In Ukraine, vaccination has always been challenging. In 2016, the country had the lowest routine immunisation rate in the world, according to Unicef.1
Data from the country’s ministry of health showed that just 44% of children under 18 months of age were fully immunised against polio. Only 30% of children up to the age of 6 were fully immunised against measles, 10% against hepatitis B, and 3% against diphtheria, pertussis, and tetanus. (For comparison, the average European Union rates in 2021 were over 95%).
Ukraine has long struggled not for vaccine access but for uptake, in large part because of a lack of trust in the government and the healthcare system that stems from Soviet times. “The health system was highly centralised. The main condition for a successful career was loyalty to the Soviet party and senior management of your hospital or university,” says Fedir Lapii, head of Ukraine’s National Immunization Technical Advisory Group.
Today, vaccine disinformation is rife, often spread by Russian trolls and bots on the Internet—the same trolls who interfered in the US presidential elections.2 “The main reason for the spread of such disinformation is not about direct harm—though it also may cause this—but to create chaos in society, to split it and confuse people. It is much easier to manipulate people when they are confused and scared. You can lead them in the direction you need,” says Lapii. “Decreasing the vaccination rate also helps to spoil the country’s reputation.”
Despite this, up until 2019, Ukraine’s vaccination rate was improving slowly. A year before the covid-19 pandemic and a year after a severe measles outbreak in Ukraine, 93% of Ukrainian children had received the first dose of the measles vaccine,3 although other vaccination rates remained low—a 2021 polio outbreak has been blamed on low vaccination rates, for instance.4
Then came the war, putting a pause on vaccination just when the risk of an epidemic—because of the lack of running water, crowded bomb shelters, and limited access to medical care—is higher than ever.
Persuasion
Anastasiia Bykova-Shelevytska, a paediatrician at the private clinic Paediatrics with Love, saw her practice shut during the first weeks of the Russian invasion in February 2022. When it reopened, one of the most cited reasons for patient visits was planned immunisation.
Bykova-Shelevytska believes that wartime has helped many to realise that vaccination matters. But not everyone is convinced. “Some people think that it is not time for vaccination. What if tomorrow we are evacuated and there are complications?”
“I try to persuade them that it is extremely important to keep up with vaccinations, especially for children, as we don’t know what’s going to happen with vaccine delivery,” she says. “War is also a time of communicable disease outbreaks as people spend time in overcrowded shelters.”
The current state of Ukraine’s vaccination programme is hard to know. Chief state sanitary doctor of Ukraine Ihor Kuzyn says that on the one hand some tracking is possible thanks to a digital healthcare system operational since 2018. But it is difficult to understand vaccination rates as millions of people have left the country.
“We know that around eight million citizens are still in other European countries according to recent UN data,5 but we’ve also had enormous migration within the country,” he says. “All these factors distort data. And gradually we are losing connection with temporary occupied territories.”
Kuzyn’s impression is that the rate of vaccination has dropped considerably, and that vaccine coverage changes month to month and varies depending on the vaccine. For instance, in April 2022 overall vaccine coverage dropped to between 5% and 7%. For the BCG vaccine, rates dropped to 3%, while hepatitis B dropped to 15%.
The vaccination rate for children under 1 has decreased noticeably, says Kuzyn. Before the full scale invasion measles, mumps, and rubella (MMR) vaccine coverage was 88% in 2021 for children aged 12-23 months3 (for comparison, the MMR vaccination rate for the EU was 93%). He says, however, that this can partly be explained by the fact that many children, as well as women of reproductive age, have fled the country.
Vaccination during Russian occupation
Kuzyn told The BMJ that when an area is retaken by the Armed Forces of Ukraine, one of the first institutions to get access is the Centers for Disease Control and Prevention (CDC) of Ukraine. And their first task is to understand how many people are still there and how many vaccines must be delivered.
When the Kyiv oblast was reoccupied, the CDC found that more than 50 vaccination points in the region had lost their stock of vaccines. “Also, only 30% of the population was still there, and it was important to adjust the need for immunological drugs and refrigeration equipment,” Kuzin adds, emphasising the importance of diversifying storage locations to reduce the risk of losing them to shelling attacks.
Vira Drobosh’s* town in the Zaporizhzhya region in south east Ukraine has been under Russian occupation since the first days of the war. Drobosh, a paediatrician and infectious disease specialist, worked in a covid designated hospital during the occupation (she is now living in the free territory in Ukraine). Parents were trying to vaccinate their children or get covid shots for themselves. Drobosh says she faced a dilemma: stay in the town to continue treating covid patients and vaccinating children, or try to leave occupied territory. In the end, she stayed for over a month.
“I couldn’t deny my patients. They came here from distant villages, contacting me any time an internet connection was back up and running.” But a lot of people couldn’t get the vaccine they needed for themselves or their children. There was no transport, for one thing. Others were too afraid to venture out for fear of being shot by Russians.
Window of opportunity
Maryna Ivanenko* is a family physician and the owner of a small private clinic in the city of Berdyansk that is also under occupation.
“For almost half of the year, vaccination stopped completely. Then, the Russian occupants delivered Russian vaccines for covid-19 (Sputnik V) and tuberculosis. These vaccines are not approved by the World Health Organization. I would never recommend these to my patients,” she says.
Ivanenko says that in the beginning of the war there was a window when the Russian army allowed deliveries of medicines and other humanitarian aid from outside the country, but they retracted this in the autumn of 2022.
“We had that window to provide vaccines to people,” says Olga Khorol, a family physician from Zaporizhzhia oblast. “We equipped volunteers with all the necessary equipment to maintain the cold chain.” Vaccines were delivered by volunteers who carried them by whatever transport they could find to the occupied city of Vasylivka, the administrative capital of the southern Vasylivka Raion region.
“The logistics of vaccine delivery to an occupied territory is the precise work of many people,” says Khorol. “It was only possible thanks to volunteers and medical workers—everyday people who understood the importance of vaccination in saving lives.”
Will that window open again? Ivanenko says that it is doubtful, pointing to the city of Donetsk in east Ukraine. The city and part of the region have seen conflict since 2014 when the Russian regular army, backed by Russia paramilitary groups, wanted to separate from Ukraine before it was occupied by Russia. One aid volunteer, Olga Novykova, told The BMJ that in the city of Mariupol in the Donetsk region, Russians have refused to give medical aid to those who won’t get a passport from the so-called Donetsk People’s Republic—an unrecognised republic of Russia in the occupied parts of eastern Ukraine’s Donetsk oblast.
Humanitarian aid from Ukraine was also blocked in the southern oblast of Kherson before it was freed by the Armed Forces of Ukraine in November 2022. “When we tried to give aid to Kherson, Russians would take it away or just destroy it,” says Novykova. “One day they shot a bus driver.”
That is one of the facts Novykova and others are at pains to emphasise: there is no way to guarantee basic medical aid, let alone vaccination, under Russian occupation.
Footnotes
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Commissioned, not externally peer reviewed
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Competing interests: None.