Robb Butler

The state of measles and rubella in the WHO European Region, 2013

Measles and rubella persist in the World Health Organization European Region despite long-standing and widespread use of vaccines against them. Our aim was to review the epidemiology of measles and rubella in relation to the goal of eliminating these diseases from the Region by 2015. We report on the number of measles and rubella cases by country in 2012 and present an analysis of preliminary measles and rubella surveillance data for 2013. We analysed data of these diseases for 2013 by age group, diagnosis confirmation (clinical, laboratory-confirmed and epidemiologically linked), and vaccination, hospitalization and importation status. We also report on measles-related deaths. For 2012, there were 26,785 [corrected] measles cases and 29,601 rubella cases reported in the Region. For 2013, these figures were 31,520 and 39,367 respectively. Most measles cases in 2013 (96%; n = 30,178) were reported by nine countries: Georgia (7830), Germany (1773), Italy (2216), the Netherlands (2499), Romania (1074), the Russian Federation (2174), Turkey (7404), Ukraine (3308) and the United Kingdom (1900). In 2013, most measles cases were among unvaccinated persons and over one in three patients were aged 20 years and older. For 2013, almost all rubella cases were reported by Poland (n = 38,585; 98%). High population immunity and high-quality surveillance are the cornerstones to eliminate measles and rubella. Without sustained political commitment and accelerated action by Member States and partners, the elimination of measles and rubella in the WHO European Region may not be achieved.

Addressing vaccine hesitancy: The potential value of commercial and social marketing principles and practices.

Many countries and communities are dealing with groups and growing numbers of individuals who are delaying or refusing recommended vaccinations for themselves or their children. This has created a need for immunization programs to find approaches and strategies to address vaccine hesitancy. An important source of useful approaches and strategies is found in the frameworks, practices, and principles used by commercial and social marketers, many of which have been used by immunization programs. This review examines how social and commercial marketing principles and practices can be used to help address vaccine hesitancy. It provides an introduction to key marketing and social marketing concepts, identifies some of the major challenges to applying commercial and social marketing approaches to immunization programs, illustrates how immunization advocates and programs can use marketing and social marketing approaches to address vaccine hesitancy, and identifies some of the lessons that commercial and non-immunization sectors have learned that may have relevance for immunization. While the use of commercial and social marketing practices and principles does not guarantee success, the evidence, lessons learned, and applications to date indicate that they have considerable value in fostering vaccine acceptance.

Improving Medical Decision Making and Health Promotion through Culture-Sensitive Health Communication An Agenda for Science and Practice

This review introduces the concept of culture-sensitive health communication. The basic premise is that congruency between the recipient’s cultural characteristics and the respective message will increase the communication’s effectiveness. Culture-sensitive health communication is therefore defined as the deliberate and evidence-informed adaptation of health communication to the recipients’ cultural background in order to increase knowledge and improve decision preparedness in medical decision making, and to enhance the persuasiveness of messages in health promotion. To achieve effective health communication in varying cultural contexts, an empirically and theoretically based understanding of culture will be indispensable. We therefore define culture, discuss which evolutionary and structural factors contribute to the development of cultural diversity, and how differences are conceptualized as scientific constructs in current models of cultural differences. Additionally, we will explicate the implications of cultural differences for psychological theorizing, because common constructs of health behavior theories and decision making, such as attitudes or risk perception, are subject to cultural variation. In terms of communication we will review both communication strategies as well as channels that are used to disseminate health messages, and discuss the implications of cultural differences for their effectiveness. Finally, we propose both an agenda for science as well as for practice to advance and apply the evidence base for culture-sensitive health communication. This calls for more interdisciplinary research: between science and practice, but also between scientific disciplines and between basic and applied research.This review introduces the concept of culture-sensitive health communication. The basic premise is that congruency between the recipient’s cultural characteristics and the respective message will increase the communication’s effectiveness. Culture-sensitive health communication is therefore defined as the deliberate and evidence-informed adaptation of health communication to the recipients’ cultural background in order to increase knowledge and improve preparation for medical decision making and to enhance the persuasiveness of messages in health promotion. To achieve effective health communication in varying cultural contexts, an empirically and theoretically based understanding of culture will be indispensable. We therefore define culture, discuss which evolutionary and structural factors contribute to the development of cultural diversity, and examine how differences are conceptualized as scientific constructs in current models of cultural differences. In addition, we will explicate the implications of cultural differences for psychological theorizing, because common constructs of health behavior theories and decision making, such as attitudes or risk perception, are subject to cultural variation. In terms of communication, we will review both communication strategies and channels that are used to disseminate health messages, and we will discuss the implications of cultural differences for their effectiveness. Finally, we propose an agenda both for science and for practice to advance and apply the evidence base for culture-sensitive health communication. This calls for more interdisciplinary research between science and practice but also between scientific disciplines and between basic and applied research.

