Impact of the Socio-political Crisis in the North West and South West Regions of Cameroon on the Expanded Vaccination Program for Children From 0 to 23 Months

Impact of the Socio-political Crisis in the North West and South West Regions of Cameroon on the Expanded Vaccination Program for Children From 0 to 23 Months | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of the Socio-political Crisis in the North West and South West Regions of Cameroon on the Expanded Vaccination Program for Children From 0 to 23 Months Judicael Marcelin Tewantsa, Cavin Epie Bekolo, Dominique Enyama, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4980037/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Socio-political crises have long been recognized as major obstacles in the fight against vaccine-preventable diseases in many parts of the world. However, in Cameroon, the impact of the ongoing socio-political crisis on the Expanded Program on Immunization (EPI) in the North West (NW) and South West (SW) regions has not been fully examined. The objective of this study was to examine the impact of this crisis on the performances of the EPI. This was a secondary data analysis. The data were obtained from the standard EPI data collection tools, from all the health districts in the two regions. The Z-test statistic was used to estimate the differences between our coverage, including BCG (Bacille Calmette-Guérin vaccine), PENTA (pentavalent vaccine), and Measles-rubella (RR) coverage, according to the time periods for each region, i.e., between the years 2014 to 2016 (pre-conflict), and 2017 to 2019 (during the conflict). In both regions, reported immunization coverage rates for key antigens, including BCG, PENTA-3 and RR1, showed a statistically significant decline except for BCG coverage in the NW region. There was a decline in vaccine coverage between the 3 years before the crisis and the first 3 years of the crisis of 7% (Z=3.40; P=0.003) in PENTA-3; 8% (Z=4.14; P<0.001) in RR1 with an increase in the overall drop-out rate of 3% (Z=3.87; P<0.001) in the NW region. In the SW, mean vaccination coverage had declined by 22% (Z=16.81; P<0.001) for BCG, 33% (Z=17.92; P<0.001) for PENTA 3, 36% (Z=12.99; P<0.001) for RR1 with an increase in the mean general dropout rate of 16% (Z=8.10; P<0.001) between the pre-crisis and early crisis years. The results found suggest that the decline in immunization performance in the conflict zone of Cameroon may be due to disruption of health services and increased insecurity limiting access to immunization services. Significant increases in vaccination strategies can improve performance in these areas, although other factors not considered in our study may contribute to the decline in vaccination performance. Socio-political crisis Performance Vaccination Cameroon. Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Vaccination is a public health intervention whose cost-effectiveness is recognized worldwide ( 1 ). This intervention is the essence of the Expanded Program on Immunization (EPI), a global program initiated in 1974 by the World Health Organization (WHO)( 1 ). It is within this immunization framework that international agencies will focus their efforts on polio eradication, measles and maternal and neonatal tetanus elimination. According to WHO estimates in 2015, nearly 2–3 million deaths are averted annually worldwide through immunization and a further 1.5 million deaths could be averted simply by improving immunization coverage( 2 ). Geographical location, gender and socio-economic status are important factors influencing equity of access to immunization services ( 3 ). Similarly, socio-political crises are major contextual determinants that influence access to immunization, as they limit immunization strategies, impact the availability of health workers and influence the management of inputs( 3 ). A study by Mashal et al. in Afghanistan in 2003 on the impact of conflict on infant immunization coverage showed a clear deterioration of the immunization system in crisis areas( 4 ). Similar deterioration, eventually triggered polio epidemics, in the Central African Republic ( 5 ) and Pakistan ( 6 ). In almost all of these countries, the onset of armed conflict led to a sudden drop in immunization coverage. Some countries recorded national coverage of less than 50 per cent( 7 ). The EPI has been effective throughout Cameroon since 1982 and its main targets are children from 0 to 23 months and pregnant women ( 8 ). This program can be presented as a major strategy for achieving the third Sustainable Development Goal (SDG) which is to "Empower people to lead healthy lives and promote well-being for all at all ages"( 9 ). However, the socio-political crisis in the North-West and South-West regions is one of the variables that mark the epidemiological situation in Cameroon. This crisis is characterized by the armed violence that broke out at the end of 2016( 10 ). More than three thousand (3000) civilians and hundreds of security forces have been killed since the beginning of the crisis. The unrest in these regions has resulted in the displacement of over half a million people ( 11 ). It has increased in intensity in 2018 posing the problem of access to primary health care in a context of high insecurity ( 10 ). The objective of this work was to assess the impact of this socio-political crisis on immunization coverage of EPI marker antigens in children aged 0–23 months. METHODOLOGY Study design This was a secondary data review (SDR) in the Health Districts of the North West and South West Regions of Cameroon. These districts were selected exhaustively. The study was conducted over a period of 6 years from January 2014 to December 2019, i.e. 3 years before (2014, 2015 and 2016) and 3 years during (2017, 2018 and 2019) the socio-political crisis. The analysis of the collected data was done using Epi Info 7.2.2.7, SPSS and Microsoft Excel 2019. To highlight the difference in means between these two periods, we conducted a comparison test of the means of the performances recorded during the 3 years preceding the crisis with those of the first 3 years of the crisis using the Z-test statistic of comparison of two means of two matched samples. The fractile of the normal distribution will be Zo=1.96. Study site and period The study was conducted at the Regional delegations of public health for the regions of South West and North West.With a total population of 1,900,547 in 2013, the South West region is divided into 18 health districts (BUEA, LIMBE, KUMBA, MANFE, MUYUKA, TOMBEL, BANGEM, TIKO, MBONGE, AKWAYA, WABANE, KONYE, and EYUMOJOCK). The North West region is also one of the crisis regions with a total population of 2,213,984 in 2013; the health system in this region is organized around 19 health districts (AKO, BAFUT, BALI, BAMENDA, BATIBO, BENAKUMA, FUNDONG, KUMBO EAST, KUMBO WEST, MBENGWI, NDOP, NDU, NJIKWA, NKAMBE, NWA, OKU, SANTA, TUBAH, WUM). These health districts comprise Health Areas that group together health facilities. Each health area has a primary health facility, which is usually public but may be private in some health areas (6). The primary facility in the health area coordinates the distribution of vaccines and supplies and reports data on EPI indicators from the other health facilities, both public and private, within the health area. All these health facilities report their activity data to the district, regional and central health service levels through the DHIS2 and the DVDMT, which are the main health information management portals. The data were collected from January 2014 to December 2019. Period of data collection: As part of this study, we collected secondary data in the Ministry of Public Health's data management tool (DHIS 2) during the period from 1 December 2020 to 30 June 2021. Data sources Data were extracted from the standard data reporting tools of the Expanded Program on Immunization (EPI) of the North West and South West District Health Services, namely the District Vaccine Data Management Tools (DVDMT) and the District Health Information System (DHIS2) of all the districts of the two regions using an extraction grid. The raw data were reviewed at the end of each day to detect inconsistencies, omissions and incomplete data. It allowed, as far as possible, to complete the data. The variables needed to assess the type of coverage problem were carefully coded and controlled (7). We mainly used EPI data on BCG (Bacilli of Chalmette and Guerin), PENTA (which is the pentavalent vaccine that protects against five major infections in one injection: diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenza type b (Hib)), and RR (which is the measles-rubella vaccine), which are the EPI marker antigens. Ethical considerations In the context of this study, we note the following points: - Secondary analysis of public data: This