Unveiling vaccine hesitancy in the Federation of Bosnia and Herzegovina

April 2018

A young girl is smiling as a doctor injects vaccine, in Bosnia and Herzegovina
Rates of immunization in the Federation of Bosnia and Herzegovina are declining.
UNICEF/Zmey

Immunization rates in the Federation of Bosnia and Herzegovina are as low as 40% in some areas and continuing to decline, increasing the risk of large disease outbreaks. But, no one knows precisely why.

Growing vaccine hesitancy, misinformation in social media, lack of trust in the health system, a shortage of health workers and supply issues are all suspected reasons for low coverage rates. However, these are mostly assumptions with little evidence.

"Right now our immunization programming is based on a lot of assumptions," says Dr Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina. "We need better data to understand which population groups have the lowest coverage and why it is so low."

Using WHO’s Tailoring Immunization Programme (TIP) – a structured research approach – the country is working to identify populations susceptible to vaccine-preventable diseases, diagnose barriers and motivators to vaccination, and recommend evidence-informed responses to improve coverage.

State of immunization

TIP was developed in 2013 by the WHO Regional Office for Europe to assist health care professionals, public health authorities and decision-makers in tailoring services to close gaps in immunization coverage. The first step in the TIP process is for countries to conduct a situational analysis to take stock of data on coverage and outbreaks, gather key stakeholders, and identify knowledge gaps.

In 2016, only 78% of children in Bosnia and Herzegovina received the third does of diphtheria-tetanus-pertussis (DTP)-containing vaccine, 79% received the third dose of polio, and 83% the first dose of measles vaccine – all falling short of global targets of at least 90 to 95%. Vaccination coverage also varies greatly within cantons and cities, and in some areas rates fall between 40-50%.

These low rates put the country’s population at-risk for large disease outbreaks. In the last decade there have been large outbreaks of measles, mumps and rubella, in part due to the disruption of immunization programmes during the war in the early 1990s, but also to vaccine hesitancy.

"With current large measles outbreaks across the Region, including in nearby Italy, Romania and Serbia, the country is constantly on high alert for outbreaks."

Dr Sanjin Musa, epidemiologist at the Institute for Public Health in Bosnia and Herzegovina

"With current large measles outbreaks across the Region, including in nearby Italy, Romania and Serbia, the country is constantly on high alert for outbreaks," says Dr Musa. Immunization is free and mandatory in the country, but there are no mechanisms to ensure compliance.

Researching reasons for low coverage

After the TIP situation analysis was completed in 2017, the country began working to identify areas where more research was needed. They are now conducting two studies.

The first study is looking at health worker attitudes towards immunization in order to develop further trainings and tools. Some health workers currently either lack knowledge about immunization or fear allegations following adverse events.

The second study is reviewing patient records in primary care centres in order to identify characteristics of caregivers who do or do not vaccinate their children, such as age, number of children or income level. Once these characteristics are defined, immunization strategies can be develop to improve access to immunization and reduce vaccine hesitancy.

"Building trust and understanding the community is essential to responding to vaccine hesitancy," says Katrine Bach Habersaat, Technical Officer, Vaccine-preventable Disease and Immunization in the WHO Regional Office for Europe. "Many people assume vaccine hesitancy is about people being unwilling to be vaccinated, but under the surface it is often about the convenience factor and how easy it is to get their children vaccinated."

The country’s TIP studies are expected to be completed later this year. It is part of WHO’s work with 11 countries in south-eastern Europe to speed up progress in reaching the goals and strategic objectives of the European Vaccine Action Plan 2015–2020 (EVAP).