----
Figure 1: Effect of conflicts on the
vaccination rates in Iraq
There are many armed conflicts around the world, and the immediate
effects of which are what draws most of our attention to calculate the
casualties including number of dead people and number of those injured or
maimed or forced to flee.
Another latent effect of such conflicts that is hard to monitor at
the time is the reduction in the rates of immunization, especially childhood
immunization.
Immunization has been proven to save the lives of many children
around the world both through individual immunity and herd immunity (when an
enough number of the community is immunized, the risk of disease outbreak
in such immunity is reduced). According to the World Health Organization (WHO)
immunization has prevented about 2 - 3 million deaths each year (1).
In conflict settings the immunizations programs could be
interrupted to a variety of reasons including lack or disturbance of
governmental funding or resources to implement the program, inability of
international organizations to help due to the security situation, inability of
the people to get their children to vaccination locations due to security
situation, vaccine material disintegration due to bad storage, and occasionally
active propaganda against vaccination activities due to belief or tradition.
Adding the mortality and morbidity rates of those who could not
benefit from vaccination during the years of conflict could hugely increase the
number of casualties of any conflict. In this paper two aspects will be
discussed: the long-term effect of prolonged war/instability and for this Iraq
will be used as an example since the country had an established vaccination
program before the Iraq – Iran war in 1981 started and to show the effect of
the brief periods of stability on the vaccination rate. As another example the association
between polio outbreaks worldwide to armed conflicts/ regional instability will
be shown.
Longstanding
conflicts and childhood immunization: Iraq
Iraq is a Middle Eastern country with a
total population of 32,778,000 in 2009. The gross national income per capita was
3,750 international $, and the total expenditure on health per capita in 2011
was 368 International $. The Probability of dying under five in 2009 was 34/1000
live births.The country has been through a series of wars and civil unrests
since 1980 including the Iraq-Iran war, the First and Second Gulf wars in 1991
and 2003 respectively, and finally the civil war between 2006 and 2007.
The Expanded Program on Immunization (EPI)
was initiated in Iraq in the early 1980s and by 1987 the immunization coverage
had reached 94% (2). In Figure 1 the effect of the conflicts on the
immunization rates can be seen including immunizations against for tuberculosis
(BCG: Bacille Calmette-Guerin vaccine), DTP (Diphtheria, Tetanus and Pertussis)
as one or the recommended three doses and on the Poliomyelitis (Polio) vaccine. The data used to create the figure was
obtained online from the WHO vaccine against preventable diseases monitoring
system (3).
After the Iraq-Iran war the vaccination
rates seem to increase reaching between 80 – 100%. In the time Iraq was not
largely affected economically by the ongoing war and the health system was
coping well. However, after the Kuwait invasion and the first Gulf war the
vaccination rates for BCG, DTP and Polio all decreased steeply reaching their
lowest level so far around 1992 (BCG: 96%, DTP-1: 86%, DTP-3: 74% and polio:
74%). The decrease was slightly alleviated after the introduction of the Oil
for Food Program in 1995, and the rates reached a plateau, though lower than
the rates achieved in the late 80s.
After the second Gulf war in 2003 the
vaccination rates showed another decline but the lowest rates were recorded
during the civil war in 2006 and 2007 where the access to vaccination or
movement of the vaccination teams and supplies was largely restricted due to the
security situation (BCG vaccination rate dropped to 89%, DTP-1: 76%, DTP-3: 59%
and Polio: 63%). Starting at 2008 the vaccination rates started showing some
improvement (2, 3). The immunization coverage rates in 2012 according to the
Iraqi Ministry of Health are shown in Table 1 (4). The rates did not reach the
level achieved in late 80s despite the improved situation and increase in
health care expenditure in the last years. The security situation is a main
reason for that lag, however, the population attitude towards vaccination and
its importance are possibly affected by the continued wars and what was
socially and traditionally accepted and welcomed is now unwanted.
Table 1:
The vaccination rate in Iraq in 2012. Source: Iraqi Ministry of Health
|
Vaccine
|
Coverage rate
|
|
BCG
|
95%
|
|
Oral Polio and DTP
-1
|
89%
|
|
Oral Polio and DTP
-3
|
74%
|
|
Measles
|
78%
|
|
Hepatitis B – 1
|
89%
|
|
Hepatitis B – 3
|
70%
|
Conflicts
and Polio outbreaks:
Polioviruses are enteroviruses that are
transmitted from person to person following excretion in feces and pharyngeal
secretions, mainly via the hand-to-hand-to-mouth route (5). After entering and
multiplies in the gastrointestinal system, the virus can invade the nervous
system where it can destroy the lower motor neurons, causing a clinically
distinctive flaccid paralysis without permanent sensory loss (5, 6). The
disease usually affects children under five years of age and one in 200
infections leads to irreversible paralysis, among those paralyzed, 5 - 10% die
when their breathing muscles become immobilized (6). The Global Polio
Eradication Initiative (GPEI) was initialed in 1988 because although there is
no treatment for Polio, vaccination can prevent the disease and save the lives
of many children. Despite the fact that in 2013, only three countries
(Afghanistan, Nigeria and Pakistan) are endemic with polio (125 countries in
1988), the vaccination program was not smoothly implemented through the years
(6) and the infection keeps re-appearing in previously polio-free countries.