research only involves the analysis of public data that has already been anonymized and in which individuals cannot be identified. We used data from national statistics. - This study was carried out in the context of an emergency: in view of the risks of destruction of the health system in the crisis regions of Cameroon, it was essential to use the available indicators to show the impact of the crisis on children's health. - The database does not collect or provide information on the ethnic identity of participants; the data is anonymized in order to protect the identity of individuals, and this anonymization process removes specific identifiers. We also consulted the institution's guidelines and the recommendations of ethics committees concerning research using secondary data. It was established that, in our specific case, a formal ethical clearance was not required. RESULTS Sample coverage. During data collection, data on EPI indicators targeting children aged 0–23 months in the 19 health districts in the North-West and the 18 health districts in the South-West included in the sample were collected. Description of the targets. The distribution of live births and children (from 2014 to 2016) and the crisis period (from 2017 to 2019) were recorded in the North-West (NW) and South-West (SW) regions before (2014, 2015 and 2016) and during (2017, 2018 and 2019) the socio-political crisis had considerably decreased as presented in Fig. 1. We noted a regression in the average number of live births of 13.65% and 16.91% respectively in the North-West and South-West regions between the pre-crisis and crisis periods. Figure 1 Distribution of the target population 0–23 months in the North West and South West regions 3 years before the crisis and 3 years during the crisis. Influence of the crisis on immunization services. The socio-political crisis hit the SW earlier than the NW. Before the crisis period, only the Bakassi Health District in the South West region was considered insecure. In 2019, all Health Districts in both regions had at least one health facility offering immunization services affected by the crisis. Figure 2 presents the distribution of the number of functional health facilities offering vaccination services. It can be seen that the number of health facilities offering immunization in the two regions had decreased considerably between the pre-crisis and crisis periods, falling by 36.14% (133/368) and 54.08% (139/257) of health facilities in the North West and South West regions respectively. Figure 2 Distribution of the number of health facilities offering vaccination services in the periods 2014–2016 and 2017–2019. In the North West region, the average number of fixed-strategy sessions carried out was 21850 before the crisis (from 2014 to 2016) and 29692 fixed-strategy vaccination sessions were carried out during the crisis (from 2017 to 2019). For Advanced/Mobile Strategies The numbers of Advanced/Mobile Strategy sessions were 11089 in the pre-crisis period and 6054 during the crisis period in the North West. The situation in the South-West region was 10959 advanced/mobile strategy immunization sessions carried out in the pre-crisis period and 20 871 fixed strategy immunization sessions carried out during the crisis period. BCG vaccination coverage. Figure 2 shows the distribution of the number of health districts according to the level of BCG vaccination coverage, which is the EPI recruitment antigen. It ranged from 50 to 79% before the socio-political crisis; a situation that changed before the crisis period to 6640 during the crisis period; i.e. a reduction of 45.40% (5035/11089) in the North West region and 39.41% (431/910959) in the South West region. Vaccination coverage in the North-West and South-West 3 years before and 3 years during the socio-political crisis among children aged 0–23 months. According to the analyses, the difference in the ratio of the number of fixed strategies carried out to those planned was 12.36, i.e. an increase from 64.79% (6192/9557) [CI: 63.83%-65.74%] to 77.15% (10706/13876) [CI: 76.45%-77.85%] between the two periods. In the South West (SW) region, 16760 immunization sessions were conducted, while in the North West, more than 50% of the health districts had average BCG coverage completely in 2019 with coverage below 50% in 68.42% (13/19) of the health districts. As observed in the South West, more than 50% of the Health Districts had BCG coverage above 80% before the crisis compared to coverage below 50% in more than 60% of the Health Districts. Based on data from the DVDMT and DHI2 of the District Health Services, cumulative BCG vaccination coverage among children aged 0–23 months was 57%, 54% and 61% respectively in 2014, 2015 and 2016 (pre-crisis period) compared to 68%, 57% and 45% in 2017, 2018 and 2019 (crisis period) in the North West. The situation in the South-West showed a more considerable variation in BCG vaccination coverage, as this went from 80%, 78% and 78% respectively in 2014, 2015 and 2016 to 68%, 54% and 47% in 2017, 2018 and 2019. Figure 3 presents this variation in BCG vaccination coverage between the period before the socio-political crisis and the crisis period. Figure 3 Cumulative BCG vaccination coverage trends in the North West and South West regions from 2014 to 2016 and from 2017 to 2018 Vaccination coverage in PENTA 1, PENTA 3 and RR: Vaccination coverage in PENTA 1 routinely administered vaccine differed from year to year. In the NW, cumulative vaccination coverage in children aged 0–23 months for the first dose of PENTA ranged from 70%, 65% and 73% respectively from 2014–2016 (the period before the socio-political crisis) and 80%, 60% and 49% from 2017–2019 (crisis period). For the situation in the SW, the results showed a distribution of cumulative vaccination coverage in PENTA 1 of 92%, 89% and 93% respectively in 2014, 2015 and 2016 against 73%, 58% and 42% from 2017–2019. These results show a lower coverage in 2019. Vaccination coverage for the third dose of PENTA administered routinely differed between the pre-crisis and crisis periods. In the NW, the cumulative coverage of PENTA 3 was 69%, 64 and 72% respectively from 2014–2016 which represents the pre-crisis period. For the crisis period (2017–2019) This coverage was 78%, 57% and 48% respectively. The variation in this coverage was more significant in the South-West, with a variation of 88%, 85% and 89% respectively from 2014–2016 to 68%, 55% and 40% from 2017–2019. The results show that vaccination coverage for the RR1 vaccine fell from 70%, 61% and 68% in the pre-crisis period (2014, 2015 and 2016) to 73%, 54% and 46% in the crisis period (2017, 2018 and 2019) in the North West region. The results also show that cumulative RR vaccination coverage in the SW fell from 84%, 82% and 86% in the pre-crisis period (2014, 2015 and 2016) to 68%, 57% and 28% in the crisis period (2017–2019). Influence of the socio-political crisis on EPI performance in children aged 0 to 23 months. Table I shows that in the north-west, PENTA, which is the EPI tracing antigen, had a difference in average vaccine coverage during the pre-crisis period of 69% ± 4% compared to 62%±16% during the crisis, i.e. a statistically significant difference in the average of 7% (P = 0.003). The decrease in mean coverage between the pre-crisis and crisis periods for the recruitment antigen (BCG) was not statistically significant in the north-west region. Identification of problems with immunization coverage in the North West and South West health districts before and during the crisis period. 