When a Ukrainian family won a Green Card to live in the United States but did not want to give their child the mandatory measles vaccination, they sought advice from Ukraine’s health ministry.
Its immunisation chief, Oleksandr Zaika, asked if they had pets.
“You bought expensive pets from the market or shop; then what did you do?” Zaika recalled the conversation. “They said, ‘We took them to the vet and got them vaccinated.’’’
When he asked why, they responded: “Because we thought they might die.”
Zaika asked them, “And you think your child might not die, if you don’t get vaccinations?”
The family got their child vaccinated, perhaps persuaded as much by the wish to move to the United States as by Zaika’s analogy, he admitted.
They will be leaving a country with the biggest increase in measles worldwide: more than 100,000 cases since mid-2017 and 39 recorded deaths, caused by years of falling vaccination rates. The United States, experiencing its worst outbreak since 1992, traces an outbreak in Washington state directly back to Ukraine, from a visitor late last year. Some 1,044 cases have been confirmed this year in the United States, according to the Centers for Disease Control.
A newly released global study on attitudes toward healthcare found that high percentages of people in several European countries, including Ukraine, distrust or are unsure of the safety of vaccines.
However, overall more than three quarters of the 140,000 respondents in 140 countries said they believe vaccinations are safe and effective, according to the Wellcome Trust, which conducted the survey.
In the scramble to change attitudes and turn the tide in Ukraine, about 280,000 children were vaccinated in an intensive five-week campaign earlier this year in the western region of Lviv, resulting in 90 percent of school-age children receiving the protective jabs, according to the Ministry of Health’s Public Health Centre. Such campaigns continue elsewhere, conducted by the ministry with help from UNICEF and local NGOs and schools.
But the crisis is far from over, with more than 53,000 cases and 18 deaths recorded this year alone, according to the Ukrainian health ministry. Among the latest victims is a three-month-old baby who died of the measles contracted by the mother during her pregnancy.
‘We’ve seen it coming’ for a decade
While campaigns for child vaccinations targeting parents and teachers are having an effect, adults are slipping through the net. Adults make up half of measles cases – and deaths – in Ukraine and there is no data on how many are getting immunised, according to Zaika. Nor is there a clear strategy to reach them, though a new law recently made public vaccination for adults free of charge.
In Ukraine, measles outbreaks were small and isolated until 2017. Nevertheless, international agencies have been predicting the current epidemic for more than a decade.
“We’ve seen it coming,” said Lotta Sylwander, UNICEF’s representative in Ukraine.
UNICEF took over state procurement of vaccines in 2016 as part of a shake-up of the entire healthcare system under acting health minister Ulana Suprun, an American-born physician. The ministry at last took warnings about measles seriously and, with the support of international agencies, started information campaigns and vaccination drives.
Measles is preventable by vaccination and had been eradicated in many countries. But it is re-emerging worldwide because of growing vaccine hesitancy, which the World Health Organisation lists among its top 10 global health threats. A highly contagious disease caused by a virus, measles is easy to spot by a red rash that starts in the face. Symptoms include fever, a dry cough, runny nose, sore throat, and inflamed eyes.
Complacency, difficulty in accessing vaccines, and lack of confidence in their quality and safety – reasons the WHO lists – all have played their part in Ukraine. It’s widely acknowledged that a cash-strapped, corrupt healthcare system, kickbacks in medical procurement, unstable government, and an armed conflict in the east all contributed to regular shortages and delays in stocks of vaccines.
By 2016, national coverage of the measles, mumps, and rubella shot was just 45 percent, down from 94.3 percent in 2008, according to the health ministry and the WHO. The WHO recommends 95 percent coverage to guarantee group immunity.
Aggressive anti-vax campaigns claiming that vaccines are unsafe and can lead to autism – a theory long disproven – drive much of the vaccine hesitancy worldwide. But that influence is relatively minor in Ukraine, according to Sylwander, who worked previously in the Philippines, which is second only to Ukraine in the explosion of measles cases.
“The anti-vax movement here is not so big and not so active,” she said. “It’s more a sort of reluctance and a lack of information among medical staff and also among caretakers of children.”
Ukrainian regulations require children be vaccinated to be admitted to school or kindergarten. But entrenched corruption means people are accustomed to paying for fake medical certificates for anything from using a swimming pool to exemption from army service. Suprun, the minister, has said that as many as 50 percent of vaccination certificates are fraudulent.
