Vaccination is safest and cheapest way of protecting from infectious diseases Family physicians are the captains of these procedures in the field. Educations should be provided to help them in reaching current affairs in immunizations. Community pediatricians can provide expert consultation. In addition, these vaccines should be under the cover social security insurance.
The morbidity and mortality of infectious diseases can be reduced by providing high immunity rate. The way of maintaining herd immunity is to meet the infection agent somehow and vaccination is the safest method of this process .
Vaccines provide simple, reliable, cheap and effective ways for public health and they are the most available mediators of protection from infectious diseases . In Turkey, the National Immunization Schedule (NIS) is applied meticulously under the control of Health Ministry of Turkish Republic (HMTR). The NIS includes vaccines against thirteen diseases .
All vaccines are supplied and administered freely at primary health care centers by family physicians. Although, rotavirus (RVV), human papilloma virus (HPVV), adult type pertussis, (Tdap), influenza and conjugated meningococcal vaccines are licensed and available for procurement, they are not included in NIS and defined as “non-NIS vaccines.
” They are available as “voluntary vaccines” and their cost are covered by families. The application depends on the recommendation of physicians or the requisition of the families. Although these immunizations are offered strongly, lack of knowledge about the diseases or immunization facilities, safety concerns, personal beliefs, other priorities, financial problems are reported to be the barriers of non- NIS vaccines . The rate of recommendation and application of non-NIS vaccines are lower than expected even in developed countries and Turkey [4,5].
Rotavirus infection is a common agent detected in acute gastroenteritis of childhood. It is the cause of 22.5% of the acute gastroenteritis cases in Turkey . It is common in winter and resistant to environmental conditions. The prevalence of infection is similar in developed and undeveloped countries which reveals that improved sanitary conditions are insufficient to prevent the infection. It is more frequent in children under five years old and causes electrolyte imbalance with dehydratation . More than 2.7 million episodes of diarrhea, 400,000 outpatient office visits, and 55,000–70,000 hospitalizations per year are attributed to rotavirus in the United States (US) . Vaccination seems to be cost-effective and able to reduce the disease burden [9,10]. Advisory Committee on Immunization Practices (ACIP) recommends the vaccine to all infants unless there is a contraindication . The vaccination schedule should begin at two months of age and completed before six-eight months by two or three doses according to the trade mark of the applied vaccine .
Meningococcal disease is an acute, potentially severe and mortal illness caused by Neisseria meningitides. It is the one of the leading causes of bacterial meningitis and sepsis or focal infections such as pneumonia and arthritis. The case-fatality ratio of meningococcal disease is 10% to 15%, even with appropriate antibiotic therapy As many as 20% of survivors have permanent sequelae, such as hearing loss, neurologic damage, or loss of a limb . Immune deficiencies related with complement pathway or asplenia are risk factors for invasive meningococcal disease (IMD) . The rate of mortality due to meningococcal infections was reported to be 18.4% . In Turkey, it was reported as to be the most common agent of bacterial meningitis and the serogroups were W-135 (38.1%), B (26.1%), A (8.4%), Y (0.9%) and non-groupable (26.4%) . In addition, nasal carriage, which is the most important notion in the epidemiology of IMD rate, is also remarkable and the serogroup distribution is similar to disease causative agents .
Meningococcal seroepidemiology of Turkey is different from other countries as serogroups W and B are the predominant strains for IMD during childhood. Serogroup C has not been reported for years. The adolescent peak is not observed and the infection is more common under five years old [11,12]. Two types of vaccines containing serogroups MenACWY and serogroup MenB are recommended for Turkey. Different trademarks of conjugated MenACWY and Men B can be used for immunization. The time of initiation, number of doses and dose intervals change according to the manufacturer’s recommendations. Men ACWY is applied to the candidate pilgrims before Hajj as one of the travel vaccines which is one of the best ways of to prevent nasal carriage problem .
HPV infections are usually asymptomatic, but clinical manifestations include anogenital warts, recurrent respiratory papillomatosis, cervical intraepitethelial neoplasia, genital and oropharyngeal cancers . As it is one of the most common agents of sexually transmitted disease (STD), it is recommended before the onset of sexual activity. That’s why adolescent coverage of the immunization is very important . HPV cytology screening is a part of women health because its strong relationship with cervical cancer has been known for a long time. The prevalence of HPV and annual cervical cancer in women is predicted to be 4.2-25% and 1.43/100000 respectively . In the US anogenital HPV is the most common STD by 79 million infected people and 14 million new infections per year . HPV is known as one of the preventable reasons of cancer and immunization, use of physical barriers and monogamous sexual activity provide effective protection . Two, four and nine- valent vaccines have been licensed for adolescents and young adults of both sexes. The schedules vary between the vaccines according to their contents .
