PRACA POGLĄDOWA

REVIEW ARTICLE

VACCINATION COVERAGE RATES AND THE INCIDENCE OF VACCINE PREVENTABLE DISEASES AMONG CHILDREN IN SUMY REGION OF UKRAINE

ODSETEK WYSZCZEPIENIA POPULACJI A WYSTĘPOWANIE CHORÓB ZAKAŹNYCH, KTÓRYM MOŻNA ZAPOBIEC DZIĘKI SZCZEPIENIOM U DZIECI W OBWODZIE SUMSKIM NA UKRAINIE

Vladyslav A. Smiianov1, Halyna S. Zaitseva2, Victorya A. Kurganskaya1, Anatoly G. Dyachenko1, Volodymyr P. Zbarazhskyi2, Yevhen V. Smiianov1, Olha A. Pilipec1

1Sumy State University, Sumy, Ukraine

2State institution «Sumy oblast laboratory centre of ministry of health of Ukraine», Sumy, Ukraine

Abstract

Introduction: Routine immunization contributes immensely to decline the incidence of vaccine preventable diseases among children. Statistical data shown the sharply decrease the vaccination coverage rates in Sumy region of Ukraine.

The aim: Assess routine immunization uptake and its effect on the incidence of vaccine preventable diseases among children in Sumy region of Ukraine.

Review: During some years, only 50-60 % of Sumy region children had received all recommended vaccines, which is far below World Health Organization target of 80 %. This has led to an increase of morbidity associated with some infectious diseases. Outbreaks of measles were registered in 2006 and 2012, when were ill 9346 and 7931 children respectively. Massive measles outbreak ongoing nowadays. Total number infected have already exceeded 35,000 cases.

Conclusions: RI uptake in Ukraine is still below World Health Organization target. The main reason for the ongoing measles outbreak was low vaccination coverage for routine immunization antigens as a result of which collective immunity decreased to a critical level. Strict monitoring of the implementation of the immunization schedule by medical institutions at all levels are recommended to improve vaccination status of Ukrainian children.

Key words: vaccine preventable diseases, vaccination coverage, children

Wiad Lek 2019, 72, 2, 255-260

INTRODUCTION

Routine childhood vaccination remains the most cost-effective public health strategies to reduce morbidity and mortality associated with vaccine preventable diseases. The World Health Organization (WHO) established the expanded program on immunization (EPI) in 1974, with the goal of ensuring full accessibility of routine vaccinations to all children. According to the EPI, a child should receive Bacillus Calmette Guerin (BCG), three doses of oral polio vaccine (OPV) and Diptheria Pertusis Tetanus (DPT), measles vaccines by 12 months of age, and some other antigens to ensure maximum protection against vaccine preventable diseases (VPDs). Receipt of these vaccines at the recommended ages and intervals will provide the children adequate protection from VPDs [1].

At the end of the 20th century, a series of WHO documents identified key aspects of modern immunization policies, one of which states that epidemic safety can be achieved due to high population coverage of preventive vaccines (at least 95%) and an adequate immune response (90% of vaccinated ones). Within the framework of this program, the end of the last century managed to get impressive results on the prevention of infectious diseases [1]. A number of countries have been certified as free of poliomyelitis, dramatically reduced tetanus, diphtheria and some other infections. Globally, vaccination has evolved from a situational campaigns aimed at preventing a specific epidemic into a permanent planned action, and vaccination in many countries, such as EU, have become an indispensable condition of health insurance.

In May 2012 194 members of World Health Assembly accepted a Global Vaccine Action Plan (GVAP) 2011–2020, aimed to improve plan vaccination, based on Decade of Vaccines concept, by providing all humanity with immunization access during 2011-2020 [2, 5]. Ukrainian vaccination schedule is familiar to the European immunization scheme and includes vaccination antigens of 10 infections (in the USA, France, the UK and Italy against 12 infections, in Germany – 13, in Poland – against 11).

However, during last quarter-century Ukraine and other European countries are facing outbreaks of well-known and emergency infections. Particularly alarming is the increase in the incidence of VPDs, which may be the result of a sharp decline in RI that leads to the accumulation of susceptible individuals in the population.

Despite significant gains with childhood routine vaccination coverage over the many years, sometimes ago coverage rates for routine immunization antigens in Ukraine decreased significantly and as a result multitude children have remained incomplete vaccinated, exposing them to disabilities or premature death [3, 7]. Even though vaccines provided free of charge by the government, routine immunization (RI) coverage in Sumy region of Ukraine fall below 50-60 % [7]. World experience suggests that uptake of vaccination services depends a little on the level of socioeconomic development of the state, since the insignificant cost of vaccines makes them accessible to the poorest countries, besides, international organizations, if necessary, help them. It depends not only on provision of these services but other factors related to maternal knowledge, geographical accessibility and many other socio-demographic characteristics. Sumy region of Ukraine represents highly developed area in terms of distribution and access to health care interventions including vaccination services [7, 9]. Thus, we conducted a study to assess immunization coverage rates and the incidence of VPDs in this area.

