Internally displaced populations and refugees are often corralled into camps. In
these camps, people are subjected to close-quarter living arrangements, limited
accessibility to potable water, and insufficient sanitation and hygienic measures
(Hermans et al., 2018). These conditions provide an almost ideal environment for the
transmission of disease. One account of a refugee camp in Greece outlined that there
was an “absence of running water and electricity” (Duke University, 2018). Similarly, in
France, journalists reported that “the camp was infested with rats, the water was
contaminated with feces, and tuberculosis was rampant” (Duke University, 2018). Keep
in mind that these are the conditions found in developed countries and they are likely
worse in underdeveloped nations.
The most common medical concern in the Lesbos refugee camp in Greece was upper
respiratory tract infection (Hermans et al., 2018). Additionally, many vaccinepreventable diseases (VPDs) are common in camps, including “measles, polio, and
depending on geographical location, meningococcal meningitis, yellow fever, hepatitis
A, and cholera” (Lam, Mccarthy & Brennan, 2015). Hermans et al. (2018) also cited that
the lack of an effective vaccination program contributes to the spread of these diseases.
Similarly, the United Nations High Commissioner for Refugees (UNHCR) (2018) states
that 92.3% of the diagnoses given at refugee health screenings were communicable
diseases, and that “the top five causes of morbidity were upper respiratory tract
infections (24.7%), malaria (22.1%), lower respiratory tract infections (11.4%), skin
diseases (6.7%) and watery diarrhea (5.7%)”. They also published that there is an
average of 22 people per latrine at the camps they monitor (UNHCR, 2018).
Conversely, another source reported that “The highest infectious disease prevalence in
refugee and asylum seeker populations have been reported for latent tuberculosis (9–
45%), active tuberculosis (up to 11%), and hepatitis B (up to 12%)” (Eiset & Wejse,
2017). From all of these sources, we can gather that respiratory tract infections are
consistently the most prevalent in camps for refugees and internally displaced persons,
with gastrointestinal (GI) issues, skin disease, and VPDs accounting for a percentage of
morbidity as well.
It’s likely that the upper and lower respiratory tract infections are caused by the cramped
living conditions, which facilitate the transfer of viruses and bacteria via coughs and
sneezes, in addition to malnutrition weakening the immune systems of the refugees.
Malaria, on the other hand, cannot be spread from person-to-person. Rather, it is
spread via mosquito bites that are infected with the parasite. The high rates of malaria
indicate that there are either limited protections in place for refugees at their campsite,
or that they come to campsites already infected. Hepatitis B can be transmitted via
contact with infectious bodily fluids and unprotected sex. Diarrheal and GI diseases
could be caused by any type of infection or contaminated water supply.
Based on my limited healthcare experience and knowledge of infectious diseases, there
are a couple of key steps that could be taken to prevent the proliferation of disease in
these camps:
1.
2.
3.
4.
5.
6.
7.
8.
Allocate more space/person
Establish a quarantine area for symptomatic patients
Change layouts of camps to prevent water contamination
Enforce hygiene standards (hand sanitizer before meals, after the latrines, etc.)
Vaccination campaigns for preventable disease
Brief screenings prior to admittance (temperature, signs of respiratory infection, etc.)
STI prevention through the distribution of condoms/other barrier devices
Allocate mosquito nets in areas malaria is common
I recognize that these actions will all have a cost associated with them and may not be
economically feasible. Unfortunately, I was unable to find any studies specifically on the
cost of prevention vs. treatment for refugee camps. The UNHCR (2018) did report,
however, that there were more than 7.5 million health consultations performed.
Performing pre-screenings and enforcing quarantines may prevent the spread of
disease and reduce the economic impact of those consultations so the money can be
redirected towards disease prevention and screening. Additionally, the solutions I
proposed may not be culturally appropriate depending on the demographics of the
refugee camp, in which case humanitarian workers will have to employ some of the
strategies and tactics that we discussed in our last discussion board. If anyone has any
other suggestions, feel free to add to my list!
