This document analyzes vaccination rates and public perceptions of vaccination in Ukraine. It finds that vaccination rates have dropped significantly in recent years due to growing anti-vaccination sentiments supported by media and experts. This threatens to undermine Ukraine's progress against infectious diseases and could turn the country into a hotbed for diseases if rates fall below critical thresholds. The document recommends improving public health communications and launching a nationwide information campaign to rebuild trust in vaccination and improve vaccination rates.

1. GRAYLING UKRAINE THINK-PIECE: HEALTHCARE
WHY UKRAINIANS ARE AFRAID OF VACCINES,
THE IMPLICATIONS OF THIS
AND WHAT CAN BE DONE IN RESPONSE
Analysis of Ukraine‘s governmental vaccination policies
and factors of Ukrainians‘ distrust in vaccination.
Communication tools and approaches to overcome threatening trends.
April 2011
Written and published by Grayling
1

2. TABLE OF CONTENTS
1. EXECUTIVE SUMMARY 3
2. INTRODUCTION 5
3. COMMUNICABLE DISEASES’ PREVALENCE IN UKRAINE 9
a) Non-seasonal vaccine prevented infections:
general tendencies and specifics 10
– tuberculosis 11
– virus hepatitis 12
– diphtheria 12
– measles 13
– rubella 13
– tetanus 14
– poliomyelitis 14
– pertussis 14
b) Seasonal vaccine preventable infections: myths and reality 15
4. UKRAINE’S STATE POLICY ON VACCINATION 18
5. PUBLIC PERCEPTION OF VACCINATION AND MEANS OF IMPROVING IT 23
a) Role of media in building public perception of vaccination in Ukraine 23
b) How to improve the situation. 25
6. CONCLUSIONS 29
7. SUGGESTED COMMUNICATION RESPONSES 31
2

3. 1. EXECUTIVE SUMMARY
A thorough analysis of the key human development factors in Ukraine such as life
expectancy, death rate, infant mortality, prevalence of the most socially dangerous
diseases etc., leads to the conclusion that the Ukrainian healthcare system needs urgent
reforms, which should address the needs of the majority of citizens, redefine priorities of
the public policy and reflect the level of country‘s social and economic development. The
reforms should be realized in parallel with the effective fight against corruption and
consequent measures aimed at restoration of the image of the national healthcare in the
eyes of the population.
The issue of vaccination became the most vivid demonstration of the depth of problems in
Ukrainian public healthcare. As a result of a number of serious factors, Ukraine found itself
on the edge of a critical decrease of the collective immunity level. In many regions of
Ukraine the level of vaccination dropped to less than 80%, which may destroy all serious
achievements of the previous years in the area of infectious diseases prevention and
management. Despite at the present moment, the epidemiologic situation in Ukraine for
non-seasonal vaccine preventable diseases can be characterized as far from being critical,
in the medium term there exist the risks of Ukraine turning into a hotbed of the most
socially dangerous communicable diseases.
Among the factors which contributed to the radical decrease of vaccination level, the most
important were:
 Growing anti-vaccination moods in the Ukrainian society, supported by numerous
media, and pseudo experts (background for this are: the total mistrust of Ukrainians
in the public healthcare system and even in the expert community; exact tragic
events of 2008 associated with vaccination); they resulted in growing number of
refusals to immunize adults and especially children;
 Possibilities to avoid vaccination openly or implicitly provided by the imperfect
Ukrainian legislation and corruption;
 Faults of the public vaccination policies, which resulted in actual shortage of
vaccines in the majority of Ukrainian regions.
3

4. The above mentioned requires urgent measures from the state, non-governmental and
international organizations, medical and expert environment and pharmaceutical business.
One of the elements of such an activity should be restoration of the populations trust in
vaccination and neutralization of the anti-vaccination hysteria of the previous years. Unlike
the legal and procedural factors, which can be modernized / improved in a relatively short
period of time, the image of the vaccination is the most difficult to change. So it should be
addressed with all seriousness and profoundness by all stakeholders and authorities. In
the result of related activities, the level of population‘s immune-protection should increase
and the morbidity rate should become lower. The mechanisms of reaching this aim
suggested as the result of the performed research are:
– Improved statistics and information exchange between the healthcare authorities
and population in the field of infectious diseases;
– Ethics code for journalists writing on medical issues;
– Media trainings for general and business media journalists;
– Nationwide information / educational campaign aimed at increasing trust and
improving awareness of the population of the immune protection of children and adults by
the means of vaccination, which has to be supported and conducted jointly by the State,
doctors, NGOs and pharmaceutical business.
In its turn, Grayling as a global PR and PA agency, which has serious international
experience in the area of healthcare communication, invites all interested parties to
discussion around this issue to be able to suggest the most appropriate solutions, which
should help Ukraine come out of this potentially critical situation.
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5. 2. INTRODUCTION
In a modern society, the level of a country‘s economic and social development is primarily
assessed not on the basis of dry figures of GDP and growth rates, but by the quality of
living. This sometimes unclear notion includes a number of socially important indicators,
which demonstrate adequateness of the material benefits distribution, level of social justice
and satisfaction of citizens with their life and living conditions, etc. In all definitions of the
quality of living the state of health and quality of medical services are always on the top
position. By the healthcare system development and key public health indicators like life
expectancy, morbidity, infant mortality and infectious diseases prevalence one can easily
judge the general country‘s and state‘s performance, priorities of public policy, material
wealth of the population, public culture, etc.
In this relation Ukraine should be regarded as a country where the quality of living is
generally much lower than in the surrounding EU member-states and even in several
former Soviet republics. According to the 20th UNDP Human Development Report 2010
the average life expectancy in Ukraine was 68,6 years 1: 62,3 years for male and 74,5
years for female.
Other important indicators are also far from being optimistic: general mortality rate is
1,574 per 100 thousand of population (almost twice higher than in the USA); the infant
mortality is about 16 children per 1,000 live births, which corresponds to less developed
countries of Asia, Middle East and Latin America. The mortality from cardiovascular
diseases in Ukraine is almost 3 times higher than in the EU and oncology is 1,5 times
more widespread 2. Ukraine is also one of the European ―leaders‖ in terms of HIV/AIDS
and tuberculosis prevalence, which raises deep concerns not only among the local
population, but in the European political and medical circles.
The above mentioned developments take place amid the growing public expenditures for
the healthcare, which were about 4,0% of the GDP in 2009 (corresponds to the level EU
members like Bulgaria, Estonia, Lithuania etc., but is less than the WHO recommended
1
http://hdrstats.undp.org/en/countries/profiles/UKR.html
2
http://medstrana.com/articles/1639/
5

