Strengthening vaccination delivery system resilience in the context of protracted humanitarian crisis: a realist-informed systematic review

Abstract

Background Childhood vaccination is among the most effective public health interventions available for the prevention of communicable disease, but coverage in many humanitarian settings is sub-optimal. This systematic review critically evaluated peer-review and grey literature evidence on the effectiveness of system-level interventions for improving vaccination coverage in protracted crises, focusing on how they work, and for whom, to better inform preparedness and response for future crises. Methods Realist-informed systematic review of peer-reviewed and grey literature. Keyword-structured searches were performed in MEDLINE, EMBASE and Global Health, CINAHL, the Cochrane Collaboration and WHOLIS, and grey literature searches performed through the websites of UNICEF, the Global Polio Eradication Initiative (GPEI) and Technical Network for Strengthening Immunization Services. Results were independently double-screened for inclusion on title and abstract, and full text. Data were extracted using a pre-developed template, capturing information on the operating contexts in which interventions were implemented, intervention mechanisms, and vaccination-related outcomes. Study quality was assessed using the MMAT tool. Findings were narratively synthesised. Results 50 studies were included, most describing interventions applied in conflict or near-post conflict settings in sub-Saharan Africa, and complex humanitarian emergencies. Vaccination campaigns were the most commonly addressed adaptive mechanism (n = 17). Almost all campaigns operated using multi-modal approaches combining service delivery through multiple pathways (fixed and roving), health worker recruitment and training and community engagement to address both vaccination supply and demand. Creation of collaterals through service integration showed generally positive evidence of impact on routine vaccination uptake by bringing services closer to target populations and leveraging trust that had already been built with communities. Robust community engagement emerged as a key unifying mechanism for outcome improvement across almost all of the intervention classes, in building awareness and trust among crisis-affected populations. Some potentially transformative mechanisms for strengthening resilience in vaccination delivery were identified, but evidence for these remains limited. Conclusion A number of interventions to support adaptations to routine immunisation delivery in the face of protracted crisis are identifiable, as are key unifying mechanisms (multi-level community engagement) apparently irrespective of context, but evidence remains piecemeal. Adapting these approaches for local system resilience-building remains a key challenge.

The epidemiological profile of incidence and mortality from epidemics in complex humanitarian emergencies from 1990 to 2022 – A scoping review

“…Continuous epidemiological surveillance systems have been shown to be essential in CE, as they reduce mortality and case fatality rates. The excess morbidity and mortality caused by communicable diseases in CE can largely be prevented when interventions are based on proper analysis, focusing on indicators proven to be associated with mortality [71,72]. These interventions should be selected based on evidence of outcomes [32], their availability, and implementation according to intervention standards [73].…”

A Systematic Review of Vaccination Guidance for Humanitarian Responses

“…There were very few guidance documents that presented both forms of vaccination campaigns or hybrid approaches. Alternative hybrid delivery modalities including leveraging other operational delivery platforms such as schools or resource distribution points should be considered [ 65 ]. Hybrid approaches should also consider the role of mobile versus static clinics as delivery modalities.…”

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon

“…Understanding of resilience is particularly limited in humanitarian settings, where challenges to health system functionality can be acute, and resources to support meaningful responses to shocks may be more limited, unpredictable and dispersed than elsewhere. Delivery of essential services such as vaccination is challenging and liable to disruption 5–7. There is consistent evidence that childhood vaccination coverage for key antigens is among the lowest in the world for countries affected by conflict or other forms of humanitarian crises8 9 and key health outcomes often fall well below those observed in stable settings 10–12.…”