Parental attitudes and decision-making regarding MMR vaccination in an anthroposophic community in Sweden - A qualitative study.

Measles outbreaks occur regularly throughout Europe, up to 31500 cases in the previous year, particularly where there are pockets of populations with lower vaccination coverage than the recommended ≥ 95%. Anthroposophic communities in Europe are one of several groups with relatively low vaccination coverage. In Sweden, outbreaks of measles and rubella were reported from an anthroposophic community. Thus the aim of this qualitative study was to explore facilitators and barriers to MMR vaccination among parents living in anthroposophic communities in Sweden. Twenty parents living in an anthroposophic community were interviewed, focusing on their views and decisions on MMR vaccination. The interviews were analyzed using qualitative content analysis. Two overarching views of health emerged, differentiating broadly parents who vaccinate vs. parents who do not vaccinate. Four themes describing parental attitudes toward measles vaccination were developed and three of these, the conformers, the pragmatists and the attentive delayers describe different approaches toward vaccinations among those who actually vaccinate. The last theme, promoters of natural immunity, represents those postponing or refusing vaccination beyond childhood. This study suggests that there is a spectrum of parental beliefs regarding MMR vaccination in this anthroposophic community. Interventions specifically targeted to the anthroposophic community and strengthening health workers capacity for a constructive dialog on vaccines benefit and risks may contribute to higher vaccination coverage. This is believed to minimize the risk of future epidemics and contribute to the WHO European Regions goal of eliminating measles.

Challenges of Maintaining Polio-free Status of the European Region

BACKGROUND The European region, certified as polio free in 2002, had recent wild poliovirus (WPV) introductions, resulting in a major outbreak in Central Asian countries and Russia in 2010 and in current widespread WPV type 1 circulation in Israel, which endangered the polio-free status of the region. METHODS We assessed the data on the major determinants of poliovirus transmission risk (population immunity, surveillance, and outbreak preparedness) and reviewed current threats and measures implemented in response to recent WPV introductions. RESULTS Despite high regional vaccination coverage and functioning surveillance, several countries in the region are at high or intermediate risk of poliovirus transmission. Coverage remains suboptimal in some countries, subnational geographic areas, and population groups, and surveillance (acute flaccid paralysis, enterovirus, and environmental) needs further strengthening. Supplementary immunization activities, which were instrumental in the rapid interruption of WPV1 circulation in 2010, should be implemented in high-risk countries to close population immunity gaps. National polio outbreak preparedness plans need strengthening. Immunization efforts to interrupt WPV transmission in Israel should continue. CONCLUSIONS The European region has successfully maintained its polio-free status since 2002, but numerous challenges remain. Staying polio free will require continued coordinated efforts, political commitment and financial support from all countries.

