Presentation by Dr Angel Kunchev, Bulgarian Ministry of Health, on implementation in Bulgaria of the WHO Guide to Tailoring Immunization Programmes (TIP), at WHO/Europe Immunization Programme Managers Meeting, Antalya, Turkey, March 2014

1. WHO Guide “Tailoring Immunization
Programmes”:
introduction in Bulgaria and first results
WHO European Regional Meeting of National Immunization Programme Managers
Antalya, Turkey, 18 – 20 March 2014
Angel Kunchev, MD,
Chief State Health Inspector,
Ministry of Health of Bulgaria
Radosveta Filipova, MD,
Head, State Health Department,
Ministry of Health of Bulgaria

2. • Southeastern Europe – Balkan peninsula
• Territory 110 993 km2 ;
• 28 administrative regions, 263 municipalities
• Total population 7 563 710
• Urban areas population 70,17 %
• Ethnic structure:
• Bulgarians 84 %
• Turks 9,4 %
• Roma 4,7 %
• Other minorities (Armenians, Vlachs,
Jews etc.) 1,9 %
• Live births 80 956
• Birth rate 10.7/ 1000
• Infant mortality rate 9,0 / 1000 life births
• Natural growth - 3,5 / 1000
• Life expectancy 73,4 yr.
Source: National Center of Health Informatics,
Basic Statistic Information for 2011

3. What a TIP Approach means?
A pathway to understand what influences caregivers when
they consider whether or not to vaccinate their child and to detect
determinants providing opportunity, ability and motivation to
vaccinate or not.
Why especially Bulgaria was chosen?
The measles outbreak in Bulgaria 2009 – 2011
predominantly affected vulnerable groups of population and
pockets of non-immunized or partially immunized individuals at
subnational levels despite the national coverage for the first dose
of MMR vaccine was near 96%.

4. MEASLES CASES IN BULGARIA AFTER THE INTRODUCTION OF
MEASLES IMMUNIZATION, 1969
Source: National Centre of Infectious and Parasitic Diseases,
Bulgaria, 2013

5. NATIONAL IMMUNIZATION COVERAGE WITH MMR VACCINE IN
BULGARIA, 2001-2012
Year
VACCINE COVERAGE (%)
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
MMR at
13 mos
90.1 92.1 95.5 94.7 96.2 95.7 96.0 95.9 96.1 96.5 94.5 93.7
MMR at
12 yrs
68.8 79.2 89.4 90.8 92.4 93.3 94.0 94.3 92.8 95.7 93.9 94.0
Source: National Centre of Infectious and Parasitic Diseases, Bulgaria, 2012

6. MEASLES OUTBREAK IN BULGARIA, 2009-2011
∞ Marinova L., Epidemiology of measles in Bulgaria during the elimination and prospects for effective surveillance. PhD thesis, Sept. 2012.
Total number
Number of Roma people
%
Measles cases 24 208 21 701 89.6
Deaths 24 22 91.7

7. VACCINATION STATUS OF MEASLES CASES IN BULGARIA, 2009-
2011
Number of
vaccine doses
Number of cases by age groups
Total
≤ 1 1-4 5-9 10-14 15-19 20-29 30+
0 3 301 1 368 266 145 120 42 20 5 262
1 18 2 085 2 174 1 259 541 69 20 6 166
2 3 107 188 329 518 80 13 1 238
No data 569 2 299 1 938 1 880 1 988 1 719 1 306 11 699
Total 3 891 5 859 4 566 3 613 3 167 1 910 1 359 24 365

8. LESSONS LEARNED
• The approach to a better measles control in Bulgaria should be focused
on the improvement of the routine immunization activities of
underserved Roma communities through better communication and
awareness of the community and permanent collaboration with the
Network of the Health Mediators and other NGOs.
• Because the level of vaccination coverage is very much depending on
the knowledge of the health care workers, different strategies and
trainings targeting health professionals should be implemented.

