- Email: [email protected]
Commentary to: Guide to tailoring immunization programmes in the WHO European Region
G Model
ARTICLE IN PRESS
JVAC-16364; No. of Pages 2
Vaccine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Commentary
Commentary to: Guide to tailoring immunization programmes in the WHO European Region Pierre Van Damme a,∗ , Ann Lindstrand b , Asli Kulane c , Angel Kunchev d a
Vaccine & Infectious Disease Institute, University of Antwerp, Belgium Department of Vaccine and Registries, The Public Health Agency of Sweden, Sweden Department of Public Health Sciences, Karolinska Institute, Sweden d Chief State Health Inspector, Ministry of Health, Sofia, Bulgaria b c
a r t i c l e
i n f o
Article history: Received 5 October 2014 Received in revised form 9 April 2015 Accepted 10 April 2015 Available online xxx
Vaccination is one of the most cost-effective health interventions available, saving millions of people from illness, disability and death each year. Effective and safe vaccines, which protect against more than 20 serious diseases, are available and many promising new vaccines are being developed. Vaccine-preventable diseases (VPDs) continue to pose an ongoing threat to health worldwide. Addressing access and coverage issues for immunization programmes is important for the currently available, as well as, future vaccines. Alongside large-scale outbreaks of measles in some countries, while a few others reported outbreaks of rubella, resurgences of pertussis and the occurrence of poliomyelitis represent a serious threat to population health. For 2013, there were 31,520 measles cases reported in 38 countries of the WHO European Region [1]. Seven measles-related deaths were reported from five countries. For the same year, 39,367 rubella cases were reported in 21 countries of the Region. However, the latter were reported almost exclusively by Poland (n = 38,585; 98%) [1]. Outbreaks of measles continue to be reported in health care settings involving patients and health care workers alike [2]. High vaccination coverage rates are crucial to halting the spread of VPDs, yet current coverage rates in many areas of the Region are sub-optimal and challenges to ensure herd immunity and protect individuals against VPDs persist. In addition, coverage rates reached during the first few years of implementing immunization programmes were suboptimal. This has resulted in immunity gaps in
∗ Corresponding author. Tel.: +32 32652538; fax: +32 32652604 E-mail addresses: [email protected] (P. Van Damme), [email protected] (A. Lindstrand), [email protected] (A. Kulane), [email protected] (A. Kunchev).
the current generation of European adolescents and young adults. Renewed attention, innovative tools and tailored catch-up vaccination are therefore required to overcome the many challenges of maintaining strong immunization programmes. The Guide to Tailoring Immunization Programmes (TIP) was developed to assist national immunization programmes by providing proven methods to design targeted strategies that increase uptake of infant and childhood vaccinations [3]. Moreover, TIP provides tools to identify susceptible populations, determine barriers to vaccination and implement evidence-based interventions. The approach draws on health programme planning models, including social marketing and social and behaviour change communications [3]. TIP is intended for use by healthcare professionals, public health authorities and decision-makers and may be particularly valuable when pockets of low vaccination coverage or increased susceptibility to VPDs are identified. After successful pilot-testing in Bulgaria in 2012, TIP was launched in April 2013 and is to be rolled out in several countries across the Region. In Bulgaria, TIP was applied to profile and target Roma populations and health care providers working within these underserved communities. As an outcome of the project, the Bulgarian Ministry of Health (MOH) plans to: introduce new tools to strengthen the quality of the dialogue between general practitioners and families regarding immunization; improve curricula and training of the Roma health mediators so that their role in promoting immunization is optimized; revise school-entry policy and introduce lessons on vaccines and infectious diseases (e.g. in Biology courses) in schools. At the current time, the MOH is considering the use of the TIP to boost immunization coverage of over 8000 refugees and asylum seekers from the Middle East now residing in Bulgaria [4].
