Immunization rates stagnating in Europe

WHO launches initiative to combat increasing complacency about immunizing children.

A new systematic review has shown the combined measles, mumps and rubella (MMR) vaccine to be safe, after public anxiety triggered a slump in MMR vaccination in Europe – which led to thousands of cases of mumps in the UK, and rising deaths from measles in Ireland. The fears fed increasing complacency about vaccination generally, which the WHO European region hopes to reverse.

(18 Oct 05)

So it’s not only countries like Nigeria that have problems with accepting vaccines. Last year polio vaccine was rejected on a false rumour in Kano state, leading to the reinfection of several African countries, but now WHO not only has to rework its polio elimination programme – the WHO European Region is having to come to the attack in Europe too, this time against fears of MMR vaccine triggered by a now discredited and disowned research paper in 1998, groups who even deny the existence of viruses, underserved minority groups, and falling commitment to vaccination generally.

So what’s the problem? And are there lessons for the rest of the world, or does the world have something to teach Europe?

First we need to be clear about one thing – what WHO means by Europe. The WHO European Region is a vast area embracing many of the world’s health problems – 52 countries stretching East and West from Portugal through Russia to the Bering Straits, and North and South from Iceland to Turkey, taking in the richest of European countries and the poorest of the old Soviet Republics, such as, Azerbaijan, Georgia, Tajikistan, Turkmenistan and Uzbekistan. And within this area WHO has become so concerned about stagnating levels of immunization, and groups opposed to immunization, that this week (17 October 2005) they launched an advocacy and immunization campaign: “European Immunization Week”.

So RealHealthNews Editor Robert Walgate asked, in this vast area are we looking at a developing country problem? Is it the poorest who are least vaccinated?

“Definitely not!” said Louise Gare (Technical Officer for the Vaccine Preventable Diseases and Immunization programme, WHO Euro, Copenhagen). “Here it’s not the poorest countries that are suffering from stagnating or decreasing immunization rates.”

There’s a great deal of complacency, said Gare, “probably due to the fact that richer countries are seeing less disease – because of historically strong immunization programmes”. The general public and even some healthcare professionals “are thinking that immunization isn’t important anymore” she said.

Immunization levels have been falling for measles, mumps and rubella in the UK, Ireland and elsewhere because of the 1998 scare that the combined MMR vaccine was associated with autism – which is itself an increasingly recognized mental problem in children, especially boys.

Scientifically, the original paper has been renounced by the editor of the journal in which it was published, and today (19 October) the independent Cochrane Collaboration, which specializes in systematic reviews of dozens of related studies to draw more definite conclusions than any of them could singly, has decisively announced that there is no credible link between MMR and any long-term disability, including autism and Crohn’s disease.

One of the reviews’ authors, Vittorio Demicheli, told News-Medical.Net yesterday: "Public health decisions need to be based on sound evidence. If this principle had been applied in the case of the MMR dispute, then we would have avoided all the fuss".

However scientific evidence is one thing – communicating it to a doubtful public is another. “Many people have got confused about the efficacy of vaccines” Gare told RealHealthNews, “and have maybe looked for other ways to protect their children, and have decided with other family members or peer groups that maybe vaccination isn’t as important as it used to be.”

But “many parents aren’t aware, for example, that measles can actually kill a child,” said Gare.

Even medical professionals have been wavering on immunization in some areas. Six countries are fully involved in coordination with WHO Euro’s Immunization Week – Belarus, Ireland, the South Tyrol region of Italy, Serbia and Montenegro, Tajikistan and the former Yugoslav Republic of Macedonia – and most have developed strategies both for the public and professionals.

“For example, the Irish Immunization Week team has decided to target both groups” said Gare, “as they believe the health professionals are less appreciative of the value and importance of immunization [than they should be]. And they think there could be more public awareness of the benefits, and higher-level political commitment. In fact that could be said for many of the countries in the Region.”

But conditions and problems vary throughout the region. In Belarus, a large cohort of the population has proved to be unimmunized against rubella. “So they’ll be running a supplementary rubella campaign, actually vaccinating from 11-19 years old.” As unprotected women reach child-bearing age, the risk of them contracting rubella and bearing a child with deformities or mental disability becomes relatively high. “The morbidity of congenital rubella syndrome is probably vastly underestimated – as surveillance systems are also underdeveloped” said Gare.

In Ireland, due to the decrease in MMR coverage, they have observed in the last couple of years outbreaks – and some deaths. So the immunization week team decided it really was time to act, and they launched their initiative through a media campaign yesterday announcing, a new national information website for parents and health-care professionals. There’s already been a good response in the media.

The South Tyrol region of North Italy [near the border with Austria] suffers from a “particularly vocal” anti-vaccination group. Members of the public and health-care professionals are involved – “and they’ve had an extremely detrimental effect on the MMR uptake,” Gare said. “MMR rates have been lower than 35% in the late 1990s and are now around 50-60%. They also have a much higher incidence of measles than the rest of the country.” A local research project discovered the direct costs associated with hospitalization of measles, mumps and rubella cases from 1996-2001 exceeded Euro 850 000.

The opponents are concerned about that supposed link to autism, “but the ‘Impfgegner’ as they are known are fanatically opposed to vaccination, denying any scientific foundation for vaccination and even denying the existence of viruses!” said Gare. “It’s actually quite an extreme and specific problem that they have in South Tyrol.”

