World Population Day: Refugee populations and vaccine coverage in Lebanon
By Maria Kmeid, Pr Hayat Azouri Tannous, Racha Aaraj, Elissa Bechara and Dr Diane Antonios, Toxicology Laboratory and Poison Control Center, Faculty of Pharmacy, Saint Joseph University, Beirut, Lebanon.
More people are on the move now than ever before. This rapid increase of population movement has public health implications and necessitates an adequate response from the health sector. According to the WHO, there are 68 million people across the world that have been forcibly displaced from their homes. 86% of these are being hosted in developing countries.
This World Population Day, we look at the vaccine coverage for Lebanese citizens and Syrian refugees in Lebanon and the impact that such a proportionally huge number of refugees is having on the health system there.
High risk of infectious outbreaks within refugees and displaced populations in the Middle East
Since 2012, Lebanon has hosted around 1.2 million Syrian refugees, a high number in a country whose population does not exceed 4.4 million. The Syrian refugees represent 30% of Lebanon’s population, resulting in the highest per capita concentration of refugees in the world.
The majority have not been placed in formal camps, but, rather, are dispersed over various locations across Lebanon. Healthcare facilities have been overburdened during this period, which has led to the spread of many infectious diseases. Reported cases of measles, mumps and hepatitis A have increased 5-fold, 4.5- fold and 2.3-fold, respectively, since 2012.
At the appearance of such outbreaks, it becomes essential to evaluate vaccine compliance and the factors influencing the vaccination rate among Lebanese residents and Syrian refugees.
Evaluation of vaccination compliance
In order to evaluate the factors responsible for these outbreaks of diseases preventable by vaccines, we estimated the rate of vaccination compliance in infants and children up to 15 years of age among Lebanese residents and Syrian refugees living in Beirut and Mount Lebanon, and evaluated the factors influencing rates of mandatory and non-mandatory vaccination.
Infants and children recruited
A total of 571 infants and children were recruited in Beirut and Mount Lebanon, two governorates that together host half of the Lebanese population. Infants and children were recruited in nurseries, schools, summer camps, waiting rooms of paediatric clinics, and dispensaries in Beirut and Mount Lebanon between July 2017 and February 2018.
In order to identify predictor variables of incomplete immunisation coverage, parents or legal representatives of each child were asked to fill in a brief questionnaire.
Data collected included: nationality; age of infant or child; age, education, and employment status of parents; medical coverage; number of children in the family; day-care centre or school; respondents’ opinions on vaccination; healthcare providers; and experience with vaccine-associated adverse events.
A copy of the vaccine record of every participant was obtained and compared with the Lebanese national immunisation calendar (LNIC). For some vaccines (such as rotavirus, hepatitis A, typhoid, varicella, seasonal influenza and HPV vaccines) that are not included in the LNIC, records were compared with WHO recommendations.
Infants and children were divided into five age categories: 0 to 6 months, 6 to 12 months, 1 to 3 years, 3 to 6 years and 6 to 15 years.
The degree of compliance with mandatory and non-mandatory vaccines in infants and children was classified into six categories: up to date or compliant, not vaccinated, hyper-vaccinated, delayed doses, missing doses and not applicable (when the vaccine was not recommended for the age of the infant or child).
Overall vaccination coverage in the study population
For mandatory vaccines, a very high rate of vaccination was reported for hepatitis B (ranging between 92.6 and 100%), polio (93.4–96.7%), Diphtheria, Tetanus and Pertussis (92.6–96.7%), Hiaemophilus influenzae type B (92.6–97.7%) and measles, mumps and rubella (MMR) (96–100%) in the five age groups. A lower compliance with Pneumococcal conjugate vaccine (56.6–69.8%) and measles (55.8–70.4%) vaccines was observed.
Among the non-mandatory vaccines, a low to very low rate of compliance was reported for rotavirus (29.4–67.2%), meningitis (0–20.8%), seasonal influenza (7.7–73.3%), hepatitis A (13–83.2%), typhoid fever (40.3–55.8%), varicella (52.2–86.3%), pneumonia 23 (0– 8.1%) and HPV (1.5%) in the five age groups.
Overall, the vaccine compliance rate was 39.2% for mandatory vaccines and 21.4% for non-mandatory vaccines. An infant or child was considered non-compliant if they had missed one or more doses or if they were not vaccinated.
The results for mandatory vaccines are low compared with international results (which are higher than 70%). Compliance with mandatory vaccines, except for the PCV13 vaccine, was comparable among Lebanese residents and Syrian refugees. Our results also showed a higher vaccination rate for all non-mandatory vaccines among Lebanese residents.
Factors associated with the immunisation coverage
A bivariate analysis showed that compliance with mandatory vaccination was highly dependent on age group. Indeed, infants aged between 0 and 6 months were more compliant with vaccination than children aged between 6 and 15 years of age (79.6% vs 24.4%).
Moreover, lower vaccination rates were detected among infants and children whose parents’ ages were under 41 years of age, whose mothers were illiterate or had not completed secondary education, and who had one or more siblings.
A higher rate of vaccination was correlated with the holding of private insurance, regular consultation of a private paediatrician (for vaccination) and vaccine price. As for compliance with non-mandatory vaccines, all parameters were significant except the father’s occupation, the number of children in the family, the role of the administration route in compliance, fear during vaccination and past experience with vaccine-associated adverse events.
This analysis showed that the rate of compliance depends only on the infant or child’s nationality. In fact, mandatory vaccines are freely distributed by the Lebanese Ministry of Public Health (MoPH) in dispensaries, where almost all Syrian refugees (98.8%) get vaccinated but only 14.5% of the Lebanese residents do, as reported by our results.
However, non-mandatory vaccines are not covered by the MoPH and are usually expensive, which might explain the very low compliance rates for these vaccines, especially among Syrian refugees.
After all the variables were adjusted, the age of the infant or child and having a private paediatrician were independently associated with immunisation coverage for mandatory vaccines. For non-mandatory vaccines, only the age of the infant or child was reported as a significant predictive factor.
Parents need guidance on vaccinations
Our study highlights the importance of offering guidance to all parents, especially those who are illiterate, under 41 years of age, or in charge of larger families. It is also essential to promote among all Lebanese residents and Syrian refugees the importance of consulting a regular paediatrician.
It is urgent that we closely and regularly monitor compliance with all mandatory and non-mandatory vaccines and follow up with Syrian refugees to investigate their reasons for not having vaccination cards.
Register for ECTMIH 2019 this September in Liverpool to hear more on populations dynamics, population movement and health population profiles including resilience to outbreaks, refugees and internally displaced persons.