6. level of 5%) 3, and the permanent attempts to reform the public healthcare sector. This
poses serious questions on the effectiveness of the Ukrainian healthcare system on the
whole, on the perception of the healthy lifestyle among the Ukrainians and on their trust in
the state medicine.
Table 1. Life expectancy, Mortality and Healthcare spending
in some counties of the World
Country Life Male Female4 Mortality, Total General
Expectancy Per 100 Expenditure government 6
thousand on Health*, expenditure
of % gross on health
population5 domestic as % of total
(2010) product expenditure
(2007) on health
(2007)
Russia 66.29 59.8 73.17 1 604 5.4 64.2
India 66.80 65.77 67.95 748 4.1 26.2
Kazakhstan 68.51 63.24 74.08 938 3.7 66.1
Ukraine 68.58 62.79 74.75 1 574 6.8 57.6
Belarus 71.20 65.57 77.18 1 377 6.5 74.9
Turkey 72.50 70.61 74.49 610 5 69.0
China 74.68 72.68 76.94 703 4.3 44.7
Poland 76.05 72.1 80.25 1 017 6.4 70.9
Georgia 77.12 73.8 80.82 992 8.2 18.4
USA 78.37 75.92 80.93 838 15.7 45.5
EU 78.82 75.7 82.13 1 033 7,76 (EU-25); –––
8,6 (EU-15)
5,8 % (New
Member
States)
Germany 80.07 77.82 82.44 1 092 10.4 76.9
One of the key reasons for the described critical situation is corruption, which became a
real ―epidemic‖ of the Ukrainian medicine and healthcare in general. It is a well-known fact
that in Ukraine free public medicine does not exist in reality. Almost all visits to doctors on
all levels are accompanied by presents or exact payments in cash in this or that form.
3
http://hdrstats.undp.org/en/countries/profiles/UKR.html
4
https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html
5
https://www.cia.gov/library/publications/the-world-factbook/fields/2066.html
6
http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf
6

7. Moreover, the majority of drugs should be purchased by the patients themselves. On the
other hand, the system of public procurement in healthcare is one of the most corrupt in
the whole country. According to independent estimations, the budget costs leakage in
healthcare is over 35% and in some cases reaches 50%. The same situation is observed
in the private sector, when doctors in many cases receive kick-backs from pharmaceutical
companies or pharmacies. All attempts to change or improve this situation in Ukraine have
failed.
The whole set of problems encountered by the Ukrainian healthcare system became the
most apparent in recent years in such an important, but very sensitive field of vaccination.
The issue of scheduled and unscheduled vaccination against infectious diseases,
including seasonal ones, always caused ambivalent reactions not only among the
population, but also in medical and expert environments of most countries. The reasons
for this can be found in the nature of vaccines; numerous instances of adverse reactions;
diseases of people regardless of previous vaccination, etc. On the other hand, the
following factors should be also considered: overall reduction of cases of major infectious
diseases, ultimate eradication of some infections, lack of awareness about the nature of
infectious diseases and of the existing danger of their spread, as well as about the role of
vaccination in their overcoming. These factors have created a sense of security, of final
eradication of infectious diseases, and therefore no need in taking preventive and
protective measures. In some cases, social movements and mass protests of parents
refusing to vaccinate their children became widespread.
The situation in Ukraine appears to be particularly dangerous, where as the result of
several incidents and circumstances, society gained a growing negative attitude towards
vaccination, which had led to a mass denial of citizens and parents from scheduled and
unscheduled vaccination. Today, according to medical experts, the level of vaccination of
Ukrainians from infectious diseases fell almost to 80% 7. At the same time, according to the
WHO, if this level among children is lower than 95%, the country could face epidemics of
various infectious diseases, as it happened in such prosperous countries as Japan and
Sweden in the 1990s.
7
http://www.gk-press.if.ua/node/2700
7

8. Taking into account this complicated situation, Grayling as a leading global company in the
field of communications set itself a goal to carry out a deep analysis of which factors have
led to anti-vaccination moods in the Ukrainian society over the last years, which drivers
support this trend at the moment, and what communication tools should be used to restore
trust of the Ukrainians to vaccination as one of the most effective means of combating the
infectious diseases prevalence.
From its part, Grayling invites representatives of the state and local governments, medical
experts and leading domestic and foreign pharmaceutical companies to join the discussion
of this timely topic and together define steps that could prevent Ukraine from becoming a
hotbed of the most socially dangerous communicable diseases.
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9. 3. PREVALENCE OF COMMUNICABLE DISEASES IN UKRAINE
The system of protection from and prevention of communicable diseases in Ukraine is the
direct descendant of the Soviet immunoprophylaxis system which inherited both its merits
and disadvantages. Due to considerable centralization and control, in the Soviet Union in
general and in Ukraine in particular, one managed to cover the majority of population by
vaccination and to reach predominantly the immune-protection level, recommended by
international health organizations. In 1964 in the Soviet Union, the victory over
poliomyelitis was officially announced; smallpox was eradicated in 1936; noticeable
progress was demonstrated in the fight against diphtheria, measles, pertussis, tetanus and
other diseases.
At the same time, due to the formalized approach to the vaccination calendars and
strategies development, «dizziness from success», suppression of facts, imperfect
information collection and epidemiological surveillance practices, the USSR‘s leadership in
the area of combating the communicable diseases prevalence should be regarded as
doubtful. Moreover, in many cases the official statistics didn‘t correspond to the real
situation, what could be confirmed by the repeating outbreaks of diphtheria, pertussis, and
even poliomyelitis, the information of which was classified. The most serious problems of
the Soviet immunoprophylaxis system were: low quality of produced vaccines and
inadequate system of their control; dependence on imports; bad equipment of vaccine
producing enterprises; low qualification of vaccination and immunoprophylaxis specialists;
standardized approaches to children vaccination regardless of the region of residence and
individual acceptability; insufficient level of epidemiological surveillance and monitoring of
post-vaccine adverse effects, etc. Almost in the unchanged shape the mentioned system
was inherited by Ukraine, combined with a generally low confidence of the population in
domestic medicine.
Due to the deep political, economic and social crisis, in early 1990s in Ukraine, the
achievements of the Soviet immunoprophylaxis system were largely lost. In particular, the
epidemiological surveillance system deteriorated; the professional level of vaccination
campaigns dramatically decreased etc. Moreover, populations‘ disorientation in the
9

