Struggling to resume childhood vaccination during war in Myanmar: evaluation of a pilot program

Abstract

Background: After the military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. After two years without vaccines for their children, parents urged a nurse-led civil society organization in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination program, which we evaluated.

Methods: A retrospective cohort study and participatory evaluation were conducted. We interviewed the healthcare workers about vaccine acquisition, transportation, and administration and assessed compliance with WHO-recommended practices. We analyzed the participating children's characteristics. We calculated the proportion of children vaccinated before and after the program. We calculated the probability children would become up-to-date after the program using inverse survival.

Results: Since United Nations agencies could not assist, private donations were raised to purchase, smuggle into Myanmar, and administer five vaccines. Cold chain standards were maintained. Compliance with other WHO-recommended vaccination practices was 74%. Of the 184 participating children, 145 (79%, median age five months [IQR 6.5]) were previously unvaccinated, and 71 (41%) were internally displaced. During five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of MMR was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); BCG 76% (95% CI 69%-83%); and OPV 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage.

Conclusions: This is the first study to describe the situation, barriers, and outcomes of a childhood vaccination program in one of the many conflict-affected states since the coup in Myanmar. Even though the proportion of previously unvaccinated children was large, the program was successful. While the target population was necessarily small, the program's success led to a donor-funded expansion to 2,000 children. Without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%.

Keywords: Developing countries; Ethnic and racial minorities; Infant; International cooperation; Myanmar; Nurses role; Parents; Retrospective studies; United nations; Vaccination; World health organization.

Fig. 1

Edited translation of a local news article on mothers’ difficulty in accessing vaccinations for their children

Fig. 2

Percentage of zero-dose (no previous vaccinations) children by age group

Fig. 3

The flow of children presenting for vaccination. Those who were/were not in the census (white text, blue background); zero-dose or incompletely vaccinated (green text, grey background); zero-dose children who were age-eligible (blue text, green background); total number and proportion of zero-dose age-eligible children vaccinated (black text); previously vaccinated children are in red. BCG: bacillus Calmette-Guérin; Penta: Diphtheria pertussis, tetanus, hepatitis B, Haemophilus influenza type B; OPV: Oral polio; MMR: Measles, mumps, rubella

Fig. 4

Inverse survival probabilities for zero-dose age-eligible children receiving recommended doses of each vaccine. BCG, bacillus Calmette-Guérin; Penta, Diphtheria pertussis, tetanus, hepatitis B, Haemophilus influenza type B; OPV, Oral polio; MMR, Measles, mumps, rubella