Pertussis is one of the frequent reasons of lower respiratory tract infections in infants (LRTI). It causes severe respiratory distress with paroxysms of numerous rapid coughs in infants and prolonged coughing attacks in adolescents. Neither experiencing infection nor vaccination provides lifelong immunity, but the severity of symptoms decrease with increasing age. People having mild symptoms may transmit the infection to the susceptible individuals such as unimmunized or incompletely vaccinated infants. Acellular pertussis vaccine cannot be administered before six weeks of age and at least three doses are necessary for the initiation of the protection . Tdap is usually recommended to adolescents, pregnant women and adults who are in contact with infants to form a “cocoon” around them. The last dose of tetanus vaccination (Td) during pregnancy or adolescent dose of Td can be administered as Tdap [14,15].
Seasonal influenza is a vaccine preventable, highly contagious infection and it can result in fatal complications in the populations who are at risk. It is a public health problem because infection causes heath care costs with loss of labor and school time . The infection can be complicated with LRTI in infants or children with chronic illnesses such as asthma, congenital heart diseases, immune deficiency, diabetes, etc. Influenza vaccination is recommended to all children aged between 6-59 months old and every individual having a chronic health problem . It should be considered as one of the components of cocooning strategy with Tdap [7,17]. The first dose can be administered after the six months of age and repeated every year before the influenza season of the country .
This study was conducted with the family physicians working at the primary health care centers of a small city in middle northern Turkey between December 15, 2019 and May 15, 2020. The data source of the study was a questionnaire consisting of six sections and 35 questions. The questions were about sociodemographic and professional features of the attendees, their knowledge and attitude about RVV, HPVV, Tdap, influenza and meningococcal vaccines, experience about the related diseases and their personal intentions about the inclusion of each vaccine to NIS. Complicated diseases were defined as cases requiring treatment by hospitalization with clinical status or laboratory abnormalities such as electrolyte imbalance. The researcher reached each physician by phone, asked participation to the study and the questionnaires were filled via email or on-call interviews with the physicians who accepted to enroll. Informed consent was asked before answering the questions.
Ethics: This study was approved by the Ethical Committee of Non-Invasive Clinical Researches of the local university with a decision number: 15386878-044 in December.
Statistical analysis: The analyses were performed by using statistical package program (SPSS v15.0 (SPSS Inc,, Chicago, IL, USA)). Descriptive statistics were presented as frequencies, percentages, arithmetical mean ± standard deviation, and median (minimum, maximum). Nominal variables were compared by using Pearson’s chi-square, Yate’s corrected chi-square, and Fisher’s exact test where appropriate. The distribution patterns of the variables were investigated by visual/analytical methods (Kolmogorov-Simirnov test/histograms). A p-value of less than 0.05 was considered as “statistically significant”. The answers such as “I do not know” or “I do not have an idea” were accepted as not answered.
The coverage of non-NIS immunizations is low globally. This study established that most of the family physicians have lack of knowledge about non-NIS vaccinations. The financial burden seems to be a significant problem. Mandatory vaccinations of NIS are under the control of primary health care centers, but the staff is in need of expert consultation for voluntary vaccinations. The patients are directed to pediatricians, but well child visits are not common in our society. Usually, well child family consultation has to be a part of examinations during a health problem and at that point the parents can only concentrate on the current problem. Families should be directed to well child clinics for immunization consultation and this service must be disseminated all around our country under the control of family physicians and community pediatricians.
Rotavirus was the most recommended vaccine in this study the group like other studies in Turkey . RV causes a highly contagious infection and dissemination chain cannot be broken easily because the virus is resistant to sanitary precautions. The infection is a frequent problem especially in children under 2 years old and vomiting prevents oral intake. Hospitalization is usually needed to replace water and electrolyte loss. This means loss of labor time of the parents who accompany their children at the hospital. However, the rates of recommendation and administration were still much lower than desired in this study. The concerns about the safety, cost, efficiency and efficacy of the vaccine, reduce the rate of recommendation and administration. Many healthcare workers think that acute gastroenteritis can cause serious problems unless well treated, but the vaccination is not considered to be a priority . The vaccines are safe and efficient in reducing the severity of the symptoms and the cost affectivity of the vaccine was established by several studies, but these are still barriers against vaccination recommendation [7,9].
Meningococcal vaccines were the second highest recommended and offered vaccine for NIS in this study group. Most of the physicians had no clinical experience, but the slight symptoms at the onset of the infection and rapid progression which can result in high morbidity and mortality intimidate the physicians. In Turkey, nasal carriage is high and Hajj season is important. The vaccine is recommended in immune deficiency, but passive smoking, crowded family life, upper tract infections can facilitate the infection, that’s why it is a significant public health problem .
In another study, the physicians declared the reason of hesitation as “serotypes of the agent in Turkish society were not compatible with the content of the vaccine totally. The children have to be vaccinated by both Men ACWY and Men B for protection. Two different vaccines for one disease increase the cost and injections . MenB is a new vaccine in Turkish market. However, insufficient knowledge and expert consultation requirement were the most common reasons of not recommending in this study group.