10. radically changing life environment and the rapidly expanding freedom of speech created a
perfect condition for appearance of a number of pseudo-doctors and propagandists, who
for different personal reasons launched a massive attack against vaccination. The
resulting numerous refusals of citizens from vaccinating themselves and their children
complicated by the general decrease in immunity and low professional level of vaccination
campaigns led to the outbreaks of diphtheria in 1993-95, which took the lives of more than
300 Ukrainians, and precipitated a general increase of the infectious diseases prevalence
in Ukraine.
Despite the increased attention of the state to the immunoprophylaxis and population
protection from infectious diseases, development and implementation of the national
vaccination plans, considerable international assistance, the epidemiologic situation in
Ukraine remains complicated.
a) Non-seasonal vaccine prevented infections: general tendencies and specifics
With a view of the geographical location of Ukraine, the infections endemic to tropical,
subtropical and subequatorial counties are not common here. At the same time, a number
of life threatening infections are traditionally spread on the Ukrainian territory, which
requires regular epidemiological surveillance, prevention and immune-protection.
The list of infections which need prevention by the means of vaccination in Ukraine, is
defined by the Decree of the Ministry of Health of Ukraine Nr. 48 from 03.02.2006 «On the
Order of Prophylactic Vaccinations in Ukraine and Control of the Quality and Turnover of
the Medical Immunobiological Drugs»8. According to it, the vaccination against the
following diseases is performed: tuberculosis, hepatitis B, diphtheria, pertussis, tetanus,
poliomyelitis, haemophilic infection, measles, rubella and parotitis.
Assessment of prevalence of the vaccine preventable infectious diseases in Ukraine is
quite a complicated task. The reasons for this are: an imperfect data collection system,
8
http://zakon.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=z0665-06
10

11. outdated laboratory equipment and technologies, suppression of the information on the
real state of affairs, insufficient openness of the healthcare authorities, etc. Consequently,
in order to receive relatively objective data, the comparative analysis of the official
statistics, scientific research results and assessments by international organizations is
strongly required.
The prevalence of tuberculosis has always been the key problem of the Ukrainian
epidemiology and medical practice. Starting from 1992, the morbidity had been steadily
growing and had increased 2,4 times to 84,5 cases per 100 thousand people by 2005,
when the maximum of this indicator was registered. The mortality during the epidemic
period increased 2,7 times from 9,5 cases in 1992 to 25,3 cases per 100 thousands of
people in 2005.
Since 2006 a gradual decrease of morbidity and mortality indicators has been registered.
In 2009, the prevalence of tuberculosis was 74,4 cases per 100 thousand of population
(totally 31,807 people), which was 7% less than in 2008 and 12% less than in 2005. The
mortality level decreased by 29% from 25,3 cases per 100 thousand of population in 2006
to 18,2 cases per 100 thousand in 2009 (7,676 people) and to 16,7 in 2010 9. About 86% of
tuberculosis patients were the people of able-bodied and reproductive age.
According to the WHO estimations, in Ukraine 16% of newly registered tuberculosis
patients have the multi-resistant disease form; among the recurrent cases the multi-
resistance occurrence exceeds 50%. Ukraine is one of 27 countries of the world, where
85% of the multi-resistant tuberculosis burden is registered and is on the 4 th place in the
world for the multi-resistant tuberculosis prevalence among the newly registered patients
(in 2008 it was on the 5 th place). In Ukraine the cases of the extended drug resistance
(almost to all anti-tuberculosis drugs) have been registered, like in 54 countries of the
world.
Considering the provided data, Ukraine ranks among the first in Europe and the CIS in
terms of tuberculosis prevalence. By a number of indicators, e.g. mortality, in Ukraine the
9
В. ХОМЯКОВ. Линия Смерти // Контракты, 04 квітня, 2011 р., С.17
11

12. tuberculosis epidemic should be stated. This requires redefinition of priorities of the public
healthcare policy and urgent joint actions with regional and global health organizations.
In 2009 the prevalence of different forms of virus hepatitis decreased by 29,6 % to 6,335
cases, which corresponded to the intensive indicator of 13,71 comparing to 19,22 in 2008.
The prevalence of hepatitis A decreased by 48,8% in all regions of Ukraine with the
intensive indicator being 5,69 comparing to 11,05 in 2008. The prevalence of hepatitis B
decreased by 7,2 % to 2,456 cases (5,32 comparing to 5,70 in 2008). At the same time,
the prevalence of acute hepatitis C (not preventable by vaccines) grew 10,65 %, which
could be also attributed to better diagnostics. In total 966 cases of HCV have been
registered, the highest rate being in Kyiv and in Cherkasy.
In should be mentioned, that in Ukraine the prevalence of tuberculosis and different forms
hepatitis in many cases is the result of unhealthy lifestyles of some groups of population
and is largely connected to the dramatic number of HIV/AIDS patients. Other specific risk
groups for such diseases are drug addicts, prisoners, prostitutes, homeless, etc.
Like in other former Soviet republics, in early 1990s the increased incidences of
diphtheria were registered in Ukraine. In 1991 the number of infected grew 10 times
comparing to 1990. The most serious situation was in 1995, when the incidence crossed
the epidemic barrier and reached 10,3 cases per 100,000 people (about 50 times higher
than in 1990). The number of victims of diphtheria in Ukraine in those years was very high:
111 deaths in 1994 and 187 in 1995. This required urgent measures from the Ukrainian
Government and international organizations, including the additional unscheduled
vaccination of children and adults. In the following years the incidence considerably
decreased and reached 1,4 cases per 100,000 people in 1998. By 2005 the number of
infected reached the level of 1990. In 2006 it was 68 people, 50 in 2008 (61 according to
WHO10), and 21 in 200911. The mortality decreased accordingly, but in comparative terms
remained considerably higher than in EU countries.
10
World Health Statistics 2010 // WHO, 2010 – P. 80
11
http://www.zn.ua/newspaper/articles/873
12

