to Canadian researchers, published in the journal JAMA. 5.2.4 Chemicals, Toxins and Unnecessary(administration of vaccines) Our doctor has advised us to avoid vaccines in absence of a direct disease risk, since the long-term side effects have not been studied writes a member of an English-speaking community. One common argument recorded in the anti-vaccination sentiment is that studies about risks and impact of vaccinations are insufficient. Vaccines have not been tested enough and have concerns regarding the lack of long-term side effects studies. Another user states that I would really want to know whether and how well vaccine manufacturers test their final vaccine products () and how much contamination they discover. A common belief is that children having a vaccine-preventable illness just need food, water, and sanitation. In Polish communities, members use the example of Scandinavian countries lobbying for a ban of questionable and potentially harmful ingredients in vaccines. The notion that Scandinavian countries banned Thimerosal a long time ago and they have a much lower percentage of children with autism was classified was an important argument for users. Drawing on that example, the most common belief in Polish communities is that mercury may cause autism. A Russian-speaking user concludes, a recent large study confirms the results of other independent observations, which compared vaccinated and unvaccinated children. They all show that vaccinated children suffer 2 to 5 times more often than non-vaccinated children. Sources or links to the recited studies are not provided. 5.2.5 Conspiracy Theory, Western Plot and Conflict of Interest In English-speaking anti-vaccination communities (24%), a strong distrust against governments and pharmaceutical industry is Page 23 recorded. The same applies for Polish (5%), Russian (1%) and Romanian (3%) at a smaller scale. However, the U.S. and western governments are viewed critically when discussing about governments and conflict of interest. In Polish networks excessive vaccinations are seen as promoted by pharmaceutical companies in order to gain profits. The role of the pharmaceutical industry is discussed mostly negatively. The sector is regarded as corrupt marketing machine. An English-speaking user states that: In the vaccine industry, scientific fraud and conflicts of interests are causing a similar cycle of deaths and injuries that is being concealed and denied by regulators and vaccine manufacturers. The industry is viewed as profit-driven and has moved from its original purpose to save lives and protect humans. Romanian discussions directly blame the U.S. for purposefully infecting people with HIV using polio vaccines. Users create a direct link between vaccines and widespread HIV in Romanian orphanages. In the same sense, users claim that vaccines are being used against the Romanian populations. According to members of the anti-vaccination sentiment, vaccines against polio and chickenpox are used in Romania, which are not used in the U.S. anymore. Polish anti-vaccination communities state the examples of swine flu and bird flu two years ago. According to the users, both cases are plots by giant pharmaceutical companies. Some countries desperately bought a huge quantity of vaccines, while Poland acted rationally and did not buy the vaccines, which saved the state budget a couple of billion. The activists are suspicious because the epidemic ended after the new vaccines were purchased by several governments. The distrust against governments is also reflected in conspiracy theories. Patterns in English-speaking communities suggest that immunization is used to control and reduce the world population. One strain of argumentation is that vaccines that are not allowed in developed countries are imported to developing countries in order to reduce population growth. 5.3 Influencers Opinion leaders in anti-vaccination sentiment show varying characteristics across countries. However, they often appear to be well educated in alternative medicine. Some have no college education; others are in the medical field (such as nurses). A high level of volume and interaction can be recorded for influencers. They often subscribe to social channels of homeopaths and Page 24 alternative medicine advocates but they can be found across platforms. The following section lists a range of influencers that are active in different channels or languages: Name Position Facebook Fans Twitter Followers Blog Language Dr. Tennpen-ny The Voice of Reason about Vaccines 36,282 1,475 Yes English The Truth About Vac-cines Answering questions from concerned parents 21,246 N/A Yes English International Medical Council on Vaccination Purpose is to counter the messages asserted by pharmaceutical com-panies, the government and medical agencies that vaccines are safe, effective and harmless 7,983 N/A Yes English The Refusers "Vaccination choice is a fundamental human right." 9,069 12,457 Yes English Mothering Magazine Mothering is the pre-mier community for naturally minded par-ents. 66,504 102,173 Yes English Oglnopo-lskie Sto-warzyszenie Wiedzy o Szczepieniach STOP NOP Protest against new laws for mandatory vaccinations in Poland and against disinforma-tion campaigns about the effectiveness and safety of vaccines. 3,203 N/A Yes Polish STOP Pr-zymusowi Szczepie Petition campaign against new new laws for mandatory vaccina-tions in Poland. 2,866 58 Yes Polish Table 1: Examples of influencers in the anti-vaccination sentiment in social media. Page 25 With respect to the above-mentioned arguments, opinion leaders in the anti-vaccination movement put an emphasis on highlighting negative stories that focus on individual cases. In some cases, they blame outbreaks on shedding vaccinated children who get unvaccinated children sick. The argumentation is based on the conviction that vaccines are unsafe and dont work. A list of common arguments by arguments by influencers per language can be obtained in Appendix B. In this section the research question will be discussed in light of the theoretical and empirical findings. It needs to be noted that the discussion only focuses on engagement with anti-vaccination advocates in the four researched languages. This does not include pro-vaccination movements, medical professionals, partners or others. The discussion will propose a model that illustrates the different drivers of anti-vaccination sentiment based on three elements. The recommendations section builds on the three elements of the model and provides practical advice for communication strategies. 