The impact of conflict on immunisation coverage in 16 countries

Grundy, John, and Biggs, Beverley Ann (2019) The impact of conflict on immunisation coverage in 16 countries. International Journal of Health Policy and Management, 8 (4). pp. 211-221.

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Background: Military conflict has been an ongoing determinant of inequitable immunisation coverage in many low-and middle-income countries, yet the impact of conflict on the attainment of global health goals has not been fully addressed. This review will describe and analyse the association between conflict, immunisation coverage and vaccine-preventable disease (VPD) outbreaks, along with country specific strategies to mitigate the impact in 16 countries.

Methods: We cross-matched immunisation coverage and VPD data in 2014 for displaced and refugee populations. Data on refugee or displaced persons was 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 16 countries were selected because they had the largest numbers of registered UNHCR “persons of interest” and received new vaccine support from Global Alliance for Vaccine and Immunisation (GAVI), the Vaccine Alliance. We 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 reviewed strategies developed to address immunisation program shortfalls in conflict settings. We also searched the peer-reviewed literature for evidence that linked immunisation coverage and VPD outbreaks with evidence of conflict.

Results: We found 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. We present data from countries where the onset of conflict has been associated with sudden drops in national and sub-national immunisation coverage. Tense security conditions, along with damaged health infrastructure and depleted human resources have contributed to infrequent outreach services, and delays in new vaccine introductions and immunisation campaigns. These factors have in turn contributed to pockets of low coverage and disease outbreaks in sub-national areas affected by conflict. Despite these impacts, 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.

Conclusion: Global and national policy and planning focus is required on the service delivery needs of conflict affected populations, with increased investment in health system support and civil partnerships, if persistent immunisation inequities in conflict affected areas are to be addressed.

Item ID: 62023
Item Type: Article (Research - C1)
ISSN: 2322-5939
Keywords: Conflict, Displaced Populations, Equity, GAVI, Immunisation, Refugees
Copyright Information: © 2019 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Date Deposited: 25 May 2020 03:04
FoR Codes: 32 BIOMEDICAL AND CLINICAL SCIENCES > 3204 Immunology > 320402 Applied immunology (incl. antibody engineering, xenotransplantation and t-cell therapies) @ 50%
42 HEALTH SCIENCES > 4202 Epidemiology > 420203 Environmental epidemiology @ 50%
SEO Codes: 92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920599 Specific Population Health (excl. Indigenous Health) not elsewhere classified @ 50%
92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920412 Preventive Medicine @ 50%
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