13. The results achieved by late 2000s became largely the consequence of adequate
vaccination policies and in case the vaccination level drops again, the morbidity may
increase dramatically and the diphtheria epidemic of the 1990s may become a reality in a
short period of time.
Measles is one of the most widespread and infectious diseases. In Ukraine since Soviet
times and currently, the measles morbidity is characterized by periodical growth and
decline. For the period of 1990-2006, 4 epidemic growths of measles were registered:
1991-1993, 1995-1996, 2001-2002 and 2005-2006. During the last outbreak, more than 45
thousand people were infected in Ukraine, and 5 of them died. At that time, Ukraine
accounted for 83% of the measles cases in the European region consisting of 53
countries. In 12 countries of Europe and Northern America ―imports‖ of measles from
Ukraine was registered. In addition, it should be noted that the structure of the infected
patients in Ukraine has changed and measles stopped being the mainly a paediatric
disease moving to the older age groups. These ―achievements‖ became one of the major
reasons of the unscheduled and controversial vaccination campaign of 2008.
According to assessments of the Ministry of Health of Ukraine and WHO experts, the
reasons for the measles outbreaks in Ukraine could be found in the inadequate
vaccination policies in early 1990s, when the level of the population immunity decreased
considerably. All this prevented Ukraine from reaching the general WHO task of total
eradication of measles by 2010. However, this data is argued by many specialists saying
that only about 15% of the population need immunity correction and the remaining 85%
have strong resistance to measles.
Anyway, in 2008, 48 cases of measles were registered in Ukraine12, in 2009, the morbidity
dropped to 30 cases, which corresponds to 0,06 cases per 100 thousand of population.
The prevalence of rubella in Ukraine is relatively high and reached the level of 162,907
cases several years ago. However, over the last years the tendency of the rubella
prevalence decrease became apparent. In 2008 – 3,495 cases of rubella were registered
12
World Health Statistics 2010 // WHO, 2010 – P. 80
13

14. in Ukraine13; in 2009 this indicator dropped 17,4 % to 2,884 cases (7,52 cases per 100
thousand people). The most considerable decrease was registered among children, who
are always considered to be the main carrier of this disease.
In 2009, 12 cases of tetanus were registered in 9 regions of Ukraine comparing to 17
cases in 2008, which corresponds to 0,03 cases per 100 of population.
On June 21, 2002 Ukraine as a part of the European region received the status of the
territory free of poliomyelitis. However, the vaccination by the most modern vaccines is
still going on according to the recommendations of the WHO.
In the last years an unfavourable situation with pertussis, an infectious disease which can
be controlled by the specific vaccination, emerged in Ukraine. In 2009, the morbidity grew
by 33,0 % in 19 regions of Ukraine. 1,364 cases were registered, which made 2,95 per
100 thousand people comparing to 2,21 in 2008 (1,025 cases).
Considering the above mentioned data, the epidemiologic situation in Ukraine for non-
seasonal vaccine preventable diseases can be characterized as relatively unstable, but far
from being critical as some experts, officials and journalists insist. In general, in Ukraine
prevalence of the most widespread communicable diseases does not considerably exceed
the level of the European countries. At the same time, periodical outbreaks of infections in
different regions of Ukraine leave serious doubts on the full control of the Ukrainian
healthcare authorities of the epidemic situation of Ukraine. The quality of immunization
campaigns, possible suppression of facts on the real infections prevalence as well as the
poor laboratory practices may result in further outbreaks of the most difficult communicable
infections. The refusals from immunization as the additional critical factor pose serious
threats to the possibility of the Ukrainian state to keep its hand on the epidemiological
situation in the country.
13
World Health Statistics 2010 // WHO, 2010 – P. 81
14

15. b) Seasonal vaccine preventable infections: myths and reality
Each year Ukraine, like other European counties, experiences the outbreaks of seasonal
acute respiratory viral infections (ARVI) and influenza. These infections are considered to
be the most widespread and by the number of sick persons they largely overcome other
communicable diseases. According to the existing data, in 2009 the number of ARVI
patients in Ukraine reached almost 9 Mln people and the number of citizens who got ill
with influenza reached 287,000. The ARVI and influenza are a common reason for
adverse effects and accompanying diseases, like pneumonia, which often lead to death. In
2005-2009 the average number of deaths from pneumonia was about 6,200.
Vaccination is one of the means of preventing influenza in parallel with the traditional
methods. However, the specifics of vaccination against influenza comparing to non-
seasonal diseases is that the strains of the virus change every season, so the one-time
vaccination does not provide immunization for the whole life and even for the medium
term, i.e. should be performed at least yearly. Even in this case it gives no guaranteed
protection as the influenza strains behaviour may change depending on the region and the
climate conditions of the exact territory. Combination of strains may also take place. All
mentioned factors make the influenza vaccination non-mandatory in the majority of
countries and a subject of severe discussion among the experts, policy makers and
patients.
However, in recent years the influenza vaccination became one of the most acute topics of
the public discussion due to the ―strange epidemic‖, which took place in Ukraine in 2009-
2010. Starting from mid October 2009 an increasing number of influenza cases have been
reported in Ukraine with the symptoms different from the usual one. Almost at the same
time the first lethal cases from the resulting diseases were registered, especially in
Western Ukraine. After a bacteriological research the epidemic of AH1N1 influenza was
officially announced in Ukraine on October 30, 2009. During November and December,
despite the quarantine in several regions of Ukraine, the morbidity increased dramatically
and the number of deaths reached about 1,000. Absence of clear explanation of the
situation from the Ministry of Health and the Government multiplied by the active media
15

