Grayling Ukraine - Vaccination Thinkpiece
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Grayling Ukraine - Vaccination Thinkpiece Grayling Ukraine - Vaccination Thinkpiece Document Transcript

  • GRAYLING UKRAINE THINK-PIECE: HEALTHCAREWHY UKRAINIANS ARE AFRAID OF VACCINES, THE IMPLICATIONS OF THIS AND WHAT CAN BE DONE IN RESPONSE Analysis of Ukraine‘s governmental vaccination policies and factors of Ukrainians‘ distrust in vaccination.Communication tools and approaches to overcome threatening trends. April 2011 Written and published by Grayling 1
  • TABLE OF CONTENTS1. EXECUTIVE SUMMARY 32. INTRODUCTION 53. COMMUNICABLE DISEASES’ PREVALENCE IN UKRAINE 9 a) Non-seasonal vaccine prevented infections: general tendencies and specifics 10 – tuberculosis 11 – virus hepatitis 12 – diphtheria 12 – measles 13 – rubella 13 – tetanus 14 – poliomyelitis 14 – pertussis 14 b) Seasonal vaccine preventable infections: myths and reality 154. UKRAINE’S STATE POLICY ON VACCINATION 185. PUBLIC PERCEPTION OF VACCINATION AND MEANS OF IMPROVING IT 23 a) Role of media in building public perception of vaccination in Ukraine 23 b) How to improve the situation. 256. CONCLUSIONS 297. SUGGESTED COMMUNICATION RESPONSES 31 2
  • 1. EXECUTIVE SUMMARYA thorough analysis of the key human development factors in Ukraine such as lifeexpectancy, death rate, infant mortality, prevalence of the most socially dangerousdiseases etc., leads to the conclusion that the Ukrainian healthcare system needs urgentreforms, which should address the needs of the majority of citizens, redefine priorities ofthe public policy and reflect the level of country‘s social and economic development. Thereforms should be realized in parallel with the effective fight against corruption andconsequent measures aimed at restoration of the image of the national healthcare in theeyes of the population.The issue of vaccination became the most vivid demonstration of the depth of problems inUkrainian public healthcare. As a result of a number of serious factors, Ukraine found itselfon the edge of a critical decrease of the collective immunity level. In many regions ofUkraine the level of vaccination dropped to less than 80%, which may destroy all seriousachievements of the previous years in the area of infectious diseases prevention andmanagement. Despite at the present moment, the epidemiologic situation in Ukraine fornon-seasonal vaccine preventable diseases can be characterized as far from being critical,in the medium term there exist the risks of Ukraine turning into a hotbed of the mostsocially dangerous communicable diseases.Among the factors which contributed to the radical decrease of vaccination level, the mostimportant were:  Growing anti-vaccination moods in the Ukrainian society, supported by numerous media, and pseudo experts (background for this are: the total mistrust of Ukrainians in the public healthcare system and even in the expert community; exact tragic events of 2008 associated with vaccination); they resulted in growing number of refusals to immunize adults and especially children;  Possibilities to avoid vaccination openly or implicitly provided by the imperfect Ukrainian legislation and corruption;  Faults of the public vaccination policies, which resulted in actual shortage of vaccines in the majority of Ukrainian regions. 3
  • The above mentioned requires urgent measures from the state, non-governmental andinternational organizations, medical and expert environment and pharmaceutical business.One of the elements of such an activity should be restoration of the populations trust invaccination and neutralization of the anti-vaccination hysteria of the previous years. Unlikethe legal and procedural factors, which can be modernized / improved in a relatively shortperiod of time, the image of the vaccination is the most difficult to change. So it should beaddressed with all seriousness and profoundness by all stakeholders and authorities. Inthe result of related activities, the level of population‘s immune-protection should increaseand the morbidity rate should become lower. The mechanisms of reaching this aimsuggested as the result of the performed research are: – Improved statistics and information exchange between the healthcare authoritiesand population in the field of infectious diseases; – Ethics code for journalists writing on medical issues; – Media trainings for general and business media journalists; – Nationwide information / educational campaign aimed at increasing trust andimproving awareness of the population of the immune protection of children and adults bythe means of vaccination, which has to be supported and conducted jointly by the State,doctors, NGOs and pharmaceutical business.In its turn, Grayling as a global PR and PA agency, which has serious internationalexperience in the area of healthcare communication, invites all interested parties todiscussion around this issue to be able to suggest the most appropriate solutions, whichshould help Ukraine come out of this potentially critical situation. 4
  • 2. INTRODUCTIONIn a modern society, the level of a country‘s economic and social development is primarilyassessed not on the basis of dry figures of GDP and growth rates, but by the quality ofliving. This sometimes unclear notion includes a number of socially important indicators,which demonstrate adequateness of the material benefits distribution, level of social justiceand satisfaction of citizens with their life and living conditions, etc. In all definitions of thequality of living the state of health and quality of medical services are always on the topposition. By the healthcare system development and key public health indicators like lifeexpectancy, morbidity, infant mortality and infectious diseases prevalence one can easilyjudge the general country‘s and state‘s performance, priorities of public policy, materialwealth of the population, public culture, etc.In this relation Ukraine should be regarded as a country where the quality of living isgenerally much lower than in the surrounding EU member-states and even in severalformer Soviet republics. According to the 20th UNDP Human Development Report 2010the average life expectancy in Ukraine was 68,6 years 1: 62,3 years for male and 74,5years for female.Other important indicators are also far from being optimistic: general mortality rate is1,574 per 100 thousand of population (almost twice higher than in the USA); the infantmortality is about 16 children per 1,000 live births, which corresponds to less developedcountries of Asia, Middle East and Latin America. The mortality from cardiovasculardiseases in Ukraine is almost 3 times higher than in the EU and oncology is 1,5 timesmore widespread 2. Ukraine is also one of the European ―leaders‖ in terms of HIV/AIDSand tuberculosis prevalence, which raises deep concerns not only among the localpopulation, but in the European political and medical circles.The above mentioned developments take place amid the growing public expenditures forthe healthcare, which were about 4,0% of the GDP in 2009 (corresponds to the level EUmembers like Bulgaria, Estonia, Lithuania etc., but is less than the WHO recommended1 http://hdrstats.undp.org/en/countries/profiles/UKR.html2 http://medstrana.com/articles/1639/ 5
