Table 6 Impact of conflict on Poliomyelitis outbreaks

Cetorelli 2015 [41]

Iraq,

October & November 2000, February to March 2006, and 2011

Children under 5 over the three timepoints in Iraq

Broader war induced

deterioration in the country’s healthcare capacity and vaccine rollout

Implemented:

Not mentioned

Suggested:

Promoting institutional deliveries and ensuring

adequate vaccine availability in primary health facilities

Akil and Ahmad, 2016 [42]

Pakistan, Afghanistan, Nigeria, Syria, Iraq, Cameroon, Equatorial Guinea, Ethiopia, Kenya, and Somalia, Conflict-affected countries,

2011–2014

Aggregated country-level data on WPV cases from conflict-affected countries

Polio was higher in countries with political conflict and instability

• Poor infrastructure

• Population movement

• Mistrust by local community in the national authorities regarding immunisation, thus increased rates of unvaccinated children

• Hard-to-reach populations

• Lack of access to clean water

• Collapsing sanitation and living

conditions

Implemented:

• WHO mandated polio vaccination for all individuals travelling to or from Pakistan, Syria, and Cameroon

• In 2013, the GPEI launched a five-year all-encompassing plan for completely eradicating polio, a strategic plan that clearly outlines measures for eliminating polio in its last strongholds and for maintaining a polio-free world

Suggested:

For displaced families and others in these high-risk areas:

• Immediate health care

• Clean water

• Increased nutritional measures

• Better sanitation

• Easy access to healthcare

• GIS maps may help to identify areas with high rates of polio and to predict the possibility of movement of the virus to neighbouring countries to assess virus origins and the current virus movement

Norris et al., 2016 [44]

Afghanistan,

2004–2009

Data collected in Afghanistan from 2004 to 2009

• Violence leads to reduced rates of polio vaccination, which is, in turn, responsible for increased polio incidence

• Vaccination campaign staff and public health staff were being directly targeted by armed groups, with abductions and murders

• Conflict creates a lack of public trust in the governmental and international organisations that run vaccination campaigns. Without trust, a successful vaccination programme is difficult

• Violence can damage infrastructure, cause suspension of vaccination activities, and influence the behaviour of whole communities

Implemented:

The GPEI, a project of the WHO, coordinated the efforts of the Afghani government, UNICEF, and various NGOs to eradicate polio. The GPEI national team was responsible for policy, planning, and vaccine supply, while provincial teams were responsible for implementation, supervision, and monitoring of programme activities:

• Organised 1,251 vaccination sites and over 2,700 vaccinators were organised to provide routine services

• Organised supplemental immunisation activities including national and subnational immunisation days

• Conducted “mop-ups:” children in the vicinity of a polio outbreak were revaccinated

Suggested:

• Support polio vaccine distribution efforts in

communities exposed to violence

• Take all available measures to avoid entangling the polio vaccination campaign in political dynamics of the armed conflict

• Direct negotiation to convince anti-government groups to allow safe passage of health staff through opposition-controlled regions

Al-Moujahed et al., 2017 [43]

Syria,

Mid 2013 and after

Population of Syria

• Systematic assaults on healthcare in politically unsympathetic areas resulted in the collapse of the healthcare system in oppositionheld territory

• Severe damage to hospitals, public health centres, and ambulances

• Deliberate target and persecution of healthcare personnel

• Emigration of healthcare personnel from both government and nongovernment territory as a result of the conflict

• Severe lack in medications and preventative services

• Children in some besieged and opposition-controlled areas were missing vaccinations

• Sharp decline in the overall vaccination coverage to only 50% in 2015

• Destruction of the country’s infrastructure

• Economic shrinkage

• Severe food and water insecurity

• Inadequate sanitation

Implemented:

The Polio Control Task Force (PCTF) was formed by eight Syrian and NGOs. This task force was able to successfully establish immunisation facilities, train about 8500 personnel from local communities and deliver vaccines to more than 1.4 million children across seven governorates in northern and eastern Syria, areas inaccessible to WHO.

Suggested:

• Important to increase international surveillance and international financial and logistical support for vaccine and immunisation of the population especially in conflict-torn countries

• Adequately support and fund the front-line NGOs that are implementing the delivery of medical and humanitarian aid in Syria and to refugee populations in neighbouring counties

• Agencies involved in global health to be able to operate impartially, from governments and all military actors involved during conflicts and enabled to provide necessary and efficient medical and humanitarian relief for civilian from governments during conflicts in order to provide adequate and efficient medical and humanitarian relief for civilians

Mohamed et al., 2022 [45]

Afghanistan

January 2021- September 2022

Population of Afghanistan

Poliomyelitis

• Polio eradication efforts in Afghanistan were challenged by a complex humanitarian emergency resulting from the combined impacts of a rapid government transition and a depressed economy, droughts, floods, food insecurity, displacement, and severe gaps in delivery of health services

• Unreachable children for vaccination due to insurgency

Implemented:

• In 2020 when Afghanistan began to report both cVDPV2 and WPV1 polio cases, the Global Polio Eradication Initiative authorised the use of tOPV for outbreak response.

• In 2022 the program reached 3.5–4.5 million children previously unreachable because access was prevented by the insurgency

• Lot quality assurance sampling (LQAS) surveys were conducted to assess SIA quality

• Development of Acute Flaccid Paralysis and also environmental surveillance with the systematic sampling and virologic testing of sewage sites

• Genomic sequence analyses were performed to assess cross border transmission between Afghanistan and Pakistan [45]

Suggested:

Not mentioned