16. hysteria caused massive panic among the population, which emptied the streets and the
pharmacies shelves, and led to financial and political speculations.
At that moment the issue of regular vaccination against influenza was raised and much
discussed in the printed media, on radio and TV. However, the level of discussion and
reaction of the population to the statements of experts and governmental officials
demonstrated low awareness of citizens of the nature of vaccination and ways of
protecting their health from the seasonal diseases. Numerous cases of self-treatment by
citizens with miserable consequences became the most vivid evidence of this.
But, surprisingly, the comparison of statistics on influenza and ARVI cases in previous
years made by several experts and journalists demonstrated that the total number of
patients didn‘t remarkably increase. Moreover, the morbidity and mortality from associated
diseases were generally lower or were on the same level than in the preceding periods.
These facts combined with the general mistrust of Ukrainians in the domestic healthcare
system made many people believe that the epidemic was virtually created by some
politicians and businessmen, who wanted to receive, respectively, political and financial
dividends from combating the unknown and terrific disease. These thoughts were
supported by some evidence that a number of governmental and healthcare officials
received considerable bonuses for purchasing drugs, medical equipment and materials for
the state budget cost. The most scandalous aspect of the epidemic was the purchase of
the Tamiflu drug, the effectiveness of which against AH1N1 influenza and safety for adult
and paediatric patients was not 100% confirmed.
On the other hand, the epidemic was quite useful for a number of politicians, who
managed to raise their image in the eyes of the population on the eve of the presidential
elections campaign.
At the same time, the epidemic revealed Ukraine‘s general unpreparedness to face such
massive healthcare challenges in terms of both material provision of patients and
information support of its antiepidemic measures. It appeared that in emergency conditions
the Ukrainian public healthcare system was unable to provide the patients with the
minimally required number of hygienic and medical products such as gauze masks, anti-
16

17. inflammatory drugs, etc. These facts undermined the image of and confidence in, the
Ukrainian healthcare system even more than before. Further, such a critical situation led to
the initiation of a number of tenders by the Ministry of Health to organize a public relations
campaign in order to raise public awareness of prevention and treatment of influenza as
well as of a number of other socially dangerous diseases.
17

18. 4. UKRAINE’S STATE POLICY ON VACCINATION
The immunoprophylaxis in Ukraine is regulated by the Law of Ukraine ―On Securing
Sanitary and Epidemiological Wellness of the Population‖ 14 and ―On the Protection of the
Population from the Infectious Diseases‖ 15. Article 12 of the latter says the prophylactic
immunization should be performed after medical examination of a person and in case of
medical contraindications absence. The full-aged legally capable citizens should receive
the vaccine based on their consent after obtaining objective information about the
vaccination, consequences of refusing it and possible post-vaccination complications. The
citizens, who did not reach the age of 15 or are legally disqualified, should receive
prophylactic vaccines after objectively informing their parents or other legal
representatives. If a person and, or his / her legal representatives refuse from obligatory
prophylactic vaccination, the doctor has a right to request their written confirmation. In
case of refusal to give such a confirmation, this fact should be certified in the presence of
witnesses.
Based on these legal documents, the vaccination in Ukraine is non-mandatory and is
based on the free will of a person or his / her legal representatives. However, in reality,
these legal provisions do not function as they are neutralized by the refusal of the majority
of schools, nurseries, kindergartens, summer camps and high schools / universities to
accept children, who had not passed the obligatory vaccination. Their refusal to accept is
based on the Law ―On Protection of the Population from the Infectious Diseases‖, Article
15 of which states that children, who have not received the vaccination according to the
Vaccination Calendar, are not allowed to visit childcare centres. In its turn, this provision of
the Law is in contradiction with the Article 53 of the Constitution of Ukraine (which has
legal superiority in this case) stating that the full general secondary educ ation is obligatory
and the State provides for the accessibility of pre-school, full secondary, professional and
high education at the public and commune institutions. In addition to that, according to
Article 12 of the Law of Ukraine ―On Protection of the Population from the Infectious
14
http://zakon1.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=4004-12
15
http://zakon1.rada.gov.ua/cgi-bin/laws/main.cgi?nreg=1645-14
18