  • level of 5%) 3, and the permanent attempts to reform the public healthcare sector. Thisposes serious questions on the effectiveness of the Ukrainian healthcare system on thewhole, on the perception of the healthy lifestyle among the Ukrainians and on their trust inthe state medicine. Table 1. Life expectancy, Mortality and Healthcare spending in some counties of the World Country Life Male Female4 Mortality, Total General Expectancy Per 100 Expenditure government 6 thousand on Health*, expenditure of % gross on health population5 domestic as % of total (2010) product expenditure (2007) on health (2007) Russia 66.29 59.8 73.17 1 604 5.4 64.2 India 66.80 65.77 67.95 748 4.1 26.2Kazakhstan 68.51 63.24 74.08 938 3.7 66.1 Ukraine 68.58 62.79 74.75 1 574 6.8 57.6 Belarus 71.20 65.57 77.18 1 377 6.5 74.9 Turkey 72.50 70.61 74.49 610 5 69.0 China 74.68 72.68 76.94 703 4.3 44.7 Poland 76.05 72.1 80.25 1 017 6.4 70.9 Georgia 77.12 73.8 80.82 992 8.2 18.4 USA 78.37 75.92 80.93 838 15.7 45.5 EU 78.82 75.7 82.13 1 033 7,76 (EU-25); ––– 8,6 (EU-15) 5,8 % (New Member States) Germany 80.07 77.82 82.44 1 092 10.4 76.9One of the key reasons for the described critical situation is corruption, which became areal ―epidemic‖ of the Ukrainian medicine and healthcare in general. It is a well-known factthat in Ukraine free public medicine does not exist in reality. Almost all visits to doctors onall levels are accompanied by presents or exact payments in cash in this or that form.3 http://hdrstats.undp.org/en/countries/profiles/UKR.html4 https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html5 https://www.cia.gov/library/publications/the-world-factbook/fields/2066.html6 http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf 6
  • Moreover, the majority of drugs should be purchased by the patients themselves. On theother hand, the system of public procurement in healthcare is one of the most corrupt inthe whole country. According to independent estimations, the budget costs leakage inhealthcare is over 35% and in some cases reaches 50%. The same situation is observedin the private sector, when doctors in many cases receive kick-backs from pharmaceuticalcompanies or pharmacies. All attempts to change or improve this situation in Ukraine havefailed.The whole set of problems encountered by the Ukrainian healthcare system became themost apparent in recent years in such an important, but very sensitive field of vaccination.The issue of scheduled and unscheduled vaccination against infectious diseases,including seasonal ones, always caused ambivalent reactions not only among thepopulation, but also in medical and expert environments of most countries. The reasonsfor this can be found in the nature of vaccines; numerous instances of adverse reactions;diseases of people regardless of previous vaccination, etc. On the other hand, thefollowing factors should be also considered: overall reduction of cases of major infectiousdiseases, ultimate eradication of some infections, lack of awareness about the nature ofinfectious diseases and of the existing danger of their spread, as well as about the role ofvaccination in their overcoming. These factors have created a sense of security, of finaleradication of infectious diseases, and therefore no need in taking preventive andprotective measures. In some cases, social movements and mass protests of parentsrefusing to vaccinate their children became widespread.The situation in Ukraine appears to be particularly dangerous, where as the result ofseveral incidents and circumstances, society gained a growing negative attitude towardsvaccination, which had led to a mass denial of citizens and parents from scheduled andunscheduled vaccination. Today, according to medical experts, the level of vaccination ofUkrainians from infectious diseases fell almost to 80% 7. At the same time, according to theWHO, if this level among children is lower than 95%, the country could face epidemics ofvarious infectious diseases, as it happened in such prosperous countries as Japan andSweden in the 1990s.7 http://www.gk-press.if.ua/node/2700 7
  • Taking into account this complicated situation, Grayling as a leading global company in thefield of communications set itself a goal to carry out a deep analysis of which factors haveled to anti-vaccination moods in the Ukrainian society over the last years, which driverssupport this trend at the moment, and what communication tools should be used to restoretrust of the Ukrainians to vaccination as one of the most effective means of combating theinfectious diseases prevalence.From its part, Grayling invites representatives of the state and local governments, medicalexperts and leading domestic and foreign pharmaceutical companies to join the discussionof this timely topic and together define steps that could prevent Ukraine from becoming ahotbed of the most socially dangerous communicable diseases. 8
  • 3. PREVALENCE OF COMMUNICABLE DISEASES IN UKRAINEThe system of protection from and prevention of communicable diseases in Ukraine is thedirect descendant of the Soviet immunoprophylaxis system which inherited both its meritsand disadvantages. Due to considerable centralization and control, in the Soviet Union ingeneral and in Ukraine in particular, one managed to cover the majority of population byvaccination and to reach predominantly the immune-protection level, recommended byinternational health organizations. In 1964 in the Soviet Union, the victory overpoliomyelitis was officially announced; smallpox was eradicated in 1936; noticeableprogress was demonstrated in the fight against diphtheria, measles, pertussis, tetanus andother diseases.At the same time, due to the formalized approach to the vaccination calendars andstrategies development, «dizziness from success», suppression of facts, imperfectinformation collection and epidemiological surveillance practices, the USSR‘s leadership inthe area of combating the communicable diseases prevalence should be regarded asdoubtful. Moreover, in many cases the official statistics didn‘t correspond to the realsituation, what could be confirmed by the repeating outbreaks of diphtheria, pertussis, andeven poliomyelitis, the information of which was classified. The most serious problems ofthe Soviet immunoprophylaxis system were: low quality of produced vaccines andinadequate system of their control; dependence on imports; bad equipment of vaccineproducing enterprises; low qualification of vaccination and immunoprophylaxis specialists;standardized approaches to children vaccination regardless of the region of residence andindividual acceptability; insufficient level of epidemiological surveillance and monitoring ofpost-vaccine adverse effects, etc. Almost in the unchanged shape the mentioned systemwas inherited by Ukraine, combined with a generally low confidence of the population indomestic medicine.Due to the deep political, economic and social crisis, in early 1990s in Ukraine, theachievements of the Soviet immunoprophylaxis system were largely lost. In particular, theepidemiological surveillance system deteriorated; the professional level of vaccinationcampaigns dramatically decreased etc. Moreover, populations‘ disorientation in the 9