THE AIM

Aim is to assess the incidence of vaccine preventable infections and the vaccination coverage for routine immunization antigens during last 10 years among children of Sumy region of Ukraine.

MATERIALS AND METHODS

Routine immunization provides according to Ministry of health care of Ukraine order No. 595 from 16.09.2011 (the last edition – 03.07.2018) which defines the nomenclature, age, and intervals between doses of antigens administered (table.I).

State Statistical Reporting Form No. 2 “Report on Certain Infections and Parasitic Diseases”, and No. 6 “Report concerning Persons of Selected Age Groups Immunized to Infectious Diseases” were used as main data sources.

REVIEW AND DISCUSSION

Hepatitis B virus

The incidence of hepatitis B infection in Ukraine and Sumy region, particularly, started decrease after 2001 (1.88 per 100,000 of Sumy region population). Thus, during 2013-2015, and during 2017 no case of hepatitis B infection among children was registered.

Beginning from 2000 all newborn have to be vaccinated against hepatitis B virus, as well as some risk groups, like medical workers. Starting from the 2002 a planned vaccination according the epidemical data was provided. According to the rates from 01.12.2017 in Ukraine more than 180,608 children of first life year were vaccinated by primary vaccine complex against hepatitis B (3 doses – during first day of life, 1 month, 6 months), that makes out 50.8 %of planned amount. The lowest vaccination coverage rates are in Transcarpathian (15.6 %), Khmelnitski (23.4 %) and Ternopil regions (30 %). The highest rates are in Chernihiv (73.9 %), Dnipro (69.8 %) and Kropivnitsky (69.3 %) regions. The rate of general vaccination against hepatitis B virus during first life year showed 12.7 % in November 2017 [10].  

According to the information of Sumy region, the vaccination coverage rate began to decrease starting from 2009 year: in 2011-2012 years it made out only 45 %, and in 2015 and 2016 39 і 44 % correspondently. During 2017 this index was to be improved, however it still reveals in quite low level (60 %) (fig. 2). One also should mention that in Sumy the vaccination coverage during last years was dangerously low: 2014 – 25.8 %, 2015 – 25.5 %, 2016 – 24.8 %. In 2017 it was still far below WHO target.

Tetanus, diphtheria, pertussis (whooping cough)

No cases of diphtheria or tetanus were registered in Sumy region, beginning from 2001. Although, there is rather inconsolable statistics about whooping cough case rate, that during this period was measured from 4.7 till 51.09 cased per 100,000 children. The highest indexes were registered during 2007, 2011, and 2016. The whooping cough is mostly spread among children at the age before 1 year, and often has such complications as pneumonia, nervous system diseases and respiratory standstill. Lethal outputs were not observed. Ukrainian Ministry of health care has quite strict opinion about epidemical situation of diphtheria, pertussis, tetanus taking into account low children immunization coverage. [7, 9] Average RI coverage along last 5 years was varying from 27 to 64 % (fig. 2). In 2017 only 47.5 % of all Ukrainian children aged 2, 4 and 6 months got initial vaccination against tetanus, diphtheria, whooping cough by 3 corresponding doses of DPT vaccine [10]. Lowest coverage rates of this vaccination were registered in Rivno (22.1 %), Volynska (24.9 %) and Ternopil (27.9 %) regions. The highest coverage index was shown by Kiev city (91.7 %), Donetsk (65.2 %), and Kropivnitsky (61.5 %) regions. First dose of the DPT vaccine received 60.9 % of all children aged before 1 year, that was rather higher than during last 3 years (in 2014 – 40.9 %, in 2015 – 31 %, in 2016 – 9 %).

Measles

Global WHO strategy against measles (total vaccination) caused sharply reduce mortality after measles during 2000-2014 period on 79 % that means almost in five times. The plan against measles mortality included its decreasing on 95 % until 2015 in comparison to the 2000 index, and fully elimination of measles and scarlet fever at least in five regions. Unfortunately, this plan was doomed to failure, as the biggest outbreak of this infection started in Europe at the end of 2017. 20 August 2018 WHO informed about one of the highest level of disease rate in European region: then infected people number at first 6 months of 2018 counted more 41,000, 37 lethal outputs [3, 4, 6].

