Vaccination in Republic of Macedonia:

Standards and Actual Trends

• INSTITUTE FOR PUBLIC HEALTH OF THE REPUBLIC OF MACEDONIA• MINISTRY OF HEALTH OF THE REPUBLIC OF MACEDONIA• DOCTOR’S CHAMBER OF MACEDONIA

Prepared by: Department for Control and Prevention of

Communicable Diseases, Institute for Public Health of the Republic of Macedonia

Presented by: Prof. Dr. Koco Cakalaroski, president

of the Doctor's Chamber of Macedonia

Vaccination and Communicable Diseases

• Vaccines are one of the greatestachievements in the history of medicineand public health, and vaccination is one ofthe most cost-effective health investments!!!

• Vaccination is a proven tool for controllingand eliminating life-threateningcommunicable diseases!!!

Legislation on Vaccination in R. Macedonia

• Law on Protection of Population against Communicable Diseases (Official Gazette of RM No. 66/2004)

• Regulations for immunoprophylaxis, chemoprophylaxis, people subject to these measures, means of realization and keeping records and documentation (Official Gazette of RM No. 65/2010)

• Compulsory Immunization Program for the population in the Republic of Macedonia and National Annual Public Health Program in the Republic of Macedonia (annually, Off. Gazette of RM)

Compulsory Vaccination in R. Macedonia

Compulsory vaccination in RM has two periods: • first campaign period until 1960 and • second continuous period since 1960.

Continuous compulsory immunization in Macedonia is implemented against:1. Tuberculosis (introduced in 1948) 2. Diphtheria (introduced in 1951) 3. Tetanus (introduced in 1951) 4. Pertussis (introduced in 1960) 5. Poliomyelitis (introduced in 1961) 6. Morbilli (introduced in 1972) 7. Parotitis epidemica (introduced in 1982) 8. Rubella (introduced in 1982) 9. Hepatitis B (since October 2004)

10. Haemophilus influenzae type B (since September 2008) 11. Human Papillomavirus (since October 2009)

Implementation of Compulsory Vaccination

of the Population in the Republic of Macedonia in 2013

VACCINATION SCHEDULE IN 2013Age of people subject to compulsory vaccination

Disease against the vaccine is administered

Vaccination Revaccination

up to 24 hours of birth, 1 and 6 months Hepatitis B (3 doses) Vaccination

up to 12 months Tuberculosis (without testing) (1 dose) Vaccination

2, 3 and 5 months

Infections with Haemophilusinfluenzae type B (Hib) (3 doses)Diphtheria, Tetanus, Pertussis (3 doses)

vaccinationVaccination

2, 3 and a half and 5 months Poliomyelitis (3 doses three-type oral vaccine) Vaccination

12 months Morbilli, Rubella, Parotitis epidemica (1 dose) Vaccination

18 months

Infections with Haemophilusinfluenzae type B (Hib) (1 dose)Diphtheria, Tetanus, Pertussis(1 dose) Poliomyelitis (1 dose)

I revaccinationI revaccinationI revaccination

4 years Diphtheria, Tetanus, Pertussis(1 dose) II revaccination

6 years (I grade) Morbilli, Rubella, Parotitis epidemica (1 dose) I revaccination

7 years (II grade) Poliomyelitis (1 dose)Diphtheria, Tetanus (1 dose)

II revaccinationIII revaccination

12 years, 2 and 6 months after the first dose (VII grade)

Infections with HumanPapillomavirus (HPV) (only girls) (3 doses)

Vaccination

14 years (final year of primary school)

Poliomyelitis (1 dose)Diphtheria, Tetanus (1 dose)

III revaccinationIV revaccination

18 years (final year of secondary school) Tetanus (1 dose) V revaccination

Primary Vaccination in Macedonia in 2013

TYPE OF VACCINE COVERAGE

DTP vaccine 98,1%

OPV vaccine 97,9%

Vaccine against Haemophilus

influenzae type B 97,1%

Vaccine against Hepatitis B 96,5%

MRP vaccine 96,1%

HPV vaccine 40,1%

Revaccination in Macedonia in 2013

Type of revaccination Order Coverage

Vaccine against Haemophilus

influenzae type B 96,2%

DTP vaccine

I 97,6%II 96,4%III 95,7%IV 97,3%V 97,8%

OPV vaccine I 97,3%

II 95,0%III 97,2%

MRP vaccine 96,2%

Vaccination and Revaccination Coverage of the Population

in Macedonia inTen-year Period from

2004 – 2013

DTP Vaccination and Revaccination Coverage in R. Macedonia, 2004-2013

80,0

85,0

90,0

95,0

100,0

Cov

erag

e %

Year

Di Te Per вакц.