3 years before the crisis in the North West, 15.75% [CI: 3.38% − 39.58%] of the Health Districts had no problems with immunization coverage according to WHO standards. However, the main problem influencing immunization coverage was the problem of access to immunization services. This problem affected 73.68% [CI: 48.80% − 90.74%] of health districts. During the 3 years of the crisis, 94.74% [CI: 73.97% − 99.87%] of the districts were affected by this same problem of access to vaccination services. Table I Average differences in EPI indicators between the period 2014 to 2016 and 2017 to 2019 among children aged 0–11 months in the North West region. Variable (Obs = 57) Before Crisis During Crisis Diff (CI 95%) Z Test P-value ) The average number of reports received on time 132.3 (± 4.93) 115(± 65.60) 17.3 (0.25–34.40) 1.08 0.02 Average BCG coverage 0.57 (± 0.03) 0.47 (± 0.11) 0.1 (-0.01-0.03) 0,66 0,25 Average PENTA1 coverage 0.69 (± 0.04) 0.63 (± 0.16) 0.06 (0.01–0.10) 2.74 < 0,001 Average coverage in PENTA3 0.69 (± 0.04) 0.62 (± 0.15) 0.07 (0.02–0.11) 3.40 < 0,001 Average coverage in RR1 0.66 (± 0.04) 0.58 (± 0.14) 0.08 (0.26–0.39) 4.14 < 0,001 Average drop-out rate specific 0.01 (± 0.00) 0.03 (± 0.009) 0.02 (0.01–0.06) 10.5 < 0.001 Average drop-out rate overall 0.02 (± 0.04) 0.06 (± 0.06) 0.04 (0.03–0.08) 3.87 < 0.001 Table II Distribution of types of vaccine coverage problems identified in the Health Districts of the North West Region according to vaccine coverage and drop-out rate. INDICATORS Before Crisis (N = 19) CI à 95% During Crisis (N = 19) CI à 95% Problems found District with average cumulative PENTA1 coverage > = 80 and Average drop-out rate = 80 and average dropout rate > 10(%) 0 (0,00) 82,35–100 0 (0,00) 82,35–100 The problem of resource use at the health facility level. District with average cumulative PENTA1 coverage < 80 and average dropout rate < 10(% 14(73,68) 48,80–90,85 18 (94,74) 78,97–99,87 The problem of access to vaccination services. District with average cumulative PENTA1 coverage 10(%) 2 (10,53) 1,30–33,14 1 (5,26) 0,13–26,35 The problem of resource use and access. Vaccination services. Discussion The results of our study helped to better describe the distribution of EPI performance, to evaluate the impact of the socio-political crisis on this performance and to diagnose the types of problems in immunization coverage during the period before the crisis and during the crisis in the North-West and South-West regions of Cameroon. Despite efforts to optimize immunization coverage, major challenges persist in providing every child with the necessary protection against vaccine-preventable diseases, particularly in the North West and South West regions of Cameroon. In the present study, the proportion of health facilities offering immunization services had declined by 36.14% and 54.08% respectively in the North West and South West regions between the period before the socio-political crisis and the period during the crisis. In terms of results, this decrease in immunization services has a direct consequence on immunization strategies, as we note from the results of our analyses a statistically significant (P < 0;001) decrease in the number of immunization sessions using advanced strategies, i.e. 45.40% (5035/11089) in the North West region and 39.41% (431/910959) in the South West region. These results are in line with those found in some surveys conducted in Côte d'Ivoire in 2011 which estimated a 61% (P < 0.001) decline in immunization services and strategies during a crisis ( 12 ). Given the difficulty of implementing mobile and advanced strategies, it is important to increase the number of fixed strategy sessions in secure areas to improve access to immunization services. We observed an increase in fixed strategies of more than 12.63% in the North West, which significantly reduced the impact of the socio-political crisis on EPI performances. These results are consistent with the findings of studies conducted in Pakistan in 2019 ( 6 ) and Côte d'Ivoire in 2011 ( 12 ). These studies underline the importance of good management of vaccine strategies in conflict areas as this EPI indicator has a considerable impact on vaccine coverage. The average vaccination coverage in PENTA 1, PENTA 3 and RR 1, had a statistically significant decrease (P < 0.001) of 6% (from 69–63%), 7% (69–62%) and 8% (66–58%) respectively in the North West region. These results in the North-West region of Cameroon remain significantly lower than those of studies conducted in the Central African Republic ( 5 ) and in Pakistan( 6 ). In the South-West region, the results of our analyses show a decrease in the average coverage of BCG, PENTA 1, PENTA 3, and RR1, respectively by 22% (from 78–56%), 33% (from 91–58%), 33% (from 87–51%) and 36% (from 87–51%). These results are similar to those of the studies conducted in Syria in 2019 ( 13 ) and Nigeria in 2018 ( 14 ). This discrepancy between coverage in the North West and other studies highlights the importance of good management of immunization strategies in times of crisis. The drop in immunization coverage regarding PENTA in both regions remains similar to that obtained by John Grundy in a study of the effect of armed conflict on immunization coverage in 16 countries in crisis 2016( 8 ). In the South-West region, our results showed a decrease in the coverage of BCG, PENTA 1, PENTA 3 and RR1 by 22% (from 78–56%), 33% (from 91–58%), 33% (from 87–51%) and 36% (from 87–51%) respectively (P < 5%). These results are similar to those of studies conducted in Syria in 2019 ( 9 ) and Nigeria in 2018 ( 10 ).This discrepancy between coverages in the North West and other studies highlights the importance of good management of immunisation strategies in times of crisis. The decline in immunization coverage regarding PENTA antigen in both regions remains similar to that obtained by John Grundy in a study of the effect of armed conflict on immunization coverage in 16 countries in crisis 2016( 8 ). We also discovered an average dropout rate before and during the crisis below the 10.0% threshold in the North West region, with a 2% increase in the specific dropout rate and a 4% increase in the general dropout rate. This rate is still significant in terms of the value of the Z test statistic and its impact on mother and child health. In the South West region, an increase in the general dropout rate of 16% was observed. The movement of the population could explain this rate. In line with previous research conducted in Lebanon ( 13 ), Nigeria ( 14 ) and Pakistan( 11 ), This study shows considerable gaps in immunization coverage among children aged 0–23 months in the crisis areas. These gaps, with wide variations across these two regions, are related to gaps in the system of recruitment, monitoring and access to immunization services. The results of this study highlight the importance of the problem of access to immunization services. It emerges from this study that in the North-West and South-West regions of Cameroon, the diagnosis after analysis of the data highlights access to immunization services as a real problem of low immunization coverage because 94.74% and 44.44% of the Health Districts in the South-West and North-West respectively had this problem of access to immunization services by the communities during the crisis. These findings are consistent with those of the 2018 GAVI study in Kenya ( 11 ). Conclusion The objective of this paper was to determine the impact of the socio-political crisis on the performance of the expanded program on immunization in the North West and South West regions of Cameroon. To achieve our objective, data were collected from the DVDMT and DHIS2 at the regional level. It was found that the crisis reduced the number of health facilities offering immunization services by 1.5/4 and 2.2/4 in the North West and South West respectively. The timeliness of EPI data reporting also fell significantly, by 8% in the North West and 35% in the South West. In both regions, there has been a drop in immunization coverage for all EPI antigens, but this drop is more significant in the South West region, with 19 districts out of 19 having average immunization coverage of less than 50% and an average drop-out rate of 6%. In the face of this conflict, the main problem of immunization coverage is that of access to immunization services by the communities. This socio-political crisis is a major determinant influencing the EPI in these regions, leading to a drop in its indicators. The objective of the EPI, which is to fight against the occurrence of vaccine-preventable diseases, is thus influenced. Declarations Conflicts of interest The authors declare having no conflicts of interest. Acknowledgements We thank the Regional Delegations of Public Health of the South West and North West regions of Cameroon for their collaboration in the implementation of this project and the Department of Public Health of the Faculty of Medicine and Pharmaceutical Sciences of the University of Dschang for approving the research protocol. Author Contributions Conceptualization: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Data curation: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Formal analysis: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Methodology: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Resources: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Software: Tewantsa Judicael Marcelin. Supervision: Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Validation : Tewantsa Judicael Marcelin, Cavin Epie Bekolo. Visualization: Tewantsa Judicael Marcelin. Writing – original draft: Tewantsa Judicael Marcelin, Cavin Epie Bekolo, Gabriel Tchatchouang Mabou, Tchatchouang Mabou, Simeon Pierre Choukem. Writing – review & editing: Tewantsa Judicael Marcelin, Cavin Epie Bekolo, Gabriel Tchatchouang Mabou, Tchatchouang Mabou, Simeon Pierre Choukem. References Einfeldt. [Continuing education on the lowest level. On the 100th colloquium of the “Westphal-Kreis”]. Zahnarztl Mitt. 1966 Jan 1;56(2):74–6. UNICEF. La vaccination sauve 2 à 3 millions de vies par an [Internet]. UNICEF. 