It was said that it is the highest index of case rate after 2010. Thus, Ukraine found itself among leading countries that spread measles around the region [7]. According to the latest data from Public health center of Ukrainnian Ministry of health care dated 10 November 2018 year Ukraine suffered measles infection with about 38,108 ill people, among them 14,609 adults and 23,499 children. Further complications caused 15 deaths (4 adults and 11 children). Case rate of measles in Ukraine continues increase: during eighteenth week, 1,682 people were reported to be sick, that is 35 % higher, than previous week. Disease rate during 9 months 2018 was in 17 times more, then in previous year. The peaks of disease appeared at the middle of May (1,610 infected) and middle of November (1,682 infected). The disease rate in Ukraine is embarrassing. The highest indexes of morbidity and mortality are fixed in the regions with the lowest vaccination coverage rate. Among those: Lviv (7,845 people: 2,276 adults, and 5,569 children), Ivano-Frankivsk (3,816 people: 1,020 adults, and 2,796 children), Zacarpathian (3,582 people: 695 adults and 2,887 children), Odessa (2,567 people: 1,279 adults and 1,288 children) regions, Kiev city (2,445 people: 1,505 adults and 940 children) and Ternopil region (2,265 people: 810 adults and 1,455 children). Previous outbreaks of measles in Ukraine were registered in 2006 and 2012 (fig. 3).

The only method of specific preventions of measles is live antivirus vaccine that is often used in complex with mumps, measles, and rubella vaccines (as components of multiple vaccines MMR and MMRV) [8]. Anti-measles vaccination is rather effective in use. After initial dose a stable antivirus immunity develops among 95% of children aged by 1 year. If vaccination coverage occurs to be more than 93% of all children population, measles outbreaks will be hardly possible. Still, they may occur after decreasing of immunization coverage [8].

Several problems with measles, and parotitis vaccination coverage happened in Ukraine after 2008, and, particularly in Sumy region, after 2013 (fig. 4). Generally, during 2017 about 87,8% of all children aged by 1 year were vaccinated. The lowest rate of vaccine coverage against measles, and parotitis were registred in Zacarpathian (67.7 %), Rivne (69.5 %) and Lviv (79.3 %) regions. The highest are in Kiev (97.5 %) and Chernihiv (95.9 %) regions and in Kiev city (94.5 %).

Analysis of vaccination status of the last measles outbreak suffers has shown, that about 22,995 people were not vaccinated. Measles are mostly spread among children at the age of 5-9 years (32 % among all children measles cases); they are the children, who did not get their booster doses of MMR in time, thus, their immunity was not complete.

Tuberculosis

The incidence of tuberculosis among children in Sumy region grows up extremely fast. For example, in 2013 it counted 4.6 per 100,000 children, in 2014 – 2.2; in 2015 – 9.09, in 2016 this index was increased to 26.9 per 100,000. Tuberculosis case rates among children in recent years were about 7.8 – 8.0 per 100, 000. Their part among all first diagnosed patients was only 1,6-1,8 %, that is much lower than in some other countries (according to the WHO data this index may vary from 3 till 25 and more). Case rate of tuberculosis among teens is more higher than among children before 14 years, and now it counts 28-30 cases per 100,000.

The state of specific tuberculosis prophylaxis is still dangerously unstable. Initial vaccination has to be done to all healthy full-term newborns in first 3-5 days of the life. According to the statistics, in Sumy anti-tuberculosis vaccination coverage was: in 2013 year – 81.5 % of children were vaccinated, in 2014 – 82.9 %, in 2015 – 63.2 %, in 2016 – 60.7 %. In 2017 this index became quite higher and counted 90.2 % (fig. ). Generally, about 75.5 % of children were vaccinated in Ukraine. The lowest immunization coverage with tuberculosis antigens was in Zhytomyr (52.6 %), Ivano-Frankivsk (66.0 %), Chernihiv regions (67.0 %). The highest was in Sumy (88.4 %), Kiev (87.6 %), and Chernivtsi (87.3 %) region.

Poliomyelitis

WHO announced Ukraine to be a country with high risk of poliomyelitis outbreak. Despite the fully absence of the disease both in region and in Ukraine generally, total vaccination coverage is not in an appropriate state. During last 5 years 3-doses vaccine coverage children by 1 year (2, 4 and 6 months) was: 2013 year — 99.0 %, 2014 — 48.6 %, 2015 — 75.6 %, 2016 — 45.7 %, 2017 — 90.2 % (fig. ). Till 01.12.2017 all regions provided an initial doses of vaccine against poliovirus to 170,832 children aged by 1 year, that makes only 47.4 % of all number. The lowest coverage rates was in Rivno (22.4 %), Volyn (27.9 %), Kherson (30.1 %) regions; the highest correspondently was in Kiev city (93.6 %), Donetsk (63.3 %), Poltava (62.0 %) regions.