Di Te Per I ревак.

Di Te Per II ревакц.

Di Te III, IV ревакц.

Те V ревак.

DTP, vacc.

DTP, I revacc.

DTP, II revacc.

DT, III, IV revacc.

T, V revacc.

MRP Vaccination and MRP Revaccination Coverage in R. Macedonia, 2004-2013

90,0

95,0

100,0

Cov

erag

e %

Year

MMR вакц.

MMR I ревакц.

MMR, vacc.

MMR, I revacc.

OPV Vaccination and Revaccination Coverage in R. Macedonia, 2004-2013

90,0

95,0

100,0

Cov

erag

e %

Year

OPV вакц.

OPV I,II,III ревакц.

OPV, vacc.

OPV, I, II, III revacc.

Vaccination Coverage against Hepatitis B and Hib in R. Macedonia, 2005-2013

40

50

60

70

80

90

100

Cov

erag

e %

Year

Хепатитис Б*

ХиБ**

ХиБ ревакцинација

* vaccination against Hepatitis B of all newborns has been initiated since 2004

** vaccination against diseases caused by Haemophilus influenzae type B has been initiated since 2008

Hepatitis B*

Hib**

Hib revaccination

Vaccine-preventable Diseases in the Republic of Macedonia –

Before and After the Introduction of the Vaccination

Diphteria• The last recorded death was in 1972• The last recorded case of disease was in 1976

27 28 15 5 3 0,2

366

486

375

27 30

100

200

300

400

500

600

просечен број умрени

просечен број заболени

Average number of deaths/affected in period 1947-1976

Vaccination introduced in 1951

Average number of deaths

Average number of affected

22

13

41 1 1 1 1 1 1

48

37

127 5

2 41 1 2 1 1 2

0

10

20

30

40

50

просечен број умрени

просечен број на заболени

Vaccination introduced in 1951

Average number of deaths/affected in the period 1947-2013

TetanusThe last recorded case in newborns was in 1993

Average number of deaths

Average number of affected

Pertussis

The last recorded epidemic was in 1987

3583

1413

403217

125 50

190

500

1000

1500

2000

2500

3000

3500

4000

Average number of affected in period 1956-2000

Просечен број на заболени

Vaccination introduced in 1960

54

1

7 7 7

2

6

9

1

0

2

4

6

8

10

12

14

16

Number of pertussis cases, 2001-2013

Број на заболени

Average number of affected

Number of affected

PertussisThe last recorded death was in 2001

22,4

3,81 0,4 0,6 0,6 0,4 0 0,2 1

0

5

10

15

20

25

Average number of deaths in period 1956-2001

Просечен број на умрени

Vaccination introduced in

1960

Average number of deaths

PoliomyelitisThe last case of disease was recorded in 1987

As a member of the European Region, in June 2002 the Republic of Macedonia achieved certification of poliomyelitis eradication by WHO.

1959 431960 1501961 181962 71963 91964 11965 51966 811967 501968 101969 111970 251971 101972 319731974 21975 619761977 901978 31979198019811982 81983 41984 119851986 31987 1

57

40

21

43

150

187 9

15

81

50

10 11

25

103 2

6

90

38 4 1 3 1

0

20

40

60

80

100

120

140

160

broj

zabo

leni

1956 1958 1960 1962 1964 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986

godi na

ДЕТСКА ПАРАЛИЗА ВО Р. МАКЕДОНИЈА 1956-1986

OPV vaccination introduced in 1961

Poliomyelitis in R.Macedonia, 1956-1986

Nu

mb

er o

f ca

ses

Year

Morbidity and changes in the Immunization schedule against measles and rubella, in period 1967-1997

Morbilli / Rubella

0

100

200

300

400

500

600

МB

/100

.000

Morbilli

Rubella

1972, M-vaccine

1983, MRP vaccine

1987, M-revaccinationR-revaccination

1997, MRP revaccination

Morbilli / Rubella

0,89 1,32 0,25

10,6

34,1

0,3 0,20,02,04,06,08,0

10,012,014,016,018,020,022,024,026,028,030,032,034,036,0

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

MB

/1

00

,00

0

МБ/100.000Рубеола

Morbidity from measles and rubella, in period 1998-2013

The last epidemic of morbilli was in 2010-2011, with 908 affected people in total

- 90.0% (n = 796) of patients with proven vaccination statuswere unvaccinated or with unknown vaccination status