9. Health mediator – what does mean?
 National network of Health mediators was established in 2007 in the frame
of a PHARE project and transferred after finishing the Project in a
municipality employees financed by the state budget.
 General requirements for Job position
Education: Secondary school
Qualification: Completed specialized training course for a health
mediator, approved by the Ministry of Health or Diploma (Certificate) from a
Medical College
Languages: Knowledge of Romany/Turkish language is commendable
Additional requirements: Knowledge about the health and social
legislation and relevant national policies
Job description: Mediates the process of ensuring access to health
services of representatives of vulnerable minority groups

10. Major responsibilities
 Work with clients: · Good knowledge and formulation of the problem;· Assessment of
the difficulties connected with the access to the respective services and elaboration of a
work plan on the case.
 Facilitation of the process of access to services in the sphere of health care for
people, needing medical assistance:· Helps (accompanies, informs, clarifies, explains)
with the contacts between the GP and/or other medical experts and the patient.
 Assistance in the communications with the Health Insurance Fund:· The health
mediator provides information on the necessity and significance of the services, provided
by the National Health Insurance Fund and helps with the filling in of the necessary
documentation.
 Assistance with the communications with the Department for Social Assistance, the
State Agency for Child Protection and the Commission for Protection against
Discrimination:· The Mediator provides information about the functioning of these
institutions and facilitates the clients’ access to them.
 Health education and prevention care for the population:· Consults the target group
on issues related to family planning and reproductive health;· Explains the benefits of
vaccinations and immunizations.

11. TIP Problem Statement - Bulgaria
• Health problem
• Potential
primary
audience
• Under-vaccination for childhood
diseases among vulnerable pockets
of the Bulgarian population,
evidenced by the 2009-2010measles
epidemic
• Health mediators who act as
gatekeepers for vaccination
communication, education, reminder
and access to health and social
services
• Caregivers/parents of children up to
3 years

12. Strategic activities 1
• Identify and share best
practices in health mediation
in the context of child
vaccination promotion
• Revise the job description
for health mediators and
include more attention to
maternal and child
health/immunization
• Use HM Internet platform to identify
best practices
www.zdravenmediator.net
• Organize regional/national
workshops to share best practices
• Identifying unregistered to local GP
children
• Provide them information on health
services available including
vaccinations and help them to take
decision
• Reminding parents for the time of
coming vaccinations

13. Strategic activities 2
• Increase competences of
health mediators in maternal
and child health and
Immunization
• Provide continuing
education to existing health
mediators
• Provide more hours in the current
curriculum of health mediators in
the field of MCH, CD protection
and immunizations
• Involve local GPs in the health
mediator training programme
• Upgrade the training with best
practices in interpersonal
communication and vaccination
promotion

14. Strategic activities 3
• Promote municipal level
relationships and
collaboration between
health mediators, social
workers, Regional Health
Inspectorates and GP’s
• Develop and disseminate
job aids for use by health
mediators
• Organize regional workshops to
improve inter-institutional
relationships and coordination –
Collect and disseminate best practices
at the municipal level
• Develop and disseminate reminder
posters, recall aids
• Develop a standard flip-chart (incl.
vaccination calendar, information on
VPD and benefits and value of
vaccination ) to guide “health-talks”
in the community
• Design standard module/plan for
holding a community “health-talk”

15. “LETS TALK ABOUT PROTECTION” PROJECT
This collaborative project aims to:
 perform cultural adaptation of the European materials on immunizations;
 facilitate the communication between healthcare providers (HCPs), Health
mediators (HMs) and parents on the topic of vaccination;
 explain in simple language, graphics and pictures the benefits and risks from
immunization;
 give answers to the most popular concerns that parents have towards
vaccination.

18. RESULTS AND WHAT COMES NEXT?
 Increasing the number of Health Mediators of national level –
130 for 2013 in 71 municipalities, 150 for 2014 in 79
municipalities
 Organize a national meeting in April 2014 with participation
of Health Mediators, epidemiologists and GP’s during the
EIW 2014
 Develop and disseminate print materials on different languages
for Roma and refugees

19. Illegal migrants identified on the
Bulgarian-Turkish green, 2012 and 2013
4000 2012
3500
3000
2500
2000
1500
1000
500
0
2013

20. Syrian children ready for immunization in
the refugee camp in Harmanly