Health Organization Eastern Mediterranean Region Research Articles

Progress Toward Measles Elimination - World Health Organization Eastern Mediterranean Region, 2019-2022.

In 2015, all 22 World Health Organization Eastern Mediterranean Region (EMR) countries and areas (countries) pledged to achieve measles elimination by 2020. Despite success in several countries, most countries in the region still have not eliminated measles. This report updates a previous report and describes progress toward measles elimination in EMR during 2019-2022. During that period, estimated regional coverage with the first and second doses of a measles-containing vaccine (MCV) was 82%-83% and 76%-78%, respectively. During 2019-2022, approximately 160 million children were vaccinated during national or subnational supplementary immunization activities. Reported confirmed regional measles incidence decreased from 29.8 cases per 1 million population in 2019 to 7.4 in 2020, but then increased 68%, to 50.0 in 2022 because of challenges providing immunization services and conducting surveillance during the COVID-19 pandemic. Surveillance indicators deteriorated in 11 (50%) of the 22 EMR countries. During 2019-2022, four countries in the region were verified as having achieved measles elimination, but other countries reported immunity gaps and increased measles incidence in 2022. To achieve measles elimination in EMR, national immunization programs, especially in those countries with high measles incidence, will need to continue to recover from the COVID-19 pandemic, increase overall vaccination coverage to close immunity gaps, and maintain high-quality disease surveillance.

Special Report: Summary of the eighth workshop of the worldwide network for blood and marrow transplantation on the status and issues related to hematopoietic stem cell transplantation in near-east countries, held in Pakistan from September 22 to 23, 2022.

The eighth workshop of the Worldwide Network for Blood and Marrow Transplantation (WBMT) was held in Islamabad, Pakistan, from September 22 to 23, 2022, aiming to foster hematopoietic stem cell transplant (HSCT) activity in the World Health Organization (WHO) Eastern Mediterranean Region (EMRO). Participating countries, including Pakistan, Oman, Iran, and Saudi Arabia, reported increased HSCT in the last few years, whereas others from the EMRO and beyond, including Qatar, United Arab Emirates, Nepal, and Bangladesh, started HSCT recently and have developed HSCT programs with excellent results. During educational sessions and open dialog, participating teams and international experts from the WBMT shared their experience and discussed minimum essential requirements for establishing and expanding HSCT in emerging countries, indications for HSCT training and dissemination of knowledge, stem cell donor selection and safety, quality assurance in transplant centers, and the value and importance of transplant outcome databases. International support, collaboration, and local engagement, including government participation and WHO assistance, are valuable in increasing HSCT access worldwide.

Arthropod-borne and arthropod-related viruses in Iran and neighboring countries

Arthropods are very significant for human and veterinary medicine and health because of the burden of diseases caused by the pathogens they transmit. Databases, including the Web of Science, PubMed, Scopus, Google Scholar, CABI, Scientific Information Database, IranMedex and Magiran were searched to the end of December 2022 for publications concerning infections in Iran caused by arboviruses. Pertinent information was extracted and analyzed. Thirty-three viral infections occur in Iran, which are biologically or mechanically known or assumed to be transmitted by arthropods. Information about agents (viruses), distribution (in 31 Iranian provinces), hosts (human and animals) and known vectors in Iran was obtained for each disease. Also, a list of arboviruses was provided for the countries neighboring Iran, including Afghanistan, Armenia, Azerbaijan, Bahrain, Iraq, Kuwait, Oman, Pakistan, Qatar, Saudi Arabia, Turkey, Turkmenistan and the United Arab Emirates, as well as Djibouti, Somalia, Sudan, Syria and Yemen, which do not neighbor Iran but, like Iran, occur in the World Health Organization Eastern Mediterranean Region. This list includes 40 viruses which are not formally recorded in Iran. The viruses are members of 19 genera representing 14 families in which three, four, 20 and 29 viruses are sandfly-borne, biting midge-borne, mosquito-borne and tick-borne, respectively.