HPV vaccine was not recommended frequently, but the physicians declared that it should be added to NIS because the infection rate is high and the potential of malign transformation cannot be neglected. The most common reason for not offering was lack of knowledge and experience about the vaccine. In literature, the barriers for HPV vaccination are cost of the vaccine and concerns about side effects and parental concerns on making unwanted sexual behaviors earlier and easier . In developing countries adolescent marriages must be taken in consideration as early sexual activity . The rate of recommendation was reported to be 45.6% in Turkey and the reasons for not recommending were the cost and not thinking HPV as a priority in the health care system .
In Japan, the coverage of HPV vaccine (HPVV) was around 70.6% when it was first introduced to NIS, but dropped to 0.6% because of adverse events following immunization . Many studies established that these events were not related with the vaccine itself, but the vaccine is coverage is still low, although it is available and supplied freely for adolescents in the country. In a study from Japan, the recommendation rate of HPVV was reported to be 21% although 53% of participants declared the necessity of immunization . The affectivity of the vaccine is high so opportunities to prevent cancer should be seized . Woman health and child health are the indispensable parts of the whole public health.
Tdap is a new vaccine for Turkey market. In many studies, it is the least recommended vaccine because the knowledge and experience about it is limited [5, 21]. In addition, pertussis is not thought to be a primary healthcare problem and the attitude of the family physicians about its addition to NIS was limited . As mentioned before, it is a part of cocooning strategy for the sake of infants who are at risk of severe, complicated LRTI . In developed countries the last doses of Td in childhood-adolescent and pregnancy immunization schedules are recommended to be Tdap .
Seasonal influenza vaccination is recommended to every individual who are at risk of complicated infection including chronically ill people, pregnant women, children under five years old and people who have to work in crowded places and may have role in the transmission of the infection in the society such as health care workers, nursery staff, etc . The coverage of influenza vaccination is lower than expected in adolescents as it is available as “voluntary vaccine” in Japan and supplied by the families with charge . Adolescent vaccination is a part of cocooning strategy of infants for influenza and pertussis unless there is a risk factor for the receiver . In the USA it is recommended to all children . In Turkey, influenza is under the cover of social security insurance in chronically ill people and the recommendation of the vaccine is usually limited with this population .
A report based on influenza vaccination during pregnancy established that thinking influenza has an effective treatment, not a serious disease, flu as an adverse effect of the vaccine itself, fear of injection, concerns about the adverse events, lack of information about the vaccine and administration facilities, inadequate vaccine efficacy, negative impact of media, not having information where to get vaccines, lack of healthcare provider recommendation, financial problems are the main reasons of vaccine abstention . In this study, family physicians declared that they need expert consultation for influenza immunization.
In the literature, there are some studies revealing that gender, working place or age and active professional time have significance on the recommendation of some vaccines. For example HPVV and Tdap were reported to be recommended by female physicians more frequently than male physicians. HPPV is one of the main reasons of gynecologic cancers and Td is in the routine schedule of pregnancy immunizations which may increase the awareness of female physicians on the subjects [5,24]. In addition, younger physicians who are new in their professions tend to recommend new vaccines which may be related with having current information about current affairs in immunization [5, 24]. However, in this study none of these variables had statistically significant effect on recommending non-NIS vaccines (Table).
The attitude of physicians about recommending the non-NIS vaccines to their relatives establish their opinion about the vaccine and this is related with their attitude about the addition of vaccines to NIS . In this study, approximately 60% of the physicians recommended RVV, HPVV, meningococcus and influenza vaccines to their relatives and their attitudes about addition of these vaccines to NIS were similar. However, Tdap was the least recommended vaccine to their relatives and NIS which may be related with lack of knowledge and experience about Tdap since it is new for Turkey.
This study established the attitude of family physicians, the captains of immunizations services in the field, about non-NIS vaccines. However, the study setting was a small city and the participation was limited. The data were obtained by a survey based on personal declaration during limited time. These limitations make it difficult to generalize the results.
In conclusion,. to increase the coverage of non-NIS vaccines the family physicians should be educated and immunizations should be administered under the coverage of social security insurances. Current affairs should be shared at the formal websites of the HMTR and stakeholders. Community Pediatrics should be practiced as a subspecialty of Pediatrics in Turkey, too and immunization consultation should be managed with family physicians at the primary health care centers during well child visits. The patients should not visit hospitals which have disease burdens for these procedures. In addition, families should be aware of the immunization opportunities of their children to benefit from these services. Family physicians have important roles to detect the priorities of public health and their attitude about new vaccines is important while the authorities think to add a new vaccine to NIS Vaccination is a right and chance for every child to be a healthy individual and a duty for everyone for the sake of the whole society to build up herd immunity.