19. Diseases‖ and to Article 27 of the Law of Ukraine ―On Securing Sanitary and
Epidemiologic Wellness of the Population‖, only 6 vaccinations are considered to be
obligatory: against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus and measles.
All this leads to numerous cases, when adults and parents refusing from vaccination reach
―informal‖ agreements with the doctors (doctors indicate the fact of vaccination in relative
documents, but do not perform it in reality).
The major regulation document in the vaccination area is the draft Decree of the Ministry
of Health ―On the Order of Prophylactic Vaccination in Ukraine and Control of the Quality
and Turnover of the Immunobiological Drugs‖. This draft should substitute the existing
2006 Decree of the same name and introduce some changes into the vaccination
calendar, procedures and mechanisms. The ―Calendar of the Prophylactic Vaccination‖
suggested by the draft foresees: seventeen vaccinations for children from the 1 st day of
birth till the age of 18 months against 11 infections. The total number of vaccinations,
including the repeated vaccination at certain age points, till the age of 17 years old is 26.
They are obligatory and are categorized as the ―age dependent vaccinations‖. In total, the
calendar consists of 4 categories: age dependent vaccinations; health condition dependent
vaccinations; vaccinations performed on endemic and enzootic territories and
recommended vaccinations.
Due to the critiques of the expert community, connected with the imperfect vaccination
calendar and a number of discrepancies in vaccination procedures, the MoH recalled the
draft decree in late December 2010 for revision and improvement.
The above mentioned obviously has all signs of the legal collision which has to be urgently
solved. On the one hand, no one should be made to receive any medication against his /
her own will and the mechanisms of the legal refusal from vaccination should be foreseen.
On the other hand, a citizen is not isolated from the society and cannot be the source of
life-threatening infections for the others. This statement is also absolutely crucial
considering the WHO recommended collective immunity level, which should not be less
than 85%.
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20. According to the present legislation, in Ukraine, all obligatory vaccines are provided for
free to all citizens, i.e. they should be purchased for the cost of the State Budget of
Ukraine and distributed to the regional / local hospitals based on their needs and
vaccination plans. Being an absolutely adequate and modern approach, in Ukraine free
vaccination works with serious difficulties, which are created by the imperfect budget
management system, bureaucracy, corruption and insufficient professionalism of doctors
responsible for vaccination.
The most problematic issue here is the public procurement procedure, which in Ukrainian
conditions does not guarantee that vaccines of the highest quality are purchased for the
State Budget cost. I.e., the citizens wishing to receive a vaccine are dependent on the
product suggested to them by the healthcare authorities; the alternative way of purchasing
the vaccines for their own cost is not affordable for the majority of the population.
The population‘s uncertainty in the quality of vaccines has caused serious discussions,
which were supported by the media, and became an important factor for the anti-
vaccination mood at the society.
Irregular budget transfers, prolonged procurement procedures and permanent budget
crisis often lead to the situation, when regional healthcare departments feel the lack of
vaccines. The situation became very dangerous in late 2010, when shortage of the most
important vaccines in several regions of Ukraine reached 70-75%. This trend developed
against the record healthcare spending foreseen in the state Budget for 2010 (UAH 300
Mln (USD 37,5 Mln) only for vaccination). Several journalists and analytics suggested that
such a budget policy was in many cases aimed at increasing the purchases of vaccines in
the pharmacies by those layers of the population, who could afford buying them for their
own cost. No evidence on this was revealed, but the level of populations‘ confidence
greatly decreased. One more factor for this became the fact, that Ukraine, which does not
produce its own vaccines, is often a recipient of the international humanitarian help, the
quality of which is in many cases under question.
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21. Considering the above mentioned, the budget planning on the central level and actual
spending schedule in Ukraine have to be radically improved. This issue was stressed upon
several times by the Minister of Health of Ukraine Ilya Yemets in his numerous interviews.
The most scandalous case, which revealed the problems of the Ukrainian vaccination
system and became the major trigger of the anti-vaccination moods in the society, was the
unscheduled vaccination campaign against measles and rubella in 2008-2009.
As a result of the outbreaks of measles in 2005-2006, Ukraine fell under surveillance of the
WHO, which had announced its plans to fully eradicate measles by 2010. As a result of
long negotiations, Ukraine agreed to carry out the unscheduled vaccination of children and
adults by the combined measles-rubella vaccine, which would be donated by the
WHO/UNISEF.
The unscheduled vaccination was accepted among the population with a severe
scepticism as the great part of the citizens had previously received the measles and
rubella vaccine according to the governmental schedule. Moreover, protests of parents
against the unscheduled vaccination were fuelled by the fact that the Indian vaccine
provided by the WHO had not been previously registered in Ukraine and had not passed
all necessary control procedures in terms of effectiveness, safety and adverse effects
required by the Ukrainian legislation. Explanations of medical experts, and MoH and WHO
officials, that the vaccine had been checked by the WHO and had been previously used in
dozens of countries, had a counterproductive effect. Additional argumentation against the
unscheduled vaccination brought up by journalists and some doctors included the facts
that the Indian vaccine had up to 25% probability of adverse effects (openly indicated by
the producer) and was made of cultures grown in different climate conditions comparing to
Ukraine. So the vaccine could be not only non-effective, but even dangerous for the
Ukrainians, according to journalists and experts. The latter arguments have reached fertile
soil and, considering the general mistrust of the population in the public medicine, resulted
in an outbreak of anti-vaccination initiatives all around the country, which interlinked
themselves through the Internet and other communication means.
21

22. The final and most powerful strike on the image of vaccination in Ukraine and of the
domestic healthcare authorities was done on May 13, 2008, when a 17-year-old school-
boy Anton Tyshchenko, from Kramatorsk, Donetsk region, died several hours after
receiving the combined measles-rubella vaccine. During the following days, about a
hundred of serious adverse effects in Kramatorsk and other places in Donetsk region and
in Ukraine in general were reported. The vaccination was stopped and several
investigation commissions started considering the case. Despite no connection between
the vaccination and the death of Anton Tyshchenko was found by medical experts and
WHO representatives, the case had a dramatic impact on the population‘s attitude of
vaccination.
Starting from May 2008, the number of refusals to take scheduled and unscheduled
vaccines increased several times. All attempts to carry out objective discussions on the
governmental, expert and media levels didn‘t reach their results. The controversial nature
of vaccines and distrust of Ukrainians in healthcare officials neutralized all attempts of the
Government to restore the image of vaccines in the eyes of the Ukrainian population.
At the present moment the level of explicit refusals to take vaccines is about 10%. Taking
into account possibilities to hide the refusal, a number of those, who just don‘t visit
hospitals to receive vaccines and the shortage of vaccines, the level of vaccination in
Ukraine is critical.
In general the Government didn‘t publicly recognize its faults in the unprofessionally
organized unscheduled vaccination campaign, though several serious criminal
investigations and dismissals followed. At the same time, the recent decision of the
Ministry of Health, announced by the Head of the State Sanitary and Epidemiological
Service of Ukraine Serhiy Ryzhenko, not to carry out any unscheduled and separate
vaccinations against measles and rubella and not to use any vaccines, which had not been
previously registered in Ukraine, might be an evidence of the on-going ―correction of
mistakes‖.
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23. 5. PUBLIC PERCEPTION OF VACCINATION AND MEANS OF IMPROVING IT
a) Role of media in building public perception of vaccination in Ukraine
The vaccination topic has been raised in Ukrainian media back in 2008 when a
widespread scare about vaccine side effects in Ukraine led to a sharp drop in
immunizations. Irresponsible media coverage of an anti-vaccination campaign was
launched after the May 2008 death of a 17-year-old boy in Kramatorsk who had received a
combined measles-rubella vaccine. As a result the unscheduled measles-rubella
vaccination campaign was interrupted and hundreds of thousands of fearful Ukrainians
have refused to take other vaccines such as those from diphtheria, mumps, poliomyelitis,
hepatitis B, tuberculosis, pertussis and others – which led to more than 10 percent drop
in vaccination rate. The alarming trend amongst parents not to immunize their children
became mainly the result of the growing pressure of the negative media coverage and
comments from those sceptical of vaccination.
It is worth noting that while Ukraine has an educated population, rumours and
misperceptions spread easily. This could be explained by low standards of living and
uncertainty in the future, on the one hand, what prevents people from critical analysis of
the reality, and, on the other hand, by the remaining total trust to media, which was
inherited from the Soviet and even previous times. Constant political turmoil and a
devastating financial crisis — one of the worst in Europe — has fuelled mistrust of
Ukraine's crumbling healthcare system, and authorities in general.
In order to understand the reasons beyond such situation we have analyzed Ukrainian
media landscape and come up with the following.
Ukrainian media outlets are numerous and mostly uncensored but do not widely follow
Western standards of fairness and accuracy. For example, some print and online reports
alleged after the boy's death that the Indian made measles-rubella vaccine would sterilize
men as part of a plot by Ted Turner, whose Washington-based United Nations Foundation
charity paid for the vaccines.
23