The Immunization Week team there “is extremely hard-working – taking time out to have workshops, particularly in rural areas, and using their evenings to explain about the dangers of measles, and how badly their region fares in terms of measles incidence, compared to other regions. So on top of that they are using a lot of additional information campaigns, and regional radio and television,” said Gare.

In Serbia “they have a large, mostly urban, Roma (‘gypsy’) minority, living in very poor conditions, so the Immunization Week team are working particularly on outreach, with a series of educational workshops, and they’ve printed the ‘Irish guide for parents’ which has been translated into Serbian and the local Roma language, and will be widely distributed around the country.

“Also, there’s a lot of mistrust of the health-care profession amongst the Roma, which means that children born in these communities often go unregistered and migration is high; and Roma communities are often unaware of their rights to health care.”

In Tajikistan [part of the old USSR, bordering Afghanistan and Pakistan], Immunization Week teams “are organizing a very large series of workshops and media activities, to make sure again that all stakeholders are aware of the importance of immunization. But they’ve been very well involved in measles elimination activities, so it’s more to do with education of the population and sensitizing them to the importance of immunization, particularly in remote rural areas.”

Access is an issue in many of the poorer countries in WHO’s ‘ Europe’, but also “a lot is to do with political commitment and public awareness. These countries are insufficiently funded, they can’t afford their own vaccines, and so they need voluntary donations from international organizations and bilateral agencies or partnerships such as the Global Alliance for Vaccines and Immunization [GAVI],” said Gare.

In Macedonia [part of the old Yugoslavia, bordering Greece], immunization is compulsory and uptake high, “but they also need outreach work among their rural, remote Roma communities, who “fall outside the system,” Gare said.

But to what extent can the lessons in one country be transferred to another, as WHO has done between Ireland and Serbia’s Roma peoples? Are there lessons that other developing countries can learn from what’s going on in Europe?

“I think we’ve learned that it’s extremely important that each country, within its national immunization plan, includes education, advocacy and communication activities on a regular basis, so people are kept up-to-date with what they should be doing – critical information about the diseases and how they might affect their children.”

Moreover, some of the communications materials and techniques that WHO Euro is using can be modified and applied elsewhere. “That’s our hope,” said Gare. We’ve ensured that all the countries in our campaign receive all the materials that we’ve developed, and some of them have been translated into local languages.”

“We’ve also ensured that all the countries went through the same processes, starting with similar pieces of research to identify the barriers to immunization, or to increasing immunization, and then developing very very targeted approaches to deal with those barriers,” Gare said.

But what about the other direction – learning from other regions? Has WHO Euro looked at the kind of communications that have been undertaken by WHO Afro, EMRO, SEARO, WPRO, and PAHO?

“Yes indeed” said Gare. “We keep a very close eye on the Americas of course because a lot of their activities are community-based, and they’ve developed a lot of advocacy guidelines, for example; and they’ve learned themselves, through many years of vaccination week activities, about the best ways of approaching the problems.”

“But there’s only a certain amount of similarities you can find between nations and the messages have to be targeted in very different and specific ways.

“I would even say that more research is needed to understand the influences and distinguish between people’s attitudes and their actual behaviour, which can differ dramatically.”

But what about the message itself, which, as Gare said, had been confusing the public and professionals over past years with the conflicting scientific arguments over MMR? How do we define the agreed facts in immunization, and its health benefits, in the face of dissidence even within the profession and among scientists, and in the face of a media which naturally loves controversy and doesn’t necessarily think of science as an objective discipline. How do we do it?

“That’s a very good question,” said Gare. “I think when you can get to the root of some of the attitudinal issues, I think then and only then can you target your communication messages in the best way.”

“But I think we have to be systematic in ensuring that the correct information is out there, from organizations that have credibility, and the communications must be backed up with information in a form that people can understand, like real figures, real evidence… including cost benefit studies…”

“…We, public health professionals, basically need to get better at communication,” Gare said. “And in such a way that people can understand, rather than producing a lot of scientific papers with unclear conclusions. I think that’s all we can do to be honest, and then it will be up to people to make their own decisions!"

Yet every adverse event after vaccination creates a negative story, and yet every medication will create some such effects in a few people… “Yes, but again” said Gare, “adverse events must be taken in context – millions of vaccines are given every year and the benefits far outweigh the rare adverse events that may occur.”

Nevertheless, Gare stressed, “Every country must have a recognized plan to respond to those kinds of situations, and they must be responded to. The facts must be stated as they occurred, not leaving any doubt in anyone’s mind as to cause and effect.”

Ultimately, of course, whether to vaccinate is a very personal decision for a parent. You have a child, you know you are going to expose them to a little risk, even though it’s very small, by taking the vaccine, you know that the child faces a different risk of getting the disease and being harmed or even dying if they don’t vaccinate, and there’s also a social responsibility to vaccinate to help stop the spread of outbreaks. It’s a very complicated decision for an individual to make rationally.

“It is, it’s extremely complex and emotive, particularly when one has heard through the grapevine or from family members of someone’s child who inexplicably became ill after vaccination,” said Gare. “It’s very easy to blame a vaccine in situations like that; especially when there are underlying stories circulating in the media generating fear and mistrust.”

“The bottom line is that a national immunization programme or organizations like WHO should be very clear about the risks of the vaccine, and of the disease,” Gare insisted. “And we must demonstrate clearly that as the vaccination rates decrease, the risks of these nearly forgotten childhood diseases re-emerging will increase.”

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