References
Centers for Disease Control and Prevention. (2019, June 24). FastStats - Leading
Causes of Death. Retrieved from https://www.cdc.gov/nchs/fastats/leading-causes-ofdeath.htm.
Duke University. (2018, March 28). Refugee Camps: Poor Living Conditions and their
Effects on Mental Health. Retrieved from
https://sites.duke.edu/refugeementalhealth/2018/03/27/refugee-camps-poor-livingconditions-and-their-effects-on-mental-health/.
Eiset, A. H., & Wejse, C. (2017). Review of infectious diseases in refugees and asylum
seekers—current status and going forward. Public Health Reviews, 38(1). doi:
10.1186/s40985-017-0065-4
Hermans, M. P. J., Kooistra, J., Cannegieter, S. C., Rosendaal, F. R., Mook-Kanamori,
D. O., & Nemeth, B. (2017). Healthcare and disease burden among refugees in longstay refugee camps at Lesbos, Greece. European Journal of Epidemiology, 32(9), 851–854. doi:
10.1007/s10654-017-0269-4
Lam, E., Mccarthy, A., & Brennan, M. (2015). Vaccine-preventable diseases in
humanitarian emergencies among refugee and internally-displaced populations. Human
Vaccines & Immunotherapeutics, 11(11), 2627–2636. doi: 10.1080/21645515.2015.1096457
UNHCR. (2018). UNHCR Public Health 2018 Annual Global Overview. Retrieved from
https://his.unhcr.org/ar2018/.
Displaced populations are incredibly vulnerable to a number of infectious disease
outbreaks. When disasters strike, existing health infrastructure is stressed, and
communities loose access to treatment of pre-existing conditions and preventative
health. For example, when Ebola struck West Africa in 2014, the existing health care
system came to a complete stop—those with diseases such as TB no longer had
access to their treatment and became even more exposed. Vaccine campaigns for
childhood illnesses also stopped, which allowed for the rise of highly contagious
illnesses such as measles (Shrivastava, Shrivastas, & Jegadeesh, 2015).
While decreased access to health infrastructure increases the vulnerability of
displaced populations, situations that require emergency relocation also set the stage
for continued health risks. The close quarters and lack of sanitation in some emergency
housing situations increase the risk for the spread vaccine preventable diseases that
are spread by contact or unfavorable sanitization conditions- such as Hepatitis B, MMR,
cholera, meningitis, and yellow fever. (Lam, Mccarthy, & Brennan, 2015) (Piarroux,
Barris, Haus, Piarroux, & Gaudart, 2011)
One important factor to be especially aware of as an international aid worker is the
risk you bring to others who are either not exposed to diseases that you are due to
geography. For example, the county of Haiti never had Cholera outbreaks until after the
2009 Earthquake. Studies now indicate that the cholera outbreak started via an
humanitarian aid worker, and was exacerbated by the lack of access to clean water and
sanitation. The outbreak became its own disaster in the shadow of the earthquake-over 700,000 Haitians were infected, and approximately 9000 people died from the
preventable disease. The cholera outbreak was then difficult to control and spread
rapidly, despite the availability of a vaccine. Disbursement of the cholera vaccine was
complicated because it required cold-chain storage, which means you need to have
electricity and the ability to keep the vaccine at a certain temperature until it is ready to
administer. The earthquake’s destruction made the cold-chain process even more
complicated. (Piarroux, Barris, Haus, Piarroux, & Gaudart, 2011)
While any disaster situation makes access to preventative health difficult, it is
important to get preventative health initiatives back up and running as soon as possible
after a disaster. Prevention is the best way to decrease the spread of contagious
diseases. In a refugee camp situation, it is important to ensure each person goes
through a basic medical screening exam prior to entering the camp. People exhibiting
symptoms of infectious diseases, even a simple cold, should be kept separate from the
general population until symptoms resolve. During the medical screening exam,
vaccination history should be obtained and appropriate vaccinations should be given
prior to entering the camp. Obviously, prevention can be a tough sell, especially in a
low-resource setting, however most studies indicate that prevention is substantially less
expensive than treating an infectious disease outbreak. (Eiset & Wejse, 2017)
In addition to medical screening and vaccine administration, education regarding
basic hygiene can go a long way. The provision of handwashing station and supplies,
along with culturally appropriate education, can prevent the spread of many diseases
such as cholera, RSV, the flu, and the common cold. One teaching method I have found
particularly beneficial for handwashing involves taking a piece of bread and passing it
around in a circle. You then allow the bread to sit and grow mold and bacteria from
everyone’s hands for a few days. It is a very simple visual of basic germ theory and
helps drive home the “why” behind the importance of handwashing, which can
substantially reduce the transmission of contagious diseases.