Operationalizing One Health: strategic guidance for prevention and control of emerging and re-emerging vector-borne and zoonotic diseases in the Eastern Mediterranean Region

Operationalizing global One Health strategies at the field level to prevent and control vector-borne and zoonotic diseases (VBZDs) is of significant public health importance. Such strategies should be coordinated at the human–animal–ecosystems interface and applied at the national, regional, and global levels through the enforcement of effective policies. We aimed to develop a regional framework that can aid countries of the World Health Organization Eastern Mediterranean region to better prevent, detect, and respond to VBZDs events. This strategic guidance is a twelve-element framework drafted using various guidance documents and peer-reviewed scientific literatures, incorporating recommendations made through expert consultations. The framework elements were then integrated within a logical framework designed for practical implementation of One Health at regional and country level.

Progress and experiences of implementing an integrated disease surveillance and response system in Somalia; 2016-2023.

In 2021, a regional strategy for integrated disease surveillance was adopted by member states of the World Health Organization Eastern Mediterranean Region. But before then, member states including Somalia had made progress in integration of their disease surveillance systems. We report on the progress and experiences of implementing an integrated disease surveillance and response system in Somalia between 2016 and 2023. We reviewed 20 operational documents and identified key integrated disease surveillance and response system (IDSRS) actions/processes implemented between 2016 and 2023. We verified these through an anonymized online survey. The survey respondents also assessed Somalia's IDSRS implementation progress using a standard IDS monitoring framework Finally, we interviewed 8 key informants to explore factors to which the current IDSRS implementation progress is attributed. Between 2016 and 2023, 7 key IDSRS actions/processes were implemented including: establishment of high-level commitment; development of a 3-year operational plan; development of a coordination mechanism; configuring the District Health Information Software to support implementation among others. IDSRS implementation progress ranged from 15% for financing to 78% for tools. Reasons for the progress were summarized under 6 thematic areas; understanding frustrations with the current surveillance system; the opportunity occasioned by COVID-19; mainstreaming IDSRS in strategic documents; establishment of an oversight mechanism; staggering implementation of key activities over a reasonable length of time and being flexible about pre-determined timelines. From 2016 to 2023, Somalia registered significant progress towards implementation of IDSRS. The 15 years of EWARN implementation in Somalia (since 2008) provided a strong foundation for IDSRS implementation. If implemented comprehensively, IDSRS will accelerate country progress toward establishment of IHR core capacities. Sustainable funding is the major challenge towards IDSRS implementation in Somalia. Government and its partners need to exploit feasible options for sustainable investment in integrated disease surveillance and response.

Infectious disease outbreaks in the World Health Organization Eastern Mediterranean Region in 2019

Infectious disease outbreaks in the World Health Organization Eastern Mediterranean Region in 2019

The global burden of metabolic disease: Data from 2000 to 2019

Global estimates of prevalence, deaths, and disability-adjusted life years (DALYs) from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were examined for metabolic diseases (type 2 diabetes mellitus [T2DM], hypertension, and non-alcoholic fatty liver disease [NAFLD]). For metabolic risk factors (hyperlipidemia and obesity), estimates were limited to mortality and DALYs. From 2000 to 2019, prevalence rates increased for all metabolic diseases, with the greatest increase in high socio-demographic index (SDI) countries. Mortality rates decreased over time in hyperlipidemia, hypertension, and NAFLD, but not in T2DM and obesity. The highest mortality was found in the World Health Organization Eastern Mediterranean region, and low to low-middle SDI countries. The global prevalence of metabolic diseases has risen over the past two decades regardless of SDI. Urgent attention is needed to address the unchanging mortality rates attributed to metabolic disease and the entrenched sex-regional-socioeconomic disparities in mortality.

Medical Oxygen as a Life-Saving Medicine: A rapid review of the oxygen landscape and innovative efforts in the World Health Organization Eastern Mediterranean Region in Response to COVID-19 and Beyond.

