WHAT IS THE EXPANDED PROGRAMME ON IMMUNIZATION (EPI)?
EPI covers vaccination services implemented in order to ensure the immunization of all vulnerable age groups by preventively reaching out to them before they contract and develop infectious diseases: pertussis, diphtheria, tetanus, measles, rubella, mumps, tuberculosis, polio, chickenpox, hepatitis A, hepatitis B, invasive Streptococcus pneumoniae and invasive Haemophilus influenzae type b. This program aims to control, and eventually, eradicate these infections with a special focus on decreasing the incidence of these infectious diseases and associated deaths.

WHAT ARE THE SERVICES IMPLEMENTED UNDER EPI?
Implementation of The Expanded Programme on Immunization (EPI) encompasses procedures such as, vaccination in line with the disease control program objectives, disease surveillance and procurement of vaccines and the supplies necessary for vaccine administration. The Turkish Ministry of Health determines the strategy and the objectives of the program, secures the logistical needs and supplies these to the Provincial Directorates of Health in Turkey’s 81 provinces accordingly.

At the provincial level, the Provincial Director of Health runs EPI services at the helm of teams consisting of province and district vaccination supervisors, cold chain managers, physicians and non-physician healthcare workers. Together, they prepare, and then track and evaluate the province and sub-province level vaccination plans, organize the training of the personnel in charge of vaccination services and raising societal awareness. They also oversee the logistics of vaccine and syringe distribution and monitor supplies and the integrity of the cold chain.

WHAT IS THE RATE OF SUCCESS IN VACCINE-PREVENTABLE DISEASES ACHIEVED BY EPI?
The Turkish Ministry of Health’s programs secured a significant decrease in the incidence of diphtheria, pertussis, tetanus, polio and measles cases between 2015 and 2019. The decrease rate in these cases between 2015 and 2019 –comprising the implementation years of EPI- are presented in the table below in comparison to the data from the 1980-1984 period.

Number of observed cases and percentage rates of decrease before and after vaccination programs against vaccine-preventable diseases (Turkey, 1980-1984 and 2015-2019).

DISEASE	NUMBER OF CASES BEFORE VACCINATION PROGRAM	NUMBER OF CASES BETWEEN 1980 and 1984*	NUMBER OF CASES BETWEEN 2015 and 2019*	RATE OF DECREASE (%)
Diphtheria	1.236 (1932-1936)	174	0	100
Pertussis	10.762 (1963-1967)	3619	84	98
Tetanus	Not reported. (1963-1967)	110	16	85
Polio	501 (1958-1962)	159	0	100
Measles	50.145 (1965-1969)	21225	713	97

* Average number of cases in 5 years.

 

WHAT ARE THE OUTCOMES OF VACCINATION PROGRAMS?
Eradication of polio
Turkey began administering the polio vaccine in 1963. Turkey attained the designation of “Polio-Free Region” by the World Health Organization (WHO) on June 21st, 2002 thanks to the country’s successful routine and supplementary immunization campaigns.

Tetanus
Vaccination against tetanus started for the first time in 1935. Turkey’s programs for clean childbirth practices, routine follow up of pregnant women, successful application of child and pregnant women vaccination, and supplementary vaccination campaigns for women of reproductive age (15-49) resulted in the elimination of maternal and neonatal tetanus (MNT) in the country, a fact documented by a joint study conducted in 2009 by WHO and the Turkish Ministry of Health.

Measles
Measles vaccine administration was added to the national immunization program in 1970. Ever since, supplementary vaccination campaigns complemented the routine childhood vaccination program when necessary. The Measles Elimination Program has been carrying on since 2002. During the Vaccination Days against Measles, held occasionally 2003-2005, 18.2 million children between 9 months and 14 years of age received an additional dose of the measles vaccine. The program aimed at first, stopping the domestic circulation of the virus, second, preventing the spread of new measles viruses coming from abroad and third, preventing measles-associated deaths. Cases of measles dropped by 97% in the years between 2015 and 2019 in comparison to the years between 1980-1984.


Elimination of rubella
Since 2006, the Elimination of Rubella and Prevention of Congenital Rubella Syndrome Program comprised a part of the national immunization program, adding the rubella (MMR) vaccine to the vaccine list. By the end of 2019 in Turkey, endemic rubella virus circulation has been cut for 36 months. Turkey which have been eliminated for the relevant period of rubella is approved by the World Health Organization.

Elimination of diphtheria
Although monovalent vaccination against diphtheria began in Turkey in 1937, a systematic vaccination programme was not implemented until after the mid-1960s. Routine vaccination services have since been carried on with a high rate of coverage, and vaccination activity has been increased when necessary. The incidence of new diphtheria cases decreased after the vaccination campaign in 1985. No cases were detected between 2004 and 2010, and only a single diphtheria case was reported in 2011. No diphtheria cases have been reported since 2012.  

Pertussis
Pertussis vaccine administration commenced in 1937 in Turkey. Routine vaccination services have since been carried on with high coverage, with increases in vaccination activity when necessary. The number of pertussis cases dropped by 98% in the period between 2015 and 2019 compared to the period 1980-1984.

Hepatitis B
In 1998, Hepatitis B vaccine was added to the vaccination program and the Hepatitis B Control Program commenced to reduce the incidence of chronic liver disease, cirrhosis and hepatocellular cancer associated with chronic hepatitis B virus infection. Routine vaccination services have since been carried on with a high rate of coverage, complemented with supplementary vaccination campaigns when necessary. Primary and secondary school students were vaccinated between 2005 and 2009 as part of a program.

In 2018, the 2018-2023 Turkish Viral Hepatitis Prevention and Control Program was formed in accordance with the targets of WHO’s global health sector strategy on viral hepatitis, 2016-2021. The aim of the program is to curb new cases of viral hepatitis and subsequent deaths, and to mitigate the negative socio-economic impact of the disease. The number of hepatitis B cases in the years between 2015 and 2019 dropped by 76% in comparison to the years between 2005 and 2009.

Other diseases
The EPI also includes mumps, chickenpox, hepatitis A, pneumonia and Hib vaccinations administered at substantial levels.

VACCINE PROGRAMS FOR ADULTS
The EPI covers in addition to the vaccination of children also immunization initiative aimed at adults.

Below is a list of ongoing vaccination programs for adults in Turkey:
1. Tetanus and diphtheria vaccination for adults 
2. Tetanus and diphtheria vaccination for pregnant women and women of reproductive age
3. Vaccination programs for individuals facing occupational risk 
•Vaccination for healthcare personnel
•Vaccination for the workers at Repatriation (Removal) Centers processing irregular immigrants and/or other workers at risk due to direct contact with irregular immigrants.
•Vaccination for individuals working as sanitation (sewage) workers
•Vaccination for people in occupational groups at risk from hepatitis B infection
•Vaccination for individuals working in medical waste management
•Vaccination for the personnel of the Ministry of National Defence of the Republic of Turkey 
4.Vaccination for conscripts serving the compulsory military service
5.Vaccination for contacts with infected individuals
6.Vaccination due to an underlying disease or other risks
7.Vaccination for people aged 65 and above
8.Vaccination for travelers, and Hajj and Umrah pilgrims