  • radically changing life environment and the rapidly expanding freedom of speech created aperfect condition for appearance of a number of pseudo-doctors and propagandists, whofor different personal reasons launched a massive attack against vaccination. Theresulting numerous refusals of citizens from vaccinating themselves and their childrencomplicated by the general decrease in immunity and low professional level of vaccinationcampaigns led to the outbreaks of diphtheria in 1993-95, which took the lives of more than300 Ukrainians, and precipitated a general increase of the infectious diseases prevalencein Ukraine.Despite the increased attention of the state to the immunoprophylaxis and populationprotection from infectious diseases, development and implementation of the nationalvaccination plans, considerable international assistance, the epidemiologic situation inUkraine remains complicated.a) Non-seasonal vaccine prevented infections: general tendencies and specificsWith a view of the geographical location of Ukraine, the infections endemic to tropical,subtropical and subequatorial counties are not common here. At the same time, a numberof life threatening infections are traditionally spread on the Ukrainian territory, whichrequires regular epidemiological surveillance, prevention and immune-protection.The list of infections which need prevention by the means of vaccination in Ukraine, isdefined by the Decree of the Ministry of Health of Ukraine Nr. 48 from 03.02.2006 «On theOrder of Prophylactic Vaccinations in Ukraine and Control of the Quality and Turnover ofthe Medical Immunobiological Drugs»8. According to it, the vaccination against thefollowing diseases is performed: tuberculosis, hepatitis B, diphtheria, pertussis, tetanus,poliomyelitis, haemophilic infection, measles, rubella and parotitis.Assessment of prevalence of the vaccine preventable infectious diseases in Ukraine isquite a complicated task. The reasons for this are: an imperfect data collection system,8 http://zakon.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=z0665-06 10
  • outdated laboratory equipment and technologies, suppression of the information on thereal state of affairs, insufficient openness of the healthcare authorities, etc. Consequently,in order to receive relatively objective data, the comparative analysis of the officialstatistics, scientific research results and assessments by international organizations isstrongly required.The prevalence of tuberculosis has always been the key problem of the Ukrainianepidemiology and medical practice. Starting from 1992, the morbidity had been steadilygrowing and had increased 2,4 times to 84,5 cases per 100 thousand people by 2005,when the maximum of this indicator was registered. The mortality during the epidemicperiod increased 2,7 times from 9,5 cases in 1992 to 25,3 cases per 100 thousands ofpeople in 2005.Since 2006 a gradual decrease of morbidity and mortality indicators has been registered.In 2009, the prevalence of tuberculosis was 74,4 cases per 100 thousand of population(totally 31,807 people), which was 7% less than in 2008 and 12% less than in 2005. Themortality level decreased by 29% from 25,3 cases per 100 thousand of population in 2006to 18,2 cases per 100 thousand in 2009 (7,676 people) and to 16,7 in 2010 9. About 86% oftuberculosis patients were the people of able-bodied and reproductive age.According to the WHO estimations, in Ukraine 16% of newly registered tuberculosispatients have the multi-resistant disease form; among the recurrent cases the multi-resistance occurrence exceeds 50%. Ukraine is one of 27 countries of the world, where85% of the multi-resistant tuberculosis burden is registered and is on the 4 th place in theworld for the multi-resistant tuberculosis prevalence among the newly registered patients(in 2008 it was on the 5 th place). In Ukraine the cases of the extended drug resistance(almost to all anti-tuberculosis drugs) have been registered, like in 54 countries of theworld.Considering the provided data, Ukraine ranks among the first in Europe and the CIS interms of tuberculosis prevalence. By a number of indicators, e.g. mortality, in Ukraine the9 В. ХОМЯКОВ. Линия Смерти // Контракты, 04 квітня, 2011 р., С.17 11
  • tuberculosis epidemic should be stated. This requires redefinition of priorities of the publichealthcare policy and urgent joint actions with regional and global health organizations.In 2009 the prevalence of different forms of virus hepatitis decreased by 29,6 % to 6,335cases, which corresponded to the intensive indicator of 13,71 comparing to 19,22 in 2008.The prevalence of hepatitis A decreased by 48,8% in all regions of Ukraine with theintensive indicator being 5,69 comparing to 11,05 in 2008. The prevalence of hepatitis Bdecreased by 7,2 % to 2,456 cases (5,32 comparing to 5,70 in 2008). At the same time,the prevalence of acute hepatitis C (not preventable by vaccines) grew 10,65 %, whichcould be also attributed to better diagnostics. In total 966 cases of HCV have beenregistered, the highest rate being in Kyiv and in Cherkasy.In should be mentioned, that in Ukraine the prevalence of tuberculosis and different formshepatitis in many cases is the result of unhealthy lifestyles of some groups of populationand is largely connected to the dramatic number of HIV/AIDS patients. Other specific riskgroups for such diseases are drug addicts, prisoners, prostitutes, homeless, etc.Like in other former Soviet republics, in early 1990s the increased incidences ofdiphtheria were registered in Ukraine. In 1991 the number of infected grew 10 timescomparing to 1990. The most serious situation was in 1995, when the incidence crossedthe epidemic barrier and reached 10,3 cases per 100,000 people (about 50 times higherthan in 1990). The number of victims of diphtheria in Ukraine in those years was very high:111 deaths in 1994 and 187 in 1995. This required urgent measures from the UkrainianGovernment and international organizations, including the additional unscheduledvaccination of children and adults. In the following years the incidence considerablydecreased and reached 1,4 cases per 100,000 people in 1998. By 2005 the number ofinfected reached the level of 1990. In 2006 it was 68 people, 50 in 2008 (61 according toWHO10), and 21 in 200911. The mortality decreased accordingly, but in comparative termsremained considerably higher than in EU countries.10 World Health Statistics 2010 // WHO, 2010 – P. 8011 http://www.zn.ua/newspaper/articles/873 12
