WHO European Regional

Meeting of National Immunization

Programme Managers

Antalya, Turkey, 18–20 March 2014

Presenter

Vaccine-preventable Diseases and Immunization

Vaccine Demand: Hesitancy and Acceptance

in the European Region

IAIM Joint Regional Meeting

Madrid

February 1&2, 2017

Robb Butler, Programme Manager

Vaccine-preventable Diseases and Immunization programme

WHO Regional Office for Europe

EVAP goals

EVAP Strategic Objectives

Resurgence…..lingering VPDs

0

500

1 000

1 500

2 000

2 500

3 000

3 500

4 000

4 500

5 000

<1 1-4 5-9 10-14 15-19 ≥20

Num

ber

of r

epor

ted

mea

sles

cas

es

Age group (years)

Unknown number of doses

Vaccinated ≥2 doses

Vaccinated 1 dose

Unvaccinated

Age known in 10 630 cases (35%)

*Data extracted 04 December 2016

Age distribution and vaccination status of measles cases, 2015*

Age distribution of measles cases in the six selected countries in 2015

*Data extracted 04 December 2016

7%

15%12%

14%16% 15%

21%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Serbia (n=304)Bosnia and Herzegovina (n=2238)*

9%

17%

8%5%

7%

20%

34%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Russian Federation (n=639)*

8%

16%

12% 13% 14%17%

20%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Germany (n=2381)*

25%

0%2% 3%

13%10% 10%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Ukraine (n=977)Kazakhstan (n=2340)

31%

24%

29%

8%

3% 4%2%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Turkey (n=342)

1%

21%

8%6% 8%

24%

33%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Italy (n=259)*

7%

15%12%

14%16% 15%

21%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Serbia (n=304)Bosnia and Herzegovina (n=2238)*

9%

17%

8%5%

7%

20%

34%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Russian Federation (n=639)*

8%

16%

12% 13% 14%17%

20%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Germany (n=2381)*

31%

24%

29%

8%

3% 4%2%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Turkey (n=342)

1%

21%

8%6% 8%

24%

33%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Italy (n=259)*

25%

0%2% 3%

13%10% 10%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Ukraine (n=977)Kazakhstan (n=2340)

7%

15%12%

14%16% 15%

21%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Serbia (n=304)Bosnia and Herzegovina (n=2238)*

9%

17%

8%5%

7%

20%

34%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Russian Federation (n=639)*

8%

16%

12% 13% 14%17%

20%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30%

of

rep

ort

ed m

easl

es c

ases

Age group (years)

Germany (n=2381)*

31%

24%

29%

8%

3% 4%2%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Turkey (n=342)

1%

21%

8%6% 8%

24%

33%

0%

10%

20%

30%

40%

<1 1-4 5-9 10-14 15-19 20-29 ≥30

% o

f re

po

rted

mea

sles

cas

es

Age group (years)

Italy (n=259)*

Outbreaks occurring in several susceptible populations

Roma and Sinti communities

Traveller communities

Followers of anthroposophy

Unvaccinated children

Orthodox protestant

communities

Ultra-orthodox jewisish

communities

Susceptible adults

Unvaccinated adolescents

Health care workers

Main public settings for measles outbreaks

Health-care settings

BulgariaCroatiaCzech RepublicDenmarkFranceGreece

LatviaItalyNetherlandsSpainSwitzerland

HCW40%

Other60%

Measles outbreak cases in Czech Republic (n=171)

HCW42%

Other58%

Laboratory -confirmed measles outbreak cases in Latvia (n= 31)

HCW25%

Other75%

Measles outbreak cases in Spain (n=120)

Further reading: WHO EpiBrief, 2014, 2:1–9 www.euro.who.int/__data/assets/pdf_file/0020/254234/EpiBrief_2_2014-rev3-with-data.pdf?ua=1

Proportion of measles among health care workers in selected countries, 2014

Educational facilities

Main public settings for measles outbreaks

AustriaFranceGermanyIreland

ItalySpainSwitzerlandUK

Kindergardens

Day care centres

Universities

Anthroposophic Schools

Schools

Can resurgence be attributed to vaccine hesitancy?