References
Eiset, A. H., & Wejse, C. (2017). Review of infectious diseases in refugees and asylum
seekers-- current status and going forward. Public Health Reviews, 38(1).
doi:10.1186/s40985-017-0065-4
Lam, E., Mccarthy, A., & Brennan, M. (2015). Vaccine-preventable diseases in
humanitarian emergencies among refugee and internally-displaced populations.
Human Vaccines & Immunotherapeutics. 11(11), 2627-2636.
doi:10.1080/21645515.2015.1096457
Piarroux, R., Barris, R., Haus, R., Piarroux, M., & Gaudart, J. (2011). Understanding the
cholera epidemic, Haiti. Emerging Infectious Diseases, 17:1161-8.
Shrivastava, S., Shrivastas, P., & Jegadeesh, R. (2015). LEgacy of Ebola outbreak:
potential risk of measles outbreak in Guinea, SIerra Leone and Libera . J Res
Med Sci, 20:529-30.
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 conflict
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
population’s susceptibility to VPD’s 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 population’s 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
2000–2001 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 2003–2004 measles and
rubella outbreak in Ivory Coast transit camps, incidence of
rubella was highest among children aged 5–15 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 reflects 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
1–12 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 field vaccine efficacy for measles in famine-affected
rural Ethiopia.
Prevention of measles deaths in Darfur, Sudan.
Emergency measles control activities–Darfur, 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
Measles–Horn of Africa
High levels of mortality, malnutrition, and measles, among recentlydisplaced Somali refugees in Dagahaley camp, Dadaab refugee camp
complex, Kenya, 2011.
Risk factors for measles mortality among hospitalized Somali refugees
displaced by famine, Kenya, 2011.
Measles outbreak response among adolescent and adult Somali refugees
displaced by famine in Kenya and Ethiopia, 2011.
Emergency settings: be prepared to vaccinate persons aged 15 and over
against measles
Outbreak of measles and rubella in refugee transit camps.
Characterization of large mumps outbreak among vaccinated Palestinian
refugees
Management of an outbreak of meningococcal meningitis in a Sudanese
refugee camp in Northern Uganda.
Epidemiology of meningococcal meningitis in Angola, 1994–2000
Bacterial meningitis following introduction of Hib conjugate vaccine in
northern Uganda.
Meningococcal disease control in countries of the African meningitis belt,
2013.
Shortage of vaccines during a yellow fever outbreak in Guinea.
Vaccination coverage survey versus administrative data in the assessment
of mass yellow fever immunization in internally displaced persons–Liberia,
2004.
Hepatitis A control in a refugee camp by active immunization.
The changing epidemiology of viral hepatitis B in Iran.
High mortality associated with an outbreak of hepatitis E among displaced
persons in Darfur, Sudan.
Investigation of hepatitis E outbreak among refugees - Upper Nile, South
Sudan, 2012–2013
Rotavirus enteritis in Dadaab refugee camps: implications for immunization
programs in Kenya and Resettlement Countries.
Use of oral cholera vaccine in complex emergencies: what next? Summary
report of an expert meeting and recommendations of WHO.
Cholera vaccine: new preventive tool for endemic countries.
Feasibility of a preventive mass vaccination campaign with 2 doses of oral
cholera vaccine during a humanitarian emergency in South Sudan
Post-licensure deployment of oral cholera vaccines: a systematic review.