Medical oxygen is an essential treatment for life-threatening hypoxemic conditions and is commonly indicated for the clinical management of many leading causes of mortality. Many countries of the World Health Organization (WHO) Eastern Mediterranean Region (EMR) lacked robust medical oxygen systems prior to the COVID-19 (corona virus disease) pandemic and this situation was exacerbated by increased needs, particularly in remote and rural health facilities, resulting in many unfortunate deaths. The aim of this article is to describe the oxygen landscape in the region and the regional initiatives undertaken by countries and WHO. We conducted a rapid review to synthesize the available literature on the needs and availability of oxygen and its related resources and the regional initiatives undertaken. We conducted search in PubMed, relevant WHO and World Bank websites, and in general using google to understand the health of conditions that could benefit from the availability of medical oxygen, oxygen related resources including health workforce available for support and usage of medical oxygen, and the initiatives by WHO, countries and partners to improve the situation. We used a snowballing technique and reviewed all available databases for reports, surveys, assessments, and studies related to medical oxygen, besides WHO internal records, assessments, and consultation reports. The data on oxygen availability, supply demand gap, infrastructure facilities, and human resources were sparse. The regional initiatives have led to increase in resources, including human resources and oxygen production infrastructure. The Live Oxygen Platform (LOP), contributed to improved availability of quality data needed for supply demand assessments. A regional enterprise strategy to promote sustainable, decentralized, and contextualized production, supply, and monitoring of oxygen together with human resource support including training and placement by WHO, partners, and governments contributed to improved availability of oxygen in the region. Additionally, with the LOP, governments, WHO, and partners have access to better data availability for policy decision making and timely resource allocation.

Adult Vaccine Hesitancy Scale in Arabic and French: Protocol for Translation and Validation in the World Health Organization Eastern Mediterranean Region.

BackgroundThe world as we know it changed during the COVID-19 pandemic. Hope has emerged with the development of new vaccines against the disease. However, many factors hinder vaccine uptake and lead to vaccine hesitancy. Understanding the factors affecting vaccine hesitancy and how to assess its prevalence have become imperative amid the COVID-19 pandemic. The vaccine hesitancy scale (VHS), developed by the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization, has been modified to the adult VHS (aVHS) and validated in English and Chinese. To our knowledge, no available aVHS has been designed or validated in Arabic or French.ObjectiveThe aim of this research is to translate the aVHS from its original English language to Arabic and French and validate the translations in the WHO Eastern Mediterranean region.MethodsThe study will follow a cross-sectional design divided into 5 phases. In phase 1, the original aVHS will be forward-translated to Arabic and French, followed by backward translation to English. An expert committee will review and rate all versions of the translations. Expert agreement will then be measured using the Cohen kappa coefficient (k). In phase 2, the translated aVHS will be pilot-tested with 2 samples of participants (n=100): a group that speaks both Arabic and English and another that speaks French and English. Participants’ responses to the English version will also be collected. In phase 3, responses will then be compared. Descriptive statistics and paired t tests or one-way analyses of variance (ANOVA) and Pearson correlation coefficient will be used in the preliminary validation. In phase 4, prefinal versions (Arabic and French) will be tested with larger sample sizes of Arabic speakers (n=1000) and French speakers (n=1000). Sociodemographic information and vaccination status will be collected and used for further analysis. In phase 5, the scale's statistical reliability and internal consistency will be measured using Cronbach alpha. An exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) will be used to examine the model fit resulting from the EFA. ANOVA and regression models will be constructed to control for confounders. All data will be electronically collected.ResultsAs of January 2022, the scale had been translated to Arabic and French and was undergoing the process of back translation. All data collection tools have been prepared (ie, sociodemographics, vaccination status, and open-ended questions) and are ready to go into their electronic formats. We expect to reach the desired sample size in this phase by June 2022.ConclusionsThis study will provide researchers with a validated tool to assess adult vaccine hesitancy within populations that speak Arabic and/or French and provide a road map to scale translation and ensure cross-cultural adaptation.International Registered Report Identifier (IRRID)PRR1-10.2196/36928

Increasing Antimicrobial Resistance in World Health Organization Eastern Mediterranean Region, 2017-2019.

To better guide the regional response to antimicrobial resistance (AMR), we report the burden of AMR over time in countries in the World Health Organization Eastern Mediterranean Region. To assess the capacities of national infection prevention and control and antimicrobial stewardship programs, we analyzed data on bloodstream infections reported to the Global Antimicrobial Resistance Surveillance System during 2017–2019, data from 7 countries on nationally representative surveys of antimicrobial prescriptions, and data from 2 regional surveys. The median proportion of bloodstream infections was highest for carbapenem-resistant Acinetobacter spp. (70.3%) and lowest for carbapenem-resistant Escherichia coli (4.6%). Results of the regional assessments indicate that few countries have capacities for infection prevention and control and antimicrobial stewardship programs to prevent emergence and spread of AMR. Overall, the magnitude of the problem and the limited capacity to respond emphasize the need for regional political leadership in addressing AMR.

