Detection of vaccine hesitation in the Federation of Bosnia and Herzegovina

The immunization rate in the Federation of Bosnia and Herzegovina is as high as 40% in some areas and continues to decline, increasing the risk of a large number of disease outbreaks. But nobody knows exactly why.

The growing hesitancy of the vaccine, misinformation on social media, lack of confidence in the health care system, lack of health care professionals and supply issues all question the reasons for the low coverage rate. However, these are mostly assumptions with little evidence.

“Currently, our immunization programming is based on a lot of assumptions,” says Dr. Sanjin Musa, an epidemiologist at the Public Health Institute in Bosnia and Herzegovina. “We need better data to understand which population groups are the lowest and why it’s so low.”

Using the WHO Custom Immunization Program (TIP) – a structured research approach – the country works to identify preventable populations, diagnose obstacles and motivators for vaccination, and recommends evidence-based responses to improve coverage.

Immunization status

In 2013, TIP was developed by the WHO Regional Office for Europe to assist healthcare professionals, public health authorities and decision-makers in tailoring services to reduce gaps in immunization coverage. The first step in the TIP process is for countries to conduct a situational analysis to review coverage and epidemics data, gather key stakeholders, and identify knowledge gaps.

In 2016, only 78% of children in Bosnia and Herzegovina received a third diphtheria-tetanus-pertussis (DTP) vaccine, 79% received a third dose of polio, and 83% had their first dose of the measles vaccine without a global target of at least 90 to 95 %. Vaccine coverage also varies greatly in cantons and cities, with rates falling between 40-50% in some areas.

These low rates threaten the country’s population due to the large outbreak. In the last decade, there have been a large number of epidemics of measles, mumps and rubella, partly due to disruption of immunization programs during the war in the early 1990s, but also due to the hesitancy of vaccines.

“With the current major epidemics of measles across the region, including nearby Italy, Romania and Serbia, the country is constantly on high alert because of epidemics,” says Dr. Musa. Immunization in the country is free and compulsory, but there are no mechanisms in place to ensure compliance.

Exploring the Reasons for Poor Coverage

After completing the TIP status analysis in 2017, the country began work on identifying areas where more research was needed. They are now conducting two studies.

The first study addresses the attitudes of healthcare professionals towards immunization to develop further training and tools. Some healthcare professionals currently either have no knowledge of immunization or are afraid of accusations after adverse events.

Another study is a review of patient records at primary care centers to determine the characteristics of caregivers who work or do not vaccinate their children, such as age, number of children, or income level. Once these characteristics are defined, immunization strategies can be developed to improve access to immunization and reduce vaccine hesitation.

“Building trust and understanding of the community is critical to responding to vaccine indecision,” says Katrine Bach Habersaat, a vaccine-preventable technical service, disease and immunization service at the WHO Regional Office for Europe. “Many people assume that hesitation with the vaccine is about not wanting to be vaccinated, but under the surface, it’s often about the convenience factor and how easy it is to vaccinate your children.”

The TIP countries are expected to be completed by the end of this year. This is part of WHO’s work with 11 Southeast European countries to accelerate progress towards the goals and strategic goals of the 2015-2020 European Vaccine Action Plan (EVAP).