24. In most Ukrainian business media there are neither special sections devoted to healthcare
nor specific editors covering the topic. Typically, a journalist covering general business will
also write about healthcare and consequently will have very little understanding of industry
specifics. In other cases, healthcare is covered by science or technology editors, who may
understand the scientific side of the industry but have little understanding of its economic
impact.
In Ukraine there is a large number of trade media covering both general and specific
healthcare topics. Most journalists at these publications have a professional medical
education and a deep understanding of the subject matter. They are interested in
interviews with key opinion leaders and scientists, detailed descriptions of new therapies,
equipment and approaches to treatment.
Journalists covering healthcare topics in consumer media rarely have a medical
background and are normally interested in medical topics from a the most basic point of
view – one that is understandable and interesting for the average reader. On a non-
commercial basis they would cover general issues (such as HPV vaccinations, or the
advantages of contact lens usage vs. glasses) without ever going into specific drugs or
companies.
Despite such lack of the professional media approach in Ukraine mass media can
substantially influence health knowledge and the use of health services. In this instance, it
is also clear that the media play a significant role in public health.
For period 2009-2010 there were around 25 different top-level publications (including TV
stories, talk shows featuring state officials and doctors, newsfeeds etc.) related to
vaccination with tonality ranging from negative to neutral which showed inconsistency in
informational campaign and actions of the Government.
Research shows that most parents get their information from the media and online – and
when it comes to immunization, much of the information has been negative.
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25. Summarized ‗vox populi‘ during that period can be outlined as follow:
I’ve read many articles on the Internet about dangers of vaccination and that is why I
believe if the child has strong immune system, has good nutrition and normal environment
which is hard to find in our country, we might be able to say that there is a chance of the
child not contracting disease.
In this regard it is worth mentioning Yevhen KOMAROVSKY – a Kharkiv-based
paediatrician – who was the only doctor in Ukraine trying to prevent flu panic stroked by
political malpractice back in November 2009. He has provided a balanced professional
analysis of the flu epidemic and shared his opinion concerning the hysteria surrounding
the flu, the irresponsible appeals of politicians and the errors of public health officials.
As a result of his informational campaign Dr. KOMAROVSKY is now considered to be one
of the well-known and respected celebrity physicians in Ukraine. He is author of many
books and hosts his own popular TV show ―Dr. KOMAROVSKY‘s School‖. Important is the
fact that he supports vaccination and proves his opinion at a very professional level:
―As a person who had been working in isolation hospital for many years, I can assure you:
vaccination is not excluding the probability of disease. Children suffering from these
diseases and outcomes are, to put it mildly, different. Therefore, for normal, sane and
sensible parents, there can be no debate about “vaccinate or not vaccinate”. To vaccinate,
definitely!”
b) How to improve the situation.
According to our analysis the following factors became the key preconditions of the anti-
vaccination moods in the Ukrainian society:
– General mistrust to and worsening image of the public and even private healthcare
among the Ukrainian population caused by the low performance of the former, widespread
corruption;
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26. – Generally poor vaccination practices in Ukraine and inability of the public
healthcare authorities to carry out coordinated information policies around vaccination;
– Specifics of vaccination as treatment against infectious diseases;
– Exact tragic events in several cities of Ukraine, which raised public fears in security
of vaccination;
– Growing negative attitude of the Ukrainians to the pharmaceutical companies, both
domestic and foreign;
– Irresponsible behaviour of journalists, who used the vaccination issue for raising
their personal and their editions‘ popularity.
Considering the above mentioned we should state, that the problem of vaccination‘s image
in Ukraine is a complex one and should be solved by combined approaches involving all
key stakeholders in this area (public healthcare authorities (central and local), medical
experts, pharmaceutical industry, journalists, NGOs, and patients / parents‘ associations).
There is obviously a need for the open public discussion of the problems of vaccination in
Ukraine, which should be initiated either by the state or by the expert / doctor community.
This discussion should result in a general nation-wide strategy on improving the
immunoprophylaxis in Ukraine and raising the image of vaccination as of the most
effective means of combating communicable/ infectious diseases.
An important element of this strategy should be improvement of statistics in the field of
communicable diseases prevalence. Availability and accessibility of the precise
information about the epidemiologic situation in Ukraine and its tendencies should become
an important precondition of the population‘s awareness of the risks connected with the
immunization level decrease. In parallel with the improvement of screening and
information collection, use of the web-based technologies could be an appropriate
mechanism of populations informing of the current situation with the communicable
diseases and correlation between vaccination and the morbidity level. Further on, this
should be developed to a full-scale web-portal on epidemiology, communicable
diseases and vaccination, which should be managed by a professional team of
communication specialists.
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27. Considering a decisive role of media and journalists in the massive hysteria around the
unscheduled vaccination of 2008 and influenza epidemic of 2009, and consequences all
this had over the level of immunization, the questions of journalist ethics in medical issues
becomes more and more actual. In our opinion, in the media environment of Ukraine,
which does not have long-lasting traditions of reasonable self-limitation and understanding
of consequences the information distribution might have onto the public health and well -
being, it is of a great importance to launch the discussion around the Code of Conduct or
the Ethical Code, which might be signed by all journalists and PR agencies writing on
healthcare and related issues. The Code could include a voluntary obligation to double
check all messages on healthcare problems for their possible consequences for the public
health; to avoid distributing unverified information and opinions of experts with doubtful
