Jefferson College Diseases of Displaced Risk Factors and Potential Solutions Paper Discussion board questions:There are a number of diseases that are consi
Jefferson College Diseases of Displaced Risk Factors and Potential Solutions Paper Discussion board questions:There are a number of diseases that are consistently seen in displaced populations. Please explain potential causes for these outbreaks. What are potential solutions for addressing these disease outbreaks? REVIEW
Human Vaccines & Immunotherapeutics 11:11, 2627–2636; November 2015; © 2015 Taylor & Francis Group, LLC
Vaccine-preventable diseases in humanitarian
emergencies among refugee
and internally-displaced populations
Eugene Lam1,*, Amanda McCarthy2, and Muireann Brennan1
1
Emergency Response and Recovery Branch; Division of Global Health Protection; Center for Global Health; Centers for Disease Control and Prevention; Atlanta, GA USA;
2
Department of Global Epidemiology; Rollins School of Public Health; Emory University; Atlanta, GA USA
Keywords: civil conflicts, displacement, humanitarian emergency, immunizations, internally displaced persons, outbreaks,
refugees, vaccines
Humanitarian emergencies may result in breakdown of
regular health services including routine vaccination programs.
Displaced populations including refugees and internally
displaced persons are particularly susceptible to outbreaks of
communicable diseases such as vaccine-preventable diseases
(VPDs). Common VPDs encountered in humanitarian
emergencies include measles, polio, and depending on
geographical location, meningococcal meningitis, yellow fever,
hepatitis A, and cholera. We conducted a review of 50 published
articles from 2000 to 2015 concerning VPDs in humanitarian
emergencies. This article provides an update on the available
literature regarding vaccinations among this highly vulnerable
population and describes the unique challenges of VPDs during
humanitarian emergencies. Humanitarian emergencies place
affected populations at risk for elevated morbidity and mortality
from VPDs due to creation or exacerbation of factors associated
with disease transmission such as mass population movements,
overcrowding, malnutrition, and poor water and sanitation
conditions. Vaccination is one of the most basic and critical
health interventions for protecting vulnerable populations
during emergencies. Growing insecurity, as seen in the
increasing number of targeted attacks on health workers in
recent years, as well as destruction of cold chain and
infrastructure for transportation of supplies, are creating new
challenges in provision of life saving vaccines in con?ict
settings. Population displacement can also threaten global VPD
eradication and elimination efforts. While highly effective
vaccines and guidelines to combat VPDs are available, the trend
of increasing number of humanitarian emergencies globally
poses new and emerging challenges in providing vaccination
among displaced populations.
Introduction
Humanitarian emergencies may result in breakdown of regular health services including routine vaccination programs.1
According to the United Nations High Commissioner for
*Correspondence to: Eugene Lam; Email: elam@cdc.gov
Submitted: 06/10/2015; Revised: 09/11/2015; Accepted: 09/16/2015
http://dx.doi.org/10.1080/21645515.2015.1096457
www.tandfonline.com
Refugees (UNHCR), there were 51.2 million people displaced
by the end of 2013 due to conflict situations.2 In 2014, there
were 4 Level 3 large-scale emergencies which led to the displacement of 5.5 million people in the Central African Republic, Iraq,
South Sudan and Syria; this was in addition to a number of other
crises in the Democratic Republic of the Congo (DRC), Libya,
Nigeria, Somalia, and Ukraine.2 Displaced populations may
include refugees who flee to escape a crisis by crossing recognized
international borders and internally displaced persons (IDPs)
who flee but remain within the borders of their own country.
Security issues and logistic challenges associated with emergency
settings can hamper the ability of affected populations to access
routine health services and receive a complete series of recommended vaccinations. In certain emergencies, health services may
be destroyed all together. Disruption of immunization services
increases the number of susceptible individuals and the likelihood
of outbreaks of vaccine-preventable diseases (VPDs).3
VPDs reported in the literature during humanitarian emergencies include measles, polio, and depending on geographical
location, meningococcal meningitis, yellow fever, hepatitis A,
and cholera. Camp settings, especially informal ones, increase a
populations susceptibility to VPDs due to over-crowding, suboptimal living conditions, poor nutrition, scarcity of safe water
and sanitation, and poor nutritional status.3,4 Furthermore, the
forced migration of populations may exacerbate pre-existing
health conditions. Risk factors for outbreaks are inextricably
linked to excess risk of morbidity and mortality from VPDs, the
reduction of which is the aim of public-health interventions during humanitarian crises.
