Implications of armed conflict for maternal and child health: A regression analysis of data from 181 countries for 2000–2019

Background Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions—all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally. Methods and findings Data for 181 countries (2000–2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country–year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9–72.0; 0.3 million excess deaths [95% CI 0.2 million–0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1–5.5; 2.0 million excess deaths [95% CI 1.6 million–2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%–8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%–11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3–5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data. Conclusions Our analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions.

Cobertura vacinal do sarampo e sua associação com os casos novos da doença no Estado do Pará, Brasil

O Sarampo é uma doença infectocontagiosa com grande importância clínica, sendo a vacinação a forma mais eficaz de prevenção e é assegurada, no Brasil, pelo Programa Nacional de Imunizações (PNI). Contudo, nos últimos anos, houve reemergência de casos de sarampo. Nesse contexto, o trabalho em questão visa analisar a cobertura vacinal contra sarampo, no Pará, no período de 2010 a 2019, e relacionar com o ressurgimento de casos da doença no estado. Trata-se de um estudo observacional do tipo transversal realizado com dados obtidos por meio do Sistema de Informação do Programa Nacional de Imunizações (SI-PNI) e de Boletins Epidemiológicos publicados pelo Ministério da Saúde (MS). Observou-se que as maiores taxas de cobertura vacinal, no Pará, ocorreram nos anos de 2010 (110,95%) a 2014 (115,73%); houve o decréscimo para 69,29%, em 2015 e, até 2019, não se alcançou a meta preconizada pelo MS de 95% de cobertura. Nesse contexto, foram confirmados 41 casos de sarampo no Estado, tornando-o o 6° estado com maior número de casos confirmados dentre os estados analisados. Desta forma, apontam-se fatores que associam o surgimento de casos novos com a diminuição da cobertura, tal qual a hesitação vacinal, alertando que o programa de vacinação deve ser fortalecido para que doenças não retornem ao meio social. ABSTRACTMeasles is an infectious disease of great clinical significance, being vaccination the most effective form of prevention, ensured by the National Immunization Program (Programa Nacional de Imunização – PNI), in Brazil. However, in recent years, there has been reemergence of measles cases. In this context, this study aims to analyze measles vaccination coverage in the State of Pará from 2010 to 2019 and relate it to the resurgence of disease cases in the state. This is an observational cross-sectional study conducted with data obtained through the Information System of the National Immunization Program (Sistema de Informação do Programa Nacional de Imunizações – SI-PNI) and Epidemiological Bulletins published by the Ministry of Health (Ministério da Saúde – MS). It was observed that highest vaccination coverage rates occurred in the years 2010 (110.95%) to 2014 (115.73%), there was a decrease to 69.29%, in 2015, and until 2019, it did not reach the goal recommended by the MS, which is 95% coverage. In this context, 41 measles cases were confirmed in state, making it the 6th state with the highest number of confirmed cases among the analyzed states. Thus, factors that link the emergence of new cases with decreased coverage are pointed out, such as vaccination hesitation, showing that strengthening the vaccination program is necessary, so that diseases do not return to the social environment.Keywords: Measles; Vaccination coverage; Immunization. RESUMENEl sarampión es una enfermedad infecciosa de gran importancia clínica, siendo la vacunación una forma de prevención más eficaz y asegurada, en Brasil, por el Programa Nacional de Inmunizaciones (PNI). Sin embargo, en los últimos años ha habido un resurgimiento de casos de sarampión. En este contexto, el trabajo en cuestión tiene como objetivo analizar la cobertura de vacunación contra el sarampión, en Pará, en el período de 2010 a 2019, y relacionarla con el resurgimiento de casos de la enfermedad en el estado. Se trata de un estudio observacional, transversal realizado con datos recolectados a través del Sistema de Información del Programa Nacional de Inmunizaciones (SI-PNI) y de los Boletines Epidemiológicos publicados por el Ministerio de Salud (MS). Se observó que las mayores tasas de cobertura de vacunación, en Pará, ocurrieron en los años 2010 (110,95%) a 2014 (115,73%); hubo una disminución a 69,29% en 2015 y, hasta 2019, no se alcanzó la meta recomendada por el Ministerio de Salud de cobertura del 95%. En este contexto, se confirmaron 41 casos de sarampión en el estado, lo que lo convierte en el sexto estado con el mayor número de casos confirmados dentro de los estados moldeados. Así, se señalan factores que asocian la aparición de nuevos casos con la disminución de coberturas, como la vacilación vacunal, advirtiendo que se debe fortalecer el programa de vacunación para que las enfermedades no regresen al ámbito social.Palabras clave: Sarampión; Cobertura de vacunación; Inmunización.