http://dx.doi.org/10.1016/j.vaccine.2015.04.032 0264-410X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Van Damme P, et al. Commentary to: Guide to tailoring immunization programmes in the WHO European Region. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.04.032
G Model JVAC-16364; No. of Pages 2 2
ARTICLE IN PRESS P. Van Damme et al. / Vaccine xxx (2015) xxx–xxx
Sweden is using TIP to improve vaccination coverage among an ethnic minority group, Somali immigrants and an anthroposophic community. Through application of the TIP methodology and with the assistance of the WHO European Regional Office, in-depth interviews with parents who refuse vaccination, postpone vaccination and accept timely vaccination, as well as with key informants were conducted in Sweden. The application of TIP in shaping the National Measles and Rubella Elimination Strategy and the national communication strategy for reaching the marginalized and underserved in Sweden is currently being assessed by the national health authorities. TIP research analysis is providing new insight to these populations in Sweden and emphasizing the importance of a respectful dialogue between healthcare providers and members of the anthroposophic community. For the Somali, there is a clear need to begin vaccine promotion via interpersonal communication and networking, through the recruitment and support of “vaccine champions”. There is also still a strong argument for the need to communicate around the risks and benefits of the combined measles–mumps–rubella (MMR) vaccine to refute the persistent rumour of a link between MMR and autism. For a third group at risk of sub-optimal vaccine coverage, undocumented migrants, TIP helped identify structural (administrative and financial) barriers within the health care system, which are beyond the healthcare decision-makers’ or providers’ abilities to address. This third subproject in Sweden clearly illustrates how the TIP approach can also be applied in complex communities with fluid legal identities. In the UK, Public Health England (PHE) and the National Health Service recently launched a TIP project to focus on addressing sub-optimal immunization coverage among Jewish orthodox communities in the Hackney Borough of London. In Kazakhstan TIP protocols and formative research tools are being applied to gauge vaccination behavioural barriers and motivators within higher socio-economic, urban, well educated populations in the major cities, where health authorities have registered a growing vaccine hesitancy affecting immunization coverage. Turkmenistan recently completed a household survey investigating vaccination
behaviours, based on the TIP checklist of research items and questions. Results from the study are to be published soon. Germany will be applying TIP to address vaccine uptake within anthroposophic communities at the beginning of 2015. All actors, in Member states, who are involved in immunization should consider adapting TIP according to the vaccination needs of their population in order to maintain equitable and high vaccination coverage across all sections of the population and to meet European Vaccine Action Plan goals, including the elimination of measles and rubella in the European Region and maintenance of the Region’s polio-free status [5]. The framework laid out in TIP can also be used to address other health issues among certain sections of the population that are not benefiting from public health interventions. Thus the guide would contribute to reduce health inequalities in line with Health 2020 targets [6]. References [1] Muscat M, Shefer A, Ben Mamou M, Spataru R, Jankovic D, Deshevoi S, et al. The state of measles and rubella in the WHO European Region, 2013. Clin Microbiol Infect 2014;20(May (suppl. 5)):12–8, http://dx.doi.org/10.1111/1469-0691.12584. [2] World Health Organization. WHO EpiBrief 2; 2014. p. 1–9. http://www.euro. who.int/ data/assets/pdf file/0020/254234/EpiBrief 2 2014-rev3-with-data. pdf?ua=1 (accessed 05.10.14). [3] World Health Organization Regional Office for Europe. The Guide to Tailoring Immunization Programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2014. http://www.euro.who.int/en/health-topics/disease-prevention/vaccinesand-immunization/publications/2013/guide-to-tailoring-immunizationprogrammes (accessed 05.10.14). [4] United Nations High Commissioner for Refugees. UNHCR regional operations profile – Northern, Western. Central and Southern Europe; 2014. http://www. (accessed unhcr.org/cgi-bin/texis/vtx/page?page=49e48db16&submit=GO# 22.09.14). [5] World Health Organization Regional Office for Europe. The European Vaccine Action Plan 2015–2020. Copenhagen, WHO Regional Office for Europe; 2014. http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-andimmunization/publications/2014/european-vaccine-action-plan-20152020 (accessed 05.10.14). [6] World Health Organization Regional Office for Europe. Health 2020: the European policy for health and well-being; 2014. http://www.euro.who.int/ health2020 (accessed 05.10.14).