But the regulations can bring positive results. When a school in Kiev began refusing to admit unvaccinated children in late 2017, the number coming for shots at the nearby government Children’s Clinic No. 3 jumped dramatically.
“In a month we did as many vaccinations as we usually do in a year,” said Nina Davidyuk, the deputy director for children’s health in the Podil district of the city.
Zaika said that a new internet-based system, a flagship of the ministry’s health reforms, should make issuing fake certificates more difficult: doctors are required to enter vaccine serial numbers directly into a centralised electronic register.
Legislation also helps. In May, the Supreme Court of Ukraine ruled against a woman who had sued a kindergarten, which, she argued, had violated the constitutional right to education by refusing entrance to her unvaccinated child.
“It is impossible to put the individual right to refuse to vaccinate against the public interest and safety of other children,” Suprun commented on the ruling in a Facebook post. “The Ministry of Health of Ukraine continues to insist on compulsory vaccination and defend the commitment to evidence-based medicine.”
Distrust and complacency
Doubts here are driven by years of distrust in a collapsing medical system, which must be tackled by improving communication between healthcare providers and citizens.
“It’s the responsibility of primary healthcare providers who summon people for immunisations, explain the regulations, and administer vaccines,” said Zaika. “They should listen to parents’ needs and provide well-argued facts referring to medical science.”
In Ukraine, though, primary healthcare providers are also a necessary target of vaccine awareness campaigns because of what Sylwander calls “over-sciencing”.
“There have been a lot of professional doubts among the medical profession around the vaccines and the vaccinations,” she said. “Everything needs to be proven, not by any global evidence but actually saying ‘No, Ukraine is different, we need to try this here.’”
The Ministry of Health is working to get vaccination included in a general medical qualification, and its Public Health Centre provides training for medics working with the public. “We need to work with medical staff to explain to them the point of the campaign and how to explain it to people,” said Zaika, who heads the centre’s immunisation strategy department.
“There was such a long gap of populations not being vaccinated at all, including the doctors and nurses themselves, and there were no outbreaks, so there is a feeling of complacency.”
Faulty vaccines previously bought from Russia or failure in the cold storage chain may be behind the high incidence of the disease among adults. But complacency from a generation that had never really seen measles is also to blame.
“There was such a long gap of populations not being vaccinated at all, including the doctors and nurses themselves, and there were no outbreaks, so there is a feeling of complacency,” said Sylwander.
Davidyuk said she always took polio immunisation seriously because she remembers seeing survivors of the crippling disease. But in the 1990s her son, then 20, caught measles as he was about to study medicine at the university. He had not been vaccinated.
“It just sort of got put off and put off and finally forgotten,” Davidyuk admitted.
‘Trust is growing’
Polio vaccination levels have been falling since the 1990s in Ukraine along with measles and diphtheria. In 2017, two cases of polio were recorded in western Ukraine. And there has been a polio outbreak in the separatist-controlled eastern part of Ukraine since 2014, when war erupted there, according to Sylwander. UNICEF has been asked to supply polio vaccines by the de facto authorities there.
Reliable information is hard to come by from areas not under government control, where only a few UN and humanitarian organisations have access. But known shortages of vaccines mean there are probably large groups of children who are not immunised, according to UNICEF. With up to a million people crossing the front line of conflict each month, that can impact the entire country.
“Infections can come across the border… because we know very little of how many children are being vaccinated there and what kind of vaccines they’re getting,” Sylwander said.
“We’ve been warned, and considering the situation in the country we were literally counting the days until we could do it.”
But in the rest of Ukraine child vaccination rates are now at 90 percent, and research shows that attitudes are changing. According to UNICEF surveys, in 2008 only 28 percent of parents in Ukraine were positive about inoculating their children. This year that has grown to 88 percent.
“People are coming of their own accord, and not just parents but adults are showing an interest in vaccines for themselves,” said Zaika. “Trust is growing.”
At Children’s Clinic No. 3, Tatiana Lyukina had brought 13-month-old Evelina for her measles shot a month later than recommended because her daughter had been ill.
“We’ve been warned, and considering the situation in the country we were literally counting the days until we could do it,” she said. “The consequences can really be much worse. It’s better to prevent it now than kick yourself later because you didn’t do it.”
(TOP PHOTO: A young boy receives his second dose of MMR (mumps, measles, rubella) vaccine on 29 March 2018, in Kiev, Ukraine.)