6.1 Discussion In order to develop engagement and messaging strategies for anti-vaccination sentiment, it is vital to have an abstract understanding of what drives users to become suspicious about vaccinations. Based on the findings, the paper proposes a model of anti-vaccination sentiment identification and salience. We classify three main spheres that attribute to a negative sentiment towards vaccine, which help us in the identification of trends within the anti-vaccination sentiment. The classification is illustrated in the following figure: DISCUSSION &RECOMMENDATIONS Page 26 The first attribute is the individual sphere. The main motivations for users to get involved are highly personal matters driven by concern and fear. When it comes to vaccinations, some parents are not sure what the right decision is. Am I a good mother if I do not get my child vaccinated or is it my responsibility as a caring parent to ensure the best protection for my child? Personal testimonies of other parents, especially negative stories, have a huge impact on the parent and fuel the concern. The second element that characterizes the anti-vaccination sentiment is the contextual sphere. The main driver behind the contextual sphere is a distrust of governments, pharmaceutical industry, scientific bodies and international organizations. It seems to be overwhelming for parents to understand the role of the big players. An interesting observation is that users in the contextual sphere do not seem to have a general resentment against vaccines per se but most arguments focus on lack of transparency in the decision processes as well as the potential conflict of interests trigger distrust. The third attribute is labeled as transcendental sphere. Negative attitudes towards vaccinations are derived from idealistic, religious and ethical beliefs. Arguments are rooted in strong beliefs and appear dogmatic, such as God creates us in the most ideal way or a body has its natural balance. Figure 7: Model of anti-vaccination sentiment identification and salience. Page 27 Individual, contextual and transcendental sphere are the key attributes of a member of the anti-vaccination movement. We argue that the various combinations of these attributes are indicators of the salience of members. We can identify four groups that derive from Figure 3. In order to understand salience within anti-vaccination community members, we propose the following classification Core Members are users that apply to all three spheres. They are concerned about side effects, distrust the government and live according to strong religious or ethical beliefs. Intense Members are members that apply to two of the three spheres. For example, a user might have concerns about vaccinations based on an individual sphere and also carry distrust against the pharmaceutical industry. But they are not driven by any idealistic beliefs. Alert Members are users that apply only to one of the three spheres. The doubt about vaccines derives only from one sphere and has human characteristics. They seem to be less convinced of the harm of vaccinations than the other two member groups. There is a fourth group of users, the Non-Members. They simply do not apply to any of the classification. We argue that Alert Members are easier to convince of the necessity of vaccines than Intense Members. Core Members are the hardest to convince, because the arguments against vaccines are based on various foundations. The findings also show that the intensity of argumentation, the interaction and the volume varies between the spheres. Therefore, the next section outlines practical recommendation on how to draft engagement strategies for each sphere. 6.2 Recommendations The following graphic summarizes the framework for the engagement and messaging plan that enables communication officers and health workers to react to the anti-vaccination sentiments. The framework is designed to be customizable for local realities. However, it does provide an overarching guidance for communication and campaigning initiatives. Members of the individual sphere should be approached with an emotional appeal. Users in this sphere go online and search for information in order to make an informed decision. Content that encourages parents to get their children vaccinated needs to be easy to find. Hence, search engine optimization plays an important role in the outreach strategy. Search marketing is used to gain visibility on search engines when users search for terms that relate to immunization. In order to appear on top if the search Page 28 results two general approaches should be considers: Organic search (SEO): When you immunization or vaccines into a search engine like Google or Yahoo!, vthe organic results are displayed in the main space of the results-page. For example, when parents search for information about vaccinations, pro-vaccine information should rank on top of the search engine results. By optimizing websites and posts, organizations and governments can improve the ranking for important search terms and phrases (keywords). Engaging actively in discussion and providing links to pro-vaccination content also helps to increase the visibility in the ranking. Paid search (SEM) enables to buy space in the sponsored area of a search engine. There are a variety of paid search programs, but the most common is called pay-per-click (PPC), meaning the information provider only pays for a listing when a user clicks the ad. The emphasis of the content strategy is to empower parents to ask doctors the right question in order to build confidence for the decision making process. Rather than criticising parents choices not to vaccinate, the messaging should promote an individuals ability to make the world a safer place for children. The communication strategy should also highlight the individual right and responsibility to choose to vaccinate. Through emotional Figure 8: Engagement Matrix for core spheres of the anti-vaccination movement. Page 29 messaging, hesitating parents should receive key information and explain how their choices affect their own children and the ones of others. The communities in the contextual sphere source their scepticism from general distrust against the large players involved in the vaccination industry. The engagement strategy should be based on a rational appeal that focuses on the hard facts of vaccines. It is important to avoid obvious communication tactics. Transparency about vaccines, testing, ingredients, potential side effects, funding and preventable diseases is crucial to reduce distrust. The messaging should also take into account past errors in vaccine campaigns by governments and suppliers in the regions and most importantly focus on the lessons learnt and how processes have been improving since then. Transparency can be built through a multi-channel approach that features the development of vaccines with expert testimonies. Successful cases, such as the near eradication of polio as a global effort, help to reduce distrust as well. This can be backed by official statistics on how infant mortality rates have been reduced over the past 20 years. Countries that generally have a favourable public perception, such as Scandinavian countries,
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