2015 [cited 2021 Jun 24]. Available from: https://www.unicef.fr Levy BS, Sidel VW. Documenting the Effects of Armed Conflict on Population Health. Annu Rev Public Health. 2016;37(1):205–18. Mashal T, Nakamura K, Kizuki M, Seino K, Takano T. Impact of conflict on infant immunisation coverage in Afghanistan: a countrywide study 2000–2003. Int J Health Geogr. 2007 Dec;6(1):1–9. Ionela Gouandjika-Vasilache. Importation de poliovirus sauvage, République centrafricaine. In 2013 [cited 2021 Apr 25]. p. 10128–1013. Available from: https://www.ncbi.nlm.nih Memon RA, Memon FN, Sultan RS, Memon HA. 6. Polio phases in Pakistan a decade’s journey at one glance: A succinct report. Pure Appl Biol PAB. 2019 May 2;8(2):1801–8. Grundy J, Biggs BA. The Impact of Conflict on Immunisation Coverage in 16 Countries. Int J Health Policy Manag. 2018 Dec 30;8(4):211–21. MINSANTE. Direction de la Lutte contre la Maladie, les Epidémies et les Pandémies [Internet]. [cited 2021 Jun 24]. Available from: https://www.minsante.cm.org ONU. Développement durable [Internet]. [cited 2021 Jun 24]. Available from: https://www.un.org/sustainabledevelopment/fr/ Ekah RE. The Anglophone Crisis in Cameroon: A Geopolitical Analysis [Internet]. Rochester, NY: Social Science Research Network; 2020 Feb [cited 2021 Jul 24]. Report No.: ID 3529815. Available from: https://papers.ssrn.com/abstract=3529815 Crisis Group. Cameroun : la crise anglophone à la croisée des chemins [Internet]. 2017 [cited 2021 Jun 24]. Available from: https://www.crisisgroup.org Tiembre I, Benie J, Coulibaly A, Dagnan S, Ekra D. Impact du conflit armé sur le système de santé d’un district sanitaire en Côte d’Ivoire. Médecine Trop. 2011;71(3):249–52. Ziad Mansour ,Randa Hamadé ,. Couverture vaccinale au Liban suite à la crise syrienne : résultats de l’enquête d’évaluation de la couverture vaccinale par district 2016 | SpringerLink [Internet]. [cited 2021 May 13]. Available from: https://link.springer.com/article/10.1186/s12889-019-6418-9 Dunn G. The impact of the Boko Haram insurgency in Northeast Nigeria on childhood wasting: a double-difference study. Confl Health. 2018 Jan 24;12(1):6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4980037","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":346997608,"identity":"4652cdc5-21c8-46c6-a792-6223f41a4e37","order_by":0,"name":"Judicael Marcelin Tewantsa","email":"data:image/png;base64,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","orcid":"","institution":"University of Dschang","correspondingAuthor":true,"prefix":"","firstName":"Judicael","middleName":"Marcelin","lastName":"Tewantsa","suffix":""},{"id":346997609,"identity":"d18d6e5d-bfdf-4d34-a455-c6a0c2330475","order_by":1,"name":"Cavin Epie Bekolo","email":"","orcid":"","institution":"University of Dschang","correspondingAuthor":false,"prefix":"","firstName":"Cavin","middleName":"Epie","lastName":"Bekolo","suffix":""},{"id":346997610,"identity":"96a985ac-2f06-4cec-a072-c5c6fecc595b","order_by":2,"name":"Dominique Enyama","email":"","orcid":"","institution":"University of Dschang","correspondingAuthor":false,"prefix":"","firstName":"Dominique","middleName":"","lastName":"Enyama","suffix":""},{"id":346997611,"identity":"d57d505c-c80f-43f5-a063-d08a552e642a","order_by":3,"name":"Gabriel Tchatchouang Mabou","email":"","orcid":"","institution":"University of Dschang","correspondingAuthor":false,"prefix":"","firstName":"Gabriel","middleName":"Tchatchouang","lastName":"Mabou","suffix":""},{"id":346997612,"identity":"f81889dd-e195-4534-be70-285483ab2cce","order_by":4,"name":"Simeon Pierre Choukem","email":"","orcid":"","institution":"University of Dschang","correspondingAuthor":false,"prefix":"","firstName":"Simeon","middleName":"Pierre","lastName":"Choukem","suffix":""}],"badges":[],"createdAt":"2024-08-26 19:56:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4980037/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4980037/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64003827,"identity":"508dafe3-e5ba-48e9-a817-c38be58f4cfa","added_by":"auto","created_at":"2024-09-04 21:14:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25745,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the target population 0-23 months in the North West and South West regions 3 years before the crisis and 3 years during the crisis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4980037/v1/4c279ab6f2bb4d58fd738e16.png"},{"id":64003829,"identity":"033e7a04-6165-4985-bfe0-87b82454bcd0","added_by":"auto","created_at":"2024-09-04 21:14:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15109,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of the number of health facilities offering vaccination services in the periods 2014-2016 and 2017-2019.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4980037/v1/8328a6cc39a2c4a8b2cd14d8.png"},{"id":64003830,"identity":"068d77eb-4b9d-4cf6-bc81-3a847a9c9a05","added_by":"auto","created_at":"2024-09-04 21:14:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":21513,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative BCG vaccination coverage trends in the North West and South West regions from 2014 to 2016 and from 2017 to 2018\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4980037/v1/bd70ed8fc1c0cfd6c85989b0.png"},{"id":64004355,"identity":"3b3cea0e-660d-423d-a9cc-f048b01ee8e4","added_by":"auto","created_at":"2024-09-04 21:22:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":627955,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4980037/v1/816e3980-289e-4445-a3b7-e49672c13520.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImpact of the Socio-political Crisis in the North West and South West Regions of Cameroon on the Expanded Vaccination Program for Children From 0 to 23 Months\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eVaccination is a public health intervention whose cost-effectiveness is recognized worldwide (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This intervention is the essence of the Expanded Program on Immunization (EPI), a global program initiated in 1974 by the World Health Organization (WHO)(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It is within this immunization framework that international agencies will focus their efforts on polio eradication, measles and maternal and neonatal tetanus elimination. According to WHO estimates in 2015, nearly 2\u0026ndash;3\u0026nbsp;million deaths are averted annually worldwide through immunization and a further 1.5\u0026nbsp;million deaths could be averted simply by improving immunization coverage(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGeographical location, gender and socio-economic status are important factors influencing equity of access to immunization services (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Similarly, socio-political crises are major contextual determinants that influence access to immunization, as they limit immunization strategies, impact the availability of health workers and influence the management of inputs(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A study by Mashal et al. in Afghanistan in 2003 on the impact of conflict on infant immunization coverage showed a clear deterioration of the immunization system in crisis areas(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Similar deterioration, eventually triggered polio epidemics, in the Central African Republic (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and Pakistan (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In almost all of these countries, the onset of armed conflict led to a sudden drop in immunization coverage. Some countries recorded national coverage of less than 50 per cent(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe EPI has been effective throughout Cameroon since 1982 and its main targets are children from 0 to 23 months and pregnant women (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This program can be presented as a major strategy for achieving the third Sustainable Development Goal (SDG) which is to \"Empower people to lead healthy lives and promote well-being for all at all ages\"(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, the socio-political crisis in the North-West and South-West regions is one of the variables that mark the epidemiological situation in Cameroon. This crisis is characterized by the armed violence that broke out at the end of 2016(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore than three thousand (3000) civilians and hundreds of security forces have been killed since the beginning of the crisis. The unrest in these regions has resulted in the displacement of over half a million people (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It has increased in intensity in 2018 posing the problem of access to primary health care in a context of high insecurity (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The objective of this work was to assess the impact of this socio-political crisis on immunization coverage of EPI marker antigens in children aged 0\u0026ndash;23 months.