Responding to a cVDPV1 Outbreak in Ukraine: Implications, Challenges and Opportunities

"The outbreak response activities generated a wealth of new knowledge and experiences that can serve as a solid foundation for reestablishing a high performing routine immunization program."

After 3-dose polio vaccine coverage in Ukraine declined from 91% in 2008 to 15% by mid-2015, an outbreak of highly divergent circulating vaccine-derived poliovirus (cVDPV) type 1 was confirmed on August 28 2015. A nationwide outbreak response was conducted, despite numerous challenges. This report reviews the epidemiologic and operational aspects of the cVDPV1 outbreak in Ukraine and its implications; the summary below focuses on the communication elements of the response.

To inform this article, the researchers reviewed epidemiologic, clinical, and virology data on cVDPV cases, surveillance and immunisation coverage data, and reports of outbreak-related surveys, country missions, and expert group meetings. Information on the immediate outcome of the public communication interventions was obtained from United Nations Children's Fund (UNICEF) knowledge, attitude, and practice (KAP) surveys and independent monitoring data collected during the outbreak response.

On September 1 2015, the World Health Organization (WHO) informed the Government of Ukraine of the outbreak. The Ministry of Health (MOH) publicly announced the outbreak and initiated response activities with support of international experts (primarily from WHO and UNICEF). As an example of the initial activities: WHO and UNICEF led trainings to build local capacity, including in the areas of effective counselling and communications. Approximately 9,000 health care workers (HCWs), 1,400 educators, and 50 journalists were reached by these trainings.

In addition to efforts to strengthen acute flaccid paralysis (AFP) and supplementary poliovirus (environmental and enterovirus) surveillance, three nationwide supplementary immunisation activities (SIAs) with trivalent oral polio vaccine (tOPV) were conducted during October 2015-February 2016 (officially reported coverage: round 1: 64.4%, round 2: 71.7%, and round 3: 80.7%). Substantial challenges to SIA implementation were posed by: lack of visible high-level governmental support; denial of the outbreak by some politicians, clinicians, and media outlets; and resistance by some prominent clinicians to OPV SIA in a country using inactivated polio vaccine (IPV) for the first two routine doses. Implementing a rapid, high-quality response was also complicated by widespread vaccine hesitancy, low perceived risk of polio, strong fear of adverse events following immunisation (AEFIs), an anti-vaccine media environment, allegations about vaccine mishandling by MOH, economic crisis, and bureaucratic hurdles for vaccine importation and distribution. To mitigate the challenges posed by the military conflict, WHO and UNICEF acted as a "bridge" between the sides and asked the diplomats involved in the negotiations to encourage local authorities to join the response efforts.

UNICEF, along with WHO, Rotary, and other partners, developed multi-channeled communication and social mobilisation interventions in an effort to increase public trust in vaccination and mitigate opposition to OPV use. Caregivers with children under 10 years of age were reached nationwide through: television, radio, outdoors, and transit advertising; digital signage; social media; proactive media advocacy; and events in busy areas. The communication campaign reached about 70% of Ukraine's population. Special plans to reach high-risk populations (Roma and internally displaced persons - IDPs) were also executed. Surveys found that the awareness of polio among caregivers increased from 68% at the beginning of the outbreak to 89% during SIA round 1, 91% during round 2, and 96% during round 3. The level of fear of vaccine-related complications among those parents who refused vaccination decreased from 67% in 2014 to 38% by round 3. By round 3, 71% of caregivers believed that supplemental polio vaccination was needed.

As suggested here, "[t]he gradual round-to-round improvement in SIA coverage and increased community demand for polio vaccination and confidence in the immunization system during the outbreak response suggests that the outbreak may have been a turning point. For Ukraine, the response set a new standard for planning and delivering evidence-based immunization and communication strategies, and afforded an opportunity for improved coordination between stakeholders."

However, even after the response, programmatic gaps in immunisation and surveillance still needed to be addressed so as to reduce the risk for VDPV emergence and circulation, as well as for other vaccine-preventable diseases (VPDs), in Ukraine. In the words of the researchers: "Actions need to be taken now to ensure that this opportunity is not lost." One specific element that is described here as crucial going forward is advocacy: high-level political commitment to appropriate legislative and regulatory frameworks supportive of a fully functioning and adequately funded routine immunisation programme.