Measles Outbreaks in Kazakhstan: Why This is More Than Vaccine Hesitancy

There were several years in independent Kazakhstan when an explosive increase in the incidence of measles was recorded. This happened in 1993, 1998, 2005 and 2015. Until 2022, the last serious outbreak that put Kazakhstan into the world’s top ten countries with measles incidence began in the fall of 2018 and hit 2019 with a wave (Zhuzzhasarova et al., 2021). The latest outbreak happened in post-COVID Kazakhstan in 2023. As of late December 2023, doctors have registered more than 24,000 cases of infection in this new outbreak (Issabekova, 2024). “We attribute the increase in incidence to the fact that children missed scheduled vaccinations, as well as to the fact that the school year has begun […]. Since measles is a very contagious disease, the incidence rate is increasing,” said Zhanibek Erbaev, director of the emergency operations center of the National Center for Public Health (Dumanova, 2023).

Measles Vaccination in Kazakhstan: An Overview

According to Kazakhstan’s vaccination schedule, the MMR vaccination is received twice in childhood – at one year and six years (Issayeva & Yeraliyeva, 2023). Revaccination in adulthood is not required unless antibodies to measles or rubella (which is especially important for women planning pregnancy) have decreased to a critical level. This can occur after another severe infection, for example, after COVID-19, which, according to some data, can affect immune memory.

According to the World Health Organization (2022), due to the COVID-19 pandemic, global measles vaccination coverage rates have fallen to critical levels not seen since 2008. The recommended coverage of measles vaccination is more than 95% of children, while according to WHO data for 2022, only about 81% of children in the world received the first and about 71% of the second measles vaccination required for maximum protection. According to WHO forecasts, this could lead to a new measles epidemic. In many countries, the outbreak of this disease began in 2022.

Kazakhstan, unfortunately, was no exception. In 2022, only four cases of measles were reported in the country (Zakharova, 2023). In 2023, according to the Ministry of Health, after tourists “brought” measles to the country from Turkey, Russia and Egypt, the number of infected people increased (Forbes Kazakhstan, 2023). In June, 636 laboratory-confirmed cases of measles were registered in Almaty alone. In July, as mentioned above, the number of young Kazakhstanis who fell ill with measles (across the country) reached approximately 16,000 since the beginning of the year.

Regarding other factors behind such a spike, not all people who received a vaccine against a particular disease in childhood will develop an immune response. Experts believe that out of 100 vaccinated people, only 95 (in some cases, only 90) will develop good immunity (WHO, 2019). The rest will not. That is, even with total vaccination, some part of the population will be unprotected. Add those who did not receive the vaccine due to a medical exemption or parental refusal. Gradually, the number of people without immunity accumulates, and outbreaks eventually occur. This fully applies to measles.

Approximately 350,000 children under one year of age receive the measles, mumps and rubella vaccine (MMR) for the first time in Kazakhstan annually (Akulova, 2021). Another 350,000 are six year-olds who receive their second doses of the vaccine. In total, this is about 700,000 people per year. It is believed that after a single vaccine, which is given at an early age, protection against infection is formed for life. The second vaccination is necessary to ensure immunity in the ten percent of children mentioned in the previous paragraph. After vaccination at the age of six, the number of people without immunity to infection should be halved. That is, there will remain not ten but five percent of people who are not protected from measles, mumps and rubella. This is approximately 17,500 people (5 percent of the 350,000 six-year-olds who are vaccinated for the second time). Let’s add those who did not receive the vaccine due to medical withdrawal or parental refusal (this figure varies annually from 6,000 to 8,000). The numbers are hypothetical, but they give an understanding of the broader trend.

Regarding vaccine hesitancy, although Kazakhstan is not considered a country in the risk zone, it is still a contributing factor. For example, according to the data from the Committee for Sanitary and Epidemiological Control of the Ministry of Health of the Republic of Kazakhstan, there were 8032 cases of parental refusal for vaccination in 2016, 5388 in 2017, 5751 in 2018 and 6003 in 2019 (Akulova, 2021). One of the main reasons for young parents refusing vaccination is religious views. Doctors involve theologians to clarify the issue and all the consequences for children’s health (Akhmetzhanova et al., 2023). Looking at the official numbers presented above, the percentage of vaccine refusal is no larger than two percent. Unfortunately, there is no other data that would counter or confirm the official data.

However, looking at those statistics, one can deduce that approximately 17,500  people without immunity to infection are added to the statistics every year. If revaccination is not carried out, in 10 years, there will already be 175,000 people. When adding those who refused vaccination, we have a critical mass that seriously affects the overall epidemiological situation. The hypothetical statistics are a representation of the world’s vaccination situation. All countries worldwide are forced to carry out so-called clean-up immunization every 10-15 years. Part of the vaccinated population does not always have a good immune response. However, if a person has been vaccinated at least once and becomes infected, the disease will proceed without complications.

