Polio in Ukraine: Crisis, Challenge, and Opportunity

"How did a modern country with aspirations toward European identity fail so dramatically on something as basic as childhood vaccines? The decline of Ukraine's immunization system is fueled primarily by corruption, coupled with ineffective public health communication, gross government neglect of the country's health system, inadequate state financing, and political game playing....Ukraine's two cases of polio present a potential launch pad for meaningful change."

This analysis paper explores the aftermath of a polio outbreak: 2 children contracted polio in the Transcarpathian region in western Ukraine in August 2015 after a 19-year absence of the disease in that country. Author Judy Twigg argues that "[t]he proper reaction from the global health community is a sober, realistic admission: we will almost certainly see a proliferation of infectious outbreaks in Ukraine and the Balkans, especially as some governments struggle with a continued massive influx of refugees." She contends that the international community can take advantage of Ukraine's membership in Western institutions as a pressure point. This is also a key moment, she suggests, to demonstrate the utility and potency of the Global Health Security Agenda (GHSA), as Ukraine is one of 30 United States (US) partner countries designated in November 2015 for priority achievement of GHSA targets.

To support this argument, Twigg provides an overview of the outbreak crisis in the opening sections of the paper. She says that "political and public health malfeasance featuring dangerous misinformation and multiple political agendas" led to the plummeting of full compliance with the government guidelines, which stipulate that children should be vaccinated against 10 infectious diseases, to below 50% in 2013 - with polio vaccines reaching only 14% of infants over the first half of 2014. The Ukrainian children were infected by circulating vaccine-derived poliovirus (cVDPV) type 1, weakened live polio strains used in oral polio vaccine (OPV) that are secreted from immunised children and mutate, which is at a higher risk of occurring when vaccination coverage is low. Vaccines were on the way: In the spring of 2015, the Canadian government had paid for the United Nations Children's Fund (UNICEF) to procure and deliver 3.7 million doses of French-manufactured OPV. During transport, the vaccines were thawed and then refrozen upon arrival in Kyiv. The vials were never opened, however, and the World Health Organization (WHO)'s and the producer's guidelines had been strictly followed. The vaccine vial monitors showed that the vaccines were in good condition, and several expert committees conducted independent assessments proving that the vaccines remained safe and potent. Nonetheless, the shipment was never delivered to refrigerators at individual vaccination sites. Further, Viktor Serdyuk, president of the so-called Ukrainian Council for Protection of Patients' Rights and Safety, circulated an online petition to the president and waged an aggressive social media campaign advocating destruction of the vaccines. Online "experts", including economists and physicians, spoke out in the digital space with reports that the vaccines were unsafe because of cold chain violations, that the Ministry of Health (MoH) was putting political pressure on officials in Transcarpathia to claim that polio had erupted, that the use of OPV (as a "Third World" vaccine) was inappropriate for Ukraine, that repeat vaccination has unknown and frightening medical consequences, that vaccines should be given only in hospitals (not in schools or other locations), and that either the faulty vaccine or the inaccurate diagnosis of polio were Russian plots designed to block Ukraine's entry into the European Union.

Against this misinformation, the international community mobilised swiftly, Twigg reports. She describes multiple efforts to counter false messages and to help Ukraine understand what dire straits the country's children were now in due to the politcal combat that was keeping the vaccines in storage. In late September 2015, the deadlock finally loosened when Bill Gates phoned Ukrainian President Petro Poroshenko directly with a plea for distribution of the UNICEF-procured vaccine. The long-awaited vaccination campaign was initially scheduled to cover 3.3 million children under the age of 6 in 2 rounds spanning late October–December 2015, followed by a final third round covering nearly 10 million kids up to age 10 in late January/early February 2016. Coverage in the first round was reported officially at around 64–65% but was actually probably closer to 50–55% and was lower in Transcarpathia where the 2 cases broke out due to parent refusals, contraindications applied by health professionals, and confusion over the WHO/UNICEF-supported strategy to vaccinate all children in the intended age group regardless of vaccination status. The second and third rounds were more successful, though still not reaching standard international targets.

