Lessons Learned from SIAs: Magnification of the Opportunities and Risks to Routine Immunization Programmes

Presented at the February 2009 4th Annual Global Immunization Meeting (New York, United States), this 28-slide PowerPoint presentation shares lessons learned from measles and rubella (hereafter, "MR") supplemental immunisation activities (SIAs) in the World Health Organization (WHO) European Region in 2008. Author Rebecca Martin demonstrates that opportunities and risks to routine immunisation programmes, including the introduction of new vaccines, are magnified during SIAs. She examines the strategies developed in the aftermath of some negative publicity that threatened to sideline the SIAs that were planned in both Ukraine and the Republic of Georgia in the context of work to strengthen health systems. The thrust of her presentation is that monitoring safety during SIAs is crucial due to factors such as increased potential for programme errors and perception of increased rate of adverse events following immunisation (AEFI).

To reinforce this point, Martin begins by exploring the initiative as implemented in Ukraine, which had the largest pool of measles and rubella (MR) viruses in circulation in the region from 2005-2007. MR SIA was to start May 26 2008, with the goal of vaccinating 7.5 million people aged 16-29 years. Prior to this effort, having established high-level political commitment and created demand for health services, government-supported efforts were implemented to deliver safe, effective vaccines. The healthcare workforce participated in capacity-building exercises, and was trained in programmatic issues and vaccinology. Organisers observed that there were known anti-vaccination groups active in Ukraine who were communicating - using CD-ROMs and booklets - that "MR vaccine is an attack on the genetic fund of Ukraine". The Ministry of Health (MOH) participated in a discussion with anti-vaccination groups in November 2007; negative press was generated. Communication activities implemented prior to the SIAs in an effort to address these factions included: focus groups conducted among students and healthcare professionals, a list of frequently asked questions (FAQs) developed to address concerns of healthcare professionals and students, and trainings held for journalists, educators, and healthcare professionals. Also planned were radio programmes featuring "ask the experts" segments and a press conference with partners giving positive messages.

However, on May 13, a 17-year-old died within 15 hours of receiving the MR vaccine in advance of the SIA. This was followed by an incomplete case investigation, "prophylactic" hospitalisation of 156 children from the same school, and a media outburst. On May 16, the state prosecutor took the case, and multiple commissions weighed in. From May 6-16, when the campaign was suspended, 116,000 people were immunised. As a consequence, there was an increase in negative coverage and misinformation from the media about not only immunisation but also about the MOH, Serum Institute of India (SII), WHO, and United Nations Children's Fund (UNICEF). Media reports featured images intended to provoke fear of the "deadly vaccine". As SIAs, death, and the vaccine become prominent public issues, mistrust was generated. This was exacerbated by the detention and questioning of the First Deputy Minister of Health and Chief Sanitary Physician. An order was put forth to quarantine the vaccine.

During this time, there was widespread confusion within the medical community exacerbated by a lack of information and general mistrust. Several high-level persons in academia were anti-vaccine, with the pro-vaccination voice barely heard. Pseudo-experts threatened to sue the MOH, WHO, and UNICEF. Meanwhile, the MOH made limited attempts to convey that the vaccine was safe. There was suspension/firing of staff, including the First Deputy Minister, the head of communicable diseases, and the heads of the two institutions involved in vaccine importation. In general, there was a lack of communication with the public, and mixed messages were common. SIA partners participated at this point by calling on international technical experts to give advice on death/hospitalised cases and vaccine storage. They created pro-immunisation media messages and conducted high-level meetings.

As Martin explains, there was a subsequent backlash against routine immunisation as well, which was fueled by the temporary gains made by the anti-vaccination movement. In essence, the public belief in vaccination as an effective public heath intervention was lost. Also, there was a negative shift in risk perception affecting health-seeking behaviours.

To rebuild trust in immunisation in Ukraine, organisers conducted knowledge, attitude, behaviour, and practices (KAPB) surveys. They maintained a high level of political advocacy, developing and implementing long-term strategy to restore public trust in immunisation. They worked to provide competent and independent sources to the media, the public, and different government bodies. They reinforced technical and communication capacity, and built a pro-vaccine coalition.

In the Republic of Georgia, an MR SIA was conducted October 20 - December 12 2008 in an effort to reach 980,136 persons aged 6-29 years. The majority of AEFIs reported were in adolescents, predominantly in females. The most frequent clinical manifestations: fainting and other symptoms related to emotional reaction (psychogenic) after vaccination.

This plan was foiled - again in large part due to negative publicity. On October 22, a news broadcast reported that "The Indian medicine used for the injections of measles and rubella is not registered in Georgia...Twelve teenagers were taken to the resuscitation department of the first clinical hospital due to extreme worsening of their health conditions in sequence of the injections." Then, an October 28 2008 news story claimed the following: "fatal experiments with measles-rubella vaccine carried out on Georgian children". Another portion of the story read: "Note that 'Big Scale' is the name of the experiment initially determined for the Ukrainian population. As the experiment failed in Ukraine, it was introduced in Georgia."

The MOH responded with intense monitoring and analysis of AEFI, and by frequently submitting positive press releases. The National Committee of Experts on AEFI reviewed reports, delivering feedback to the sub-national level. The SIA was extended through December 12 2008, and 50.3% of national coverage was achieved.

Lessons Learned:

• Political commitment and trust are key.
• Conduct a situational analysis: carry out a KAPB of healthcare professionals and the general population; assess the nature of the anti-vaccine movement.
• AEFI surveillance must be operational and risk management strategy developed prior to SIA or introduction of new vaccine.
• Develop a preventive communication plan.
• Educate and work with the media.
• Document and share experiences among countries and regions.

Editor's note: Please contact Rebecca Martin at RMA@euro.who.int to inquire about obtaining a copy of this presentation.