Dr  Claudia  TruppaRegional   Primary  Health  Care  Program  Manager

International   Committee   of  the  Red  CrossBeirut,  12th of  May  2017

IMMUNIZATION  IN  CONFLICT  SETTINGS

IMMUNIZATION  IN  CONFLICT  SETTINGS

OUTLINEOUTLINE

• Introduction

• Magnitude  of  the  Problem

• Literature  Review

• State  of  the  Art  

• The  Case  of  Lebanon

• Conclusions

INTRODUCTIONINTRODUCTION

INTRODUCTIONINTRODUCTION

INTRODUCTIONINTRODUCTION

INTRODUCTIONINTRODUCTION

Taiz,   Dahra area   of  Janad district.   Amidst  the  destruction,  the  civilian   population  struggle   to  survive.   Every  day  brings  new  challenges   and  new  dangers.   CC  BY-­‐NC-­‐ND/ICRC/A.  Mahyoub

Eastern  Aleppo,  Syria,  30/11/2016.  (S  Turkmani/Syrian  Arab  Red  Crescent)

A  displaced  family  in  Sana'a.  Two  years  of  conflict  in  Yemen  has  forced  over  two  million  people  to  flee  their  homes.  CC  BY-­‐NC-­‐ND  /  ICRC  /  Mohammed  Yaseen Ahmed  Ibrahim

Rural  Homs,  Malaha village,  Syria.  ICRC  supported  Mobile  Health  Unit.  Women  and  children  queuing.Photo  by  Pawel  Krzysiek/ICRC

Taiz,  Yemen.Water,  food  and  other  essential  items  remain  in  short  supply.CC  BY-­‐NC-­‐ND/ICRC/A.  Mahyoub

Taiz,  Yemen.   Dozens  of  people  line  to  buy  wheat  amid  extreme  food  shortages  across  the  country.  Ninety  percent  of  the  country’s  food  is  imported.   CC  BY-­NC-­ND/ICRC/A.  Mahyoub

IMMUNIZATION  IN  CONFLICT  SETTINGS  –MAGNITUDE  OF  THE  PROBLEMIMMUNIZATION  IN  CONFLICT  SETTINGS  –MAGNITUDE  OF  THE  PROBLEM

• Almost  2/3  of  all  unvaccinated  children  live  in  conflict-­‐affected  Countries  (UNICEF  2016)

• Increased  health  expenditure  for  clinical  care  of  cases

• Vaccine  Preventable  Diseases  mortality  increases  during  war  times  (e.g.  measles  mortality  in  refugee  camps  30%  vs  <1%  in  non-­‐conflict  settings)

• DALYs  lost

IMMUNIZATION  IN  CONFLICT  SETTINGS  –MAGNITUDE  OF  THE  PROBLEMIMMUNIZATION  IN  CONFLICT  SETTINGS  –MAGNITUDE  OF  THE  PROBLEM

Gaza.  An  ambulance  destroyed  during  2014  conflict.ICRC  Archives

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Vaccine  Preventable  Diseases  (VPD)

Source:  WHO  2013,  Vaccination  in  acute  humanitarian  emergencies:  a  framework  for  decision  making

=  VPD  frequently  reported  during  humanitarian  emergencies  

IMMUNIZATION  IN  CONFLICT  SETTINGS  –LITERATURE  REVIEWIMMUNIZATION  IN  CONFLICT  SETTINGS  –LITERATURE  REVIEW

• Limited  evidence  available  (natural  disasters  >  man-­‐made  disasters)

• Dysfunctional  health  systems  in  conflict  (infrastructure,  logistic,  human  resources)

• ICRC  role  in  ensuring  immunization  services  to  bridge  the  gap  towards  SDGs  2030

IMMUNIZATION  IN  CONFLICT  SETTINGS  –LITERATURE  REVIEWIMMUNIZATION  IN  CONFLICT  SETTINGS  –LITERATURE  REVIEW

Factors  to  be  taken  into  account  in  assessment  and  decision  making  process:

1. Epidemiological

2. Vaccine  related

3. Contextual

4. Ethical

IMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ARTIMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ART

Vaccination  Strategies

• No  outbreak  confirmed  AND  functional  EPI:  Step-­‐up  Routine  Vaccination  Program  

• No  outbreak  confirmed  AND  poorly  functioning  EPI:  Additional  National  Immunization  Days

• Confirmed  outbreak  OR  dysfunctional  EPI:  Mass  Vaccination  Campaign

IMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ARTIMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ART

Level  of  recommendation VPD

Universally recommended   • Measles• Polio   (if   threatening   eradication program)• Tetanus   (for  wounded   and  pregnant  women)

Recommended   preemptively   only   in  endemic areas • Cholera

Recommended   only   after  onset   of  an  outbreak • Hepatitis   A• Meningococcal   meningitis• Yellow fever

Generally   not   recommended   for  mass vaccination  campaigns

• DPT• Influenza• Typhoid fever

IMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ARTIMMUNIZATION  IN  CONFLICT  SETTINGS  –STATE  OF  THE  ART

Summary  of  recommendations

Adapted  and  modified  from  “Vaccination  in  humanitarian  emergencies:  literature  review  and  case  studies”.  SAGE  Working  Group  Report,  2012

THE  CASE  OF  LEBANONTHE  CASE  OF  LEBANON

The  Lebanese  Ministry  of  Public  Health  Vaccination  Campaigns  and  the  ICRC  support

CONCLUSIONSCONCLUSIONS

• Whether  to  vaccinate  or  not  during  an  armed  conflict  is  a  decision  based  on  the  careful  evaluation  of  multiple  complex  factors

• Mass  vaccination  campaigns  are  a  quick  and  effective  approach  to  increase  vaccination  coverage  in  conflict-­‐affected  area  and  in  populations  not  directly  concerned  but  that  can  be  affected  by  spill-­‐over  effects

• Routine  immunization  services  remain  the  most  effective  way  of  ensuring  sustained  coverage,  and  should  be  resumed  as  early  as  possible  

• With  displaced  population,  integration  of  the  humanitarian  response  into  the  existing  EPI  is  a  successful  strategy  to  both  rapidly  increasing  coverage  and  strengthening  health  systems  in  the  long  term

Some  referencesSome  references

Thank  you  for  your  kind  attentionThank  you  for  your  kind  attention