  • The results achieved by late 2000s became largely the consequence of adequatevaccination policies and in case the vaccination level drops again, the morbidity mayincrease dramatically and the diphtheria epidemic of the 1990s may become a reality in ashort period of time.Measles is one of the most widespread and infectious diseases. In Ukraine since Soviettimes and currently, the measles morbidity is characterized by periodical growth anddecline. For the period of 1990-2006, 4 epidemic growths of measles were registered:1991-1993, 1995-1996, 2001-2002 and 2005-2006. During the last outbreak, more than 45thousand people were infected in Ukraine, and 5 of them died. At that time, Ukraineaccounted for 83% of the measles cases in the European region consisting of 53countries. In 12 countries of Europe and Northern America ―imports‖ of measles fromUkraine was registered. In addition, it should be noted that the structure of the infectedpatients in Ukraine has changed and measles stopped being the mainly a paediatricdisease moving to the older age groups. These ―achievements‖ became one of the majorreasons of the unscheduled and controversial vaccination campaign of 2008.According to assessments of the Ministry of Health of Ukraine and WHO experts, thereasons for the measles outbreaks in Ukraine could be found in the inadequatevaccination policies in early 1990s, when the level of the population immunity decreasedconsiderably. All this prevented Ukraine from reaching the general WHO task of totaleradication of measles by 2010. However, this data is argued by many specialists sayingthat only about 15% of the population need immunity correction and the remaining 85%have strong resistance to measles.Anyway, in 2008, 48 cases of measles were registered in Ukraine12, in 2009, the morbiditydropped to 30 cases, which corresponds to 0,06 cases per 100 thousand of population.The prevalence of rubella in Ukraine is relatively high and reached the level of 162,907cases several years ago. However, over the last years the tendency of the rubellaprevalence decrease became apparent. In 2008 – 3,495 cases of rubella were registered12 World Health Statistics 2010 // WHO, 2010 – P. 80 13
  • in Ukraine13; in 2009 this indicator dropped 17,4 % to 2,884 cases (7,52 cases per 100thousand people). The most considerable decrease was registered among children, whoare always considered to be the main carrier of this disease.In 2009, 12 cases of tetanus were registered in 9 regions of Ukraine comparing to 17cases in 2008, which corresponds to 0,03 cases per 100 of population.On June 21, 2002 Ukraine as a part of the European region received the status of theterritory free of poliomyelitis. However, the vaccination by the most modern vaccines isstill going on according to the recommendations of the WHO.In the last years an unfavourable situation with pertussis, an infectious disease which canbe controlled by the specific vaccination, emerged in Ukraine. In 2009, the morbidity grewby 33,0 % in 19 regions of Ukraine. 1,364 cases were registered, which made 2,95 per100 thousand people comparing to 2,21 in 2008 (1,025 cases).Considering the above mentioned data, the epidemiologic situation in Ukraine for non-seasonal vaccine preventable diseases can be characterized as relatively unstable, but farfrom being critical as some experts, officials and journalists insist. In general, in Ukraineprevalence of the most widespread communicable diseases does not considerably exceedthe level of the European countries. At the same time, periodical outbreaks of infections indifferent regions of Ukraine leave serious doubts on the full control of the Ukrainianhealthcare authorities of the epidemic situation of Ukraine. The quality of immunizationcampaigns, possible suppression of facts on the real infections prevalence as well as thepoor laboratory practices may result in further outbreaks of the most difficult communicableinfections. The refusals from immunization as the additional critical factor pose seriousthreats to the possibility of the Ukrainian state to keep its hand on the epidemiologicalsituation in the country.13 World Health Statistics 2010 // WHO, 2010 – P. 81 14
  • b) Seasonal vaccine preventable infections: myths and realityEach year Ukraine, like other European counties, experiences the outbreaks of seasonalacute respiratory viral infections (ARVI) and influenza. These infections are considered tobe the most widespread and by the number of sick persons they largely overcome othercommunicable diseases. According to the existing data, in 2009 the number of ARVIpatients in Ukraine reached almost 9 Mln people and the number of citizens who got illwith influenza reached 287,000. The ARVI and influenza are a common reason foradverse effects and accompanying diseases, like pneumonia, which often lead to death. In2005-2009 the average number of deaths from pneumonia was about 6,200.Vaccination is one of the means of preventing influenza in parallel with the traditionalmethods. However, the specifics of vaccination against influenza comparing to non-seasonal diseases is that the strains of the virus change every season, so the one-timevaccination does not provide immunization for the whole life and even for the mediumterm, i.e. should be performed at least yearly. Even in this case it gives no guaranteedprotection as the influenza strains behaviour may change depending on the region and theclimate conditions of the exact territory. Combination of strains may also take place. Allmentioned factors make the influenza vaccination non-mandatory in the majority ofcountries and a subject of severe discussion among the experts, policy makers andpatients.However, in recent years the influenza vaccination became one of the most acute topics ofthe public discussion due to the ―strange epidemic‖, which took place in Ukraine in 2009-2010. Starting from mid October 2009 an increasing number of influenza cases have beenreported in Ukraine with the symptoms different from the usual one. Almost at the sametime the first lethal cases from the resulting diseases were registered, especially inWestern Ukraine. After a bacteriological research the epidemic of AH1N1 influenza wasofficially announced in Ukraine on October 30, 2009. During November and December,despite the quarantine in several regions of Ukraine, the morbidity increased dramaticallyand the number of deaths reached about 1,000. Absence of clear explanation of thesituation from the Ministry of Health and the Government multiplied by the active media 15
  • hysteria caused massive panic among the population, which emptied the streets and thepharmacies shelves, and led to financial and political speculations.At that moment the issue of regular vaccination against influenza was raised and muchdiscussed in the printed media, on radio and TV. However, the level of discussion andreaction of the population to the statements of experts and governmental officialsdemonstrated low awareness of citizens of the nature of vaccination and ways ofprotecting their health from the seasonal diseases. Numerous cases of self-treatment bycitizens with miserable consequences became the most vivid evidence of this.But, surprisingly, the comparison of statistics on influenza and ARVI cases in previousyears made by several experts and journalists demonstrated that the total number ofpatients didn‘t remarkably increase. Moreover, the morbidity and mortality from associateddiseases were generally lower or were on the same level than in the preceding periods.These facts combined with the general mistrust of Ukrainians in the domestic healthcaresystem made many people believe that the epidemic was virtually created by somepoliticians and