Immunization in Estonia Irina Filippova

23-24 of January 2017

Main information

• Immunization is voluntary in Estonia;

• Immunization programme vaccines are financed by the Government;

• Immunization programme vaccines are free of charge for all Estonian children and dT vaccine for adults;

• Parent`s agreement is needed for vaccination of children;

• Immunization programme vaccines and vaccination service are available for all children and adults;

• Family doctor is responsible for vaccination of his patients in the frame of immunization programme.

Routine immunization (main facts, 2016)

• Birth cohort – 13 625

• Number of distributed doses – 253 828

• Number of immunization services – ca 1200

• Amount of governmental funds spent on vaccine used for routine immunization – ca 2,4 mln € (in 2015)

• Number of registrated AEFI – 42 (serious – 8)

Main “players”

• Ministry of Social Affairs

• Advisory Committee on Immunization

• Health Board

• State Agency of Medicines

• Estonian Insurance Fund

• Training facilities

• Vaccine suppliers

• Vaccinators

Ministry of Social Affairs

• Developing of the national legislation and immunization strategies;

• Composing vaccine procurement plans;

• Management of public procurements;

• Monitoring of the performance of all components of the immunization system;

• Leading of NITAG activity;

• Communication with professionals and general public.

Health Board

• Forecasting/planning of vaccines and safe-injection equipment required to run the immunization programme;

• Management of vaccine stockpile;

• Storage, distribution, logistics, bookkeeping and stocktaking of vaccines;

• Collection of immunization data;

• Supervision of implementation of immunization programme;

• Official control and evaluation of immunization services;

• Membership in the National Advisory Committee on Immunization;

• International activity (reporting, participation in networks, projects and surveys);

Health Board (communication)

• Preparation of guides, recommendations and information materials;

• Conduction of surveys;

• Participation in training activity;

• Communication with professionals and general public.

State Agency of Medicines

• Authorization (market authorization, import approval);

• Expertise of applications;

• Registration of vaccines;

• Surveillance of AEFI;

• Vaccine use information;

• Collecting of vaccine uptake reports;

• Membership in the Advisory Committee on Immunization;

• Communication with professionals and general public.

Estonian Insurance Fund

• Funding of vaccinators;

• Control of vaccinators activity;

• Participation in the Advisory Committee on Immunization;

• Communication with professionals and general public.

Education and training facilities

• Tartu University

• Medical schools

Partners:

• Hospitals

• Professional societies (Estonian Association of CD, Estonian Association of Family Doctors, Estonian Pediatric Association)

• Health Board

• State Agency of Medicines

• Vaccine suppliers

Vaccinators

• Family doctors • School health care providers • Hospitals • Vaccination cabinets/infectious centers • Travel medicine cabinets Responsibilities: • Logistics, storage, registration, bookkeeping and stocktaking of vaccines; • Vaccination servise; • Reporting to Health Board, Insurance Fund and State Agency of Medicines; • Communication with patients and HCW.

Advisory Committee on Immunization (since 2006)

• Ministry of Social Affairs

• Health Board

• State Agency of Medicine

• Insurance Fund

and professional associations and institutions:

• Estonian Association of Iinfectious Diseases

• Estonian Association of Family Doctors

• Estonian Paediatric Association

• Estonian Association of Immunologists and Allergists

• Estonian Union for Child Welfare

• Tallinn Municipality

Immunization programme (since 1.07.2014.a)

• 12 hours HepB 1 • 1–5 days BCG • 1 month HepB 2 • 2 months RV1 • 3 months IPV 1, DTPa 1, Hib 1, RV2 • 4,5 months IPV 2, DTPa 2, Hib 2, RV3* • 6 months IPV 3, DTPa 3, Hib 3, HepB 3 • 1 year MMR 1 • 2 years DTPa 4, IPV 4, Hib 4 • 6-7 years DTPa 5, IPV 5 • 12 years HepB 1,2,3** • 13 years MMR 2 • 15-16 years dTpa 6 • 25, 35.. years (every 10 years) dT

* For 5-valent vaccine ** For children born in 1995–2003, who were not vaccinated against HepB

Since 2018 will be introdused HPV (2 doses) for 12-14 girls.

Vaccination coverage, 2011-2015

Vaccination coverage in a certain age

group

2011

2012

2013

2014

2015

Diphtheria, tetanus (7 months – 14 years) 97,1 97,0 96,7 96,4 96,2

Pertussis (7 months – 10 years) 96,3 96,3 96,0 95,7 95,4

Hib (2 years) 95,3 95,1 95,1 95,0 94,1

Measles, rubella, mumps (1 – 14 years) 96,6 96,3 96,0 95,7 95,5

HepB (2 years) 95,0 94,7 94,7 94,1 93,4

Polio (7 months – 14 years) 97,1 97,0 96,7 96,4 96,2

Tuberculosis (0 – 11 months) 97,0 97,9 95,9 95,1 95,5

Rotavirus (1 year) - - - - 65,6

Influenza (No of vaccinated/%) 17 119 (1,3%) 13 618 (1,0%) 18 130 (1,4%) 17 382 (1,4%) 20 331 (1,6%)

Tick-born encephalitis

No of vaccineted/revaccineted

17 763/20 978 13 725/16 540 13 324/17029 8 980/ 16 595 10 084/ 18 008

Refusals from vaccination, 2015

Vaktsineerimine Refusals (%) No of vaccinated person

Diphtheria, tetanus 2,8% 6727 (1-14 years)

Pertussis (0 – 10 years)

3,4% 7078 (1-14 years)

Measles, rubella, mumps 3,3% 7066 (2-14 years)

Polio 2,9% 6865 (1-14 years)

HepB 3,5% 8668 (vanuserühmas 1-14 aastat)

Hib 2,7% 3623 (vanuserühmas 1-5 aastat)

Tuberculosis 2,1% 568 (alla 1-aastastel)

Rotavirus 3,2% 58797 (1-5 aastat)

Possible reasons of refusing from vaccination

• Immunization is voluntary;

• Favourable epidemiological situation;

• Insufficient level of public knowledge in vaccination;

• Low level of public trust to information from government agencies;

• Doubts about the effectiveness of vaccines and vaccination;

• Doubts about vaccine safety;

• Skeptical attitude to new vaccines.