• Social determinants are not so helpful – FRA, GER, ITA, KAZ

• Service delivery and programmatic weaknesses, now and historically (F, I)

• Vaccine safety management and response capacity (IRE, DEN, BiH,

KYR)

• Hesitant parents today or those of yesteryear ? (UNK, GER, ITA, RUS)

• Resilient communities: how do they come about? Education; whose

responsibility? The narrow window of opportunity and untapped potential

of inter-sectoral collaboration.

• ‘Worthy pursuit or welcome distraction?’ Exercise

Exercise

Belief – Behavioural Segmentation/Research

Homogenous?

Information based communications help?

Spray and pray?

Research and insight

Target populations?

Demand-Uptake-Acceptance

Determinant Categories

Perceived risks VPD low;

vaccination not deemed a

necessary preventive

action. Other life /health

responsibilities higher

priority at time

Trust in vaccines, in

delivery system, in

the policy-makers

who decide which

vaccines are needed

and when.

Physical access-

availability,

affordability,

willingness to pay;

geographical access,

ability to understand

(language, health

literacy); appeal of

immunization services

Confidence Convenience

Complacency

SAGE Working Group on Vaccine hesitancy Report 2014

Antivaxers

May influence

Today, anecdote often wins over fact

Sensationalist emotional stories

have impact

- She won lotto big prize after HEPATITIS B vaccination

- “It was just after the 2nd shot”, she said

BIG VACCINE PRIZE on the news

Social Copying

RSA talk- Earls & Bentley

24

WELL INFORMED

BADLY INFORMED

COPYINGSOCIAL

INDEPENDENTAUTONOMOUS

Group polarisation

So, in European Region:

• Demand is at least counterbalance to supply factors

• End-user insight/experience is rare

• Knowledge not predict action

• Traditional susceptible not the susceptibles of today ?

programmes need to adapt

• Resilience: programmatic and community

• Vaccine scares affecting traditionally strong programmes

• Acknowledge social copying: educate early

Additional slides

Pertussis Data Update

Updated as of 01-Feb-2017

Region

Reported pertussis in the WHO European Region

• Thousands of cases of pertussis continue to be reported

• Recent large outbreaks in Spain, Denmark and Austria

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40,000

60,000

80,000

100,000

120,000

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f re

po

rted

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tuss

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ases

32

Pertussis cases by Age and Vaccination Status in

WHO European Region, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: Pertussis cases reported by 38 member states. The cases with unknown age are excluded from the graph.

Pertussis cases with Known Age and Vaccination

Status in WHO European Region, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: Pertussis cases reported by 38 member states. The cases with unknown age and unknown vaccination status are excluded (67%) from the graph.

Pertussis cases by Age and Vaccination Status in

WHO European Region, 2015

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 1144 380 207 109 71 98 1442 16

1 Dose 373 65 54 51 24 21 105 22

2 Doses 191 57 30 14 5 12 29 0

3+ Doses 119 690 1648 2716 1248 813 1602 6

Unknown doses 2492 556 874 852 547 930 8557 12506

Grand Total 4319 1748 2813 3742 1895 1874 11735 12550

Age Group

Dose group

Data source: WHO/UNICEF JRF 2015 data

Note: Pertussis cases reported by 38 member states.

Top 4 countries

Spain, Netherlands, Israel and

United Kingdom

Pertussis cases by Age and Vaccination Status, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age are excluded from the graph.