businessmen, who wanted to receive, respectively, political and financialdividends from combating the unknown and terrific disease. These thoughts weresupported by some evidence that a number of governmental and healthcare officialsreceived considerable bonuses for purchasing drugs, medical equipment and materials forthe state budget cost. The most scandalous aspect of the epidemic was the purchase ofthe Tamiflu drug, the effectiveness of which against AH1N1 influenza and safety for adultand paediatric patients was not 100% confirmed.On the other hand, the epidemic was quite useful for a number of politicians, whomanaged to raise their image in the eyes of the population on the eve of the presidentialelections campaign.At the same time, the epidemic revealed Ukraine‘s general unpreparedness to face suchmassive healthcare challenges in terms of both material provision of patients andinformation support of its antiepidemic measures. It appeared that in emergency conditionsthe Ukrainian public healthcare system was unable to provide the patients with theminimally required number of hygienic and medical products such as gauze masks, anti- 16
  • inflammatory drugs, etc. These facts undermined the image of and confidence in, theUkrainian healthcare system even more than before. Further, such a critical situation led tothe initiation of a number of tenders by the Ministry of Health to organize a public relationscampaign in order to raise public awareness of prevention and treatment of influenza aswell as of a number of other socially dangerous diseases. 17
  • 4. UKRAINE’S STATE POLICY ON VACCINATIONThe immunoprophylaxis in Ukraine is regulated by the Law of Ukraine ―On SecuringSanitary and Epidemiological Wellness of the Population‖ 14 and ―On the Protection of thePopulation from the Infectious Diseases‖ 15. Article 12 of the latter says the prophylacticimmunization should be performed after medical examination of a person and in case ofmedical contraindications absence. The full-aged legally capable citizens should receivethe vaccine based on their consent after obtaining objective information about thevaccination, consequences of refusing it and possible post-vaccination complications. Thecitizens, who did not reach the age of 15 or are legally disqualified, should receiveprophylactic vaccines after objectively informing their parents or other legalrepresentatives. If a person and, or his / her legal representatives refuse from obligatoryprophylactic vaccination, the doctor has a right to request their written confirmation. Incase of refusal to give such a confirmation, this fact should be certified in the presence ofwitnesses.Based on these legal documents, the vaccination in Ukraine is non-mandatory and isbased on the free will of a person or his / her legal representatives. However, in reality,these legal provisions do not function as they are neutralized by the refusal of the majorityof schools, nurseries, kindergartens, summer camps and high schools / universities toaccept children, who had not passed the obligatory vaccination. Their refusal to accept isbased on the Law ―On Protection of the Population from the Infectious Diseases‖, Article15 of which states that children, who have not received the vaccination according to theVaccination Calendar, are not allowed to visit childcare centres. In its turn, this provision ofthe Law is in contradiction with the Article 53 of the Constitution of Ukraine (which haslegal superiority in this case) stating that the full general secondary educ ation is obligatoryand the State provides for the accessibility of pre-school, full secondary, professional andhigh education at the public and commune institutions. In addition to that, according toArticle 12 of the Law of Ukraine ―On Protection of the Population from the Infectious14 http://zakon1.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=4004-1215 http://zakon1.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=1645-14 18
  • Diseases‖ and to Article 27 of the Law of Ukraine ―On Securing Sanitary andEpidemiologic Wellness of the Population‖, only 6 vaccinations are considered to beobligatory: against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles.All this leads to numerous cases, when adults and parents refusing from vaccination reach―informal‖ agreements with the doctors (doctors indicate the fact of vaccination in relativedocuments, but do not perform it in reality).The major regulation document in the vaccination area is the draft Decree of the Ministryof Health ―On the Order of Prophylactic Vaccination in Ukraine and Control of the Qualityand Turnover of the Immunobiological Drugs‖. This draft should substitute the existing2006 Decree of the same name and introduce some changes into the vaccinationcalendar, procedures and mechanisms. The ―Calendar of the Prophylactic Vaccination‖suggested by the draft foresees: seventeen vaccinations for children from the 1 st day ofbirth till the age of 18 months against 11 infections. The total number of vaccinations,including the repeated vaccination at certain age points, till the age of 17 years old is 26.They are obligatory and are categorized as the ―age dependent vaccinations‖. In total, thecalendar consists of 4 categories: age dependent vaccinations; health condition dependentvaccinations; vaccinations performed on endemic and enzootic territories andrecommended vaccinations.Due to the critiques of the expert community, connected with the imperfect vaccinationcalendar and a number of discrepancies in vaccination procedures, the MoH recalled thedraft decree in late December 2010 for revision and improvement.The above mentioned obviously has all signs of the legal collision which has to be urgentlysolved. On the one hand, no one should be made to receive any medication against his /her own will and the mechanisms of the legal refusal from vaccination should be foreseen.On the other hand, a citizen is not isolated from the society and cannot be the source oflife-threatening infections for the others. This statement is also absolutely crucialconsidering the WHO recommended collective immunity level, which should not be lessthan 85%. 19