The 2013 publication by the World Health Organization
(WHO) Strategic Advisory Group of Experts on Immunization
(SAGE) on vaccination in acute humanitarian emergencies was
the first WHO document to provide a framework on decision
making regarding vaccination strategies in emergencies.5 This
review article aims to build on the WHO SAGE framework by
providing a more current review of the available literature on
VPDs among refugees and IDPs. The objectives of this article are
to describe the risk factors for outbreaks of VPDs in emergency
settings, key issues and challenges related to vaccination activities,
and possible solutions to crisis-related impacts on vaccination
efforts among displaced populations.
Human Vaccines & Immunotherapeutics
2627
Methods
We searched the PubMed database for articles published from
January 1st, 2000 to March 18th, 2015, providing a 15-year overview of VPDs among refugees and IDPs. Figure 1 provides the
search terms used and the selection process of articles. The initial
search term results with restriction to the 15 year time frame
yielded 484 results, which were further reduced to 305 articles
when accounting for articles only in English and related to
human subjects. Review of the articles and abstracts further narrowed the search to 50 original articles, literature reviews, and
published perspective pieces such as commentaries and letters to
the editor.
We defined a humanitarian crisis as a socio-political conflict
or instability that threatened a populations safety and well-being
by increasing morbidity and mortality above baseline and resulting in significant breakdown of national authority. We selected
articles that addressed refugees or IDPs in the acute emergency
phase as well as in the long-term phase recognizing that some crises may become protracted for years. Articles addressing influenza
or H1N1 pandemic situations were excluded from this review as
influenza vaccines are not often recommended in emergency situations. We excluded articles focused on natural disasters because
the response to these events may differ from that of humanitarian
emergencies. Articles focused on refugee resettlement were
excluded because health issues and resources available to migrants
may differ from those of refugees and IDPs. Articles addressing
vaccinations among responders, national preparedness activities,
capacity building, and serological surveys were also excluded.
Results
All articles from the final search results were grouped by disease and refugee or IDP status for review. A summary of the
articles categorized by VPD and displacement status is presented
in Table 1 and a reference list of articles by VPD, authors, and
title in Table 2. The following provides a summary of the literature review according to various VPD groupings from the search
term results.
Measles, mumps, and rubella
Measles is a well-documented epidemic-prone VPD in the
emergency context. An assessment of risk factors for measles mortality in a 2011 outbreak among Somali refugees in Kenya found
that gastrointestinal and respiratory complications of measles
were common, and increased mortality was associated with malnutrition and neurologic complications.6 This was compounded
by factors related to severe famine and drought and an intensified
civil war resulting in mass population displacement from Somalia
to neighboring countries. Case fatality rates (CFR) of measles
cases among displaced populations are often higher than those
observed in stable populations.3,4,6 Recommendations for case
management include vitamin A supplementation, enrollment in
feeding programs if necessary, as well as oral rehydration and/or
antibacterial treatment as needed.4,7 However, diagnosis and
2628
management of severe measles complications in refugee camps
and other resource-limited settings can be extremely difficult;
therefore every effort should be made to achieve >95% 2-dose
measles vaccination coverage to prevent outbreaks as an effective
alternative.6
We reviewed articles related to measles outbreaks among displaced populations in Tanzania, Ivory Coast, Darfur, Ethiopia,
Somalia and Kenya.8-11 Movement of new arrivals into a refugee
camp may introduce measles transmission. For example, initial
cases in concurrent measles outbreaks in the Dollo Ado refugee
camp in Ethiopia and the Dadaab refugee camp in Kenya during
2010 and 2011 were likely new arrivals from Somalia, a country
that was also experiencing an ongoing measles outbreak.11,12 A
20002001 outbreak of measles in 4 established Burundi refugee
camps in Tanzania was an extension of an outbreak in Burundi
and precipitated by a large influx and inadequate vaccination of
new arrivals.9 Therefore, priority should be placed on disease surveillance to camp areas with the newest refugee arrivals where
timely and reliable disease reporting is likely to be weakest.6
Although camp conditions are common risk factors for measles transmission, movement between camp and host populations
also contributes to measles outbreaks.9-11,13 Close interactions
between Liberian refugees and Ivorian host community in the
urban setting of Abidjan contributed to an outbreak of measles
and rubella in 2003 and 2004 in transit camps within Ivory
Coast.10 When both the displaced and host communities have
apparent immunity gaps for VPDs, it is therefore recommended
to vaccinate both groups of susceptibles, as was done in the mass
measles vaccination efforts of both refugee and non-displaced
populations in Abidjan.10 Although not always possible due to
political and security reasons, establishment of transit and reception centers at crossing points can ensure timely screening of
those with measles and help provide appropriate case management during mass population movement.6
Various target age-groups were reported for measles vaccination campaigns in the available literature within the African
region.11,14,15 Over the past 15 years, increasing consideration in
examining the local epidemiology and context of measles virus
transmission in various settings are reflected in the evoluation of
recommendations and different target age groups in outbreak
response.16
Collaboration with key agency and community partners are
also crucial in outbreak response vaccination strategies. In 2004,
grassroots community organizations and mass media were
engaged to social mobilize IDP camps of West and North Darfur
for a measles vaccination campaign targeting those aged 9
months to 15 years.8 Given the insecurity in Western Darfur and
limited access due to the rainy season, this large-scale vaccination
campaign was made possible through stakeholder cooperation
including negotiations with opposition forces which allowed for
vaccinations to take place in hard-to-reach areas.8,15
Outbreaks of rubella and mumps have also been reported
among displaced populations. In the 20032004 measles and
rubella outbreak in Ivory Coast transit camps, incidence of
rubella was highest among children aged 515 years old. Cases
among relatively older children may have resulted from limited
Human Vaccines & Immunotherapeutics
Volume 11 Issue 11
Figure 1. Literature search inclusion and exclusion criteria.