Lessons learned during COVID-19: Building critical care/ICU capacity for resource limited countries with complex emergencies in the World Health Organization Eastern Mediterranean Region.

Lessons learned during COVID-19: Building critical care/ICU capacity for resource limited countries with complex emergencies in the World Health Organization Eastern Mediterranean Region.

Challenges facing COVID-19 vaccination in India: Lessons from the initial vaccine rollout.

Challenges facing COVID-19 vaccination in India: Lessons from the initial vaccine rollout.

Views of stakeholders on factors influencing shared decision-making in the Eastern Mediterranean Region: a systematic review.

Shared decision-making is advocated as a key component of patient-centred care and associated with many benefits that improve patient outcomes. However, shared decision-making is not yet embedded in clinical practice and confronts many barriers that hinder its implementation especially in countries of the World Health Organization (WHO) Eastern Mediterranean Region. We conducted a systematic review to identify and understand factors influencing shared decision-making in the Region. We searched PsycINFO, CINAHL, PubMed, Medline, Scopus and Saudi Digital Library for articles published between January 1997 and February 2019. Studies conducted in the Region that reported barriers, facilitators, experiences, expectations and attitudes to shared decision-making were included. The Mixed Methods Appraisal Tool (MMAT) was used to assess the methodological quality of the studies in this review. Of the 1813 initial articles retrieved, 19 eligible articles were identified. The main factors that emerged were grouped under three broad themes: participant factors (patients/families and physicians); consultation factors (relationship between participants, engaging patients, evaluating preferences, introducing options, providing information, and decision making); and healthcare system factors (organizational characteristics, time constraints, continuity of care, and healthcare resources). There is growing interest in shared decision-making in several countries in the Region. However, there are many existing barriers that hinder the implementation of shared decision-making. These need to be addressed before shared decision-making can be fully adopted in these countries.

Influence of Age on 2040 Cancer Burden in the Older Population of the Gulf Cooperation Council (GCC) Countries: Public Health Implications.

Introduction and Study Aims:The underlying population of global regions varies widely and is a major determinant of regional cancer differences. The aims were to: (1) estimate the cancer burden in Gulf Cooperation Council (GCC) countries in 2040 for the ≥70 population and (2) assess the public health implications for this cancer increase.Methods:We used Global Cancer Observatory (GLOBOCAN) estimates of cancer incidence and mortality for people aged 70 years or more in GCC countries from 2018 to 2040 from the International Agency for Research on Cancer. For population growth, we used data for the same period from the Population Division of the United Nations Department of Economic and Social Affairs. From these, we calculated the predicted increase in the number of cancer cases and cancer deaths from 2018 to 2040 and the proportion of cases/deaths represented by those aged 70+ for the 2 time periods.Findings:In the GCC countries, the predicted number of newly diagnosed cancers and cancer deaths in the older population will increase by 465% and 462% respectively due to demographic changes—greater than other countries in the World Health Organization Eastern Mediterranean Region, or in countries of similar economic development. The largest predicted increases will be for Qatar and the United Arab Emirates. Based on the predicted population age, cancer burden among older people in the GCC countries will increase by approximately 460%.Conclusion:By the year 2040, the relationship between cancer and age will cause a 4- to 5-fold increase in the cancer burden in the GCC. These predictable changes will require additional planning and resources to provide appropriate healthcare.

Evolution of insecticide resistance and its mechanisms in Anopheles stephensi in the WHO Eastern Mediterranean Region