Vaccine-Preventable
Disease
Polio
Polio
Polio
Polio
Polio, Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles
Measles, Rubella
Mumps
Meningitis
Meningitis
Meningitis
Meningitis
Yellow fever
Yellow fever
Hepatitis A
Hepatitis B
Hepatitis E
Hepatitis E
Rotavirus
Cholera
Cholera
Cholera
Cholera
(Continued on next page)
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Human Vaccines & Immunotherapeutics
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Table 2. Reference list of articles by vaccine-preventable disease, authors, and title (Continued)
Author
Year
Published
WHO WER
2014
Howard, N., et al.
Moszynski, P.
2011
2013
Shimakawa, Y., et al.
Morris, K.
Koop, D. G., et al.
2010
2000
2001
Leus, X., et al.
Bhatia, S., et al.
Connolly, M. A., et al.
Avogo, W. A., Agadjanian, V.
Moodley, K., et al.
2001
2002
2004
2010
2013
Caplan, A. L., Curry, D. R.
Devi, S.
2015
2015
Name of Article
Oral cholera vaccine campaign among internally displaced persons in
South Sudan.
Reproductive health for refugees by refugees in Guinea III: maternal health.
Refugees in South Sudan to receive pneumococcal vaccine after delays
over price.
Outbreak of chickenpox in a refugee camp of northern Thailand.
Agency warns of crisis in beleaguered Democratic Republic of Congo.
Results of the expanded program on immunization in the Macedonian
refugee camps.
Internally displaced persons
A social and demographic study of Tibetan refugees in India.
Communicable diseases in complex emergencies: impact and challenges
Forced migration and child health and mortality in Angola.
Ethical considerations for vaccination programmes in acute humanitarian
emergencies.
Refugees, humanitarian aid and the right to decline vaccinations
Long-term planning needed for Iraq’s displaced.
Vaccine-Preventable
Disease
Cholera
Tetanus
Pneumococcus
Varicella
General
General
General
General
General
General
General
General
General
Abbreviations: CDC, Centers for Disease Control and Prevention; MMWR, Morbidity and Mortality Weekly Report; WHO, World Health Organization; WER,
Weekly Epidemiological Report.
and malnutrition. As part of the response, mass vaccination of 1
to 30 year olds was successfully conducted to control the initial
outbreak. The decision to extend the upper limit of the target
age-group to 30 years was based on analysis of age-specific attack
rates. The sudden influx of refugees overwhelmed screening at
registration resulting in 11,000 refugees not being screened or
vaccinated upon arrival. This may have led to the second consecutive meningitis outbreak that required a catch-up vaccination
campaign in 1995. However, this outbreak demonstrated the
effectiveness of rapid mass vaccination campaigns with high coverage in controlling outbreaks of serogroup A meningococcal
meningitis among refugee population.
Cholera and rotavirus
Diarrheal diseases are one of the leading causes of death
among children under 5 years of age in emergency settings. Rotavirus has not been well studied among displaced populations.
WHO recommends introduction of rotavirus vaccine into
national immunization programs for countries where diarrheal
deaths account for 10% of mortality among children under
5 years of age. In 2011, a diarrheal disease surveillance system
implemented in the Dadaab refugee camp in Kenya found rotavirus circulating year-round with 23% of children under 5 years of
age presenting with diarrhea in a health facility to be infected
with rotavirus.27 This study supports the use of rotavirus vaccination in refugee camps; however, additional evaluation in other
refugee settings is needed to provide further evidence of its efficacy among refugee populations.
