Crippling Violence: Conflict and Incident Polio in Afghanistan

Norris, Alison; Hachey, Kevin; Curtis, Andrew; Bourdeaux, Margaret

doi:10.1371/journal.pone.0149074

Cited by 22 publications

(35 citation statements)

References 12 publications

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“…We observe low sensitivity of lab-diagnostics (compared to clinical diagnosis) associated with lower social strata and higher homicide risk. However, as with other studies exploring fine-scale relationships between disease and violence [ 65 ], data deficiencies limit sophisticated modeling. In Cali, these deficiencies are likely under-reported in disease surveillance and unavailable or context-poor spatial data on violence.…”

Section: Discussionmentioning

confidence: 99%

Neighborhood Violence Impacts Disease Control and Surveillance: Case Study of Cali, Colombia from 2014 to 2016

Krystosik

Curtis

LaBeaud

et al. 2018

IJERPH

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Arboviruses are responsible for a large burden of disease globally and are thus subject to intense epidemiological scrutiny. However, a variable notably absent from most epidemiological analyses has been the impact of violence on arboviral transmission and surveillance. Violence impedes surveillance and delivery of health and preventative services and affects an individual’s health-related behaviors when survival takes priority. Moreover, low and middle-income countries bear a disproportionately high burden of violence and related health outcomes, including vector borne diseases. To better understand the epidemiology of arboviral outbreaks in Cali, Colombia, we georeferenced chikungunya (CHIKV), dengue (DENV), and Zika (ZIKV) viral cases from The National System of Surveillance in Public Health between October 2014 and April 2016. We extracted homicide data from the municipal monthly reports and kernel density of homicide distribution from IdeasPaz. Crucially, an overall higher risk of homicide is associated with increased risk of reported DENV, lower rates of acute testing, and higher rates of lab versus clinical discordance. In the context of high violence as a potential barrier to access to preventive health services, a community approach to improve health and peace should be considered.

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Section: Discussionmentioning

confidence: 99%

Neighborhood Violence Impacts Disease Control and Surveillance: Case Study of Cali, Colombia from 2014 to 2016

Krystosik

Curtis

LaBeaud

et al. 2018

IJERPH

Self Cite

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“…This is supported by the co-location of violent events and polio cases in sub-national areas, including northern Nigeria, southwestern Somalia, and along the Pakistan-Afghanistan border. Our work builds on previous studies by Norris and Kennedy by looking at the additional predictive value of insecurity measures, instead of focusing on the association between violence and polio [ 13 , 14 ]. However, the large number of variables comprising the GPI and FSI make it challenging to isolate the most significant contributing factors, requiring further research into the nuances of political instability.…”

Section: Discussionmentioning

confidence: 99%

“…Their findings suggest a link between post-2011 Islamist insurgencies and polio cases, although not between other conflicts and polio [ 13 ]. Another recent paper examined the relationship between Improvised Explosive Device (IED) detonations and polio, and found a strong association between sites of recent IED explosions and the location of polio cases in recent years in Afghanistan [ 14 ]. These authors conclude that knowledge of the geographic locations of violence can contribute to effective vaccination campaign planning as well as to the successful prediction of future polio incidence.…”

