Immunization in the context of adolescent health Sao Paulo, Brazil, 24-25 July 2018 Advocacy, promotion and communication across the spectrum of adolescence Vaccine hesitancy and acceptance Katrine Bach Habersaat, Technical Officer Vaccine-preventable Diseases and Immunization programme WHO Regional Office for Europe
WHO Region of Europe 53 Member States 15 time zones (capital cities -2 to +5 hr from Copenhagen) Population 900 Million Infants 11 Million < 5yr 55 Million <15yr 157 Million 2
Trends of Immunization Coverage of Major Antigens in European Region, 1980-2016* *Data source: WHO/UNICEF Estimates (WUENIC) 3
Outbreaks occurring in several susceptible populations
Measles Verification Status, 2012 2017 19 23 21 24 33 3 14 13 12 14 2 9 18 14 4 4 3 2 2 9 4 2 7 9 37 4 1 10 Eliminated Interrupted - 24m Interrupted - 12m Endemic Inconclusive No Report 2012 2013 2014 2015 2016 2017 Pending RVC Clarifications: one country
Number of measles in the WHO European Region, 2007-2018* 2016: 5273 cases in 34 countries 2017: 22 360 cases in 43 countries 2018*: 18 329 cases in 36 countries Bulgaria 24 410 France 19 997 Ukraine 14 079 Georgia 11 060 Kyrgyzstan 18 097 Romania 6201 Italy 5910 Ukraine 13529 * Preliminary data for Jan-Mar 2018 Data source: CISID, extracted 8 May 2018 6
Age distribution and vaccination status of measles, WHO European Region, 2017 (n=22,351) Number of reported measles cases 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 Unknown status Vaccinated 2 doses Vaccinated 1 dose Unvaccinated 0 <1 1-4 5-9 10-14 15-19 20 Age group (years) Data source: CISID, extracted 16 April 2018 7
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Vaccine hesitancy Complex Context-specific Varies across time, place and vaccines SAGE Working Group on Vaccine hesitancy Report 2014
Tailoring Immunization Programmes (TIP) A structured process informed by behavioural science and theory undertaken to understand enablers and barriers with a view to defining evidence-informed interventions to increase vaccination coverage
TIP projects Fed. Bosnia and Herzegovina TIP initiated 2017 Target: health workers and parents (childhood vacc.) Armenia TIP initiated 2017 Target: medical experts (childhood vacc.) Montenegro TIP initiated 2014 Target: health workers (influenza) Bulgaria TIP initiated 2012 Target: vulnerable and Roma populations (childhood vacc.) United Kingdom TIP initiated 2014 Target: orthodox Jewish Charedi community (measles) Sweden TIP initiated 2013 Targets: Somali community + Undocumented migrants + Anthroposophic community (childhood vacc.) Lithuania TIP initiated 2014 Target: pregnant women (influenza) Country self-initiated projects inspired by the TIP approach Germany (measles) Finland (childhood immunization) Ireland (influenza) Italy (measles) Serbia TIP initiated 2017 Target: health workers (action research project) Romania Initiated 2017 (TIP-inspired) Target: parents and health workers (measles) Out of Region Australia TIP initiated 2016 Target: vulnerable communities in Maitland, NSW (childhood vaccination) Mauritania TIP initiated 2018 Target: parents and health workers (to be defined)
Case ex : United Kingdom Charedi community 12 Photo credits: Jewish News Online and Jewish Home La
Why are Sarah s children not Not enough time to discuss her concerns with doctor Does not believe measles is a serious disease immunized? Is not aware of the schedule Wanted to do it, but never got round to it Does not trust her non- Charedi doctor Believes vaccination may cause autism Info materials culturally inappropriate Opening hours not convenient Waiting time too long The waiting rooms not child friendly Community resistance against vaccination Does not trust national health authorities Religious concerns
Why are Sarah s children not Not enough time to discuss her concerns with doctor Does not believe measles is a serious disease immunized? Is not aware of the schedule Wanted to do it, but never got round to it Does not trust her non- Charedi doctor Believes vaccination may cause autism Info materials culturally inappropriate Opening hours not convenient Waiting time too long The waiting rooms not child friendly Community resistance against vaccination Does not trust national health authorities Religious concerns
Why are Sarah s children not Not enough time to discuss her concerns with doctor Does not believe measles is a serious disease immunized? Is not aware of the schedule Wanted to do it, but never got round to it Does not trust her non- Charedi doctor Believes vaccination may cause autism Info materials culturally inappropriate Opening hours not convenient Waiting time too long The waiting rooms not child friendly Community resistance against vaccination Does not trust national health authorities Religious concerns
What did we learn? Assumptions challenged Asssumptions confirmed Behavioural determinants are complex and context-specific Evidenceinformed interventions to increase coverage
What else? Better data Decision-maker attention, commitment and investment Strengthened intersectoral collaboration Critical for sustainable increase in coverage Strengthened community relations 17
In conclusion... Vaccination continues to be a great success Hesitancy is complex and highly context-specific Knowledge does not predict behaviour Beneficiaries are not always the problem - consider system weaknesses Behavioural insights allow cost-effective interventions
THANK YOU Email: Habersaatk@who.int For further information: https://www.euro.who.int/vaccine Twitter: @WHO_Europe_VPI Facebook: https://www.facebook.com/whoeurope 19
Extra 20
Limited data Limited evidence Limited capacity Limited political prioritization 21
The complexity Service delivery convenience, appeal, appropriateness Health worker education, knowledge, attitudes or ability False contraindications Poverty, health systems access Low health literacy Social and cultural norms and beliefs, social copying Inefficient monitoring of under-vaccinated Inefficient call and reminder systems Trust issues: programme response to vaccine safety events Trust issues: lack of due care in creating resilience, maintain trust Anti-vaxxers Hesitant parents of the past
Insights Assumption of a cultural/religious anti-vaccination sentiment was disproved: Reasons for vaccination refusals/delays broadly similar to the wider population Critical issue was immunization services: Lack of child-friendly waiting space; inconvenient opening hours, booking process and transportation Inadequate call/recall systems Poor monitoring of delayed/refused vaccination Inadequate funding for clinical practices, due to high number of children in the community with no additional funding Poor information access making easily available information on vaccination schedule more important 23
Interventions Increased tariffs for vaccination to cover additional cost Charedi nurse re-hired, offering vaccination through outreach and home visits Improved flexibility: booking, drop-in and vaccination in community venues Monitoring of vaccination delays/refusals improved Call/recall systems improved, more proactive reminding Information materials updated and reprinted. Leading rabbi actively advocating for immunization 24