Several oral cholera vaccines (OCV) have been developed as a
public health intervention for vulnerable populations in emergency settings.28,29 Mass vaccinations with OCV acquired from
the global stockpile have been used in several emergency contexts
to prevent outbreaks of cholera in camp situations.28-32 A meeting among WHO experts noted that OCV could be used as a
2632
preventive intervention in humanitarian emergencies.29 Further
studies are needed to determine the possible cost-benefit of
OCV, number of doses needed for adequate protection, and best
practices for cold chain implementation in the emergency
context.29
In 2012–2014 the first use of the global OCV stockpile was
conducted in OCV campaigns in IDP camps and surrounding
communities in South Sudan during a humanitarian crisis. The
OCV campaigns were completed through fixed outreach posts
and mobile door-to-door teams targeting individuals >1 year of
age, excluding pregnant women.31,33 Distribution of vaccination
cards were used to track immunization status, and soap as an
incentive to receive the second OCV dose.31,32 However, despite
the success of campaigns, there were security, logistical, and
financial challenges related to the 2 dose administration schedule
as well as weakened cold chain capacity due to the ongoing conflict.31 Furthermore, additional costs were required to transport
OCV via charter flights due to insecurity. Curfew and access constraints limited staff movement and resulted in restricted and
delayed operations. This study showed that mass OCV campaigns in emergency settings is possible but not without additional human resources, cold-chain capacity, logistical and
communications support from all relevant partners.31
Yellow fever
The mosquito vector Aedes aegypti for yellow fever thrives in
densely-populated areas such as urban areas and camps. In 2004,
2 yellow fever mass vaccination campaigns were launched in IDP
camps and surrounding communities in Liberia after reports of 4
lab-confirmed cases.33 Due to the 14 years of civil war, much of
Liberia’s healthcare infrastructure, public health disease surveillance, and immunization programs were severely disrupted. Survey assessment of vaccination coverage reported 90% by selfreport and 80% by proof of vaccination card. The success of the
Human Vaccines & Immunotherapeutics
Volume 11 Issue 11
mass vaccination efforts among IDPs required intensive social
mobilization, efficient logistical networks, well-trained health
staff, and safe vaccine delivery.33
During a time Liberian and Sierra Leonean refugees and IDPs
were in Guinea, a yellow fever outbreak was reported with 688
cases and 225 deaths (CFR 33%) in 2000.34 Movement through
the forested areas of Guinea where yellow fever is endemic into
densely-populated camps and urban areas may have led to
increased transmission. In addition, this outbreak highlighted at
that time the global shortage of available yellow fever vaccines,
which ultimately resulted in the creation of the UNICEF stockpile of 2 million doses of yellow fever vaccine to be used in
response to future outbreaks.
Hepatitis A and E
Several types of viral hepatitis were noted among displaced
populations in our review. In 1999, a hepatitis A outbreak among
Kosovar refugees in Croatia was primarily a result of poor sanitation and housing.35 Outbreak response included sanitation
improvement, health education, screening of children 1–15 years
of age and vaccination for seronegative children. Serological studies conducted 4 weeks post-vaccination reported 97% seroconversion. The authors suggested active vaccination was a successful
component in disrupting hepatitis A transmission in this refugee
population.35
Hepatitis E virus (HEV) infection is generally a self-limiting
condition with low fatality to the general population, although
there is high case-fatality among pregnant women. In 2004, a
HEV outbreak in Mornay IDP Camp, Darfur, reported a CFR
of 33% among pregnant women highlighting the need for rapid
interventions to prevent mortality in this special population.36 A
2012–2013 outbreak of HEV in the refugee camps of Maban
County in South Sudan had a CFR of 10% among pregnant
women.37 HEV transmission control often includes improvements to water and sanitation, clinical care, and surveillance.
Although there is currently no HEV vaccine available globally,
recent developments of a hepatitis E vaccine in China may have
utility in controlling outbreaks among displaced populations.38
The vaccine has yet to achieve WHO prequalification and
requires further studies regarding safety in children and pregnant
women. Additional research is needed to assess appropriate dosing regimen and efficacy of HEV vaccine to control outbreaks
among refugees and IDPs.
Varicella
Varicella is not included in most national routine vaccination
programs, though outbreaks may be of particular concern among
displaced populations in tropical settings. While the majority of
individuals in temperate climates develop natural immunity from
previous infection before adolescence, high levels of seronegativity are typically still observed among adults in tropical regions.
Adults infected with varicella may suffer from increased disease
severity and greater complications. Moving from rural areas of
low population density to densely populated refugee camps may
also increase transmission. In 2008, a varicella outbreak in refugee settings was documented among Lao Hmong refugees in
www.tandfonline.com
Thailand.39 The affected population was between 3 months and
53 years old in this outbreak with 14% of cases 15 years old or
older. Moreover, hospitalizations occurred exclusively among
adults aged 15 years. Preventive varicella vaccination may be
warranted in refugee camps if epidemiological evidence suggests
increased risk of an outbreak with high levels of morbidity.