background; to present different points of view etc. This process could be initiated by some
prominent and respected journalists, which should give an example of ethical behavior by
themselves and suggest launching the discussion on this issue, inviting expert / doctor
community to this process.
These activities could be accompanied by trainings for general and business
journalists on vaccination problematic. During such trainings medical and
communications experts from Ukraine and foreign countries could give their expert opinion
on vaccination, providing both pros and cons of it, what should make the coverage of
vaccination issues more professional and neutral.
At the same time, the analysis of public mood performed by us leads to a conclusion that
there is an acute need of restoring the image of vaccination in Ukraine, which didn‘t
improve greatly since 2008, when it was destroyed by the unscheduled measles-rubella
vaccination campaign. Under such circumstances an integrated nation-wide
communication campaign could be the most effective way of improving attitude of the
Ukrainians to the immunoprophylaxis by the means of vaccination. The campaign should
have the following targets:
– to increase populations‘ awareness of the infectious diseases and their prevalence
in Ukraine (including statistics and tendencies overview);
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28. – to distribute information about the ways of preventing communicable diseases
among children and adults and of risks for individuals and society in general resulting from
the low immunization level;
– to popularly describe advantages and risks of vaccination for different age groups;
– to inform the citizens of the national vaccination calendars and schedules, etc.
Information and propaganda activities within the campaign should be effectively combined
with educational elements for different categories of population interested or concerned
about vaccination, e.g. seminars and trainings for journalists, parents, doctors, and even
children.
One of the first remarkable attempts to change the situation was made in June 2010, when
a social advertising campaign on the protection of children against infectious diseases was
presented in Kyiv and initiated by UNICEF. Dissemination of the information on
vaccination via radio and television as well as distribution of educational materials in
healthcare facilities was a part of this campaign.
At the same time such individual actions, despite their non-discussable importance, will not
reach their target in the scale it is required in Ukraine. In our opinion, for radical change of
attitudes to vaccination joint efforts of the public authorities, expert / doctor environment,
pharmaceutical industry, NGOs, patient associations and international organizations are of
key importance. Ideal development in this case could be a round table on communications
around vaccination bringing together all key stakeholders, in the result of which a common
strategy development in this area could be initiated. However, it should be remembered,
that a massive and sudden campaign might have a counterproductive effect in the
Ukrainian society, which is suspicious to all initiatives coming from the public authorities
and pharmaceutical industry.
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29. 6. CONCLUSIONS
On the basis of the performed research and analysis of the open data we have come to a
conclusion, that epidemiological situation in Ukraine should be c onsidered as relatively
stable with the major parameters of morbidity and mortality from infectious diseases being,
in general, within the norms specified for the European region by the international health
organisations like WHO. At the same time, periodically the outbreaks of various infections
are observed in different regions of Ukraine and in the country in general. Moreover, in
some cases, the epidemics of different diseases (e.g. tuberculosis and outbreaks of
diphtheria and measles) could be stated in Ukraine at some time periods. This raises
serious concerns of the effectiveness of the Ukrainian healthcare system and
adequateness of the prevention practices.
During the last years in Ukraine one can observe an actual destruction of the effective
immunoprophylaxis system caused by a number of serious reasons. Among them the
following should be named: low professional level of vaccination campaigns against major
communicable diseases; critical situation with the supply of drugs for scheduled
vaccinations; general mistrust of the population to the public healthcare system etc. The
key milestone, which triggered massive anti-vaccination campaigns, became the death of
a school-boy from Kramatorsk in May 2008 after non-scheduled measles-rubella
vaccination as well as numerous adverse affects in a number of school children in Donetsk
region and other parts of Ukraine. Fuelled by the media, the anti-vaccination hysteria
resulted in massive refusal to vaccinate children and adults. As of now we should state
that the image of vaccination in Ukraine is considerably undermined, the direct result of
which is the decrease population‘s immunoprotection level to the threshold values
specified by the WHO or even their crossing. The above mentioned allows us to assume,
that in the medium term Ukraine will fall under threat of massive infections and even
epidemics.
The above mentioned requires urgent measures from the state, non-governmental and
international organizations, medical and expert environment and pharmaceutical business.
One of the elements of such an activity should be restoration of the populations trust in
vaccination and neutralization of the anti-vaccination hysteria of the previous years. Due to
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30. this the level of population‘s immune-protection should increase and the morbidity should
become lower. The suggested mechanisms of reaching this aim are:
– Improved statistics and information exchange between the healthcare authorities
and population in the field of infectious diseases;
– Ethics code for journalists writing on medical issues;
– Media trainings for general and business media journalists;
– Nation-wide information-educational campaign aimed at increasing trust and
improving awareness of the population of the immunoprotection of children and adults by
the means of vaccination, which has to be supported and conducted jointly by the State,
doctors, NGOs and pharmaceutical business.
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31. 7. SUGGESTED COMMUNICATION RESPONSES
1. Improved statistics and information exchange between the healthcare
authorities and population in the field of infectious diseases.
2. Creation of the integrated Web-Portal on Communicable Diseases and
Vaccination
3. Development and propagation of the Ethics code for journalists writing
on medical issues
4. Media trainings for general and business media journalists on
vaccination issues
5. Nation-wide information-educational campaign aimed at increasing trust
and improving awareness of the population of the immunoprotection of
children and adults by the means of vaccination, supported and
conducted jointly by the State, doctors, NGOs and pharmaceutical
business
31