Integrating Oral Cholera Vaccine into the Malawi National Cholera Prevention and Control Plan
Between 2016-2017 the Malawi National Ministry of Health (MOH) developed the country's first National Cholera Prevention and Control Plan. The plan includes an integrated approach to prevention and control including surveillance; laboratory support; clinical care; water, sanitation and hygiene; social and behavior change, and the use of the oral cholera vaccine (OCV) among high-risk populations. In March 2017 the MOH convened a stakeholder meeting to validate the plan, propose an integrated OCV plan, and submit the first-ever application to the global OCV stockpile for multi-year non-emergency use of the vaccine.
- The stakeholder meeting included national and district ministry officials as well as global experts from The United Nations Children’s Fund (UNICEF), The World Health Organization (WHO), International Vaccine Institute of South Korea, Malawi Red Cross, Médecins Sans Frontiéres (MSF), Agence de Médecine Préventive (AMP), and The Johns Hopkins University Bloomberg School of Public Health, including the Delivering Oral Vaccine Effectively (DOVE) Project.
- In order to accurately target deployment of OCV to areas with regular cholera transmission, the MOH, Johns Hopkins University and the WHO collected and analyzed historical cholera data from each district in the country from 2001 to 2016. The findings found that the majority of sub-districts with high or moderately high cholera incidence were located in three areas in the country including the Lower Shire River Basin, Lake Chilwa, and the Northern Lake Malawi area.
- During the stakeholder meeting, the historical cholera data was presented alongside qualitative and contextual data. Qualitative information and contextual data, including descriptions of water, sanitation and hygiene (WASH) conditions, of Malawi’s three regions were presented by districts health leaders. This information served as the basis for discussion regarding the selection of high-priority districts.
- Attendees also discussed the objectives for successful OCV implementation, epidemiology of cholera in Malawi, hotspots, recent cholera outbreaks, populations disproportionally affected by cholera, previous OCV campaigns in the country, and the need for integration with WASH programs.
- From all of the information presented, participants worked in groups to prioritize districts for vaccination, taking in to consideration the most vulnerable populations and geographic areas in which OCV should be administered.
- At the end of the meeting, 12 districts were identified as high-priority areas for vaccination and at-risk target populations were identified.
- The findings and discussions from the stakeholder meeting were carried forward by a team at the MOH who then developed an integrated OCV plan and submitted an application to the global OCV stockpile for non-emergency use of the vaccine.
- 3.2 million doses of OCV were approved by the global stockpile, making this the first application for non-emergency use from the stockpile.
- The application outlined plans for all individuals, over one year of age living in high-priority areas to receive vaccination, implemented by community health workers. In addition, the application outlined plans for monitoring and evaluation, including coverage surveys, impact assessments and surveillance, in coordination with national and international organizations.
 Blantyre, Chikwawa, Dowa, Karonga, Lilongwe, Machinga, Mangochi, Nkhatabay, Nsanje, Phalombe, Salima, and Zomba.
- Stakeholder Support and Coordination: Commitment from the Malawi MOH played a vital role in integrating OCV into the National Cholera Prevention and Control Plan. Finding champions within the MOH and within other stakeholder organizations, including the WHO, who can educate and advocate for OCV campaigns is an important component of the eventual administration of vaccinations in designated cholera hotspots.
- Data for Decision-Making: Historical cholera data should be collected, reviewed and validated among various stakeholders to identify the most at-risk districts and populations for a targeted OCV intervention.
- Flexibility: Flexibility is required in order to address competing priorities should an outbreak occur during rollout of a preventive campaign. Strategies for how urgent needs will be addressed should be included in OCV plans.
- Stakeholder Involvement: Having a well-positioned organization, like WHO, coordinate a workshop among stakeholders can be beneficial to advocate for the use of OCV among other influential decision makers.
- Multi-Sector Involvement: OCV is only a short-term fix for cholera. Characterization of cholera risk and intervention planning must involve other sectors, like those responsible for water and sanitation, who have a key role to play in the cholera endgame. OCV may reduce cholera risk in today but all efforts must be made to improve water and sanitation at the same time.
- Data: Utilize historical, qualitative and contextual data as well as data on vaccine effectiveness and success to mobilize support from stakeholders, to increase education and awareness surrounding OCV use, and to identify cholera hotspots and populations at greatest risk of a cholera outbreak. Knowing this information ahead of time can help focus vaccination campaigns to locations where implementation will have the greatest impact.
- Micro planning: For successful implementation of the OCV campaign, a written micro plan of campaign operations should be shared with partners directly involved in the campaign including those tasked with monitoring and evaluation.
*For more information read: M’bangombe, Maurice, et al. "Oral cholera vaccine in cholera prevention and control, Malawi." Bulletin of the World Health Organization 96.6 (2018): 428.
Contributors: Maurice Mwesawina, MOH Malawi; Andrew Azman, Johns Hopkins University DOVE Project; Moise Ngwa, Johns Hopkins University DOVE Project.