  • According to the present legislation, in Ukraine, all obligatory vaccines are provided forfree to all citizens, i.e. they should be purchased for the cost of the State Budget ofUkraine and distributed to the regional / local hospitals based on their needs andvaccination plans. Being an absolutely adequate and modern approach, in Ukraine freevaccination works with serious difficulties, which are created by the imperfect budgetmanagement system, bureaucracy, corruption and insufficient professionalism of doctorsresponsible for vaccination.The most problematic issue here is the public procurement procedure, which in Ukrainianconditions does not guarantee that vaccines of the highest quality are purchased for theState Budget cost. I.e., the citizens wishing to receive a vaccine are dependent on theproduct suggested to them by the healthcare authorities; the alternative way of purchasingthe vaccines for their own cost is not affordable for the majority of the population.The population‘s uncertainty in the quality of vaccines has caused serious discussions,which were supported by the media, and became an important factor for the anti-vaccination mood at the society.Irregular budget transfers, prolonged procurement procedures and permanent budgetcrisis often lead to the situation, when regional healthcare departments feel the lack ofvaccines. The situation became very dangerous in late 2010, when shortage of the mostimportant vaccines in several regions of Ukraine reached 70-75%. This trend developedagainst the record healthcare spending foreseen in the state Budget for 2010 (UAH 300Mln (USD 37,5 Mln) only for vaccination). Several journalists and analytics suggested thatsuch a budget policy was in many cases aimed at increasing the purchases of vaccines inthe pharmacies by those layers of the population, who could afford buying them for theirown cost. No evidence on this was revealed, but the level of populations‘ confidencegreatly decreased. One more factor for this became the fact, that Ukraine, which does notproduce its own vaccines, is often a recipient of the international humanitarian help, thequality of which is in many cases under question. 20
  • Considering the above mentioned, the budget planning on the central level and actualspending schedule in Ukraine have to be radically improved. This issue was stressed uponseveral times by the Minister of Health of Ukraine Ilya Yemets in his numerous interviews.The most scandalous case, which revealed the problems of the Ukrainian vaccinationsystem and became the major trigger of the anti-vaccination moods in the society, was theunscheduled vaccination campaign against measles and rubella in 2008-2009.As a result of the outbreaks of measles in 2005-2006, Ukraine fell under surveillance of theWHO, which had announced its plans to fully eradicate measles by 2010. As a result oflong negotiations, Ukraine agreed to carry out the unscheduled vaccination of children andadults by the combined measles-rubella vaccine, which would be donated by theWHO/UNISEF.The unscheduled vaccination was accepted among the population with a severescepticism as the great part of the citizens had previously received the measles andrubella vaccine according to the governmental schedule. Moreover, protests of parentsagainst the unscheduled vaccination were fuelled by the fact that the Indian vaccineprovided by the WHO had not been previously registered in Ukraine and had not passedall necessary control procedures in terms of effectiveness, safety and adverse effectsrequired by the Ukrainian legislation. Explanations of medical experts, and MoH and WHOofficials, that the vaccine had been checked by the WHO and had been previously used indozens of countries, had a counterproductive effect. Additional argumentation against theunscheduled vaccination brought up by journalists and some doctors included the factsthat the Indian vaccine had up to 25% probability of adverse effects (openly indicated bythe producer) and was made of cultures grown in different climate conditions comparing toUkraine. So the vaccine could be not only non-effective, but even dangerous for theUkrainians, according to journalists and experts. The latter arguments have reached fertilesoil and, considering the general mistrust of the population in the public medicine, resultedin an outbreak of anti-vaccination initiatives all around the country, which interlinkedthemselves through the Internet and other communication means. 21
  • The final and most powerful strike on the image of vaccination in Ukraine and of thedomestic healthcare authorities was done on May 13, 2008, when a 17-year-old school-boy Anton Tyshchenko, from Kramatorsk, Donetsk region, died several hours afterreceiving the combined measles-rubella vaccine. During the following days, about ahundred of serious adverse effects in Kramatorsk and other places in Donetsk region andin Ukraine in general were reported. The vaccination was stopped and severalinvestigation commissions started considering the case. Despite no connection betweenthe vaccination and the death of Anton Tyshchenko was found by medical experts andWHO representatives, the case had a dramatic impact on the population‘s attitude ofvaccination.Starting from May 2008, the number of refusals to take scheduled and unscheduledvaccines increased several times. All attempts to carry out objective discussions on thegovernmental, expert and media levels didn‘t reach their results. The controversial natureof vaccines and distrust of Ukrainians in healthcare officials neutralized all attempts of theGovernment to restore the image of vaccines in the eyes of the Ukrainian population.At the present moment the level of explicit refusals to take vaccines is about 10%. Takinginto account possibilities to hide the refusal, a number of those, who just don‘t visithospitals to receive vaccines and the shortage of vaccines, the level of vaccination inUkraine is critical.In general the Government didn‘t publicly recognize its faults in the unprofessionallyorganized unscheduled vaccination campaign, though several serious criminalinvestigations and dismissals followed. At the same time, the recent decision of theMinistry of Health, announced by the Head of the State Sanitary and EpidemiologicalService of Ukraine Serhiy Ryzhenko, not to carry out any unscheduled and separatevaccinations against measles and rubella and not to use any vaccines, which had not beenpreviously registered in Ukraine, might be an evidence of the on-going ―correction ofmistakes‖. 22
  • 5. PUBLIC PERCEPTION OF VACCINATION AND MEANS OF IMPROVING ITa) Role of media in building public perception of vaccination in UkraineThe vaccination topic has been raised in Ukrainian media back in 2008 when awidespread scare about vaccine side effects in Ukraine led to a sharp drop inimmunizations. Irresponsible media coverage of an anti-vaccination campaign waslaunched after the May 2008 death of a 17-year-old boy in Kramatorsk who had received acombined measles-rubella vaccine. As a result the unscheduled measles-rubellavaccination campaign was interrupted and hundreds of thousands of fearful Ukrainianshave refused to take other vaccines such as those from diphtheria, mumps, poliomyelitis,hepatitis B, tuberculosis, pertussis and others – which led to more than 10 percent dropin vaccination rate. The alarming trend amongst parents not to immunize their childrenbecame mainly the result of the growing pressure of the negative media coverage andcomments from those sceptical of vaccination.It is worth noting that while Ukraine has an educated population, rumours andmisperceptions spread easily. This could be explained by low standards of living anduncertainty in the future, on the one hand, what prevents people from critical analysis ofthe reality, and, on the other hand, by the remaining total trust to media, which wasinherited from the Soviet and even previous times. Constant political turmoil and adevastating financial crisis — one of the worst in Europe — has fuelled mistrust ofUkraines crumbling healthcare system, and authorities in general.In order to understand the reasons beyond such situation we have analyzed Ukrainianmedia landscape and come up with the following.Ukrainian media outlets are numerous and mostly uncensored but do not widely followWestern standards of fairness and accuracy. For example, some print and online reportsalleged after the boys death that the Indian made measles-rubella vaccine would sterilizemen as part of a plot by Ted Turner, whose Washington-based United Nations Foundationcharity paid for the vaccines. 23