Please cite this article in press as: Van Damme P, et al. Commentary to: Guide to tailoring immunization programmes in the WHO European Region. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.04.032
ARTICLE IN PRESS
JVAC-16364; No. of Pages 2
Vaccine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Commentary
Commentary to: Guide to tailoring immunization programmes in the WHO European Region Pierre Van Damme a,∗ , Ann Lindstrand b , Asli Kulane c , Angel Kunchev d a
Vaccine & Infectious Disease Institute, University of Antwerp, Belgium Department of Vaccine and Registries, The Public Health Agency of Sweden, Sweden Department of Public Health Sciences, Karolinska Institute, Sweden d Chief State Health Inspector, Ministry of Health, Sofia, Bulgaria b c
a r t i c l e
i n f o
Article history: Received 5 October 2014 Received in revised form 9 April 2015 Accepted 10 April 2015 Available online xxx
Vaccination is one of the most cost-effective health interventions available, saving millions of people from illness, disability and death each year. Effective and safe vaccines, which protect against more than 20 serious diseases, are available and many promising new vaccines are being developed. Vaccine-preventable diseases (VPDs) continue to pose an ongoing threat to health worldwide. Addressing access and coverage issues for immunization programmes is important for the currently available, as well as, future vaccines. Alongside large-scale outbreaks of measles in some countries, while a few others reported outbreaks of rubella, resurgences of pertussis and the occurrence of poliomyelitis represent a serious threat to population health. For 2013, there were 31,520 measles cases reported in 38 countries of the WHO European Region [1]. Seven measles-related deaths were reported from five countries. For the same year, 39,367 rubella cases were reported in 21 countries of the Region. However, the latter were reported almost exclusively by Poland (n = 38,585; 98%) [1]. Outbreaks of measles continue to be reported in health care settings involving patients and health care workers alike [2]. High vaccination coverage rates are crucial to halting the spread of VPDs, yet current coverage rates in many areas of the Region are sub-optimal and challenges to ensure herd immunity and protect individuals against VPDs persist. In addition, coverage rates reached during the first few years of implementing immunization programmes were suboptimal. This has resulted in immunity gaps in
∗ Corresponding author. Tel.: +32 32652538; fax: +32 32652604 E-mail addresses: [email protected] (P. Van Damme), [email protected] (A. Lindstrand), [email protected] (A. Kulane), [email protected] (A. Kunchev).
the current generation of European adolescents and young adults. Renewed attention, innovative tools and tailored catch-up vaccination are therefore required to overcome the many challenges of maintaining strong immunization programmes. The Guide to Tailoring Immunization Programmes (TIP) was developed to assist national immunization programmes by providing proven methods to design targeted strategies that increase uptake of infant and childhood vaccinations [3]. Moreover, TIP provides tools to identify susceptible populations, determine barriers to vaccination and implement evidence-based interventions. The approach draws on health programme planning models, including social marketing and social and behaviour change communications [3]. TIP is intended for use by healthcare professionals, public health authorities and decision-makers and may be particularly valuable when pockets of low vaccination coverage or increased susceptibility to VPDs are identified. After successful pilot-testing in Bulgaria in 2012, TIP was launched in April 2013 and is to be rolled out in several countries across the Region. In Bulgaria, TIP was applied to profile and target Roma populations and health care providers working within these underserved communities. As an outcome of the project, the Bulgarian Ministry of Health (MOH) plans to: introduce new tools to strengthen the quality of the dialogue between general practitioners and families regarding immunization; improve curricula and training of the Roma health mediators so that their role in promoting immunization is optimized; revise school-entry policy and introduce lessons on vaccines and infectious diseases (e.g. in Biology courses) in schools. At the current time, the MOH is considering the use of the TIP to boost immunization coverage of over 8000 refugees and asylum seekers from the Middle East now residing in Bulgaria [4].
