Uganda - Background - Combatting Antivaccination Rumours: Lessons Learned from Case Studies in East Africa

Uganda - Summary Points

• The vaccination decline predated the antivaccination FM radio blitz.
• Shifts in NIDs dates to the malaria high season led to popular association of child deaths with the NIDs season. Temporal association became a causal association in the minds of many.
• Official responses, though correct, were long in coming.
• FM attacks, though articulate, were not shown to be effective.
• The government has not ruled out a sledgehammer response.
• Confusion continues over different official answers to the media blitz.

The anti-vaccination campaign in Uganda began at the time of the 1997 rainy season, coinciding with the National Immunisation Days (NIDs) of that year. Mothers observed high mortality, probably from malaria, in their vaccinated children in the south-western districts. Mothers and fathers then went to a popular FM radio station for possible explanations of the deaths. Thus, the FM station was the ultimate link in the chain of events starting with the logical decision to synchronise polio NIDs in East Africa. Two factors have made the official response less effective than it would have been: the failure of the authorities to respond early to the public anxieties about the excess mortality perceived during the vaccination campaign, and the sometimes inconsistent responses of officialdom to media questions about vaccination.

Remarkably, there is much evidence to show that declines in Uganda's immunisation programme predated the FM radio scares, and that these scares, though widely discussed, had little if any quantifiable impact on the polio campaigns.

Uganda - Country Background

Located on the equator, Uganda is bordered by Sudan, Kenya, Tanzania, Rwanda and Zaire. Nearly 90 percent of Uganda's population lives in rural areas. The country's largest population centres are in rural areas.

In the early 1990's, Uganda began decentralising government services to give more decision-making power to local jurisdictions. This political process has involved creating new districts, which now number 56, an increase from 39 in 1997. According to the Local Chairman V (LC V) interviewed in Ntungamo District, the "power, resources, and responsibility have moved from the centre to rural areas."

The vaccination programme in Uganda started in 1963 with polio and smallpox in 1968. The reign of Idi Amin, 1971 to 1979, led to massive cuts in basic health services. By 1980, BCG coverage, 70 percent before his seizure of power, had dropped to one percent.[1] After his demise, a vast effort to relaunch vaccinations was cosponsored by the new government, with NGO and UN assistance. The Uganda Expanded Programme on Immunisation (UNEPI) began in 1983, with support from UNICEF, Save the Children Fund, and the WHO. Immunisation made slow progress until 1986, by which time most areas of the country had become secure.[2] In 1988, Uganda voted for polio eradication. The country has not seen a case of polio since 1996.

In 1988 Uganda supported the World Health Assembly's resolution to eradicate polio by 2000. In 1995, Uganda began planning for its first NIDs in 1996. In its 1996 report on its first National Immunisation Days, UNEPI reported that it had achieved about 75 to 80 percent coverage in routine immunisation in most remote areas of the country. However, the following table, given in a press briefing to kick off the 2001 SNIDs, shows coverage for polio coverage in 1996 to have been more than 95 percent and shows coverage in the mass campaigns since1996.[3]

Results of National Polio Campaigns, 1996 – 2000, and Absence of Impact from FM Radio Antivaccination Campaigns

Note: After the start of the media blitz, NIDS vaccinations rose from 4.4 to 4.6 million.

Source: Uganda National EPI

Constraints to the mass polio immunisation campaign were noted in a 1996 report. They included problems with refrigeration and vaccine storage (cold chain), late and insufficient funding, rumours, and limited time. Other constraints included the following:

• The planning process for NIDs was centralised with minimal district input, resulting in omission of some crucial activities in certain districts.
• Planning coincided with national presidential and parliamentary elections, making it difficult to involve districts and lower levels early enough.
• Both central and district levels lacked experience in planning for NIDs.
• Time was limited.

All these subsidiary factors were later to feed into the official reaction to the rumour campaign. Structures hard pressed to deal with the predictable challenges of planning and managing mass campaigns were hard pressed to deal with the wild card of antivaccination rumours.

Programme communication was done, but not always to a high standard. As in other countries, there was an emphasis on mass media and printed materials, and little effort was made in the early stages of the NIDs to target health workers themselves, who were thought to be loyal supporters of the government initiative. The 1996 NIDS report notes that social mobilisation was targeted at all levels of the population, and mass media were used effectively to promote NIDs, especially through a variety of radio programmes. Government run Radio Uganda and Capital Radio were used extensively. In addition to mass media, many print materials were produced, but these later proved inadequate because they were in English, a language not read by most Ugandans.

To counter negative rumour campaigns, health officials used current affairs and other popular radio programmes, including live call-in programmes, for answering questions and doubts expressed by the public and putting down rumours. The 1996 report does not specify who was spreading rumours against polio vaccination.

The 1997 report on NIDs states that health workers did not participate in the planning of 1996 NIDs. As a result, most of them did not support NIDs. According to this report, some health workers had doubts and misgivings and openly campaigned against NIDs. In some areas of the country, they tried to discourage clients from immunising their children, and the health workers themselves did not take their children for immunisation.[4] In 1997, as in 1996, UNEPI conducted intense community mobilisation. At the same time, deliberate attention was given to health workers. Senior medical officers and other health workers from Mulago Hospital, as well as other government and NGO hospitals, were involved in planning for 1997 NIDs. A number of sensitisation meetings targeted health workers at all levels and a booklet titled “National Immunisation Days in Uganda – A Guide for Health Workers” was prepared and distributed.[5]

The scheduled dates for NIDs were changed from December and January (1996-97) to August and September in 1997. It was this change in timing, well indicated on programme grounds, which led to the coincidence in time of the vaccination campaign and the malaria season, which peaks in August. One official questioned about the scheduling change said that he thought the change was implemented when the East Africa countries – Kenya, Tanzania, and Uganda – co-ordinated their NIDs efforts.

In the first round of NIDs in 1997 eight districts of the central and eastern regions showed low coverage, covering under 75 percent of the targeted children. The 1997 report says that lowered coverage might be the result of:

• Rumours and misconceptions – As in the 1996 NIDs, some individuals and media organisations (not identified by name) spread rumours that OPV was contaminated with HIV.
• Poor mobilisation – Social mobilisation activities were started very late in most districts due to late disbursement of funds.
• Lack of adequate knowledge - Explanations about the objectives of NIDs and the reasons for immunising children who had completed the schedule (antigens in routine immunisation) were not given.[6]

By 1997, officialdom began to react. Between the first and second rounds of NIDs in that year, teams were dispatched to districts with lower coverage to hold sensitisation meetings for local leaders, opinion leaders, health workers and mobilisers. At these meetings, information about NIDs was presented and openly discussed. According to the 1997 report, these meetings and an intensified media campaign on radio and television helped to dispel rumours and improve coverage in the second round.[7]

By 1998, officials were concerned with the continuing decline in routine immunisation, a trend that dated from 1994, before the NIDs, and was largely related to changes in funding and administration of vaccination services. As a result, the Ministry of Health (Ministry of Health) commissioned a KAP study, published in 1998, to investigate the causes of the perceived decline in routine immunisation coverage.[8] The Executive Summary to the KAP study notes that “most players in the programme seem to agree that there is a decline in immunisation coverage nationally although this is not backed by detailed data because it is scanty.” The KAP study quotes a senior officer from UNICEF: “There seems to be no data at hand to substantiate decline.” The KAP study does not say why data was not available.

8 KAP Study Report on Immunisation Services in Uganda. 1998. Health Management Consult Uganda funded by UNICEF. P. 15.