BackgroundWhile Iran is on the path to eliminating malaria, the disease with 4.9 million estimated cases and 9300 estimated deaths in 2018 remains a serious health problem in the World Health Organization (WHO) Eastern Mediterranean Region. Anopheles stephensi is the main malaria vector in Iran and its range extends from Iraq to western China. Recently, the vector invaded new territories in Sri Lanka and countries in the Horn of Africa. Insecticide resistance in An. stephensi is a potential issue in controlling the spread of this vector.MethodsData were collated from national and international databases, including PubMed, Google Scholar, Scopus, ScienceDirect, SID, and IranMedex using appropriate search terms.ResultsIndoor residual spaying (IRS) with DDT was piloted in Iran in 1945 and subsequently used in the malaria eradication programme. Resistance to DDT in An. stephensi was detected in Iran, Iraq, Pakistan, and Saudi Arabia in the late 1960s. Malathion was used for malaria control in Iran in 1967, then propoxur in 1978, followed by pirimiphos-methyl from 1992 to 1994. The pyrethroid insecticide lambda-cyhalothrin was used from 1994 to 2003 followed by deltamethrin IRS and long-lasting insecticidal nets (LLINs). Some of these insecticides with the same sequence were used in other malaria-endemic countries of the region. Pyrethroid resistance was detected in An. stephensi in Afghanistan in 2010, in 2011 in India and in 2012 in Iran. The newly invaded population of An. stephensi in Ethiopia was resistant to insecticides of all four major insecticide classes. Different mechanisms of insecticide resistance, including metabolic and insecticide target site insensitivity, have been developed in An. stephensi. Resistance to DDT was initially glutathione S-transferase based. Target site knockdown resistance was later selected by pyrethroids. Esterases and altered acetylcholinesterase are the underlying cause of organophosphate resistance and cytochrome p450s were involved in pyrethroid metabolic resistance.ConclusionsAnopheles stephensi is a major malaria vector in Iran and many countries in the region and beyond. The species is leading in terms of development of insecticide resistance as well as developing a variety of resistance mechanisms. Knowledge of the evolution of insecticide resistance and their underlying mechanisms, in particular, are important to Iran, considering the final steps the country is taking towards malaria elimination, but also to other countries in the region for their battle against malaria. This systematic review may also be of value to countries and territories newly invaded by this species, especially in the Horn of Africa, where the malaria situation is already dire.

Developing health accounts following SHA 2011: a situational analysis of countries in WHO Eastern Mediterranean Region

National health accounts provide data for health-financing policy analysis, reforms and strategies to attain national health development goals and objectives such as universal health coverage. However, in the World Health Organization (WHO) Eastern Mediterranean Region there are many challenges, making it difficult for health accounts teams to provide timely reports and for policy-makers to use them to inform policy change. To undertake a situational analysis of health accounts in the Region and assess the health accounts production process. Additionally, the study looked at challenges facing health accounts teams in institutionalizing the health accounts process. The WHO Regional Office for the Eastern Mediterranean has been conducting country missions to its 22 countries to assist health accounts teams and assess the status of health accounts production and institutionalization. A survey administered at a regional training workshop in October 2018 examined the challenges and successes in health accounts production. Three countries in the Region produce annual health accounts but most take several years between reports. Only 55% of the countries use System of Health Accounts (SHA) 2011 methodology while 27% still use SHA 1.0. The main challenges facing countries include a high turnover of employees involved in health accounts production, and time lag of data. Notable successes include policy changes based on health accounts findings. Few countries in the Region produce annual health accounts and many still use SHA 1.0. The commitment of a country's top management is vital to ensure successful health accounts production.

One Health operational framework for action for the Eastern Mediterranean Region, focusing on zoonotic diseases.

Human health is intrinsically linked to the health of animals and to the environment, and efforts by just one sector alone cannot prevent or adequately address the complex problems at the human-animal-environment interface. Countries of the World Health Organization Eastern Mediterranean Region, as any other region, face the threat of emerging and remerging zoonoses. However, the challenges in this Region are high given the lack of resources, poor health systems, and political factors. Hence, adopting the One Health approach becomes urgent to assist those countries. Subsequently, based on analysis of One Health capacities in the Region and in close consultation with representatives and subject matter experts from countries in the Region, a framework for action towards effectively implementing the One Health approach was developed. The framework capitalizes on current opportunities in the region and provide countries with a list of practical key activities towards optimal use of their resources and strengthening their capabilities to tackle concurrent and future health challenges at the interface. Strong governance structures and building on existing mechanisms are crucial for achieving effective disease surveillance and response. Additionally, using intersectoral approaches for risk assessment and risk mitigation for health issues at the human-animal-environment interface can improve efficiency and result in more successful outcomes.

Prevalence of dental caries among children aged 5-15 years from 9 countries in the Eastern Mediterranean Region: a meta-analysis.