Factors associated with measles vaccination status in children under the age of three years in a post-soviet context: a cross-sectional study using the DHS VII in Armenia

Background The resurgence of measles globally and the increasing number of unvaccinated clusters call for studies exploring factors that influence measles vaccination uptake. Armenia is a middle-income post-Soviet country with an officially high vaccination coverage. However, concerns about vaccine safety are common. The purpose of this study was to measure the prevalence of measles vaccination coverage in children under three years of age and to identify factors that are associated with measles vaccination in Armenia by using nationally representative data. Methods Cross-sectional analysis using self-report data from the most recent Armenian Demographic Health Survey (ADHS VII 2015/16) was conducted. Among 588 eligible women with a last-born child aged 12–35 months, 63 women were excluded due to unknown status of measles vaccination, resulting in 525 women included in the final analyses. We used logistic regression models in order to identify factors associated with vaccination status in the final sample. Complex sample analyses were used to account for the study design. Results In the studied population 79.6% of the children were vaccinated against measles. After adjusting for potential confounders, regression models showed that the increasing age of the child (AOR 1.07, 95% CI: 1.03–1.12), secondary education of the mothers (AOR 3.38, 95% CI: 1.17–9.76) and attendance at postnatal check-up within two months after birth (AOR 2.71, 95% CI: 1.17–6.30) were significantly associated with the vaccination status of the child. Conclusions The measles vaccination coverage among the children was lower than the recommended percentage. The study confirmed the importance of maternal education and attending postnatal care visits. However, the study also showed that there might be potential risks for future measles outbreaks because of delayed vaccinations and a large group of children with an unknown vaccination status.

The importance of supplementary immunisation activities to prevent measles outbreaks during the COVID-19 pandemic in Kenya

Background The COVID-19 pandemic has disrupted routine measles immunisation and supplementary immunisation activities (SIAs) in most countries including Kenya. We assessed the risk of measles outbreaks during the pandemic in Kenya as a case study for the African Region. Methods Combining measles serological data, local contact patterns, and vaccination coverage into a cohort model, we predicted the age-adjusted population immunity in Kenya and estimated the probability of outbreaks when contact-reducing COVID-19 interventions are lifted. We considered various scenarios for reduced measles vaccination coverage from April 2020. Results In February 2020, when a scheduled SIA was postponed, population immunity was close to the herd immunity threshold and the probability of a large outbreak was 34% (8–54). As the COVID-19 contact restrictions are nearly fully eased, from December 2020, the probability of a large measles outbreak will increase to 38% (19–54), 46% (30–59), and 54% (43–64) assuming a 15%, 50%, and 100% reduction in measles vaccination coverage. By December 2021, this risk increases further to 43% (25–56), 54% (43–63), and 67% (59–72) for the same coverage scenarios respectively. However, the increased risk of a measles outbreak following the lifting of all restrictions can be overcome by conducting a SIA with ≥ 95% coverage in under-fives. Conclusion While contact restrictions sufficient for SAR-CoV-2 control temporarily reduce measles transmissibility and the risk of an outbreak from a measles immunity gap, this risk rises rapidly once these restrictions are lifted. Implementing delayed SIAs will be critical for prevention of measles outbreaks given the roll-back of contact restrictions in Kenya.

Are the Objectives Proposed by the WHO for Routine Measles Vaccination Coverage and Population Measles Immunity Sufficient to Achieve Measles Elimination from Europe?

Background: The World Health Organization (WHO) proposed two-dose measles vaccination coverage of at least 95% of the population and percentages of measles immunity in the population of 85%−95% in order to achieve measles elimination in Europe. The objectives of this study were: (1) to determine the measles vaccination coverage required to establish herd immunity against measles viruses with basic reproduction numbers (Ro) ranging from 6 to 60, and (2) to assess whether the objectives proposed by the WHO are sufficient to establish herd immunity against measles viruses. Methods: The herd immunity effects of the recommended objectives were assessed by considering the prevalence of protected individuals required to establish herd immunity against measles viruses with Ro values ranging from 6 to 60. Results: The study found that percentages of two-dose measles vaccination coverage from 88% to 100% could establish herd immunity against measles viruses with Ro from 6 to 19, assuming 95% measles vaccination effectiveness. The study found that the objective of 95% for two-dose measles vaccination coverage proposed by the WHO would not be sufficient to establish herd immunity against measles viruses with Ro ≥ 10, assuming 95% measles vaccination effectiveness. By contrast, a 97% measles vaccination coverage objective was sufficient to establish herd immunity against measles viruses, with Ro values from 6 to 13. Measles immunity levels recommended in individuals aged 1−4 years (≥85%) and 5−9 years (≥90%) might not be sufficient to establish herd immunity against most measles viruses, while those recommended in individuals aged 10 or more years (≥95%) could be sufficient to establish herd immunity against measles viruses with Ro values from 6 to 20. Conclusion: To meet the goal of measles elimination in Europe, it is necessary to achieve percentages of two-dose measles vaccination coverage of at least 97%, and measles immunity levels in children aged 1−9 years of at least 95%.