Progress and challenges in measles and rubella elimination in the WHO European Region

INTRODUCTION Despite availability of safe and cost-effective vaccines to prevent it, measles remains one of the significant causes of death among children under five years of age globally. The World Health Organization (WHO) European Region has seen a drastic decline in measles and rubella cases in recent years, and a few of the once common measles genotypes are no longer detected. Buoyed by this success, all Member States of the Region reconfirmed their commitment in 2010 to eliminating measles and rubella, and made this a central objective of the European Vaccine Action Plan 2015-2020 (EVAP). Nevertheless, sporadic outbreaks continue, recently affecting primarily adolescents and young adults with no vaccination or an incomplete vaccination history. The European Regional Verification Commission for Measles and Rubella Elimination was established in 2011 to evaluate the status of measles and rubella elimination based on documentation submitted annually by each countrys national verification committee. DISCUSSION Each countrys commitment to eliminate measles and rubella is influenced by competing health priorities, and in some cases lack of capacity and resources. All countries need to improve case-base surveillance for both measles and rubella, ensure documentation of each outbreak and strengthen the link between epidemiology and laboratory data. Achieving high coverage with measles- and rubella-containing vaccines will require a multisectoral approach to address the root causes of lower uptake in identified communities including service delivery challenges or vaccine safety concerns caused by circulating myths about vaccination. CONCLUSIONS The WHO European Region has made steady progress towards eliminating measles and rubella and over half of the countries interrupted endemic transmission of both diseases by 2015. The programmatic challenges in disease surveillance, vaccination service delivery and communication in the remaining endemic countries should be addressed through periodic evaluation of the strategies by all stakeholders and exploring additional opportunities to accelerate the ongoing elimination activities.

Measles and rubella elimination in the WHO Region for Europe: progress and challenges

Globally measles remains one of the leading causes of death among young children even though a safe and cost-effective vaccine is available. The World Health Organization (WHO) European Region has seen a decline in measles and rubella cases in recent years. The recent outbreaks have primarily affected adolescents and young adults with no vaccination or an incomplete vaccination history. Eliminating measles and rubella is one of the top immunization priorities of the European Region as outlined in the European Vaccine Action Plan 2015-2020. Following the 2010 decision by the Member States in the Region to initiate the process of verifying elimination, the European Regional Verification Commission for Measles and Rubella Elimination (RVC) was established in 2011. The RVC meets every year to evaluate the status of measles and rubella elimination in the Region based on documentation submitted by each countrys National Verification Committees. The verification process was however modified in late 2014 to assess the elimination status at the individual country level instead of at regional level. The WHO European Region has made substantial progress towards measles and rubella elimination over the past 5 years. The RVCs conclusion in 2016 that 70% and 66% of the 53 Member States in the Region had interrupted the endemic transmission of measles and rubella, respectively, by 2015 is a testament to this progress. Nevertheless, where measles and rubella remain endemic, challenges in vaccination service delivery and disease surveillance will need to be addressed through focused technical assistance from WHO and development partners.