http://dx.doi.org/10.1016/j.vaccine.2015.04.032 0264-410X/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Van Damme P, et al. Commentary to: Guide to tailoring immunization programmes in the WHO European Region. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.04.032
G Model JVAC-16364; No. of Pages 2 2
ARTICLE IN PRESS P. Van Damme et al. / Vaccine xxx (2015) xxx–xxx
Sweden is using TIP to improve vaccination coverage among an ethnic minority group, Somali immigrants and an anthroposophic community. Through application of the TIP methodology and with the assistance of the WHO European Regional Office, in-depth interviews with parents who refuse vaccination, postpone vaccination and accept timely vaccination, as well as with key informants were conducted in Sweden. The application of TIP in shaping the National Measles and Rubella Elimination Strategy and the national communication strategy for reaching the marginalized and underserved in Sweden is currently being assessed by the national health authorities. TIP research analysis is providing new insight to these populations in Sweden and emphasizing the importance of a respectful dialogue between healthcare providers and members of the anthroposophic community. For the Somali, there is a clear need to begin vaccine promotion via interpersonal communication and networking, through the recruitment and support of “vaccine champions”. There is also still a strong argument for the need to communicate around the risks and benefits of the combined measles–mumps–rubella (MMR) vaccine to refute the persistent rumour of a link between MMR and autism. For a third group at risk of sub-optimal vaccine coverage, undocumented migrants, TIP helped identify structural (administrative and financial) barriers within the health care system, which are beyond the healthcare decision-makers’ or providers’ abilities to address. This third subproject in Sweden clearly illustrates how the TIP approach can also be applied in complex communities with fluid legal identities. In the UK, Public Health England (PHE) and the National Health Service recently launched a TIP project to focus on addressing sub-optimal immunization coverage among Jewish orthodox communities in the Hackney Borough of London. In Kazakhstan TIP protocols and formative research tools are being applied to gauge vaccination behavioural barriers and motivators within higher socio-economic, urban, well educated populations in the major cities, where health authorities have registered a growing vaccine hesitancy affecting immunization coverage. Turkmenistan recently completed a household survey investigating vaccination
behaviours, based on the TIP checklist of research items and questions. Results from the study are to be published soon. Germany will be applying TIP to address vaccine uptake within anthroposophic communities at the beginning of 2015. All actors, in Member states, who are involved in immunization should consider adapting TIP according to the vaccination needs of their population in order to maintain equitable and high vaccination coverage across all sections of the population and to meet European Vaccine Action Plan goals, including the elimination of measles and rubella in the European Region and maintenance of the Region’s polio-free status [5]. The framework laid out in TIP can also be used to address other health issues among certain sections of the population that are not benefiting from public health interventions. Thus the guide would contribute to reduce health inequalities in line with Health 2020 targets [6]. References [1] Muscat M, Shefer A, Ben Mamou M, Spataru R, Jankovic D, Deshevoi S, et al. The state of measles and rubella in the WHO European Region, 2013. Clin Microbiol Infect 2014;20(May (suppl. 5)):12–8, http://dx.doi.org/10.1111/1469-0691.12584. [2] World Health Organization. WHO EpiBrief 2; 2014. p. 1–9. http://www.euro. who.int/ data/assets/pdf file/0020/254234/EpiBrief 2 2014-rev3-with-data. pdf?ua=1 (accessed 05.10.14). [3] World Health Organization Regional Office for Europe. The Guide to Tailoring Immunization Programmes (TIP). Copenhagen: WHO Regional Office for Europe; 2014. http://www.euro.who.int/en/health-topics/disease-prevention/vaccinesand-immunization/publications/2013/guide-to-tailoring-immunizationprogrammes (accessed 05.10.14). [4] United Nations High Commissioner for Refugees. UNHCR regional operations profile – Northern, Western. Central and Southern Europe; 2014. http://www. (accessed unhcr.org/cgi-bin/texis/vtx/page?page=49e48db16&submit=GO# 22.09.14). [5] World Health Organization Regional Office for Europe. The European Vaccine Action Plan 2015–2020. Copenhagen, WHO Regional Office for Europe; 2014. http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-andimmunization/publications/2014/european-vaccine-action-plan-20152020 (accessed 05.10.14). [6] World Health Organization Regional Office for Europe. Health 2020: the European policy for health and well-being; 2014. http://www.euro.who.int/ health2020 (accessed 05.10.14).
Please cite this article in press as: Van Damme P, et al. Commentary to: Guide to tailoring immunization programmes in the WHO European Region. Vaccine (2015), http://dx.doi.org/10.1016/j.vaccine.2015.04.032