Vaccination Coverage and Access among Children and Adult Migrants and Refugees in the Middle East and North African Region: A Systematic Review and Meta-analysis

"Host countries should tailor services to address specific drivers identified in this review, using participatory, co-design approaches with migrant communities and integrating migrants into health information systems for better vaccination monitoring."

The Middle East and North African (MENA) region's 40-plus million migrants may be an under-vaccinated group due to barriers to vaccination services and non-systematic inclusion in national vaccination policies. This systematic review and meta-analysis synthesises the evidence on coverage, acceptance, drivers of uptake, and policies pertaining to vaccination for children and adult migrants in MENA in order to explore tailored interventions for these groups.

For context, it is important to acknowledge that national vaccination coverage, even in non-migrant populations, has dropped markedly in war-torn MENA countries since the conflicts began and has stagnated ever since, with multiple polio and measles outbreaks disproportionately affecting children in conflicts and displaced settings. This situation has also been exacerbated by the backslide in immunisation precipitated by the COVID-19 pandemic.

The researchers searched six databases for peer-reviewed literature (and other websites for grey literature) on coverage, acceptance, drivers of uptake, and policies for any vaccination in migrants in the MENA region published between 2000 and August 27 2024 in any language. Studies without disaggregated migrant data were excluded. Primary outcomes were coverage (% individuals receiving ≥1 doses of any vaccine) and acceptance (% individuals accepting any vaccine). The researchers separately synthesised data on children (<18 years) and adults (≥18). Estimates were pooled using a random-effects meta-analysis where possible or narratively synthesised, and drivers of uptake were synthesised using the World Health Organization (WHO) Behavioural and Social Drivers (BeSD) model.

This process identified 6088 database and 282 grey literature records and included 55 studies and 1,906,975 migrants across 15 countries (including mostly refugees in the Middle East and expatriates in Gulf Cooperation Council countries).

Coverage for childhood vaccination amongst migrants was low, with only 36.0% of 589 migrant children fully vaccinated according to national schedules (95% confidence interval (CI) 35.0%-43.0%, I2 = 67%; data from migrants in Lebanon, Morocco, Sudan). Likewise, data on specific routine vaccines in children was generally low: measles containing vaccines (MCV): MCV dose 1 63.9%-66.9%; MCV dose 2 25.4%-85.6%; oral polio vaccine (OPV): OPV dose 3 65.1%-76.4%; diphtheria, tetanus, and pertussis (DTP) containing vaccines: DTP dose 1 81.8%-86.7%; DTP dose 3 59.7%-76.6%). Drop-out rates across all routine vaccines for subsequent vaccine doses ranged from 12.4%-38.5%, suggesting that migrants face a range of barriers to vaccine uptake beyond the first dose that need to be better considered when designing interventions.

For adults, the review found 11 studies on coverage (including 9 on COVID-19) showing that COVID-19 vaccination coverage ranged 33.5%-84.8% in migrants and 25.0%-59.0% in host populations. With respect to hesitancy, a study in Jordan found that being a migrant was associated with lower odds of COVID-19 vaccine hesitancy compared to host populations (49.9% in 501 migrants vs 60.0% in 491 nationals (odds ratio (OR) 1.50, 95% CI 1.17-1.93).

Drivers of uptake of childhood vaccination in migrants included limited availability of vaccines and vaccination personnel, communication and administrative barriers, financial difficulties, lack of caregiver knowledge about services, and concerns expressed by caregivers around safety and benefits. Social processes underlying uptake were reported in two studies and included the lack of autonomy and decision-making power by mothers regarding child vaccination, household and professional responsibilities of the mother, and absence of health worker recommendation. For adults, drivers were mainly related to the COVID-19 vaccine and included concerns around safety, quality, side effects, and mistrust in vaccines and the systems that deliver them.

Thus, the findings suggest that routine vaccination is complex and that efforts to increase uptake should address health-system-related barriers such as shortages in health staff, which affect both migrants and nationals, while also raising awareness about vaccination among migrant parents and caregivers through targeted outreach interventions.

Panel 1 in the paper outlines key areas for policy, practice, and research going forward. Here are just a few examples:

Policy - examples:
 

• Systematically integrate migrants into routine health information systems to capture coverage, uptake and completion of recommended vaccines.
• Collaborate with non-governmental organisations (NGOs), civil society organisations (CSOs), and humanitarian actors in the MENA region to address access barriers and to increase knowledge among migrant communities about their entitlement to services.
• Increase data collection on vaccine acceptance and demand among migrants in the MENA region to build a stronger evidence base for policy and practice

Practice - examples:
 

• Work with migrant communities to co-design tailored interventions, promote trust in vaccines, and support vaccine champions to engage migrant communities in these initiatives.
• Identify alternative and innovative vaccine delivery models using lessons learned during the COVID-19, such as the deployment of outreach strategies and collaboration with faith-based and community-based organisations (CBOs), and leverage successful models in delivering health interventions in conflict zones.
• Collaborate with migrant communities and grassroot migrant community organisations to co-develop approaches to vaccination information which reach the migrant groups and address persisting concerns and rumours surrounding vaccination to promote trust in vaccines.

Research - examples:
 

• Invest in large-scale research to better understand the drivers of under-vaccination and vaccine hesitancy among different migrant groups and to identify the most effective interventions to address drivers of non-uptake and the appropriate access and intervention points.
• Conduct studies to explore the most used and trusted information channels among specific groups to increase the reach of information on vaccination services and entitlement to free services.
• Support research among the most marginalised and under-studied migrant groups such as undocumented migrants and migrant workers to identify specific barriers to accessing vaccination for these groups.

"In conclusion, this review has shown that despite migrant inclusive policies for vaccination in many countries across the MENA region, migrants experience a range of practical and individual level drivers affecting uptake of vaccination services. The low percentage of fully vaccinated migrant children and the inadequate coverage for OPV, MCV, and DTP-containing vaccines suggest that migrants in the MENA region may be an at-risk group for VPDs [vaccine-preventable diseases]. Therefore, they should be prioritised in vaccination outreach efforts....It is...crucial for health policies in the region to adopt a life-course approach and deploy innovative strategies by working with communities on innovative and tailored delivery approaches to address the identified drivers."