Due to continuous conflicts worldwide and to
a lack of trust in the public immunization campaign or to religious beliefs
(7), the immunization programs did not take root in some places, and in facts
anti-immunization campaigns prevented people from vaccinating their children
against polio. This situation led to the formation of the polio endemic areas
from which infections are spreading around the world. In most of the polio
epidemics that happened in Africa in the last decade, the virus was genetically
related to the virus circulating in Northern Nigeria. The outbreak in Nigeria
has occurred because about 20% of children remain unimmunized in high risk
areas in the north of the country. From 2003 to 2006, an outbreak in northern
Nigeria after the announcement by the religious leaders of several Northern
states brought the immunization campaign to a halt by telling parents not immunize
their children because “ the vaccine could be contaminated with anti-fertility
agents, HIV, and cancerous agents” (7). This outbreak led to national and
international spread of the disease, leading to re-infection of 20 previously
polio-free countries, causing outbreaks in places as far away as Indonesia and
Yemen, and resulting in 1,475 cases in these 20 countries (8). Polio outbreak from
Sudan between 2004 and 2006 caused re-infection of several countries, including
Saudi Arabia, Somalia, Yemen and Indonesia, causing outbreaks that resulted in
more than 1,200 cases.
Epidemics
in Asia or Europe (Tajikistan and Russian Federation) originated in India or
Pakistan. In the Middle East the viruses were imported from both of Nigerian or
Indian/ Pakistani origin. Radical groups in these regions do not only
antagonize the vaccination campaigns, but movement of members of these groups
from a country to another contributes widely to the spread of the polio
epidemic. The best example is the current polio epidemic in Syria; the immunization
rates estimated by the WHO declined from 91% in 2010 to 68% in 2012 mostly
because of the worsened security situation and the difficulty in conducting
routine immunizations in the areas under the anti-government groups. Meantime
foreign fighters joined either side of the struggle, including fighters from
areas endemic with polio. On October 17, 2013 a cluster of acute flaccid
paralysis cases in Syria was reported in Deir Al-Zour province after the
country was polio-free since 1999. The genetic sequencing performed by the
regional reference laboratory of the Eastern Mediterranean Region of WHO and
showed that the isolated viruses are most closely linked to virus detected in
environmental samples in Egypt in 2012 which in turn had been linked to wild
poliovirus circulating in Pakistan (8) indicating a possible rule of the
foreign fighters in Syria in the spread of the disease.
Table 2: Summary of the polio epidemics in
the last decade according to the country of virus origin
|
Virus origin
|
Countries spread to
|
Year
|
|
India
|
1. China
2. Angola
3. Bangladesh
4. Namibia
5. Congo and Angola
6. Tajikistan
7. Congo and Angola
|
1. 2000
2. 2005
3. 2006
4. 2006
5. 2007
6. 2010
7. 2010
|
|
Nigeria
|
1.
Togo, Burkina Faso
and Ghana
2.
Chad
3.
Kenya
4. Chad
5. Nigeria
and West/Central Africa
6. Côte d'Ivoire
7. Niger
8. Cameroon
|
1. 2003
2. 2003
3. 2006
4. 2007
5. 2008
6. 2010
7. 2013
8. 2013
|
|
Sudan
|
1.
Yemen
2.
Saudi Arabia
3.
Indonesia
4.
Ethiopia
|
1. 2005
2. 2005
3. 2005
4. 2005
|
|
Not
reported
|
1.
Somalia
2.
Horn of Africa
(Somalia, Ethiopia, Kenya)
3.
Israel and West
Bank and Gaza Strip
|
1. 2005
2. 2013
3. 2013
|
|
Pakistan
|
1.
Pakistan
2.
China
3.
Egypt
4.
Syria
|
1. 2011
2. 2011
3. 2012
4. 2013
|
Conclusion:
Childhood immunization can saves the lives
of millions of children worldwide; it protects children against many diseases
that we cannot treat. However, in conflict settings the immunization efforts
could be thwarted by lack of security, lack of funds or resources required to
achieve successful immunization programs or campaigns. Bad or spoiled
vaccinations could prove a risk to the children instead of protecting them. In
some of the conflicts community leaders advocate against immunizations and
could result in huge outbreaks not only in their region, but in different
countries around the world, and free travel of carriers could make this risk more
palpable.
The individual countries as well as the
international organizations should do all they can to ensure the continuity of
the ongoing vaccination programs even in conflict setting and try to provide
security to the vaccination locations and personnel, outbreaks should be stopped
as early as possible and anti-immunization leaders need to be contacted and
convinced or shown wrong preferably by other local and respectable individuals.
References:
(1) World Health
Organization. Immunization. http://www.who.int/topics/immunization/en/ Last accessed
November 18, 2013
(2) Expanded Programme on
Immunization (EPI). Iraq. http://www.emro.who.int/irq/programmes/expanded-programme-on-immunization-epi.html Last accessed November 18, 2013
(3) WHO
vaccine-preventable diseases: monitoring system 2013 global summary. http://apps.who.int/immunization_monitoring/globalsummary/estimates?c=IRQ Last accessed
November 18, 2013
(4) Republic of Iraq
Ministry of Health Annual report 2012. http://www.planning.moh.gov.iq/pdf/t2012.pdf
(5)
Nathanson,
N., & Kew, O. M. 2010. From emergence to eradication: the epidemiology of
poliomyelitis deconstructed. American
journal of epidemiology, 172(11):
1213-1229.
(6) World Health
Organization: Poliomyelitis. http://www.who.int/topics/poliomyelitis/en/index.html Last accessed
November 18, 2013
(7) Jegede, A.S. 2007. What
Led to the Nigerian Boycott of the Polio Vaccination Campaign? PLoS Med. 4(3):
e73.
(8) World Health
Organization: Global Alert and Response (GAR) – Poliomyelitis. http://www.who.int/csr/don/archive/disease/poliomyelitis/en/index.html
Last accessed November 22, 2013
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