Struggling to Resume Childhood Vaccination during War in Myanmar: Evaluation of a Pilot Program

"Perhaps as important as the coverage, the pilot represented a ray of hope in the state, where vaccines were largely unavailable. The pilot was locally led, did not require working with the military junta, and was not subjected to top-down policies and political infighting that have plagued vaccination programs in ethnic minority states..."

After a military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. The proportion of children who received their third dose of diphtheria-containing vaccine fell from 84% in 2020 to 37% in 2021. In response, parents urged a nurse-led civil society organisation in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination programme, which this paper evaluates.

The programme was conceived in 2022 and 2023 in response to queries from parents who were aware of the importance of childhood vaccination programmes and worried about the lack of one in their state. Many who had fled the war could not afford transportation and other expenses to travel to the state capital, where children could be vaccinated at no cost. The parents urged local ethnic health workers to vaccinate their children.

In early 2023, one team member raised funds through private donations. Other team members chose a village and surrounding internally displaced person (IDP) camps. The village had a 16-bed hospital and, before the coup, a peaceful and pastoral population with low health literacy. IDPs migrated to the village because it was believed to be secure.

While maintaining the cold chain, the team smuggled the vaccines into Myanmar. All aspects of the vaccination sessions were supervised by Civil Disobedience Movement health personnel, who had mid-level positions in the pre-coup ministry of health. Parents in the village and IDP camps were alerted about the date of the vaccination sessions. On the day of each vaccination session, parents received an orientation session that included information about the diseases that vaccines prevent, the benefits of getting vaccines, and possible side effects after vaccination. When mothers brought children to the immunisation session, vaccinators asked the parents if the child had received any previous vaccines, determined which vaccines were needed, and entered the vaccinations received on a handwritten line-list registry.

The village or IDP camp leaders contacted the families of children who did not participate, asked why they did not participate, and were reminded about the next vaccination session. Demand for vaccination continued through July 2023, but vaccines could not be restocked due to monsoon-flooded roads and the military junta's blockade of traditional supply routes.

The researchers conducted a retrospective cohort study and participatory evaluation that involved, in part, interviews with the healthcare workers. Of the 184 participating children, 145 (79%, median age five months) were previously unvaccinated, and 71 (41%) were internally displaced. 

At the end of the five monthly vaccination sessions, the probability that zero-dose children would receive the recommended doses of the five vaccines was greater than two-thirds. Specifically, during five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of measles, mumps, and rubella (MMR) was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); Bacillus Calmette-Guérin (BCG) 76% (95% CI 69%-83%); and oral polio vaccine (OPV) 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage.

Although the prespecified end date for this evaluation was July 2023, the vaccine demand continued. The researchers note that the process "provided much-needed refresher training to Civil Disobedience Movement health personnel in the state, without whom vaccination could never be resumed. Finally, the pilot led to donor funding for expansion to 2,000 children in the state and programs in other states of Myanmar."

In conclusion, the researchers stress that, without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%. A sub-national approach that empowers local organisations and their health systems, such as those that led the pilot, is essential and may be the only way to address the continued obstacles in Myanmar's conflict areas. Such partnerships can help bridge gaps in healthcare delivery and provide local insights. However, even with more support, addressing the problem will not be short term.