  • In most Ukrainian business media there are neither special sections devoted to healthcarenor specific editors covering the topic. Typically, a journalist covering general business willalso write about healthcare and consequently will have very little understanding of industryspecifics. In other cases, healthcare is covered by science or technology editors, who mayunderstand the scientific side of the industry but have little understanding of its economicimpact.In Ukraine there is a large number of trade media covering both general and specifichealthcare topics. Most journalists at these publications have a professional medicaleducation and a deep understanding of the subject matter. They are interested ininterviews with key opinion leaders and scientists, detailed descriptions of new therapies,equipment and approaches to treatment.Journalists covering healthcare topics in consumer media rarely have a medicalbackground and are normally interested in medical topics from a the most basic point ofview – one that is understandable and interesting for the average reader. On a non-commercial basis they would cover general issues (such as HPV vaccinations, or theadvantages of contact lens usage vs. glasses) without ever going into specific drugs orcompanies.Despite such lack of the professional media approach in Ukraine mass media cansubstantially influence health knowledge and the use of health services. In this instance, itis also clear that the media play a significant role in public health.For period 2009-2010 there were around 25 different top-level publications (including TVstories, talk shows featuring state officials and doctors, newsfeeds etc.) related tovaccination with tonality ranging from negative to neutral which showed inconsistency ininformational campaign and actions of the Government.Research shows that most parents get their information from the media and online – andwhen it comes to immunization, much of the information has been negative. 24
  • Summarized ‗vox populi‘ during that period can be outlined as follow:I’ve read many articles on the Internet about dangers of vaccination and that is why Ibelieve if the child has strong immune system, has good nutrition and normal environmentwhich is hard to find in our country, we might be able to say that there is a chance of thechild not contracting disease.In this regard it is worth mentioning Yevhen KOMAROVSKY – a Kharkiv-basedpaediatrician – who was the only doctor in Ukraine trying to prevent flu panic stroked bypolitical malpractice back in November 2009. He has provided a balanced professionalanalysis of the flu epidemic and shared his opinion concerning the hysteria surroundingthe flu, the irresponsible appeals of politicians and the errors of public health officials.As a result of his informational campaign Dr. KOMAROVSKY is now considered to be oneof the well-known and respected celebrity physicians in Ukraine. He is author of manybooks and hosts his own popular TV show ―Dr. KOMAROVSKY‘s School‖. Important is thefact that he supports vaccination and proves his opinion at a very professional level:―As a person who had been working in isolation hospital for many years, I can assure you:vaccination is not excluding the probability of disease. Children suffering from thesediseases and outcomes are, to put it mildly, different. Therefore, for normal, sane andsensible parents, there can be no debate about “vaccinate or not vaccinate”. To vaccinate,definitely!”b) How to improve the situation.According to our analysis the following factors became the key preconditions of the anti-vaccination moods in the Ukrainian society: – General mistrust to and worsening image of the public and even private healthcareamong the Ukrainian population caused by the low performance of the former, widespreadcorruption; 25
  • – Generally poor vaccination practices in Ukraine and inability of the publichealthcare authorities to carry out coordinated information policies around vaccination; – Specifics of vaccination as treatment against infectious diseases; – Exact tragic events in several cities of Ukraine, which raised public fears in securityof vaccination; – Growing negative attitude of the Ukrainians to the pharmaceutical companies, bothdomestic and foreign; – Irresponsible behaviour of journalists, who used the vaccination issue for raisingtheir personal and their editions‘ popularity.Considering the above mentioned we should state, that the problem of vaccination‘s imagein Ukraine is a complex one and should be solved by combined approaches involving allkey stakeholders in this area (public healthcare authorities (central and local), medicalexperts, pharmaceutical industry, journalists, NGOs, and patients / parents‘ associations).There is obviously a need for the open public discussion of the problems of vaccination inUkraine, which should be initiated either by the state or by the expert / doctor community.This discussion should result in a general nation-wide strategy on improving theimmunoprophylaxis in Ukraine and raising the image of vaccination as of the mosteffective means of combating communicable/ infectious diseases.An important element of this strategy should be improvement of statistics in the field ofcommunicable diseases prevalence. Availability and accessibility of the preciseinformation about the epidemiologic situation in Ukraine and its tendencies should becomean important precondition of the population‘s awareness of the risks connected with theimmunization level decrease. In parallel with the improvement of screening andinformation collection, use of the web-based technologies could be an appropriatemechanism of populations informing of the current situation with the communicablediseases and correlation between vaccination and the morbidity level. Further on, thisshould be developed to a full-scale web-portal on epidemiology, communicablediseases and vaccination, which should be managed by a professional team ofcommunication specialists. 26