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a secondary data review (SDR) in the Health Districts of the North West and South West Regions of Cameroon. These districts were selected exhaustively. The study was conducted over a period of 6 years from January 2014 to December 2019, i.e. 3 years before (2014, 2015 and 2016) and 3 years during (2017, 2018 and 2019) the socio-political crisis. The analysis of the collected data was done using Epi Info 7.2.2.7, SPSS and Microsoft Excel 2019. To highlight the difference in means between these two periods, we conducted a comparison test of the means of the performances recorded during the 3 years preceding the crisis with those of the first 3 years of the crisis using the Z-test statistic of comparison of two means of two matched samples. The fractile of the normal distribution will be Zo=1.96.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy site and period\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted at the Regional delegations of public health for the regions of South West and North West.With a total population of 1,900,547 in 2013, the South West region is divided into 18 health districts (BUEA, LIMBE, KUMBA, MANFE, MUYUKA, TOMBEL, BANGEM, TIKO, MBONGE, AKWAYA, WABANE, KONYE, and EYUMOJOCK). \u0026nbsp; The North West region is also one of the crisis regions with a total population of 2,213,984 in 2013; the health system in this region is organized around 19 health districts (AKO, BAFUT, BALI, BAMENDA, BATIBO, BENAKUMA, FUNDONG, KUMBO EAST, KUMBO WEST, MBENGWI, NDOP, NDU, NJIKWA, NKAMBE, NWA, OKU, SANTA, TUBAH, WUM). These health districts comprise Health Areas that group together health facilities. Each health area has a primary health facility, which is usually public but may be private in some health areas\u0026nbsp;(6). \u0026nbsp;The primary facility in the health area coordinates the distribution of vaccines and supplies and reports data on EPI indicators from the other health facilities, both public and private, within the health area. All these health facilities report their activity data to the district, regional and central health service levels through the DHIS2 and the DVDMT, which are the main health information management portals. The data were collected from\u0026nbsp;January 2014 to December 2019.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePeriod of data collection:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs part of this study, we collected secondary data in the Ministry of Public Health's data management tool (DHIS 2) during the period from 1 December 2020 to 30 June 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Data sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were extracted from the standard data reporting tools of the Expanded Program on Immunization (EPI) of the North West and South West District Health Services, namely the District Vaccine Data Management Tools (DVDMT) and the District Health Information System (DHIS2) of all the districts of the two regions using an extraction grid.\u003c/p\u003e\n\u003cp\u003eThe raw data were reviewed at the end of each day to detect inconsistencies, omissions and incomplete data. It allowed, as far as possible, to complete the data. The variables needed to assess the type of coverage problem were carefully coded and controlled\u0026nbsp;(7).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;We mainly used EPI data on BCG (Bacilli of Chalmette and Guerin), PENTA (which is the pentavalent vaccine that protects against five major infections in one injection: diphtheria, tetanus, pertussis, hepatitis B and \u003cem\u003eHaemophilus influenza\u003c/em\u003e type b (Hib)), and RR (which is the measles-rubella vaccine), which are the EPI marker antigens.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;In the context of this study, we note the following points:\u003c/p\u003e\n\u003cp\u003e- Secondary analysis of public data: This research only involves the analysis of public data that has already been anonymized and in which individuals cannot be identified. We used data from national statistics.\u003c/p\u003e\n\u003cp\u003e- This study was carried out in the context of an emergency: in view of the risks of destruction of the health system in the crisis regions of Cameroon, it was essential to use the available indicators to show the impact of the crisis on children's health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;- The database does not collect or provide information on the ethnic identity of participants; the data is anonymized in order to protect the identity of individuals, and this anonymization process removes specific identifiers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe also consulted the institution's guidelines and the recommendations of ethics committees concerning research using secondary data. It was established that, in our specific case, a formal ethical clearance was not required.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSample coverage.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring data collection, data on EPI indicators targeting children aged 0\u0026ndash;23 months in the 19 health districts in the North-West and the 18 health districts in the South-West included in the sample were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of the targets.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe distribution of live births and children (from 2014 to 2016) and the crisis period (from 2017 to 2019) were recorded in the North-West (NW) and South-West (SW) regions before (2014, 2015 and 2016) and during (2017, 2018 and 2019) the socio-political crisis had considerably decreased as presented in Fig.\u0026nbsp;1. We noted a regression in the average number of live births of 13.65% and 16.91% respectively in the North-West and South-West regions between the pre-crisis and crisis periods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistribution of the target population 0\u0026ndash;23 months in the North West and South West regions 3 years before the crisis and 3 years during the crisis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfluence of the crisis on immunization services.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe socio-political crisis hit the SW earlier than the NW. Before the crisis period, only the Bakassi Health District in the South West region was considered insecure. In 2019, all Health Districts in both regions had at least one health facility offering immunization services affected by the crisis. Figure\u0026nbsp;2 presents the distribution of the number of functional health facilities offering vaccination services. It can be seen that the number of health facilities offering immunization in the two regions had decreased considerably between the pre-crisis and crisis periods, falling by 36.14% (133/368) and 54.08% (139/257) of health facilities in the North West and South West regions respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDistribution of the number of health facilities offering vaccination services in the periods 2014\u0026ndash;2016 and 2017\u0026ndash;2019.\u003c/p\u003e\n\u003cp\u003eIn the North West region, the average number of fixed-strategy sessions carried out was 21850 before the crisis (from 2014 to 2016) and 29692 fixed-strategy vaccination sessions were carried out during the crisis (from 2017 to 2019).\u003c/p\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003eFor Advanced/Mobile Strategies\u003c/h2\u003e\n \u003cp\u003eThe numbers of Advanced/Mobile Strategy sessions were 11089 in the pre-crisis period and 6054 during the crisis period in the North West. The situation in the South-West region was 10959 advanced/mobile strategy immunization sessions carried out in the pre-crisis period and 20 871 fixed strategy immunization sessions carried out during the crisis period.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBCG vaccination coverage.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eFigure 2 shows the distribution of the number of health districts according to the level of BCG vaccination coverage, which is the EPI recruitment antigen. It ranged from 50 to 79% before the socio-political crisis; a situation that changed before the crisis period to 6640 during the crisis period; i.e. a reduction of 45.40% (5035/11089) in the North West region and 39.41% (431/910959) in the South West region.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVaccination coverage in the North-West and South-West 3 years before and 3 years during the socio-political crisis among children aged 0\u0026ndash;23 months.