Polio Vaccination Activities in Conflict-affected Areas

"Prioritizing trust-building activities through community engagement and responsiveness to other emergent health needs within these areas would be pertinent to finding sustainable solutions to the problem of access."



Polio outbreaks spreading from reservoir countries into once polio-free countries threatens the progress achieved by the Global Polio Eradication Initiative (GPEI). Within the context of armed conflict, the emergence of these outbreaks is often driven by the destabilising effects of war on healthcare systems or compromises to security and access for the conduct of vaccination activities. This article examines the implementation of polio vaccination activities in settings of war and other armed conflict with an aim to understand the approaches that have been adopted in these settings and how they have influenced the successes and failures of the GPEI.



Findings of the literature review are organised into 2 broad categories: (i) polio vaccination in endemic countries, with a specific focus on activities in conflict-affected areas and (ii) outbreak vaccination activities within the context of war and insecurity or political instability. Within each of these categories, the article: provides an overall context for polio eradication activities; describes the nature of extant conflict or insecurity and its impact on polio activities; identifies approaches and strategies adopted for the conduct of vaccination activities; and highlights ongoing risks and challenges to polio vaccination activities in these areas.



With regard to (i), in the past decade, Afghanistan, Pakistan, and, until 2016, Nigeria were endemic for wild poliovirus (WPV) transmission. They have also experienced multiple outbreaks of circulating vaccine-derived poliovirus (cVDPV). Conflict and insecurity have exerted substantial impact in altering the scope and quality of both national immunisation days (NIDs) and sub-national imminisation days (SNIDs) in these countries. GPEI, taking advantage of its political neutrality and interagency structure, continues to work with national governments, local authorities, and humanitarian organisations in security-compromised areas to improve access for vaccination. Other initiatives that have been undertaken to increase the reach of vaccination activities to children and families in conflict-affected areas include the establishment of transit-point vaccination teams, synchronisation of SIAs between Afghanistan and Pakistan in the light of cross-border movements between both countries (especially among itinerant Pashto-speaking communities), and implementation of health camps. Despite best efforts, large numbers of children remain unreached, thus sustaining a pool of susceptible children that maintain the chain of endemic or reestablished transmission of WPV and allow for new emergences of cVDPVs.



With regard to (ii), the article examines outbreaks of WPV that occurred in Somalia and Syria during 2013-2014 and subsequent cVDPV2 outbreaks that began in 2017. In Syria, important factors in ensuring cessation of the 2017 outbreak within months of its identification were the successful implementation of response vaccination activities coupled with the narrowing of the pool of susceptibles to mostly children aged under 2 years due to the large-scale 2013-2014 response SIAs to the WPV outbreak. Historically good coverage prior to the war, the ability to conduct response activities in areas of insurgency in the midst of active combat, and favourable community attitudes toward vaccination proved to be crucial factors in the successful responses.



Reflecting on these experiences, the author suggests the following communication-centred ways forward to address inaccessibility of eligible children for vaccination activities in conflict-afflicted settings:

• The polio programme needs to adopt a multi-pronged approach reflecting the local context that recognises the limitations of working in these settings and adapting accordingly.
• Establishment of community-based vaccination programmes, where feasible, could provide an avenue to actively engage resistant communities and to build the necessary trust needed for polio vaccinators to operate in areas that would otherwise be treacherous.
• Wherever possible, polio vaccination activities should be integrated with the delivery of other essential health services that meet the felt needs of communities that are affected by conflict and insecurity.
• GPEI can continue to partner with humanitarian organisations in negotiating access and helping to create humanitarian corridors and days of tranquility for the delivery of polio vaccines and other health services

"Even with these initiatives, it is likely that conflict will continue to pose a significant threat to polio eradication efforts as long as large pockets of susceptible children remain inaccessible for vaccination activities due to insecurity."