Communication in immunization field

HCW

Crisis communication

Routine communication

Training

Guidance

Public

Crisis communication

Routine communication

Communication with specific groups

Media

Crisis communication

Routine communication

Communication with HCW

Training • Immunization in curriculum of the Tartu University Medical Faculty and

medical schools; • Requirements for training of vaccinators are regulated by regulation of the

Minister of Social Affairs; • Programme for training and a list of trainers is approved by the Ministry of

Social Affairs. Guidance • Guide for implementation of the immunization programme; • Other written materials, vaccination website www.vaktsineeri.ee ; • Regional seminars.

Health Board website

Routine communication with HCW via:

• Health Board and vaccination websites;

• Professional Societies;

• Co-partners (Health Insurance Fund, State Agency of Medicines, Ministry of Social Affairs);

• E-mail; mail; telephone.

Individual communication with HCW

• „Late“ vaccination of children;

• Vaccination schedules for different situations;

• Contraindications, vaccine safety, side effects of vaccination;

• Vaccine availability in the country;

• Introduction of new vaccines into the NIP;

• Vaccine cold-chain;

• Registration of vaccination (e-health system);

• Technical and organizational questions.

Routine communication with general public and specific groups (aims)

• Build awareness and knowledge on risks and benefits of immunization and diseases;

• Monitor public opinion on immunization and shape communications accordingly;

• Research and understand the different opinions to and behavioural patterns in relation to immunization.

Communication with general public (information sources)

Estonia participated in VACSATC Project („Vaccine Safety – Attitudes, Training and Communication, ECDC, 2008-2009)

One of the questions for the parents of young children:

7. What information source is the most trustable for you?

• - media – 1%

• - booklets, posters, books – 1%

• - hospital stuff - 6%

• - internet – 2%

• - school health care providers– 0%

• - family nurse– 2%

• - family doctor – 76%

• - family, friends– 2%

• - Health Board – 6%

• - TV, radio – 1%

• - Other - 3%

Regulation of the Minister of Social Affairs No 116 • Immuniseerimist tohib teostada arst, õde või ämmaemand, kes on täies

mahus läbinud immuniseerimisalase täiendusõppekursuse vastavalt Sotsiaalministeeriumi poolt heakskiidetud programmile ja saanud selle lõpetamise kohta tunnistuse. Kursuse minimaalne maht on 16 tundi.

• Immuniseerimise läbiviimisele peab vahetult eelnema immuniseerimise ajutiste ja püsivate vastunäidustuste tuvastamine, mille eest vastutab immuniseerimist teostav tervishoiutöötaja. Immuniseerimise teostaja selgitab patsiendile või tema seaduslikule esindajale immuniseerimise vajalikkust, teavitab teda immuniseerimisega kaasneda võivatest kõrvaltoimetest ja nõustab muudes immuniseerimisega seotud küsimustes.

Vaccination manual for vaccinators

Communication guide for vaccinators

Vaccination website

Vaccination manual for parents

Vaccination manual for young mothers

Examples of booklets

Information campaign during the HepA outbreak in 2011

Creative experience of communication

• Tartu University students make lecturers on immunization;

• Most part of „family schools“ are covered;

• High quality of information;

• Excellent acceptance;

• Feedback.

European Immunization Week

• European Immunization Week (EIW) is celebrated across the European Region every April.

• The goal of EIW is to increase vaccination coverage by raising awareness of the importance of immunization among parents, health care professionals, policy and decision-makers, and the media.

• Activities in 2016 were focused on the progress and challenges in the Region’s concerted effort to eliminate measles and rubella.

• Estonia takes regularly part in EIW activities.

Communication group on vaccination (since 2014)

• WHO Estonia (1)

• Ministry of Social Affairs (2)

• Health Board (4)

• State Agency of Medicines (2)

• Estonian Insurance Fund (1)

Responsibility

• Crisis communication

• Communication in difficalt situations

• Consulting, preparation of important messages

Reasons for crisis communication

• Outbreaks of infectious diseases;

• Delay in vaccine supply, absence of needed vaccines;

• Vaccine/vaccination side effects;

• Vaccinator`s mistakes

• Other reasons.

Crisis communication (our principles)

• Be the first to share information. This allows to affect how the events are presented before someone else does it. Often, the first source of information becomes the preferred source;

• Provide information on a continuous, frequent basis;

• Try to make sure that all key stakeholders speak with one voice;

• Avoid attacking the credibility of those with higher perceived credibility, even if you do not agree with them;

• Prepare messages to address these and try to bridge the gap between the experts and the public;

• Be highly visible and available.

Pandemic season 2009-2010

Communication measurable results in Estonia

• High vaccination coverage by the NIP vaccines in children;

• Favourable epidemiological situation on 11 vaccine preventable diseases due to routine vaccination;

• Relatively low % of refusals from vaccination;

• Low number of complaints concerning immunization;

• Most of the people trust their family doctors.

Need to be improved

• Education of vaccinators;

• Training vaccinators in vaccine safety and interpersonal communication;

• Establish trust and awareness among decision-makers, influencers, allies, experts, media and the public;

• Develop a crisis communications plan, and prepare documents and messages for use in a crisis;

• Appoint and train spokesperson;

• Influenza communication.

Thank you!