Thus, RI coverage was temporary reduced that soon led to increase incidence of some VPD. The epidemic situation regarding the incidence of vaccine-dependent infections among the child population of Sumy region and Ukraine in general. Sporadic cases can cause infection outbreaks. During 10-15 years, several large-scale outbreaks took place, the most powerful of which is still ongoing. Undoubtedly, the reason for the latest epidemic of measles in Ukraine is to reduce the coverage of children vaccinations, which led to a catastrophic decline in collective immunity. Against the background of high contagiousness, this provides a rapid spread of infection, especially in children’s collectives, which leads to the introduction of quarantine measures. The peculiarities of the epidemic are a large proportion of adult patients, and the large number of fully vaccinated children. There are also cases of the disease of children under 1 year old and even congenital measles. We consider it expedient to make the obligatory revaccination of adults (to make it into the vaccination plan). To decrease the incidence of VPDs and to keep epidemic welfare RI coverage should be not less than 95 % as it was established by WHO and General state immune-prophylaxis program. Encouraging mothers to attend antenatal care and educational interventions targeted at mothers are recommended to improve vaccination status of children in Ukraine. All these aspects can be done after total vaccine coverage for all medical establishments for further regular regional supplying by specific medicines [8]. It is clear, that progress in vaccine-prophylaxis works would be impossible without strict state control over immune medicaments safety and quality, and providing an appropriate social and medical protection for patients with post-vaccine complications.

CONCLUSIONS

RI uptake in Ukraine is still below WHO target. The main reason for the ongoing measles outbreak was low vaccination coverage for routine immunization antigens as a result of which collective immunity decreased to a critical level. Strict monitoring of the implementation of the immunization schedule by medical institutions at all levels are recommended to improve vaccination status of Ukrainian children.

REFERENCES

1. National Primary Health Care Development Agency. National Immunisation Policy 2009. Available at http://www.jhsph.edu/research/

2. World Health Organization (WHO). United Nations Children’s Fund (UNICEF). Global immunization data. Geneva: WHO; 2014. Jul. Available from: http://www. who.int/immunization/monitoring_surveillance/global_immunization.

3. World Health Organization. The Global Vaccine Action Plan 2011-2020. Introduction and Immunization Landscape Today. Available from: http://www.who.int/immunization/global_vaccine_action_plan/GVAP_Introduction_and_Immunization_Landscape_Today.

4. Strategic Advisory Group of Experts on Immunization. 2016 midterm review of the Global Vaccine Action Plan. WHO; 2016. 26p. Available from: http://www.who.int/immunization/global_vaccine_action_plan/SAGE_GVAP_Assessment_Report_2016

5. I. Abdulraheem, A. Onajole, A. Jimoh. Reasons for incomplete vaccination and factors for missed opportunities among rural Nigerian children. Public Health Epidemiology. 2011;3(4):194–203.

6. World Health Organization. «Measles vaccines: WHO position paper». Weekly epidemiological record. 2017;84 (35):349–360.

7. Ministry of Health of Ukraine. Order № 551: Оn the improvement of preventive vaccination in Ukraine. Available from: http:// www.moz.gov.ua/ua/portal/dn_20140811_0551. Accessed: August 11, 2014. (in Ukrainian).

8. V. A. Smeyanov, S. V. Tarasenko, O. I. Smeyanova. Development and implementation of the internal audit mechanisms to be used in the health care facilities. Georgian Medical News. 2013;6 (219):58-60.

9. Ministry of Health of Ukraine. Information on the state of implementation of the National program of immunoprophylaxis and rotection of population against infectious diseases 2009-2015 for 2014. Available from: http://www.moz.gov.ua/ua/portal/pgrep_imun_2014. html. (in Ukrainian)

10. World Health Organization. Immunization coverage. Fact sheet. Available from: http://www.who.int/mediacentre/factsheets/ fs378/en/. Accessed: July 2017.

Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Vladyslav A. Smiianov

Sumy State University

Rymskoho-Korsakova St., 2, 40007 Sumy, Ukraine

e-mail: v.smiyanov@med.sumdu.edu.ua

Received: 24.11.2018

Accepted: 31.01.2019

Table I. Vaccination schedule, Ukraine

During first 18 months after birth

2-16 years

Adults

1 day

3-5 day

2 months

4 months

6 months

12 months

18 months

6 years

14 years

16 years

every 10 years

Hepatitis В

Tuberculosis

Measles, Mumps, Rubella

Diphtheria, Tetanus

Pertussis

Poliomyelitis

HiB

Figure 1. Vaccination coverage for Hepatitis B antigens in Sumy Region

Figure 2. The incidence of vaccine preventable diseases among the children in Sumy region (per 100,000 population).

Figure 3. The incidence of children’s measles in Ukraine and Sumy Region (per 100,000 population)

Figure 4. Vaccination coverage by MMR-1 and MMR-2 of children in Ukraine and Sumy region (%).