Routine immunizations
Establishment of routine immunization services is not well
studied in the emergency context. Three articles discussed integration of routine vaccination schedules of host country national
expanded program on immunization (EPI) program for refugee
populations.40-42 Tibetan refugees in India were provided routine
childhood immunizations according to the national EPI schedule
of the India Ministry of Health.40 The program reported challenges in delivery of vaccine to the target population, with less
than half of the Tibetan refugee children reported as fully vaccinated.40 As a solution to improve routine immunization coverage
among displaced populations, the Macedonian Ministry of
Health delivered vaccines to Albanian Kosovar refugees living in
camps and the surrounding communities through weekly mobile
immunization clinics.42 In Guinea, more than 90% of Liberian
and Sierra Leonean refugee mothers knew about tetanus vaccination during pregnancy, though only 11–42% utilized the free
antenatal care in government facilities sponsored by UNHCR.41
EPI programs for refugees may differ between that of host
nations and their countries of origin thereby creating both ethical
and logistical challenges.43,44 Ethical concerns have also been
raised regarding the ability of the host nations to deny humanitarian assistance to refugees refusing vaccinations during emergency
situations. Such was the case in 2014 during the response of the
governments of Lebanon, to resistance from Syrian refugees, and
Pakistan, to Afghan refugees, in receiving polio vaccination upon
entrance into camps.45 The authors argued that host governments
and supporting agencies have the responsibility to require such
vaccinations in humanitarian emergencies where the risk of VPD
outbreaks can endanger both host and displaced communities.
EPI programs can often become non-functional during
humanitarian emergencies.46-48, To address this, multiple opportunities for vaccination, including child health days and catch-up
vaccination campaigns, can be used to boost population immunity.48 Protracted emergencies reinforce the importance of thinking beyond the emergency mindset and including long-term
strategies in basic health service provisions.48,49 WHO and other
UN agencies can play a critical role in coordinating the establishment of regular health services, including routine immunizations,
in situations where the national government is unwilling or
unable to provide the necessary aid to IDPs.50
In regards to financing and use of newer vaccines among displaced populations, 2 articles mentioned the support of the
Global Alliance for Vaccines and Immunization (GAVI) in
acquiring Haemophilus influenza type b (Hib) and pneumococcal
conjugate vaccine (PCV) in emergencies.51,52 GAVI has helped
fund the provision of pentavalent vaccines for IDPs in Uganda
from 2002 to 2006 and PCV for Yida refugee camp in South
Sudan in 2013.51,52
Human Vaccines & Immunotherapeutics
2633
Discussion
Mass population movement can increase risk of VPDs among
IDPs, refugees, and host communities. Displaced populations
can introduce endemic pathogens to a new place as well as make
contact with new pathogens either on their journey or within the
host community. The same conditions that increase transmission
of communicable diseases—high prevalence of malnutrition,
unsanitary conditions, population displacement, overcrowding,
and lack of clean water—can result in VPD outbreaks and high
rates of morbidity and mortality. The primary objective of vaccination in an acute humanitarian emergency is to rapidly reduce
the risk of disease to protect a population during periods of
extreme vulnerability.5
While the goals of vaccination during an acute phase of an
emergency focus on limiting the number of preventable deaths,
the goals of routine vaccination programs aim to ensure longterm protection against a given disease through progressive
increase of population immunity. In particular, protracted emergencies need to consider reestablishing regular immunization
services as soon as possible given the rapid accumulation of susceptible populations with missed opportunities of routine vaccinations. According to UNHCR, protracted camps with 25,000
or more displaced persons should implement routine services
equivalent to host country immunization policies with occasional
supplementary vaccination campaigns.11 Mass vaccination campaigns in camps may consider administering multiple antigens
with the aim of reducing administrative and logistical costs.8,15,33
Forced migration may result in incomplete vaccinations of
routine immunizations placing both the displaced and the host
population at an elevated risk for contracting disease. In situations where the displaced population is unstable or there is frequent population movement, mobile clinics have been used to
effectively achieve high vaccination coverage.23,33,34,42 Vaccination schedules in the country of origin may not always align with
that of the host country, thereby creating challenges in providing
interventions that are well understood by the displaced population. Intensive social mobilization is needed in situations where
the perceived importance of vaccination is low.41 Opportunities
for defaulter tracing activities and catch up campaigns should
also be in place for those who may have missed routine vaccinations during the emergency.