Spain Netherlands

Israel UK

Top 4 Countries Reported Pertussis cases, 2015

Data source: WHO/UNICEF JRF 2015 data

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 46 2 3 0 0 0 12 1

1 Dose 38 0 0 0 0 0 0 0

2 Doses 4 0 0 1 0 0 0 0

3+ Doses 5 12 20 7 0 0 0 5

Unknown doses 435 104 89 42 7 16 134 7547

Total 528 118 112 50 7 16 146 7553

0 Dose 104 98 50 24 12 18 247 0

1 Dose 27 1 1 2 1 1 1 0

2 Doses 16 2 3 3 0 0 2 0

3+ Doses 27 171 505 1378 504 263 292 0

Unknown doses 0 2 1 13 33 202 2562 0

Total 174 274 560 1420 550 484 3104 0

0 Dose 165 53 50 28 7 13 264 0

1 Dose 74 0 0 0 0 0 0 0

2 Doses 48 0 0 0 0 0 0 0

3+ Doses 37 190 542 408 56 81 434 0

Unknown doses 170 215 469 325 61 169 1479 0

Total 494 458 1061 761 124 263 2177 0

0 Dose 110 15 13 16 7 21 445 0

1 Dose 43 0 4 9 13 13 87 0

2 Doses 9 2 2 4 3 10 23 0

3+ Doses 9 47 177 369 198 218 345 0

Unknown doses 61 28 81 128 92 214 2396 0

Total 232 92 277 526 313 476 3296 0

0 Dose 719 212 91 41 45 46 474 15

1 Dose 191 64 49 40 10 7 17 22

2 Doses 114 53 25 6 2 2 4 0

3+ Doses 41 270 404 554 490 251 531 1

Unknown doses 1826 207 234 344 354 329 1986 4959

Total 2891 806 803 985 901 635 3012 4997

Others

Dose groupAge Group

Spain

Netherlands

Israel

United

Kingdom

Country

Spain

Pertussis cases by Age and Vaccination Status,

Spain, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age are excluded from the graph.

Pertussis cases by Known Age and Vaccination

Status, Spain, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age and unknown vaccination status are excluded from the graph.

Pertussis cases by Age and Vaccination Status,

Spain, 2015

Data source: WHO/UNICEF JRF 2015 data

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 46 2 3 0 0 0 12 1

1 Dose 38 0 0 0 0 0 0 0

2 Doses 4 0 0 1 0 0 0 0

3+ Doses 5 12 20 7 0 0 0 5

Unknown doses 435 104 89 42 7 16 134 7547

Grand Total 528 118 112 50 7 16 146 7553

Dose group

Age Group

Netherlands

Pertussis cases by Age and Vaccination Status,

Netherlands, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age are excluded from the graph.

Pertussis cases by Known Age and Vaccination

Status, Netherlands, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age and unknown vaccination status are excluded from the graph.

Pertussis cases by Age and Vaccination Status,

Netherlands, 2015

Data source: WHO/UNICEF JRF 2015 data

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 104 98 50 24 12 18 247 0

1 Dose 27 1 1 2 1 1 1 0

2 Doses 16 2 3 3 0 0 2 0

3+ Doses 27 171 505 1378 504 263 292 0

Unknown doses 0 2 1 13 33 202 2562 0

Grand Total 174 274 560 1420 550 484 3104 0

Dose group

Age Group

Israel

Pertussis cases by Age and Vaccination Status,

Israel, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age are excluded from the graph.

Pertussis cases by Known Age and Vaccination

Status, Israel, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age and unknown vaccination status are excluded from the graph.

Pertussis cases by Age and Vaccination Status,

Israel, 2015

Data source: WHO/UNICEF JRF 2015 dataNote: Pertussis cases reported by 38 member states.

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 165 53 50 28 7 13 264 0

1 Dose 74 0 0 0 0 0 0 0

2 Doses 48 0 0 0 0 0 0 0

3+ Doses 37 190 542 408 56 81 434 0

Unknown doses 170 215 469 325 61 169 1479 0

Grand Total 494 458 1061 761 124 263 2177 0

Dose group

Age Group

United Kingdom

Pertussis cases by Age and Vaccination Status,

United Kingdom, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age were excluded from the graph.

Pertussis cases by Known Age and Vaccination

Status, United Kingdom, 2015

Data source: WHO/UNICEF JRF 2015 data

Note: The cases with unknown age and unknown vaccination status are excluded from the graph.

Pertussis cases by Age and Vaccination Status,

United Kingdom, 2015

Data source: WHO/UNICEF JRF 2015 dataNote: Pertussis cases reported by 38 member states.

<1 01-04 05-09 10-14 15-19 20-29 30+ Unknown Age

0 Dose 110 15 13 16 7 21 445 0

1 Dose 43 0 4 9 13 13 87 0

2 Doses 9 2 2 4 3 10 23 0

3+ Doses 9 47 177 369 198 218 345 0

Unknown doses 61 28 81 128 92 214 2396 0

Grand Total 232 92 277 526 313 476 3296 0

Dose group

Age Group