Outbreaks in Kazakhstan and Their Causes

Graph 1. Measles Incidence Data for 1981-2020 in Kazakhstan. Source: Vlast.kz

In 2005, doctors did not have time to register everyone due to the large number of infection cases. The 16,118 sick people who appear in the statistics (Graph 1) are the cases that health workers were able to record. In fact, some experts, such as Nurshai Azimbayeva, highlight that there were slightly more of them (Akulova, 2021). During the spread of any infection, problems with hospitalization and recording occur; there are asymptomatic or low-symptomatic patients who do not go to doctors and do not stay in hospitals, and accordingly, they are not counted. This does not mean that someone is hiding the facts. According to doctors, it was physically impossible to control the correctness of accounting at all levels.

One interesting fact about this outbreak is that it was expected. There were forecasts based on which a large-scale additional vaccination was planned for 2004. However, epidemiologists could not prove to the government that Kazakhstan needed to conduct a mass vaccination campaign. According to Azimbayeva, epidemiologists cannot always explain to other doctors why this is necessary, and as a result, the vaccine was purchased, but with a delay of at least six months.

The spread of infection began in November 2004, and re-vaccination began in early 2005 (Khetsuriani et al., 2011). It was carried out in two stages: in February, only young people aged 20-30 were vaccinated against measles. In September, when this infection began to decline, they began vaccinating women of childbearing age against rubella (at that time, mono vaccines were used for both measles and rubella). These were people who were born in the late ‘80s and early ‘90s. At that time, vaccines were distributed from Moscow; there were not enough of them, and in the ‘80s, there were problems with supplies. This shortage led to Kazakhstan having a serious measles outbreak in the early 2000s.

In 2009, Kazakhstan reached a figure of zero cases of infection (Akulova, 2021). At the global level, it is called measles elimination – stopping the spread of local cases. Since the outbreak in 2005, Kazakhstan has provided additional vaccinations in certain age groups. There were fewer people susceptible to infection, the situation gradually stabilized, and after a few years, there were zero cases in the statistics. There were four cases in 2010. The man became infected with measles while on a trip abroad, and after returning home, he infected three more people. It was one small site, and the outbreak was quickly contained. But then the number of cases of measles became more and more numerous. However, starting at the end of 2014, an explosive spread began throughout the world.

A similar situation happened in 2015. Mostly young people aged 15-25 years-old fell ill – those who were born in the late ‘90s and early 2000s. According to expert reports, the vaccines were not stored properly in some hospitals at this time. This naturally affected the effectiveness of live vaccines such as the measles vaccine. Some doctors reported that even when vaccines were delivered in good condition, there were no proper conditions for their storage at the district level: the power could be turned off for a day, affecting their quality. Even so, vaccination continued. It is crucial to note that vaccines exposed to heat do not become dangerous to humans, as some people think, but rather, they become ineffective; the virus contained inside the vaccine dies. Regardless of this fact, people were vaccinated with these improperly stored vaccines.

In 2019, 13,326 measles cases were registered, including 9,409 among children under the age of 14. This is almost 71 percent. Most of them were not vaccinated – 7,802 people. The reasons for non-vaccination vary: failure to reach vaccination age (babies under one year old – 3,703), medical exemptions – 2,364, refusals to vaccinate – 1,735 children. Therefore, an additional vaccination of young people aged 20-29 years (1,759,459 people) was carried out during the outbreak. Moreover, the state decided to start vaccinating children against measles, mumps and rubella, not from the age of one, as before, but from nine months (273,655 people). Thanks to these measures, this measles outbreak was contained.

In an ideal world, according to experts, babies should not get measles until they are six to nine months-old. This is because babies receive maternal immunity, but this only happens when a mother has antibodies against this infection (Albrecht & Arck, 2020). When a mother has the antibodies, it protects the child, but the immunity transmitted from the mother gradually disappears, completely disappearing by the age of one, and thus, the baby becomes vulnerable to infection. Therefore, it is at this moment in their life that children are given their first measles vaccination. However, during the outbreak in 2019, there were many children under one year old – a month old, two months old – and got infected. This suggests that their mothers did not have immunity. This connects back to the problems discussed above, such as the mismanagement of vaccines in the ‘80s to ‘90s when these children’s mothers were born. The ministry decided to start the vaccination at nine months old, but the outbreak continued nonetheless. The doctors could not vaccinate pregnant women against measles – it is contraindicated. As a result, they gave birth to children who also had no protection; after some time, these babies fell ill and ended up in the measles statistics. It was a complicated outbreak.

Many reports and experts, when addressing the 2019 outbreak, mention the importance of external factors. In 2018, Russia hosted the FIFA World Cup. Many Kazakhstanis went to the matches, and the stadium was a great environment for the spread of infection (Memish et al., 2019). At that time, Ukraine was already burning with the outbreak, and Ukrainian tourists also poured into Russia for the World Cup. Thus, one of the reasons for the outbreak was the importation of measles into Kazakhstan. This was where it all started, and other factors came into play.

