Approaches to Vaccination Among Populations in Areas of Conflict

Without developing and refining approaches to reach and vaccinate children and other vulnerable populations in areas of conflict or insecurity, polio and other vaccine-preventable diseases (VPDs) may persist in these settings and spread across subnational and international borders. This article examines key strategic and operational tactics that have led to increased polio vaccination coverage among populations in Nigeria, Somalia, and Pakistan, and how these could be applied to reach and vaccinate populations in other conflict settings across the world.

Experience indicates that, with a good understanding of the nuances of the conflict and a great deal of operational flexibility, reaching and immunising eligible populations in these settings may continue to be viable. Key strategies that have been used in the polio eradication programme include:

• Security assessments are core to planning and safe implementation of field activities. Incorporating local knowledge and information networks in security assessments is critical.
• Negotiations with key actors in a conflict, including state and nonstate actors and their allies, can be critical. For example, in Somalia, putative governments and insurgent nonstate actors have allowed indirect access to populations by trusted individuals or organisations for purposes of providing immunisation and other healthcare services in these settings.
• Close community engagement in the form of advocacy with local traditional and religious leaders, information sharing with communities, the training of local residents as vaccinators, and community mobilisation networks supported by community "gatekeepers" may help shed light on the felt needs of the communities and build trust between the community and the vaccination programme. Finding solutions to some of these needs, including working with other development partner agencies, may be key to gaining trust, interest, and access to the community. In northern Nigeria, the Volunteer Community Mobilizer programme, a focused initiative that recruited and trained local community women as social mobilisers and vaccination workers, is considered to have bolstered participation in house-to-house polio and other routine immunisation programmes, especially in security-compromised and hard-to-reach communities.
• Use of high-resolution Geographic Information Systems (GIS) technology can guide decision-making in inaccessible areas. In Nigeria, the use of satellite imagery is being employed to develop a greater understanding of potentially eligible populations living in areas currently inaccessible to polio vaccination workers.
• Coordination with other humanitarian relief activities may be key to improving immunisation coverage and efficient use of public health resources. In many settings, closely coordinating delivery of medicines, food, and clothing with vaccine delivery has helped improve vaccine reach in communities.
• Flexibility around vaccine scheduling and dosing options is important, considering that multiple birth cohorts may have missed age-appropriate vaccines.

A number of operational approaches may be available for safe delivery of vaccines to populations in conflict settings. Key strategies that have been used in the polio eradication programme include: offering opportunistic vaccination during days of tranquility, establishing barrier vaccination zones, collaborating with military and other security personnel, establishing permanent vaccination teams, strengthening vaccination activities at transit and border-crossing sites, and vaccinating at camps for refugee and internally displaced persons (IDPs) and other sites of mass gathering. As an example of the latter strategy, religious institutions, including mosques, temples, churches, and other places of worship, and traditional or cultural gatherings have served as useful access points to populations cut off from sites for vaccine delivery in conflict settings.

In conclusion: "Given the upward trend in the number of fragile nation states and the rising proportion of the global population projected to live in settings experiencing violent conflicts around the world..., understanding and refining approaches to support continued vaccine delivery and disease surveillance in these settings may be of substantial value to the global VPDs control efforts."