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAccording to the analyses, the difference in the ratio of the number of fixed strategies carried out to those planned was 12.36, i.e. an increase from 64.79% (6192/9557) [CI: 63.83%-65.74%] to 77.15% (10706/13876) [CI: 76.45%-77.85%] between the two periods. In the South West (SW) region, 16760 immunization sessions were conducted, while in the North West, more than 50% of the health districts had average BCG coverage completely in 2019 with coverage below 50% in 68.42% (13/19) of the health districts. As observed in the South West, more than 50% of the Health Districts had BCG coverage above 80% before the crisis compared to coverage below 50% in more than 60% of the Health Districts.\u003c/p\u003e\n \u003cp\u003eBased on data from the DVDMT and DHI2 of the District Health Services, cumulative BCG vaccination coverage among children aged 0\u0026ndash;23 months was 57%, 54% and 61% respectively in 2014, 2015 and 2016 (pre-crisis period) compared to 68%, 57% and 45% in 2017, 2018 and 2019 (crisis period) in the North West.\u003c/p\u003e\n \u003cp\u003eThe situation in the South-West showed a more considerable variation in BCG vaccination coverage, as this went from 80%, 78% and 78% respectively in 2014, 2015 and 2016 to 68%, 54% and 47% in 2017, 2018 and 2019. Figure\u0026nbsp;3 presents this variation in BCG vaccination coverage between the period before the socio-political crisis and the crisis period.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFigure 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eCumulative BCG vaccination coverage trends in the North West and South West regions from 2014 to 2016 and from 2017 to 2018\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eVaccination coverage in PENTA 1, PENTA 3 and RR:\u003c/h2\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003eVaccination coverage in PENTA 1 routinely administered vaccine differed from year to year. In the NW, cumulative vaccination coverage in children aged 0\u0026ndash;23 months for the first dose of PENTA ranged from 70%, 65% and 73% respectively from 2014\u0026ndash;2016 (the period before the socio-political crisis) and 80%, 60% and 49% from 2017\u0026ndash;2019 (crisis period). For the situation in the SW, the results showed a distribution of cumulative vaccination coverage in PENTA 1 of 92%, 89% and 93% respectively in 2014, 2015 and 2016 against 73%, 58% and 42% from 2017\u0026ndash;2019. These results show a lower coverage in 2019. Vaccination coverage for the third dose of PENTA administered routinely differed between the pre-crisis and crisis periods.\u003c/p\u003e\n \u003cp\u003eIn the NW, the cumulative coverage of PENTA 3 was 69%, 64 and 72% respectively from 2014\u0026ndash;2016 which represents the pre-crisis period. For the crisis period (2017\u0026ndash;2019) This coverage was 78%, 57% and 48% respectively. The variation in this coverage was more significant in the South-West, with a variation of 88%, 85% and 89% respectively from 2014\u0026ndash;2016 to 68%, 55% and 40% from 2017\u0026ndash;2019. The results show that vaccination coverage for the RR1 vaccine fell from 70%, 61% and 68% in the pre-crisis period (2014, 2015 and 2016) to 73%, 54% and 46% in the crisis period (2017, 2018 and 2019) in the North West region. The results also show that cumulative RR vaccination coverage in the SW fell from 84%, 82% and 86% in the pre-crisis period (2014, 2015 and 2016) to 68%, 57% and 28% in the crisis period (2017\u0026ndash;2019).\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cstrong\u003eInfluence of the socio-political crisis on EPI performance in children aged 0 to 23 months.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTable I shows that in the north-west, PENTA, which is the EPI tracing antigen, had a difference in average vaccine coverage during the pre-crisis period of 69% \u0026plusmn; 4% compared to 62%\u0026plusmn;16% during the crisis, i.e. a statistically significant difference in the average of 7% (P\u0026thinsp;=\u0026thinsp;0.003). The decrease in mean coverage between the pre-crisis and crisis periods for the recruitment antigen (BCG) was not statistically significant in the north-west region.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eIdentification of problems with immunization coverage in the North West and South West health districts before and during the crisis period.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e3 years before the crisis in the North West, 15.75% [CI: 3.38% \u0026minus;\u0026thinsp;39.58%] of the Health Districts had no problems with immunization coverage according to WHO standards. However, the main problem influencing immunization coverage was the problem of access to immunization services. This problem affected 73.68% [CI: 48.80% \u0026minus;\u0026thinsp;90.74%] of health districts. During the 3 years of the crisis, 94.74% [CI: 73.97% \u0026minus;\u0026thinsp;99.87%] of the districts were affected by this same problem of access to vaccination services.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable I\u0026nbsp;\u003c/strong\u003eAverage differences in EPI indicators between the period 2014 to 2016 and 2017 to 2019 among children aged 0\u0026ndash;11 months in the North West region.\u003c/p\u003e\n \u003ctable id=\"Taba\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003cp\u003e(Obs\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBefore Crisis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDuring Crisis\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eDiff (CI 95%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eZ Test\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eThe average number of reports received on time\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e132.3 (\u0026plusmn;\u0026thinsp;4.93)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e115(\u0026plusmn;\u0026thinsp;65.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.3 (0.25\u0026ndash;34.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage BCG coverage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.57 (\u0026plusmn;\u0026thinsp;0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.47 (\u0026plusmn;\u0026thinsp;0.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1 (-0.01-0.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage PENTA1 coverage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69 (\u0026plusmn;\u0026thinsp;0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.63 (\u0026plusmn;\u0026thinsp;0.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.06 (0.01\u0026ndash;0.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2.74\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0,001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage coverage in PENTA3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.69 (\u0026plusmn;\u0026thinsp;0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.62 (\u0026plusmn;\u0026thinsp;0.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.07 (0.02\u0026ndash;0.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e3.40\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0,001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage coverage in RR1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66 (\u0026plusmn;\u0026thinsp;0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.58 (\u0026plusmn;\u0026thinsp;0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08 (0.26\u0026ndash;0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e4.14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0,001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage drop-out rate specific\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01 (\u0026plusmn;\u0026thinsp;0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.03 (\u0026plusmn;\u0026thinsp;0.009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02 (0.01\u0026ndash;0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e10.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eAverage drop-out rate overall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02 (\u0026plusmn;\u0026thinsp;0.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.06 (\u0026plusmn;\u0026thinsp;0.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04 (0.03\u0026ndash;0.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e3.87\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026lt;\u0026thinsp;0.001\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable II\u0026nbsp;\u003c/strong\u003eDistribution of types of vaccine coverage problems identified in the Health Districts of the North West Region according to vaccine coverage and drop-out rate.