WHO Guide “Tailoring Immunization Programmes”:

introduction in Bulgaria and first results

WHO European Regional Meeting of National Immunization Programme ManagersAntalya, Turkey, 18 – 20 March 2014

Angel Kunchev, MD, Chief State Health Inspector, Ministry of Health of Bulgaria

Radosveta Filipova, MD,Head, State Health Department, Ministry of Health of Bulgaria

Bulgaria – background information

• Southeastern Europe – Balkan peninsula • Territory 110 993 km2 ; • 28 administrative regions, 263 municipalities• Total population 7 563 710• Urban areas population 70,17 %• Ethnic structure:

• Bulgarians 84 %• Turks 9,4 %• Roma 4,7 %• Other minorities (Armenians, Vlachs,

Jews etc.) 1,9 %• Live births 80 956• Birth rate 10.7/ 1000• Infant mortality rate 9,0 / 1000 life births• Natural growth - 3,5 / 1000• Life expectancy 73,4 yr.

Source: National Center of Health Informatics, Basic Statistic Information for 2011

What a TIP Approach means?

A pathway to understand what influences caregivers when they consider whether or not to vaccinate their child and to detect determinants providing opportunity, ability and motivation to vaccinate or not.

Why especially Bulgaria was chosen?

The measles outbreak in Bulgaria 2009 – 2011 predominantly affected vulnerable groups of population and pockets of non-immunized or partially immunized individuals at subnational levels despite the national coverage for the first dose of MMR vaccine was near 96%.

MEASLES CASES IN BULGARIA AFTER THE INTRODUCTION OF

MEASLES IMMUNIZATION, 1969

Source: National Centre of Infectious and Parasitic Diseases, Bulgaria, 2013

NATIONAL IMMUNIZATION COVERAGE WITH MMR VACCINE IN

BULGARIA, 2001-2012

Year

VACCINE COVERAGE (%)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

MMR at 13 mos 90.1 92.1 95.5 94.7 96.2 95.7 96.0 95.9 96.1 96.5 94.5 93.7

MMR at 12 yrs 68.8 79.2 89.4 90.8 92.4 93.3 94.0 94.3 92.8 95.7 93.9 94.0

Source: National Centre of Infectious and Parasitic Diseases, Bulgaria, 2012

MEASLES OUTBREAK IN BULGARIA, 2009-2011

∞ Marin ova L., E p idemiology of measles in Bu lg ar ia d u rin g th e elimin ation an d pr osp ects for effect ive su rveillance. Ph D t hesis, S ep t. 20 12 .

Total number Number of Roma people

%

Measles cases 24 208 21 701 89.6

Deaths 24 22 91.7

VACCINATION STATUS OF MEASLES CASES IN BULGARIA, 2009-

2011 Number of

vaccine dosesNumber of cases by age groups

Total≤ 1 1-4 5-9 10-14 15-19 20-29 30+

0 3 301 1 368 266 145 120 42 20 5 262

1 18 2 085 2 174 1 259 541 69 20 6 166

2 3 107 188 329 518 80 13 1 238

No data 569 2 299 1 938 1 880 1 988 1 719 1 306 11 699

Total 3 891 5 859 4 566 3 613 3 167 1 910 1 359 24 365

LESSONS LEARNED

• The approach to a better measles control in Bulgaria should be focused on the improvement of the routine immunization activities of underserved Roma communities through better communication and awareness of the community and permanent collaboration with the Network of the Health Mediators and other NGOs.

• Because the level of vaccination coverage is very much depending on the knowledge of the health care workers, different strategies and trainings targeting health professionals should be implemented.

Health mediator – what does mean?

National network of Health mediators was established in 2007 in the frame of a PHARE project and transferred after finishing the Project in a municipality employees financed by the state budget.

General requirements for Job positionEducation: Secondary school

Qualification: Completed specialized training course for a health mediator, approved by the Ministry of Health or Diploma (Certificate) from a Medical College

Languages: Knowledge of Romany/Turkish language is commendable

Additional requirements: Knowledge about the health and social legislation and relevant national policies

Job description: Mediates the process of ensuring access to health services of representatives of vulnerable minority groups

Major responsibilities

Work with clients: ·  Good knowledge and formulation of the problem;·  Assessment of the difficulties connected with the access to the respective services and elaboration of a work plan on the case. 

Facilitation of the process of access to services in the sphere of health care for people, needing medical assistance:·  Helps (accompanies, informs, clarifies, explains) with the contacts between the GP and/or other medical experts and the patient.  

Assistance in the communications with the Health Insurance Fund:·  The health mediator provides information on the necessity and significance of the services, provided by the National Health Insurance Fund and helps with the filling in of the necessary documentation.  

Assistance with the communications with the Department for Social Assistance, the State Agency for Child Protection and the Commission for Protection against Discrimination:·  The Mediator provides information about the functioning of these institutions and facilitates the clients’ access to them. 

Health education and prevention care for the population:·  Consults the target group on issues related to family planning and reproductive health;·  Explains the benefits of vaccinations and immunizations.

TIP Problem Statement - Bulgaria

• Health problem

• Potential primary audience

• Under-vaccination for childhood diseases among vulnerable pockets of the Bulgarian population, evidenced by the 2009-2010measles epidemic

• Health mediators who act as gatekeepers for vaccination communication, education, reminder and access to health and social services

• Caregivers/parents of children up to 3 years

Strategic activities 1• Identify and share best

practices in health mediation in the context of child vaccination promotion

• Revise the job description for health mediators and include more attention to maternal and child health/immunization

• Use HM Internet platform to identify best practices

www.zdravenmediator.net • Organize regional/national

workshops to share best practices

• Identifying unregistered to local GP children

• Provide them information on health services available including vaccinations and help them to take decision

• Reminding parents for the time of coming vaccinations

Strategic activities 2• Increase competences of

health mediators in maternal and child health and Immunization

• Provide continuing education to existing health mediators

• Provide more hours in the current curriculum of health mediators in the field of MCH, CD protection and immunizations

• Involve local GPs in the health mediator training programme

• Upgrade the training with best practices in interpersonal communication and vaccination promotion

Strategic activities 3• Promote municipal level

relationships and collaboration between health mediators, social workers, Regional Health Inspectorates and GP’s

• Develop and disseminate job aids for use by health mediators

• Organize regional workshops to improve inter-institutional relationships and coordination –Collect and disseminate best practices at the municipal level

• Develop and disseminate reminder posters, recall aids

• Develop a standard flip-chart (incl. vaccination calendar, information on VPD and benefits and value of vaccination ) to guide “health-talks” in the community

• Design standard module/plan for holding a community “health-talk”

“LETS TALK ABOUT PROTECTION” PROJECT

This collaborative project aims to: perform cultural adaptation of the European materials on immunizations; facilitate the communication between healthcare providers (HCPs), Health

mediators (HMs) and parents on the topic of vaccination; explain in simple language, graphics and pictures the benefits and risks from

immunization; give answers to the most popular concerns that parents have towards

vaccination.

RESULTS AND WHAT COMES NEXT? Increasing the number of Health Mediators of national level –

130 for 2013 in 71 municipalities, 150 for 2014 in 79 municipalities

Organize a national meeting in April 2014 with participation of Health Mediators, epidemiologists and GP’s during the EIW 2014

Develop and disseminate print materials on different languages for Roma and refugees

Illegal migrants identified on the Bulgarian-Turkish green, 2012 and 2013

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Syrian children ready for immunization in the refugee camp in Harmanly