The Impact of Conflict on Immunisation Coverage in 16 Countries

"This research reinforces a rights approach for children's health and health workers in conflict settings, and in doing so, has the potential to improve strategy, partnerships and advocacy efforts for both child protection and health worker security."

Military conflict has been an ongoing determinant of inequitable immunisation coverage in many low- and middle-income countries (LMICs). This review describes and analyses the association between conflict, immunisation coverage, and vaccine-preventable disease (VPD) outbreaks across 16 high-risk countries, with a view to generating themes that inform global and national policy on reducing immunisation inequities in conflict-affected settings.

The 16 countries were selected because they received support from Global Alliance for Vaccine and Immunisation (GAVI), the Vaccine Alliance, and they had the largest numbers of registered UNHCR "persons of interest". The researchers cross-matched immunisation coverage and VPD data in 2014 for displaced and refugee populations in those countries. Data on refugee or displaced persons were sourced from the United Nations High Commissioner for Refugees (UNHCR) database, and immunisation coverage and disease incidence data from World Health Organization (WHO) databases. Demographic and Health Survey (DHS) databases provided additional data on national and sub-national coverage. The researchers used national planning and reporting documentation including immunisation multiyear plans, health system strengthening strategies, and GAVI annual progress reports (APRs) to assess the impact of conflict on immunisation access and coverage rates, and they reviewed strategies developed to address immunisation programme shortfalls. They also searched the peer-reviewed literature for evidence that linked immunisation coverage and VPD outbreaks with evidence of conflict.

The investigation revealed that these 16 countries, representing just 12% of the global population, were responsible for 67% of global polio cases and 39% of global measles cases between 2010 and 2015. Fourteen out of the 16 countries were below the global average of 85% coverage for diphtheria, pertussis, and tetanus (DPT3) in 2014. The article presents data from countries where the onset of conflict has been associated with sudden drops in national and sub-national immunisation coverage.

In these places, tense security conditions, along with damaged health infrastructure and depleted human resources, contribute to infrequent outreach services and delays in new vaccine introductions and immunisation campaigns. For example, highest-risk areas for polio transmission (see Table 2 in the paper for details on polio outbreaks in the 16 countries) were from the Somali region of Ethiopia, which is characterised by insecurity, weak infrastructure, and communication shortfalls. In 2018, the country conducted a polio campaign to focus on pastoralists, refugees, internally displaced persons (IDPs), and those in hard-to-reach and border areas.

An example of another conflict-afflicted country's service delivery strategies comes from Sudan, where plans include, among other activities, opening a channel of communication with armed groups through local leaders and United Nations (UN) agencies along with involvement of non-governmental organisations (NGOs). On this note, 7 countries describe an enhanced role of NGOs/civil society organisations (CSOs), who have more ready access to hard-to-reach populations, in conflict-affected settings; for instance, planners observed in Myanmar that in a "complex landscape of remote, geographically dispersed, non-government control and border areas together with migrant and other ethnic groups, increasing access to immunisation is only successful through the involvement of CSOs and NGOs."

Lessons from Nigeria, Somalia, and Pakistan illustrate that tactics such as conducting security assessments, negotiating secure physical access, engaging local communities, coordinating humanitarian aid deliveries, developing transit or cross-border vaccination strategies, and collaborating with the military or other security personnel are all applied to assist reduction of VPD morbidity and mortality in conflict settings. However, only 2 countries describe a specific communication strategy with combatants or local authorities to enable access to populations in conflict-affected areas.

More broadly, there was limited reference to the health needs of conflict-affected populations in immunisation planning and reporting documents in all 16 countries. Development partner investments were heavily skewed towards vaccine provision and working with partner governments, with comparatively low levels of health systems support or civil partnerships.

Per the analysis, this means that there is a need for national planners to seek out solutions through both health and political dialogue. At the local level, Nigeria, Pakistan, and Afghanistan report that the key ingredient for success in conflict settings will most likely result from careful development of a local area communication strategy with local authorities, religious leaders, and combatants. Furthermore, more balanced humanitarian and development assistance portfolios are required in conflict settings, particularly given the stated need of countries for health system support and civil society partnerships.

In conclusion: "Global policy and strategy dialogue are urgently needed to devise best practice approaches and investment pathways for rebuilding human resources and delivery systems in conflict areas. The widespread impact of conflict on immunisation access and resulting disease outbreaks in Africa, the Middle East, South Asia and more recently in Eastern Europe, provides a strong rationale for improve technical guidance on how planners can mitigate the impact of conflict on the attainment of global health goals."