www.tandfonline.com
Human Vaccines & Immunotherapeutics
2629
Table 1. Summary of articles by vaccine-preventable diseases and population type
By disease
Polio
Measles
Rubella
Mumps
Meningitis
Yellow Fever
Hepatitis A
Hepatitis B
Hepatitis E
Rotavirus
Cholera
Tetanus
Pneumococcus
Varicella
Total*
Refugees
IDPs
Both
4
7
1
0
1
1
1
0
0
1
4
1
1
1
25
1
5
0
1
2
1
0
1
2
0
1
0
0
0
17
0
4
0
0
1
0
0
0
1
0
0
0
0
0
8
*Total re?ects number of articles; some articles addressed multiple antigens
Abbreviations: IDPs D internally displaced persons.
exposure to infection when living in remote areas.10 This study
also highlights the importance of testing for both measles and
rubella in febrile rash outbreaks in refugee settings. In addition,
index cases among refugees were not vaccinated in transit camps
on arrival; these situations highlight the importance of early vaccination upon arrival at camps according to existing guidelines.17
From 2003 to 2005, a large mumps outbreak among 6 to 15
year olds was reported in Palestinian refugee camps. While
mumps remained endemic in the Palestinian West Bank, cases
among individuals born after 1994 with historical vaccination
coverage over 85% suggested inadequate protection against
mumps with only one dose of measles-mumps-rubella (MMR)
vaccination. As a result of this mumps outbreak, a campaign
using MMR vaccine took place in May of 2005 targeting grades
112 and college students.18
Polio
Despite significant progress in the global polio eradication
efforts, outbreaks of poliomyelitis can take place in displaced
populations until poliovirus transmission is stopped in all countries globally. Due to political instability, inadequate sanitation,
and displacement of unvaccinated individuals in highly dense
urban centers, a polio outbreak took place in Luanga province of
Angola.19 In addition, the presence of landmines and collapsed
infrastructure resulted in reduced access to health services in
many districts of the country. This outbreak highlights the
impact of war on access to routine immunizations and vaccination campaigns for all children during periods of conflict and displacement. In 2015, only 3 countries continue to have endemic
circulation of wild polio virus: Afghanistan, Pakistan, and
Nigeria, and the last reported WPV case in Nigeria was in July
2014. After airstrikes in Afghanistan in 2001, Afghani refugees
were expected to enter Pakistan thereby raising concerns of
increasing transmission of polio between the 2 countries.20,21 As
2630
a result, National Immunization Days were conducted in Pakistan and Afghanistan in September of 2001 vaccinating over
30 million children under the age of 5 years. Moreover, all
incoming refugee children were preemptively vaccinated against
polio and measles in Pakistan.21
After more than 10 years without polio, laboratory-confirmed
cases reemerged in Syria in 2013 due to recent conflicts, following confirmation of poliovirus in the sewers of Egypt, Israel, and
West Bank, Gaza. 22 Outbreaks can provide opportunities to sensitize populations at risk and strengthen eradication efforts. In
addition to the local outbreak response immunization efforts in
Syria, regional vaccination responses were launched in surrounding countries of Lebanon, Jordan, Turkey, Palestine, and Egypt.