Destruction of cold chain equipment and infrastructure for
transportation provide significant challenges to vaccination during humanitarian conflicts. Growing insecurities, as seen in the
increasing number of targeted attacks on health workers in recent
years during polio eradication efforts in Pakistan, can dramatically limit the ability of humanitarian players to provide the necessary vaccinations.53-55 These issues may be even more
pronounced in IDP camps, where operations are within the borders of a country in conflict and the status of protection and assistance from the international community may not apply.50
Collaboration with defacto local authorities to deliver vaccination
to chronically insecure areas are warranted at times.48
Other major challenges in addition to insecurity, logistical,
and access issues encountered during emergencies may include
2634
insufficiently trained staff, insufficient supplies and equipment,
communication issues and perception within the host community, and limited camp capacity after massive population
influx.4,33 For example, observation of polio vaccination teams in
2013 in Kenya noted errors in the injection technique of IPV in
the field and cold chain issues during the OPV and IPV combined campaign; thereby stressing the need for appropriate training of vaccinators and supervisors.23 In a 2014 mass OCV
vaccination campaign in South Sudan, there was lower participation from men who believed vaccination was for women and children.33 There may be local resistance to the idea of expanding
refugee or IDP camps to accommodate new arrivals that can lead
to unplanned transition camps.11,56 In addition, new waves of
displaced persons can come suddenly and overwhelm existing
capacity.
Guidelines to protect populations against VPDs in conflict
settings include the UNHCR handbook for emergencies, the
UNICEF’s code of conduct, the WHO SAGE framework document, and the Sphere handbook which includes internationally
recognized principles and universal minimum standards for
response to humanitarian emergencies.5,17,57,58 Recent WHO
position papers also provide guidance on vaccinations during
emergencies, including development of new OCVs and their
safety, effectiveness, and efficacy profiles.59. WHO also released a
new Meningococcal position paper in 2015 addressing the conjugate vaccine safety, schedule, and efficacy based on preventive
mass campaigns, along with updated recommendations that are
particularly relevant in the African meningitis belt.60 In 2012,
polio was declared a global public health emergency; the WHO
position paper on polio vaccination recommends the inclusion of
one dose of IPV for routine immunization programs in countries
using only OPV.61
Limitations of this review include possible omission of
articles, as this review was restricted to articles written in English
and available on PubMed. The articles were also restricted by
publication date from 2000 to 2015. However, this review provides an update on the available literature regarding vaccinations
among a highly vulnerable population and describes the unique
challenges of VPDs during humanitarian emergencies. Further
operational research is needed to evaluate the prioritization of
public health interventions such as vaccinations, timing of implementation during the various phases of emergencies, and the use
of newer vaccines including PCV, OCV, Hib, rotavirus, and pentavalent vaccines.
Epidemic-prone VPDs are of particular concern during acute
emergencies. Displaced populations are at an increased risk for
outbreaks of 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. 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 ensuring all susceptible individuals have
access to life saving vaccines.
Human Vaccines & Immunotherapeutics
Volume 11 Issue 11
Disclosure of Potential Conflicts of Interest
Acknowledgments
None of the authors have a commercial or other financial
interest associated with the information presented in this article.
The findings and conclusions in this report are those of the
authors and do not necessarily represent the official position of
the Centers for Disease Control and Prevention.
We would like to thank Jennifer Head, MPHc, and Anyie Li,
MPHc, from the Rollins School of Public Health, Emory University, for their editorial assistance and help in review of the current literature.
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