Reaching People in Fragile and Conflict-Affected Settings with Immunization Services

"People living in situations of fragility or who are affected by conflict are especially vulnerable to being overlooked in immunization plans."

During the COVID-19 pandemic, people living in fragile and conflict-affected settings faced particularly acute challenges in accessing preventive care, such as immunisations, due to quarantines and other issues. The circulation of misinformation and disinformation about COVID-19 vaccines also undermined confidence in immunisations overall, contributing to decreased vaccine coverage. This report analyses challenges to ensuring vaccine access in situations of fragility, discusses the pre-COVID-19 policy landscape, and outlines steps that can be taken to improve trust in disease prevention measures, to reach global goals regarding access to immunisations, and to move toward a more equitable approach to pandemic preparedness and response.

The report begins by providing context. World Health Organization (WHO)/United Nations Children's Fund (UNICEF) estimates of national immunisation coverage reveal that, in 2021, 5 of the 10 countries with the lowest coverage for the 3 recommended doses of the diphtheria, tetanus, and pertussis vaccine (DTP3) are also among the top 10 countries on the Fragile States Index. Following the launch of the Expanded Program on Immunization in the mid-1970s, civil wars and internal conflicts in several regions fueled concerns among health authorities that children living in disputed zones or areas controlled by non-state armed groups might be missing out on routine immunisations. Negotiated Days of Tranquility proved to be an important innovation in ensuring vaccine delivery to communities in active war zones or those affected by civil conflict. A 2017 revision of the approach, which was renamed the Fragility, Emergencies, and Refugees policy, offered guidance on engaging with non-state actors to ensure delivery of vaccines in conflict-affected settings, as well.

However, beyond the fact that some missed populations may live in remote, conflict-afflicted, or hard-to-reach areas, factors limiting the delivery of healthcare to such groups include a complex set of economic, political, and cultural barriers. For example, negative experiences with public officials or fear of deportation may cause vulnerable populations in fragile settings to mistrust public services, leading them to avoid or reject services even when they are offered. The arrival of the COVID-19 pandemic and its vaccines only exacerbated such issues. A July 2022 evaluation from the United Nations High Commission on Refugees (UNHCR) indicated that many countries were failing to protect refugees' rights to COVID-19 vaccines. Even when national policies do include refugees, building and sustaining community trust in vaccines can be daunting. In Lebanon, which early on adopted an inclusive policy with respect to COVID-19 vaccines, rumours fueled hesitancy among refugee populations, requiring tailored communications that assured members of the diaspora that they would be safe from abuse by security forces.

Despite these challenges, approaches have been developed to enable providers to reach remote populations living in insecure situations. In the Horn of Africa, for example, where pastoralists move across the borders between Ethiopia, Somalia, and Kenya, service providers have adopted the use of digital tools to locate and share information about clusters of unimmunised adults, while also working with religious leaders and community mobilisers to answer questions about and build trust in the new vaccines. By working with religious groups, such as the Christian Health Association and the Muslim Women's Association, as well as mothers' groups, public officials have begun to counter rumours and negative messages spread on social media to build trust in vaccines. However, according to the report, much work remains to be done to ensure widespread access and uptake in these conflict-affected areas.

This examination leads the authors to argue for the importance of: engaging vulnerable communities in the design of immunisation programmes; ensuring that health services for people living in fragile and conflict-affected settings are tailored to be culturally, linguistically, and socially relevant; and allowing for innovations and flexibility in the financing and delivery of immunisation services within fragile and humanitarian contexts. They conclude that "Including refugees, migrants, displaced people, and mobile populations, incorporating those affected by conflict, in routine immunization plans can protect their health, as well as that of the communities in which they live. It can also strengthen immunization systems to ensure equitable and timely access to new vaccines in the event of future health emergencies."