- Most of the affected were in the age group above 20 years (n = 380)

MorbilliRubella

Parotitis epidemica

8436

5161

1016

4321

35860

5865

10920

0

2000

4000

6000

8000

10000

12000

Number of parotitis epidemica cases, 1967-2013

Број на заболени1983 МРП вакцина на 13 месеци

1997 МРП ревакцина на 7г

The last epidemic was in 2008-2009, with over 15,000 affected people

Number of affected1983, MRP vaccination at 13 months

1997, MRP revaccination at 7 years

Epidemics of parotitis epidemica,2008-2009

• Most affected is the group born in 1991-1995, whichaccounts for 51.8% of the recorded cases in total

• The age grouping of patients and the outbreak of theepidemic was probably due to omissions in vaccination inthe corresponding period

• There is a negative correlation between the number of affected people by year of birth and vaccination coverage(r = -0,84, p <0,01)

Vaccination Coverage in Period 1983-2007 and Distribution of Cases in 2009, Per Year of Birth

814

1238

922

697

538

30

35

40

45

50

55

60

65

70

75

80

85

90

95

100

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

130019

78-

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

Vac

cin

atio

n c

over

age

%

Nu

mb

er o

f p

arot

itis

epid

emic

aca

ses

Year of birth

Број на заболени

% Опфат со МР(П) вакцина

% Опфат со МР(П) ревакцина

Number of affected

% MR(P) vaccination coverage

% MR(P) revaccination coverage

Conclusion• Primary vaccination against diphtheria, tetanus and whooping cough

continuously has maintained high coverage over 95% in the last decade, with an exception of three years – when it was between 90 and 95%.

• Vaccination and revaccination with OPV vaccine against poliomyelitis wasimplemented in the country with high coverage over 95% in the previous tenyears, with an exception of four years when primary-vaccination coverage wasbetween 90% and 95%.

• Vaccination and revaccination coverage against morbilli, rubella and parotitisepidemica (MRP vaccine) was high - over 95% in the past ten-year period, with an exception in 2006 and 2008, when the range was between 90 and 95%.

• Since the introduction of compulsory vaccination against hepatitis B for all newborns in 2004, this vaccination coverage has ranged from 90.4% (2010) to the highest 98.1% in 2012.

• Vaccination against infections with Haemophilus influenzae type B (Hib) wasinitiated in 2008, primary vaccination and revaccination coverage remainedunder 90% by 2010, after which it increased above the recommended 95%.

• Only the last introduced vaccine in the regular Immunization schedule in 2009 - HPV vaccine has coverage under the recommended 95%.

Conclusion

• Drastic reduction in the number of affected and deaths from vaccine-preventable diseases is evident as a result of the vaccination effects.

• The last recorded case of diphtheria – in 1976, and of poliomyelitis – in 1987.

• In the past ten-year period there were 7 recorded cases of tetanus in total, 3 of which ended with death.

• There were individual cases of whooping cough reported, with mostcases in the previous ten years recorded in 2012 (n = 9). The last death was reported in 2001.

• There has been a steady decline in the morbidity from morbilli and rubella since 1998, with an exception in 2008 and 2010-2011 when there were two outbreaks of morbilli.

• There has been a continuing decline in the number of parotitisepidemica cases since 1997, except in 2008-2009 when there was epidemic of parotitis epidemica.

Challenges

• Continuous maintenance of the coverage over 95% with vaccination and revaccination in each separate territory ("micro" - "macro" area) around the country

- Continuous and active searching for unrecorded, unvaccinated and under-vaccinated individuals, with a special emphasis on hard-to-reach populations (Roma population, migrants, etc.), finding and vaccinating these individuals to complete their vaccination status

• Promotion and strengthening the system of supervision over vaccine-preventable diseases.

• Introduction of polyvalent vaccines for successful implementation of continuous immunization, providing an opportunity for introduction of new vaccines in the Immunization schedule

• Implementation of standardized immunological studies to control the immunity status of the vaccinated people, determining the level of collectiveimmunity, i.e. assessment of the vulnerability to vaccine-preventable diseases in the population.

• Unification (universality) of the system of planning, implementing, recording and supervising the immunization, i.e. introduction of single software with database on immunization.

Challenges

Challenges

• Intensive campaign by all relevant factors in the healthcare system related to the vaccination, which would limit and reduce the effect of emerging anti-vaccine lobby groups that threaten to compromise the regular vaccination.

- In urban areas, especially in the capital, there is a strong influence by anti-vaccine campaign, already reflected in the reduction of vaccination coverage,especially MRP vaccination coverage.