The challenges facing vaccination in fragile and conflict-affected settings

October 11, 2024

Hands, medical and doctor with patient for vaccine in a clinic for healthcare treatment for prevention. Closeup of a nurse doing a vaccination injection with a needle syringe in a medicare hospital. — image: ©Jacob Wackerhausen | iStock

Sian Williams, Senior Policy Adviser for Child Health at the UK Committee for UNICEF (UNICEF UK), explains the barriers to childhood vaccination and the health consequences of missed immunisations

In 2023, nearly 21 million children missed out on one or more life-saving vaccines. (1) Of these, 14.5 million children received no vaccinations at all, leaving them vulnerable to life-threatening yet preventable diseases.

The COVID-19 pandemic fueled the biggest sustained decline in childhood vaccinations in 30 years (2) as health resources were redirected to the pandemic response. Catch-up initiatives have been working to close the gap. However, children around the world are still feeling the impact of backsliding vaccination rates. The latest vaccination coverage numbers – released in July 2024 by UNICEF and the World Health Organization – show that global vaccination coverage has still not fully recovered to pre-pandemic levels. This leaves children at risk while also jeopardising the hard-won gains made over the last few decades to reduce childhood mortality.

Immunisation programmes in conflict-affected and insecure settings

In an increasingly unstable world, vaccination programmes are continuing to fall by the wayside, and it’s not just the lasting effects of the pandemic that must be contended with. Of children who received no vaccinations at all in 2023 – so-called ‘zero-dose’ children – 51% live in fragile or conflict-affected countries. (3) In these settings, children not only face direct violence and insecurity but can also lose access to so many other protections that play an important part in securing their futures. This includes a stable education, nutritious food, a clean environment, reliable healthcare, and life-saving vaccines.

In conflict, routine healthcare services and immunisation programmes are frequently disrupted. For example, health resources might be redeployed to deal with more pressing issues like casualties or infrastructure like hospitals might be damaged and rendered non-functional. The availability of key products like vaccines can be limited due to obstructions in supply chains, or there may be a shortage of healthcare workers to deliver services where their pay is disrupted, or their safety is compromised.

Displacement of populations because of conflict and insecurity poses additional challenges. Large populations moving into new areas make it hard to track the immunisations children need due to a lack of records. It is also complex to ensure immunisation programmes have appropriate capacity in host communities to meet the needs of a dynamic population, especially where services are already stretched.

The cost of missed immunisations

Missed vaccinations put children’s lives at risk from diseases that are easily preventable. For example, over the last five years, measles outbreaks have been seen in 103 countries where low vaccine coverage (below 80%) was a major contributing factor. (3) Disease outbreaks are a particular concern where unprotected children and their families are living in crowded conditions like refugee camps, especially if water, sanitation and hygiene infrastructure is inadequate.

In the long term, lower vaccination rates can leave large cohorts of children unprotected, diminishing herd immunity that also helps to protect unvaccinated children. This also negatively affects long-running eradication programmes like the Global Polio Eradication Initiative (GPEI), setting back progress previously made towards ending this debilitating disease.

Ultimately, all these factors together have the scope to undo some of the great progress made in reducing child mortality, which has seen a 51% decline since the year 2000. (4) Instead, an increase in disease burden is expected, putting children directly at risk and additional strain on already stretched and underfunded health services, which in turn leads to even more excess deaths.

The role of UNICEF in vaccinating every child

UNICEF provides vaccines to immunise almost half of the world’s children, supporting immunisation programmes in over 100 countries to keep children safe. (5) In settings facing conflict and other kinds of insecurity, UNICEF is working to address coverage gaps by running supplementary immunisation services and tailoring programmes to meet the specific needs of children where they are. To extend reach and impact, these vaccination programmes often link with wider humanitarian services such as food aid and clean water distribution.

Innovative partnerships help to deliver these programmes. For example, UNICEF works closely with Gavi, the Vaccine Alliance that supports countries in coordinating their demand for vaccines, negotiating products at affordable prices, and securing the financing needed to implement vaccination strategies. Importantly, Gavi is planning to expand its ability to support countries experiencing conflict. This will include prioritisation of essential vaccines for those living in internally displaced population camps and making funding available for countries experiencing a humanitarian crisis.

Sudan conflict takes its toll on children’s health

Since April 2023, Sudan’s health system has collapsed as a direct result of the war. Two-thirds of the population cannot go to a hospital or see a doctor. (6) The situation is even worse in areas of active conflict, including Darfur, Kordofan, and Khartoum.

Sudan’s health system was already stretched before the war, but periods of progress have been undone, and delivery of routine immunisation activities has suffered even more. National vaccination coverage plummeted from 85% to just 50%, with rates averaging 30% in active conflict areas and as low as 8% in South Darfur. (7) It is estimated that over one million children under 12 months old are entirely unvaccinated, compared to around 400,000 prior to the war. As a result, outbreaks of vaccine-preventable diseases like measles, rubella, and polio are common.

UNICEF is committed to restoring and protecting lifesaving immunisation interventions for children across Sudan. This has included the implementation of localised and accelerated immunisation campaigns and the identification of new routes to deliver vaccine supplies to the Darfur region via Chad. Through UNICEF’s efforts, in the first five months of 2024, more than 6.7 million children were vaccinated against measles and rubella, and over three million children were vaccinated against polio. (7) These efforts will not only protect children from vaccine-preventable disease outbreaks that are common during times of crisis but also safeguard their future health and wellbeing into adulthood.

But above all, children need peace. Extraordinary vaccination programmes can help children survive through a crisis, but they do not resolve the underlying issues that are causing so many children to suffer unnecessarily. Mediation efforts must be redoubled to achieve a ceasefire in Sudan and so many other conflicts around the world. In the meantime, all parties to conflict must respect their international obligations, allowing for unimpeded humanitarian access and ending attacks against children, medical facilities, and other civilian infrastructure that so many lives depend on.

References

About UNICEF

UNICEF works in some of the world’s toughest places to reach the world’s most disadvantaged children. Across more than 190 countries and territories, we work for every child, everywhere, to build a better world for everyone.
The UK Committee for UNICEF (UNICEF UK) raises funds for UNICEF’s emergency and development work for children. We also promote and protect children’s rights in the UK and internationally.