Section: Introductionmentioning

confidence: 99%

Violence, insecurity, and the risk of polio: A systematic analysis

et al. 2017

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BackgroundSince the introduction of polio vaccines in the 1950’s and 60’s, eradication of poliovirus from the world has been technically feasible. Progress towards this goal, however, has been uneven and influenced by social and political factors that challenge the implementation of robust immunization programs. While violence and insecurity are often cited as barriers to eradication, current global risk models are largely based on virologic and immunologic indicators measured at national levels. In this manuscript, we quantify the relevance of indicators of violence and insecurity on the risk of polio spread.Methods and findingsUsing logistic regression models and public data sources, we evaluate the relationship between measures of violence and instability and the location of poliomyelitis cases between 2006 and 2015 at the country-level, both individually and after controlling for more proximal determinants of disease, such as nearby circulating poliovirus and vaccination rates. We found that increases in a country’s Fragile States Index (FSI) and Global Peace Index (GPI), aggregate indicators of violence and instability, were associated with the occurrence of poliovirus cases in the subsequent year (p< 0.01), even after controlling for established risk factors. These effects of violence and insecurity must be mediated through immunity and exposure to poliovirus, coarse measures of which are included in our model. This also implies that in our study, and in risk models in general, the interpretation depends on the quality and granularity of available data.ConclusionNational virologic and immunologic indicators understate the risk of poliovirus spread in areas with violence and insecurity, and the inclusion of such factors improves precision. In addition, the link between violence and incidence of disease highlights the broader challenge of implementing health interventions in conflict areas. We discuss practical implications of this work in understanding and measuring the risks to polio eradication and other global health initiatives, and the policy implications of the need to reach vulnerable populations in conflict zones.

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“…Armed insurgency has been associated with country-level polio incidence after 2011 (13), however country-level comparisons are limited as polio cases are confined to relatively few countries. Studies in Afghanistan, Sierra Leone, and Angola identified an association between insecurity and reduced vaccination or polio incidence (14)(15)(16)(17), but they are limited in drawing a causal linkage because insecure areas were designated using expert opinion rather than objective data, vaccination rates and polio incidence were not studied together, vaccinator access was not examined, and/or temporal changes in exposure to insecurity were not captured. Numerous articles have commented on the relationship between insecurity and poliovirus transmission (6,12,(18)(19)(20), but none of these provide empirical evidence to support their anecdotal observations.…”

Section: Discussionmentioning

confidence: 99%

Insecurity, polio vaccination rates, and polio incidence in northwest Pakistan

Verma

Jiménez

Tangermann

et al. 2018

Proc. Natl. Acad. Sci. U.S.A.

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Pakistan is one of three countries in which endemic transmission of poliovirus has never been stopped. Insecurity is often cited but poorly studied as a barrier to eradicating polio. We analyzed routinely collected health data from 32 districts of northwest Pakistan and constructed an index of insecurity based on journalistic reports of the monthly number of deaths and injuries resulting from conflict-related security incidents. The primary outcomes were the monthly incidence of paralytic polio cases within each district between 2007 and 2014 and the polio vaccination percentage from 666 district-level vaccination campaigns between 2007 and 2009, targeting ∼5.7 million children. Multilevel Poisson regression controlling for time and district fixed effects was used to model the association between insecurity, vaccinator access, vaccination rates, and polio incidence. The number of children inaccessible to vaccinators was 19.7% greater (95% CI: 19.2-20.2%), and vaccination rates were 5.3% lower (95% CI: 5.2-5.3%) in "high-insecurity" campaigns compared with "secure" campaigns. The unadjusted mean vaccination rate was 96.3% (SD = 8.6) in secure campaigns and 88.3% (SD = 19.2) in high-insecurity campaigns. Polio incidence was 73.0% greater (95% CI: 30-131%) during high-insecurity months (unadjusted mean = 0.13 cases per million people, SD = 0.71) compared with secure months (unadjusted mean = 1.23 cases per million people, SD = 4.28). Thus, insecurity was associated with reduced vaccinator access, reduced polio vaccination, and increased polio incidence in northwest Pakistan. These findings demonstrate that insecurity is an important obstacle to global polio eradication.

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Crippling Violence: Conflict and Incident Polio in Afghanistan

Cited by 22 publications

References 12 publications

Neighborhood Violence Impacts Disease Control and Surveillance: Case Study of Cali, Colombia from 2014 to 2016

Neighborhood Violence Impacts Disease Control and Surveillance: Case Study of Cali, Colombia from 2014 to 2016

Violence, insecurity, and the risk of polio: A systematic analysis

Insecurity, polio vaccination rates, and polio incidence in northwest Pakistan

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