\u003c/p\u003e\n \u003ctable id=\"Tabb\" border=\"1\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eINDICATORS\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eBefore Crisis\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCI \u0026agrave; 95%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDuring Crisis\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCI \u0026agrave; 95%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProblems found\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict with average cumulative PENTA1 coverage\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;80 and Average drop-out rate\u0026thinsp;\u0026lt;\u0026thinsp;10 (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (15,75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3,38\u0026ndash;39,58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0,00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82,35\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo coverage problems.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict with average cumulative PENTA1 coverage\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;80 and average dropout rate\u0026thinsp;\u0026gt;\u0026thinsp;10(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0,00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82,35\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0,00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e82,35\u0026ndash;100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe problem of resource use at the health facility level.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict with average cumulative PENTA1 coverage\u0026thinsp;\u0026lt;\u0026thinsp;80 and average dropout rate\u0026thinsp;\u0026lt;\u0026thinsp;10(%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(73,68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48,80\u0026ndash;90,85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (94,74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e78,97\u0026ndash;99,87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe problem of access to vaccination services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistrict with average cumulative PENTA1 coverage\u0026thinsp;\u0026lt;\u0026thinsp;80 and average dropout rate\u0026thinsp;\u0026gt;\u0026thinsp;10(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (10,53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1,30\u0026ndash;33,14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5,26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0,13\u0026ndash;26,35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eThe problem of resource use and access. Vaccination services.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results of our study helped to better describe the distribution of EPI performance, to evaluate the impact of the socio-political crisis on this performance and to diagnose the types of problems in immunization coverage during the period before the crisis and during the crisis in the North-West and South-West regions of Cameroon.\u003c/p\u003e \u003cp\u003eDespite efforts to optimize immunization coverage, major challenges persist in providing every child with the necessary protection against vaccine-preventable diseases, particularly in the North West and South West regions of Cameroon. In the present study, the proportion of health facilities offering immunization services had declined by 36.14% and 54.08% respectively in the North West and South West regions between the period before the socio-political crisis and the period during the crisis. In terms of results, this decrease in immunization services has a direct consequence on immunization strategies, as we note from the results of our analyses a statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0;001) decrease in the number of immunization sessions using advanced strategies, i.e. 45.40% (5035/11089) in the North West region and 39.41% (431/910959) in the South West region. These results are in line with those found in some surveys conducted in C\u0026ocirc;te d'Ivoire in 2011 which estimated a 61% (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) decline in immunization services and strategies during a crisis (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the difficulty of implementing mobile and advanced strategies, it is important to increase the number of fixed strategy sessions in secure areas to improve access to immunization services. We observed an increase in fixed strategies of more than 12.63% in the North West, which significantly reduced the impact of the socio-political crisis on EPI performances. These results are consistent with the findings of studies conducted in Pakistan in 2019 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) and C\u0026ocirc;te d'Ivoire in 2011 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). These studies underline the importance of good management of vaccine strategies in conflict areas as this EPI indicator has a considerable impact on vaccine coverage.\u003c/p\u003e \u003cp\u003eThe average vaccination coverage in PENTA 1, PENTA 3 and RR 1, had a statistically significant decrease (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) of 6% (from 69\u0026ndash;63%), 7% (69\u0026ndash;62%) and 8% (66\u0026ndash;58%) respectively in the North West region. These results in the North-West region of Cameroon remain significantly lower than those of studies conducted in the Central African Republic (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and in Pakistan(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the South-West region, the results of our analyses show a decrease in the average coverage of BCG, PENTA 1, PENTA 3, and RR1, respectively by 22% (from 78\u0026ndash;56%), 33% (from 91\u0026ndash;58%), 33% (from 87\u0026ndash;51%) and 36% (from 87\u0026ndash;51%). These results are similar to those of the studies conducted in Syria in 2019 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and Nigeria in 2018 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). This discrepancy between coverage in the North West and other studies highlights the importance of good management of immunization strategies in times of crisis. The drop in immunization coverage regarding PENTA in both regions remains similar to that obtained by John Grundy in a study of the effect of armed conflict on immunization coverage in 16 countries in crisis 2016(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In the South-West region, our results showed a decrease in the coverage of BCG, PENTA 1, PENTA 3 and RR1 by 22% (from 78\u0026ndash;56%), 33% (from 91\u0026ndash;58%), 33% (from 87\u0026ndash;51%) and 36% (from 87\u0026ndash;51%) respectively (P\u0026thinsp;\u0026lt;\u0026thinsp;5%). These results are similar to those of studies conducted in Syria in 2019 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and Nigeria in 2018 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).This discrepancy between coverages in the North West and other studies highlights the importance of good management of immunisation strategies in times of crisis.\u003c/p\u003e \u003cp\u003eThe decline in immunization coverage regarding PENTA antigen in both regions remains similar to that obtained by John Grundy in a study of the effect of armed conflict on immunization coverage in 16 countries in crisis 2016(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe also discovered an average dropout rate before and during the crisis below the 10.0% threshold in the North West region, with a 2% increase in the specific dropout rate and a 4% increase in the general dropout rate. This rate is still significant in terms of the value of the Z test statistic and its impact on mother and child health. In the South West region, an increase in the general dropout rate of 16% was observed. The movement of the population could explain this rate.\u003c/p\u003e \u003cp\u003eIn line with previous research conducted in Lebanon (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), Nigeria (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and Pakistan(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), This study shows considerable gaps in immunization coverage among children aged 0\u0026ndash;23 months in the crisis areas. These gaps, with wide variations across these two regions, are related to gaps in the system of recruitment, monitoring and access to immunization services. The results of this study highlight the importance of the problem of access to immunization services. It emerges from this study that in the North-West and South-West regions of Cameroon, the diagnosis after analysis of the data highlights access to immunization services as a real problem of low immunization coverage because 94.74% and 44.44% of the Health Districts in the South-West and North-West respectively had this problem of access to immunization services by the communities during the crisis. These findings are consistent with those of the 2018 GAVI study in Kenya (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe objective of this paper was to determine the impact of the socio-political crisis on the performance of the expanded program on immunization in the North West and South West regions of Cameroon. To achieve our objective, data were collected from the DVDMT and DHIS2 at the regional level. It was found that the crisis reduced the number of health facilities offering immunization services by 1.5/4 and 2.2/4 in the North West and South West respectively. The timeliness of EPI data reporting also fell significantly, by 8% in the North West and 35% in the South West. In both regions, there has been a drop in immunization coverage for all EPI antigens, but this drop is more significant in the South West region, with 19 districts out of 19 having average immunization coverage of less than 50% and an average drop-out rate of 6%. In the face of this conflict, the main problem of immunization coverage is that of access to immunization services by the communities. This socio-political crisis is a major determinant influencing the EPI in these regions, leading to a drop in its indicators. The objective of the EPI, which is to fight against the occurrence of vaccine-preventable diseases, is thus influenced.