Dental caries affects all age groups, although children are affected to a greater extent. Several studies have assessed the prevalence of dental caries in the World Health Organization (WHO) Eastern Mediterranean Region. However, prevalence data for dental caries have not been pooled for all countries in the Region. To estimate by meta-analysis the pooled prevalence of dental caries among children aged 5-15 years in the Region. The study protocol was registered in PROSPERO with registration number CRD42016037157. Twenty-one studies (37 estimates) were identified through systematic search for articles published between 1 January 2005 and 5 July 2018. The required data from each article were extracted into the datasheet. A random-effects meta-analysis was performed for the overall age group and for age 5, 12 and 15 years individually. Data were available for only 9 of the 21 countries in the Region. Heterogeneity between studies was high (I²>98%). There was considerable variation among the countries for the prevalence of dental caries at different ages. The pooled prevalence for deciduous dentition in children aged 5 years was 65% (45-85%); 61% (50-72%) for permanent dentition in children aged 12 years; 70% (64-75%) for children aged 15 years; and 66% (59-73%) for children aged 6-15 years. The most common index used for oral examination to calculate caries experience was WHO Basic Oral Health Survey Criteria, 1997. Dental caries continues to be an oral health concern among children in 9 countries in the Region.

Recent Outbreaks of Dengue Fever in the WHO Eastern Mediterranean Region: A Narrative Mini-review

Dengue Fever (DF) is the most important, rapidly spreading, emerging/re-emerging, arboviral disease that threats a global human health and economic development. Dengue viral infection is transmitted to human by infected female Aedes mosquito vector, significantly Aedes aegypti. This article reviewed the recent status of dengue fever outbreaks indicated in the World Health Organization (WHO) Eastern Mediterranean Region (EMR) in the last five years (2016-2020), based on reports of WHO, and other available data. Recent DF outbreaks were in Sudan (2017, 2019), Yemen (2016, 2018, 2019), Oman (2018), and Pakistan (2017, 2018, 2019, 2020). The two species, Aedes aegypti and Aedes albopictus were geographically distributed and mapped by country-level according to the published reports. There are several factors contributing to the emergence and rapid transmission of dengue in the region, include rapid prevalence of the main dengue vector, host vulnerability, favorable environmental conditions (temperatures, precipitation and humidity), and unplanned expanding urbanization. In addition to the movement of traveler’s people during an outbreak responsible for introducing DF to new locations. Early detection of diseases and effective mosquito vector control is an essential strategy for preventing the transmission of diseases outbreaks.

Progress Toward Measles Elimination — Eastern Mediterranean Region, 2013–2019

In 1997, during the 41st session of the Regional Committee for the Eastern Mediterranean, the 21 countries in the World Health Organization (WHO) Eastern Mediterranean Region* (EMR) passed a resolution to eliminate† measles (1). In 2015, this goal was included as a priority in the Eastern Mediterranean Vaccine Action Plan 2016-2020 (EMVAP) (2), endorsed at the 62nd session of the Regional Committee (3). To achieve this goal, the WHO Regional Office for the Eastern Mediterranean developed a four-pronged strategy: 1) achieve ≥95% vaccination coverage with the first dose of measles-containing vaccine (MCV1) among children in every district of each country through routine immunization services; 2) achieve ≥95% vaccination coverage with a second MCV dose (MCV2) in every district of each country either through implementation of a routine 2-dose vaccination schedule or through supplementary immunization activities§ (SIAs); 3) conduct high-quality, case-based surveillance in all countries; and 4) provide optimal measles clinical case management, including dietary supplementation with vitamin A (4). This report describes progress toward measles elimination in EMR during 2013-2019 and updates a previous report (5). Estimated MCV1 coverage increased from 79% in 2013 to 82% in 2018. MCV2 coverage increased from 59% in 2013 to 74% in 2018. In addition, during 2013-2019, approximately 326.4 million children received MCV during SIAs. Reported confirmed measles incidence increased from 33.5 per 1 million persons in 2013 to 91.2 in 2018, with large outbreaks occurring in Pakistan, Somalia, and Yemen; incidence decreased to 23.3 in 2019. In 2019, the rate of discarded nonmeasles cases¶ was 5.4 per 100,000 population. To achieve measles elimination in the EMR, increased visibility of efforts to achieve the measles elimination goal is critically needed, as are sustained and predictable investments to increase MCV1 and MCV2 coverage, conduct high-quality SIAs, and reach populations at risk for not accessing immunization services or living in areas with civil strife.