Next, Twigg examines vaccine coverage and financing pre-2015. One communication-centred point she makes here is that the fault lies with "gross government neglect of the country's health system, inadequate state financing for vaccine purchase, corrupt public procurement practices that hike prices to levels far above international norms, and webs of rumor and misinformation leading to widespread vaccine refusal". With regard to the latter, Twigg notes that parent hesitation would limit coverage even if vaccines were widely available. She traces current confusion to May 2008 and the death of a 17-year-old in the Donetsk region who had just been vaccinated for measles and rubella. "Health experts report that [Anton] Tyschenko died from bacterial meningitis, completely unrelated to the vaccine, but media coverage of the event and contradictory government statements sowed distrust among parents and even health professionals....Almost a decade later, parental attitudes still vary widely....A 2014 UNICEF/WHO survey showed that only 18 percent of mothers thought that polio was a dangerous disease, and 27 percent knew it could cause paralysis. However, almost three-quarters had a positive attitude toward vaccination in general - a dramatic change from 28 percent in 2008 - and only 13 percent were actively opposed to vaccination."

According to Twigg, medical professionals in Ukraine also have mixed feelings toward vaccines. "They recall fondly the perceived safety and predictability of a Soviet-era environment where efficacy and quality were guaranteed by a strong state apparatus. Now, vaccination campaigns are associated with black-market activity, with decisionmakers suspected of prioritizing kickbacks from drug companies over quality standards....Ukrainian physicians also doubt the applicability of WHO guidelines and expertise in what they perceive as a distinct Ukrainian context, doubting vaccine quality in the absence of specific registration and testing in Ukraine, and worrying about locally unique allergens and poorly understood lingering impacts from Chernobyl." Furthermore, Ukrainian medical policies hold that, if a child dies from any cause within 30 days of receiving a vaccine, the vaccine itself is listed as a cause of death until an investigation is completed; these rules are "a harsh disincentive for clinicians to do their jobs....Acting in self-preservation, Ukrainian pediatricians are known to practice double bookkeeping. If a physician judges a child to be too weak or ill to 'withstand' a vaccine, she will recommend delay to the parents - but nevertheless, under pressure from local public health departments insisting on 100 percent compliance, report complete coverage."

There is also confusion and resistance stemming from corruption in public procurement of vaccines, which takes multiple forms: staging tenders among multiple companies controlled by one actual owner; collusion between independent companies to coordinate bids and increase prices; use of shell companies to purchase drugs overseas and sell them to the MoH at artificially high prices; and use of the Register of Bulk Release Prices to overestimate tender prices by taking advantage of differential requirements for foreign and domestic drugs. "Corrupt drug-company interests have strong ties to - and sometimes a controlling interest in - key media outlets, contributing to misleading and sensationalist rhetoric around vaccines and deliberately confusing both health professionals and the public. Social media and shell company-financed Internet 'trolls' regularly hype rumors about alleged vaccine toxicity, the existence of conspiracies masking the “truth” that there was no polio outbreak at all, and the diabolical international plot underlying the entire outbreak storyline." Worrisome signs continue to emerge, Twigg observes, as outlined in a March 2016 report from WHO stating that the standard coalition of vested interests is blocking Sanofi Pasteur's application for a license to supply bivalent vaccine (a newer vaccine type that eliminates the risk of vaccine-derived polio) prequalified by UNICEF.

Given the location of Ukraine's recent outbreak - the western-most part of the country, bordering Hungary, Poland, Romania, and Slovakia - concerns have mounted over the potential for further transmission into unvaccinated pockets of the European Union. These countries could join the international community in speaking up to echo a November 2015 GHSA external country assessment that found: "challenges with licensing and procurement of essential vaccines and other medical supplies, the need for structural and legislative reform, absence of an effective system for forecasting of epidemics and biological risks, cumbersome and time-consuming paper-based reporting, widespread antivaccine sentiment, chronic underfunding, irresponsible media, and lack of trust in health care providers". According to Twigg, the US, the Ukrainian government, and other partners are developing a plan for Ukraine to meet GHSA and full Joint External Evaluation targets leading up to the Netherlands' hosting of the third high-level GHSA event in autumn 2016. In the meantime, the MoH needs more personnel to support the cause and health workers need protection in the wake of adverse events or even rumours of adverse events.

In light of the "rot in public procurement", Twigg argues that media management is key so that control over the message presented to the public is firm and consistent over an extended period of time, requiring collaborations with media partners across multiple levels and platforms: print, broadcast, and digital. "Western media specialists have considerable expertise to share in this area, as do WHO and UNICEF."

Twigg concludes that now is the time to ramp up political will and commitment at the highest levels. "WHO and UNICEF are a strong, outspoken presence, and their sustained efforts pave the most likely path toward an improved overall immunization climate. Bilateral donors are, for the most part, on board, but their political pressure specifically on polio could be escalated....If the Ukrainian president or prime minister were to make unambiguous statements about the risk of polio and the importance of vaccination, the lives of health professionals would ease considerably and the tolerance of corruption in this specific area might abate."