2023

According to the Ministry of Health in Kazakhstan, the first cases in early 2023 were imported from Turkey and Russia (Forbes Kazakhstan, 2023). As doctors note, the increase in people infected with measles in 2023 is not specific to Kazakhstan. In the first four months of 2023, measles cases were reported in 17 countries in the WHO European Region (European Centre for Disease Prevention and Control, 2023). By the end of February, 900 cases were officially reported, more than in 2022. At the same time, WHO emphasized that authorities in all countries, including those in which the elimination of endemic measles transmission has been confirmed, must remain vigilant against this highly contagious disease. The “record holders” for the number of diseases are Tajikistan, Türkiye, and Russia (UN News, 2023). These countries have reported the highest number of measles cases in recent months. Austria, Serbia, Great Britain and Uzbekistan have also seen an increase in incidence since the beginning of 2023.

The main reason for the outbreak in 2023 was that there was a pause in vaccination during the pandemic. Back in November 2021, WHO released a report warning that many children were not vaccinated on time during the pandemic. The WHO estimated that a record number of nearly 40 million children were not fully vaccinated in 2021. Of these, 25 million missed the first dose, and 14.7 million missed the second dose. Kazakhstani doctors and scientists did not stand by and, for several months, warned about the need for preventive measures. This is primarily the vaccination of children who are in the main risk group. It is also a recommendation for adults, especially women planning a pregnancy, to ensure that they receive two doses of the vaccine.

The pandemic has also created vaccine hesitancy and fear. This is not about the anti-vaccination movement per se but rather about parents’ confusion and doubts. These are sensible parents who doubt whether or not to vaccinate their children due to the abundance of conflicting information (Abdirakhman et al., 2023). They have reasonable questions about vaccination, which health workers cannot always answer fully.

The third reason that influenced the outbreak is the political situation in Kazakhstan. According to the Migration Service Committee of the Ministry of Internal Affairs of Kazakhstan, 406,000 citizens of the Russian Federation entered the country in September of 2022 alone (Lambrecht, 2023). Before this, an average of 8,000-9,000 Russians crossed the border per day, and then at the end of September, the average daily influx from the Russian Federation reached 30,000 people, Tengrinews reported (2022). The problem is that the migration service of Kazakhstan does not record data on children who crossed the border. Nothing is known about their age, much less about their vaccination status. Russia is now one of the main sources of outbreaks. The epidemiological situation worsened there earlier than in Kazakhstan. In addition, polio has awakened in Russia due to catastrophically low vaccination coverage, and Russians are increasingly refusing vaccinations (Topluoglu, 2023). In this political situation, vaccination coverage in Kazakhstan has changed significantly due to migration, among other things.

Due to the measles outbreak in 2023, the Ministry of Health decided to carry out additional vaccinations (Vaal, 2023). Children are now vaccinated starting at six months. Additional vaccinations are being given to children ages two to five years old.

Where Does the Hesitancy Come from?

Another factor to which experts attribute the outbreaks is vaccine hesitancy. This phenomenon, particularly in Central Asia, including Kazakhstan, has not received adequate research attention. One of the latest studies on vaccine hesitancy in Kazakhstan by Akhmetzhanova et al. (2020) investigates the reasons behind existing vaccine hesitancy. Their cross-sectional online-based study, conducted between September and November of 2019, included 387 participants, with 70% being females, primarily under the age of 40, and having one or more children. A notable 35% of participants expressed vaccine hesitancy, while 71% believed in vaccine effectiveness, and overall, 65% held positive views about vaccines.

The responses depended on the source of information about vaccination, with those receiving guidance from healthcare providers displaying fewer concerns about vaccination. This study stands as the inaugural effort to identify factors associated with vaccine hesitancy in Kazakhstan, revealing a significant prevalence of hesitancy alongside a corresponding lack of vaccine knowledge among participants. Healthcare providers hold a unique position in augmenting parents’ comprehension and acceptance of vaccines.

Distrust in the healthcare system is another significant factor (Abdirakhman et al., 2023). Some parents lack confidence in the procurement process of vaccines and question their quality based on their country of origin. Additionally, there is a perception that healthcare practitioners do not adequately assess children’s medical history and health status before administering vaccines, leading to concerns about safety. Social learning factors also play a role, with parents being influenced by credible or influential individuals in their social circles or online communities. Misinformation and negative reviews about vaccines on social media platforms can contribute to hesitancy.

Overall, these findings highlight the diverse range of factors contributing to vaccine hesitancy among mothers in Kazakhstan, emphasizing the importance of targeted education and interventions to address these concerns and improve vaccine acceptance.

It is important to highlight the recent studies that all try to understand the reasons behind vaccination hesitancy. One crucial finding presented by the above-mentioned studies is the discrepancy between data gathered by scholars and data provided by regional governments on vaccine coverage. It highlights the importance of independent research and interviews to understand why Kazakhstan has frequent measles outbreaks. Still, the studies do highlight that vaccination coverage in Kazakhstan is still high. Unfortunately, it is not at the 95% goal that the government sets every year.

Prepared by Darina Zhunussova. February 29, 2024.

See references here.