Another example of a post-outbreak opportunity to eradicate
poliomyelitis was the response to a 2013 outbreak of wild polio
virus that took place in the Horn of Africa.23 As part of the vaccination response, a combined inactivated poliovirus (IPV) and
oral poliovirus vaccine (OPV) campaign targeting children under
5 years of age took place in refugee camps and surrounding communities near the Kenya-Somalia border.23 The addition of IPV
in the response was to boost population immunity among children who have received OPV to ensure interruption of any residual polio virus transmission and prevent any future outbreaks
from new importations.
Meningitis
Meningitis outbreaks can have significant economic and psychological impacts on households and communities, particularly
when the majority of cases are among adults and adolescents. In
endemic situations, meningococcal meningitis mostly affects
young children; however, persons aged 15 to 29 years old were
the most affected in the outbreaks reported among displaced
populations in Angola. The greater number of cases in this older
age group is not unusual in epidemics within areas of high density such as refugees and IDP camps. The International Coordinating Group on Vaccine Provision for Epidemic Meningitis
Control is tasked with maintaining an emergency vaccine stockpile to respond to meningitis outbreaks globally.24
In the Yambala area in Angola, insecurity constrained outbreak response immunization activities and disease transmission
in inaccessible areas stopped only with the onset of the rainy season. Population movement across borders also raised concerns
about the spread of disease outside of the meningitis belt. Six
meningococcal meningitis outbreaks in Angola affected displaced
populations during the civil conflict.25 Mass population movements due to civil war, rampant urbanization, and formation of
informal camps and settlements contribute to meningococcal disease transmission. Economic decline and the collapse of public
health and health service infrastructure in Angola highlighted the
crisis-related impacts of implementing surveillance and outbreak
response to communicable diseases.
After a large influx of Sudanese refugees into camps in Northern Uganda in 1994, there were 2 consecutive outbreaks of group
A meningococcal meningitis.26 Maintaining effective surveillance
system in refugee settings was proved difficult with competing
health care priorities including concurrent epidemics of measles
Human Vaccines & Immunotherapeutics
Volume 11 Issue 11
Table 2. Reference list of articles by vaccine-preventable disease, authors, and title
Author
Year
Published
Valente, F., et al.
2000
Ahmad, K.
Mohammadi, D.
Sheikh, M. A., et al.
2001
2013
2014
Bonn, D.
Kamugisha, C., et al.
Talley L, Salama P.
2001
2003
2003
WHO WER
CDC MMWR
Mupere, E., et al.
2004
2004
2005
Guerrier, G., et al.
2009
Kouadio, I. K., et al.
2010
Kamadjeu, R., et al.
2011
Grais, R. F., et al.
2011
WHO WER
Polonsky, J. A., et al.
2012
2013
Mahamud, A., et al.
2013
Navarro-Colorado, C., et al.
2014
Kaiser, R.
2014
Kouadio, I. K., et al.
Hindiyeh, M. Y., et al.
2009
2009
Santaniello-Newton, A.,
Hunter, P. R.
Gaspar, M., et al.
Iriso, R., et al.
2000
2001
2008
WHO WER
2014
Nathan, N.
Huhn, G. D., et al.
2001
2006
Kaic, B., et al.
Alavian, S. M., et al.
Boccia, D., et al.
2001
2007
2006
CDC MMWR
2013
Ope, M., et al.
2014
Chaignat, C. L., Monti, V.
2007
Verma, R., et al.
Porta, M. I., et al.
2012
2014
Martin, S., et al.
2014
Name of Article
Massive outbreak of poliomyelitis caused by type-3 wild poliovirus in
Angola in 1999.
Fears that Afghan exodus threatens polio eradication
Middle Eastern countries scramble to stop spread of polio
Combined use of inactivated and oral poliovirus vaccines in a large-scale
campaign in refugee camps and host communities
Infectious diseases threaten refugees entering Pakistan.
An outbreak of measles in Tanzanian refugee camps
Short report: assessing ?eld vaccine ef?cacy for measles in famine-affected
rural Ethiopia.
Prevention of measles deaths in Darfur, Sudan.
Emergency measles control activitiesDarfur, Sudan
Impact of emergency mass immunisations on measles control in displaced
populations in Gulu district, northern Uganda.
Malnutrition and mortality patterns among internally displaced and nondisplaced population living in a camp, a village or a town in Eastern Chad.
Measles outbreaks in displaced populations: a review of transmission,
morbidity and mortality associated factors
Measles control and elimination in Somalia: the good, the bad, and the
ugly.
Measles vaccination in humanitarian emergencies: a review of recent
practice
MeaslesHorn of Africa
High levels of mortality, malnutrition, and m…
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