Date of Award

January 2014

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Kaveh Khoshnood


Background: Conflict is one of the main reasons for our failure to reach worldwide immunization targets. An objective of 90% immunization coverage is included in the fourth Millennium Development Goal to reduce under-five mortality by two thirds, which is still far from achieved in the conflict-ridden Eastern Mediterranean Region (EMR). Despite global progress, vaccine-preventable deaths still account for 20% of childhood mortality under five years of age in the EMR, and communicable disease a third of all mortality. Conflict remains a critical root cause of low vaccination coverage in the EMR, resulting in high levels of vaccine-preventable disease, disability, and death.

Research Question: The aim of this review is to assess the impact of conflict on vaccine-preventable disease vaccination coverage and outcomes in children under five in the Eastern Mediterranean Region. While international attention is drawn to outbreaks of polio and measles, several other easily avoidable infections are also responsible for high rates of morbidity and mortality, especially in children. This review will give a more holistic view on the burden of vaccine-preventable disease associated with conflict, as well as identify gaps in our current knowledge and explore common factors in prevention of immunization uptake.

Methods: This systematic review was performed using the PRISMA guidelines. Search terms related to conflict, the EMR, vaccines in the WHO Expanded Programme for Immunization (EPI) package, and children were entered into MEDLINE, Embase, Global Health, and Cochrane. Eighty seven unique articles were identified, and after an abstract and full text review and a forward search, 26 were retained for data extraction and analysis.

Results: Results were distributed between four different countries of origin (Afghanistan, Pakistan, Somalia, and Sudan), five different countries of study (Afghanistan, Pakistan, Sudan, Somalia, and Kenya), and six out of ten diseases in the EPI (poliovirus, measles, hepatitis B, tetanus, diphtheria, and pertussis). The majority of results addressed poliovirus (n=16) and measles (n=9). Outcomes, vaccination coverage, and barriers to vaccination was analyzed according to disease.

Conclusions: There is a large gap of knowledge regarding vaccine-preventable diseases in children under five in conflict-affected areas of the Eastern Mediterranean Region. Understanding the prevalence, mortality, and barriers to vaccination involved in these challenging environments will help us reach the WHO goals of 90% vaccination coverage and reduce worldwide childhood mortality.


This is an Open Access Thesis.

Open Access

This Article is Open Access