  • Considering a decisive role of media and journalists in the massive hysteria around theunscheduled vaccination of 2008 and influenza epidemic of 2009, and consequences allthis had over the level of immunization, the questions of journalist ethics in medical issuesbecomes more and more actual. In our opinion, in the media environment of Ukraine,which does not have long-lasting traditions of reasonable self-limitation and understandingof consequences the information distribution might have onto the public health and well -being, it is of a great importance to launch the discussion around the Code of Conduct orthe Ethical Code, which might be signed by all journalists and PR agencies writing onhealthcare and related issues. The Code could include a voluntary obligation to doublecheck all messages on healthcare problems for their possible consequences for the publichealth; to avoid distributing unverified information and opinions of experts with doubtfulbackground; to present different points of view etc. This process could be initiated by someprominent and respected journalists, which should give an example of ethical behavior bythemselves and suggest launching the discussion on this issue, inviting expert / doctorcommunity to this process.These activities could be accompanied by trainings for general and businessjournalists on vaccination problematic. During such trainings medical andcommunications experts from Ukraine and foreign countries could give their expert opinionon vaccination, providing both pros and cons of it, what should make the coverage ofvaccination issues more professional and neutral.At the same time, the analysis of public mood performed by us leads to a conclusion thatthere is an acute need of restoring the image of vaccination in Ukraine, which didn‘timprove greatly since 2008, when it was destroyed by the unscheduled measles-rubellavaccination campaign. Under such circumstances an integrated nation-widecommunication campaign could be the most effective way of improving attitude of theUkrainians to the immunoprophylaxis by the means of vaccination. The campaign shouldhave the following targets: – to increase populations‘ awareness of the infectious diseases and their prevalencein Ukraine (including statistics and tendencies overview); 27
  • – to distribute information about the ways of preventing communicable diseasesamong children and adults and of risks for individuals and society in general resulting fromthe low immunization level; – to popularly describe advantages and risks of vaccination for different age groups; – to inform the citizens of the national vaccination calendars and schedules, etc.Information and propaganda activities within the campaign should be effectively combinedwith educational elements for different categories of population interested or concernedabout vaccination, e.g. seminars and trainings for journalists, parents, doctors, and evenchildren.One of the first remarkable attempts to change the situation was made in June 2010, whena social advertising campaign on the protection of children against infectious diseases waspresented in Kyiv and initiated by UNICEF. Dissemination of the information onvaccination via radio and television as well as distribution of educational materials inhealthcare facilities was a part of this campaign.At the same time such individual actions, despite their non-discussable importance, will notreach their target in the scale it is required in Ukraine. In our opinion, for radical change ofattitudes to vaccination joint efforts of the public authorities, expert / doctor environment,pharmaceutical industry, NGOs, patient associations and international organizations are ofkey importance. Ideal development in this case could be a round table on communicationsaround vaccination bringing together all key stakeholders, in the result of which a commonstrategy development in this area could be initiated. However, it should be remembered,that a massive and sudden campaign might have a counterproductive effect in theUkrainian society, which is suspicious to all initiatives coming from the public authoritiesand pharmaceutical industry. 28
  • 6. CONCLUSIONSOn the basis of the performed research and analysis of the open data we have come to aconclusion, that epidemiological situation in Ukraine should be c onsidered as relativelystable with the major parameters of morbidity and mortality from infectious diseases being,in general, within the norms specified for the European region by the international healthorganisations like WHO. At the same time, periodically the outbreaks of various infectionsare observed in different regions of Ukraine and in the country in general. Moreover, insome cases, the epidemics of different diseases (e.g. tuberculosis and outbreaks ofdiphtheria and measles) could be stated in Ukraine at some time periods. This raisesserious concerns of the effectiveness of the Ukrainian healthcare system andadequateness of the prevention practices.During the last years in Ukraine one can observe an actual destruction of the effectiveimmunoprophylaxis system caused by a number of serious reasons. Among them thefollowing should be named: low professional level of vaccination campaigns against majorcommunicable diseases; critical situation with the supply of drugs for scheduledvaccinations; general mistrust of the population to the public healthcare system etc. Thekey milestone, which triggered massive anti-vaccination campaigns, became the death ofa school-boy from Kramatorsk in May 2008 after non-scheduled measles-rubellavaccination as well as numerous adverse affects in a number of school children in Donetskregion and other parts of Ukraine. Fuelled by the media, the anti-vaccination hysteriaresulted in massive refusal to vaccinate children and adults. As of now we should statethat the image of vaccination in Ukraine is considerably undermined, the direct result ofwhich is the decrease population‘s immunoprotection level to the threshold valuesspecified by the WHO or even their crossing. The above mentioned allows us to assume,that in the medium term Ukraine will fall under threat of massive infections and evenepidemics.The above mentioned requires urgent measures from the state, non-governmental andinternational organizations, medical and expert environment and pharmaceutical business.One of the elements of such an activity should be restoration of the populations trust invaccination and neutralization of the anti-vaccination hysteria of the previous years. Due to 29
  • this the level of population‘s immune-protection should increase and the morbidity shouldbecome lower. The suggested mechanisms of reaching this aim are: – Improved statistics and information exchange between the healthcare authoritiesand population in the field of infectious diseases; – Ethics code for journalists writing on medical issues; – Media trainings for general and business media journalists; – Nation-wide information-educational campaign aimed at increasing trust andimproving awareness of the population of the immunoprotection of children and adults bythe means of vaccination, which has to be supported and conducted jointly by the State,doctors, NGOs and pharmaceutical business. 30
  • 7. SUGGESTED COMMUNICATION RESPONSES 1. Improved statistics and information exchange between the healthcare authorities and population in the field of infectious diseases. 2. Creation of the integrated Web-Portal on Communicable Diseases and Vaccination 3. Development and propagation of the Ethics code for journalists writing on medical issues 4. Media trainings for general and business media journalists on vaccination issues5. Nation-wide information-educational campaign aimed at increasing trust and improving awareness of the population of the immunoprotection of children and adults by the means of vaccination, supported and conducted jointly by the State, doctors, NGOs and pharmaceutical business 31