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare having no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the Regional Delegations of Public Health of the South West and North West regions of Cameroon for their collaboration in the implementation of this project and the Department of Public Health of the Faculty of Medicine and Pharmaceutical Sciences of the University of Dschang for approving the research protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eData curation: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eFormal analysis: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eMethodology: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eResources: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eSoftware: Tewantsa Judicael Marcelin.\u003c/p\u003e\n\u003cp\u003eSupervision: Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eValidation : Tewantsa Judicael Marcelin, Cavin Epie Bekolo.\u003c/p\u003e\n\u003cp\u003eVisualization: Tewantsa Judicael Marcelin.\u003c/p\u003e\n\u003cp\u003eWriting – original draft: Tewantsa Judicael Marcelin, Cavin Epie Bekolo, Gabriel Tchatchouang Mabou, Tchatchouang Mabou, Simeon Pierre Choukem.\u003c/p\u003e\n\u003cp\u003eWriting – review \u0026amp; editing: Tewantsa Judicael Marcelin, Cavin Epie Bekolo, Gabriel Tchatchouang Mabou, Tchatchouang Mabou, Simeon Pierre Choukem.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEinfeldt. [Continuing education on the lowest level. On the 100th colloquium of the \u0026ldquo;Westphal-Kreis\u0026rdquo;]. Zahnarztl Mitt. 1966 Jan 1;56(2):74\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eUNICEF. La vaccination sauve 2 \u0026agrave; 3 millions de vies par an [Internet]. UNICEF. 2015 [cited 2021 Jun 24]. Available from: https://www.unicef.fr\u003c/li\u003e\n \u003cli\u003eLevy BS, Sidel VW. Documenting the Effects of Armed Conflict on Population Health. Annu Rev Public Health. 2016;37(1):205\u0026ndash;18.\u003c/li\u003e\n \u003cli\u003eMashal T, Nakamura K, Kizuki M, Seino K, Takano T. Impact of conflict on infant immunisation coverage in Afghanistan: a countrywide study 2000\u0026ndash;2003. Int J Health Geogr. 2007 Dec;6(1):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eIonela Gouandjika-Vasilache. Importation de poliovirus sauvage, R\u0026eacute;publique centrafricaine. In 2013 [cited 2021 Apr 25]. p. 10128\u0026ndash;1013. Available from: https://www.ncbi.nlm.nih\u003c/li\u003e\n \u003cli\u003eMemon RA, Memon FN, Sultan RS, Memon HA. 6. Polio phases in Pakistan a decade\u0026rsquo;s journey at one glance: A succinct report. Pure Appl Biol PAB. 2019 May 2;8(2):1801\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eGrundy J, Biggs BA. The Impact of Conflict on Immunisation Coverage in 16 Countries. Int J Health Policy Manag. 2018 Dec 30;8(4):211\u0026ndash;21.\u003c/li\u003e\n \u003cli\u003eMINSANTE. Direction de la Lutte contre la Maladie, les Epid\u0026eacute;mies et les Pand\u0026eacute;mies [Internet]. [cited 2021 Jun 24]. Available from: https://www.minsante.cm.org\u003c/li\u003e\n \u003cli\u003eONU. D\u0026eacute;veloppement durable [Internet]. [cited 2021 Jun 24]. Available from: https://www.un.org/sustainabledevelopment/fr/\u003c/li\u003e\n \u003cli\u003eEkah RE. The Anglophone Crisis in Cameroon: A Geopolitical Analysis [Internet]. Rochester, NY: Social Science Research Network; 2020 Feb [cited 2021 Jul 24]. Report No.: ID 3529815. Available from: https://papers.ssrn.com/abstract=3529815\u003c/li\u003e\n \u003cli\u003eCrisis Group. Cameroun : la crise anglophone \u0026agrave; la crois\u0026eacute;e des chemins [Internet]. 2017 [cited 2021 Jun 24]. Available from: https://www.crisisgroup.org\u003c/li\u003e\n \u003cli\u003eTiembre I, Benie J, Coulibaly A, Dagnan S, Ekra D. Impact du conflit arm\u0026eacute; sur le syst\u0026egrave;me de sant\u0026eacute; d\u0026rsquo;un district sanitaire en C\u0026ocirc;te d\u0026rsquo;Ivoire. M\u0026eacute;decine Trop. 2011;71(3):249\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003eZiad Mansour ,Randa Hamad\u0026eacute; ,. Couverture vaccinale au Liban suite \u0026agrave; la crise syrienne : r\u0026eacute;sultats de l\u0026rsquo;enqu\u0026ecirc;te d\u0026rsquo;\u0026eacute;valuation de la couverture vaccinale par district 2016 | SpringerLink [Internet]. [cited 2021 May 13]. Available from: https://link.springer.com/article/10.1186/s12889-019-6418-9\u003c/li\u003e\n \u003cli\u003eDunn G. The impact of the Boko Haram insurgency in Northeast Nigeria on childhood wasting: a double-difference study. Confl Health. 2018 Jan 24;12(1):6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Socio-political crisis, Performance, Vaccination, Cameroon.","lastPublishedDoi":"10.21203/rs.3.rs-4980037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4980037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSocio-political crises have long been recognized as major obstacles in the fight against vaccine-preventable diseases in many parts of the world. However, in Cameroon, the impact of the ongoing socio-political crisis on the Expanded Program on Immunization (EPI) in the North West (NW) and South West (SW) regions has not been fully examined. The objective of this study was to examine the impact of this crisis on the performances of the EPI.\u003c/p\u003e\n\u003cp\u003eThis was a secondary data analysis. The data were obtained from the standard EPI data collection tools, from all the health districts in the two regions. The Z-test statistic was used to estimate the differences between our coverage, including BCG (Bacille Calmette-Guérin vaccine), PENTA (pentavalent vaccine), and Measles-rubella (RR) coverage, according to the time periods for each region, i.e., between the years 2014 to 2016 (pre-conflict), and 2017 to 2019 (during the conflict).\u003c/p\u003e\n\u003cp\u003eIn both regions, reported immunization coverage rates for key antigens, including BCG, PENTA-3 and RR1, showed a statistically significant decline except for BCG coverage in the NW region. There was a decline in vaccine coverage between the 3 years before the crisis and the first 3 years of the crisis of 7% (Z=3.40; P=0.003) in PENTA-3; 8% (Z=4.14; P\u0026lt;0.001) in RR1 with an increase in the overall drop-out rate of 3% (Z=3.87; P\u0026lt;0.001) in the NW region. In the SW, mean vaccination coverage had declined by 22% (Z=16.81; P\u0026lt;0.001) for BCG, 33% (Z=17.92; P\u0026lt;0.001) for PENTA 3, 36% (Z=12.99; P\u0026lt;0.001) for RR1 with an increase in the mean general dropout rate of 16% (Z=8.10; P\u0026lt;0.001) between the pre-crisis and early crisis years.\u003c/p\u003e\n\u003cp\u003eThe results found suggest that the decline in immunization performance in the conflict zone of Cameroon may be due to disruption of health services and increased insecurity limiting access to immunization services. Significant increases in vaccination strategies can improve performance in these areas, although other factors not considered in our study may contribute to the decline in vaccination performance.\u003c/p\u003e","manuscriptTitle":"Impact of the Socio-political Crisis in the North West and South West Regions of Cameroon on the Expanded Vaccination Program for Children From 0 to 23 Months","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 21:14:19","doi":"10.21203/rs.3.rs-4980037/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"424e85c7-a915-4474-acee-387a38f48a47","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-14T07:17:42+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-04 21:14:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4980037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4980037","identity":"rs-4980037","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}