Commentary to: How to respond to vocal vaccine deniers in public

In spite of the huge positive impact of immunization on fighting infectious diseases and improving health outcomes, acceptance of vaccines cannot be taken for granted. Sadly, vaccine refusal and denial persists. Denying the necessity and safety of recommended vaccines presents a major threat to a healthy society as it subverts community protection against vaccine-preventable diseases [1]. This commentary introduces the new evidence-informed guidance document of the World Health Organization on how to respond to vaccine refusal and denial in public (available online, see link below). The spreading of vaccine misinformation by vocal vaccine deniers contributes to vaccine hesitancy [2]. Vocal vaccine deniers are at the extreme end of the subgroup of vaccine refusers [3] and actively advocate against vaccination, using science denialism techniques to justify their beliefs i.e. ‘‘the employment of rhetorical arguments to give the appearance of legitimate debate where there is none” [4] ‘‘an approach that has the ultimate goal of rejecting a proposition on which a scientific consensus exists” [5 p.2]. They reject any pro-vaccine argument and, on principle, do not accept recommended vaccines. The potential damage a vocal vaccine denier can cause through mass media as an amplifier of myths and misinformation is significant. Furthermore, unprepared or rash responses to vocal vaccine deniers in public fora may undermine the pro-vaccine stance of the audience and shift their beliefs [6]. When engaging in a public discussion with a vocal vaccine denier it is not only necessary to provide scientific evidence, but also to mitigate his or her negative influence on the public audience by responding in a way that appeals to and is understood by the public. This poses a challenge when vocal vaccine deniers refer to alleged or quasi-scientific evidence [7] and play on emotions that appeal to and raise concerns in the audience [8]. While general skills on engaging in a public debate or interview are helpful, they do not provide a strategy for how to address the specific issues and rhetoric techniques used by the vocal vaccine deniers. Given the potential impact of vocal vaccine deniers, the lack of readily available advice in this area and the frequent requests for support from WHO Member States, a best practice evidence-informed guidance document has been developed by the WHO Regional Office for Europe. The document introduces an algorithm to develop responses to anti-vaccination rhetoric and guides health authority spokespersons in assessing whether to engage in the specific public discussion with the vaccine denier or not. The document is based on public health data, literature reviews in the areas of public health, psychology, communication and vaccinology as well as expert opinion. The document was reviewed and discussed by the members of the European Technical Advisory Group of Experts on Immunization (ETAGE) at their annual meeting (2015; Copenhagen, Denmark) and by participants of the WHO European Regional Meeting of National Immunization Programme Managers (2015; Antwerp, Belgium), which included the immunization programme managers of the 53 Member States of the WHO European Region, and it was tested and evaluated by national immunization managers of Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Montenegro, Serbia and the former Yugoslav Republic of Macedonia during the Technical consultation on addressing vaccination opposition (2016; Belgrade, Serbia). The guiding principles of the algorithm are: (1) the general public is the target audience, not the vocal vaccine denier and (2) the aim is to correct the misinformation content and to unmask the techniques used by the vocal vaccine denier. In a public discussion vocal vaccine deniers are not likely to be convinced by any quantity of evidence; on the contrary they are likely to question the science of immunization as a whole. But even if evidence will not change the mind of the vocal vaccine denier, it may still appeal to the general public. By following the first guiding principle the spokesperson should see it as his or her role to inform undecided individuals, equip vaccine advocates with evidencebased arguments and even convince sceptics and not be distracted by any ambition to convince the vaccine denier. Knowing the common science denialism techniques [5] and the topics most often raised by vocal vaccine deniers, the health authority spokesperson can prepare responses which aim to correct misinformation as well as to unmask the techniques used. The algorithm (see Fig. 1) illustrates this process. Building on the literature reviewed, the core topics of vocal vaccine deniers have been reduced to five: threat of disease, alternatives to vaccines,

Slow Progress In Finalizing Measles And Rubella Elimination In The European Region.

All countries in the World Health Organization European Region committed to eliminating endemic transmission of measles and rubella by 2015, and disease incidence has decreased dramatically. However, there was little progress between 2012 and 2013, and the goal will likely not be achieved on time. Genuine political commitment, increased technical capacity, and greater public awareness are urgently needed, especially in Western Europe.

Simulation Exercises to Strengthen Polio Outbreak Preparedness: Experience of the World Health Organization European Region

BACKGROUND Poliovirus importations and related outbreaks continue to occur in polio-free countries, including those in the World Health Organization (WHO) European Region. National preparedness plans for responding to poliovirus introduction are insufficient in many countries of the European Region. We describe a series of polio outbreak simulation exercises that were implemented to formally test polio outbreak preparedness plans in the European Region. METHODS We designed and implemented the exercises, reviewed the results, made recommendations, and assessed the role of outbreak simulation exercises in maintaining regional polio-free status. In addition, we performed a comprehensive review of the national plans of all WHO Member States in the European Region. RESULTS Three exercises, delivered during 2011-2013 (for the Balkans, United Kingdom, and the Caucasus and Ukraine), revealed that participating countries were generally prepared for poliovirus introduction, but the level of preparedness needed improvement. The areas in particular need of strengthening were national preparedness plans, initial response, plans for securing vaccine supply, and communications. CONCLUSIONS Polio outbreak simulation exercises can be valuable tools to help maintain polio-free status and should be extended to other high-risk countries and subnational areas in the European Region and elsewhere.