South Sudan: Mass Vaccination Alongside a World Food Programme Headcount

Background 

In South Sudan, years of protracted conflict and chronic underdevelopment have contributed to many areas having extremely limited access to adequate safe water and sanitation. Water points have been destroyed and many areas lack sources of safe drinking water. An estimated 74% of the population defecates in the open and around 59% of the population has to drink dirty, unsafe water every day, making them highly susceptible to life-threatening waterborne and hygiene-related diseases such as cholera and acute watery diarrhea. Against this background, it is little surprise that cholera is now endemic in South Sudan. Cholera outbreaks have been confirmed in South Sudan every year since 2014. The current outbreak has spread across the country since July 2016.

The only long-term solution to beating cholera is consistent access to safe water and sanitation facilities. However, sometimes a short-term solution is also needed to save lives in those situations where there is neither the time nor stability to implement such services. ‘Buying time’ until safe water and sanitation can be established, an oral vaccine given in one or two doses may help protect an individual for over five years against cholera depending on their age, the vaccine, dosing and other factors. The World Health Organization (WHO) has identified South Sudan as a priority area for mass Oral Cholera Vaccine (OCV) campaigns targeting the most vulnerable populations in the ongoing outbreak.
 

Implementation 

  • Medair, an international emergency relief and recovery organization working in South Sudan, ran an OCV campaign in a particularly remote, insecure, and difficult-to-access area of the country alongside a World Food Programme (WFP) headcount. 
  • Limited access to the area has resulted in few water, sanitation, and hygiene services, extremely limited primary health care provision, and no secondary health care facilities. Since October 2016, the area had reported over 90 cholera cases, yet this number is likely to be much higher, in view of the limited surveillance.
  • There was little capacity on the ground to scale up activities in response to an escalation of the outbreak, which might be anticipated during the rainy season. Therefore, this vulnerable population, many living in swamps and the bush, were prioritized for an OCV campaign. 
  • A rare window of opportunity to access the whole population was gained when the WFP were planning a headcount of all individuals for food distribution in the location. WFP identified three sites to simultaneously count the entire population in one or two days. The time frame from the announcement of the dates was short, and Medair’s Emergency Response Team worked around the clock to plan the OCV campaign over a matter of days.
  • A single dose per person of the vaccine was made available from the WHO global stockpile for the campaign within an extremely short period of time (approximately two weeks). The vaccines reached the capital, Juba, just in time to be dispatched to the field location for the campaign. 
  • Medair planned to administer the first dose of OCV to all individuals over 12 months of age immediately following their WFP headcount and token distribution. People were lined up in rows arranged by WFP, then social mobilisers guided them along demarcated lines to the vaccination tables. 
  • A few days beforehand, the headcount day was brought forward by two days, making the time frame even tighter. 
  • Medair teams flew from Juba to the three sites and joined WFP colleagues on the ground just one or two days before the headcount and OCV campaign were to begin. This gave an extremely short window of time to meet with local authorities and leaders, plan set-up, hire and train over 700 local staff, and organize the logistics of the vaccines on the ground. 
  • Over the next few days, Medair faced challenges with staffing and crowd control, and had limited time available for community sensitization to the vaccine. 
  • Overall, 30,772 people were vaccinated in just two days.
 

Lessons Learned 

  • Coordination: Good coordination among agencies and authorities on the ground is essential. Having good relations with community leaders and authorities increases community acceptance of the vaccine, and allows for smooth running of the campaign. Coordinating crowds during the campaign also proved important for a well-run campaign on the day.
  • Time: Ensure adequate time for recruitment and training prior to OCV campaigns and for community sensitization to the vaccine. Community sensitisation to the vaccine – assisted by local NGO staff on the ground prior to the campaign – ideally would have been more extensive had time allowed.
  • Flexibility: Flexibility among staff is important as timelines and plans can rapidly change.
  • Staff: Ensure the correct number of staff for the campaign – both over and understaffing for OCV campaigns can be a challenge, and particularly recruiting enough literate staff. Having enough people in a supervisory capacity also proved critical to a smooth campaign.
 

Further Considerations 

  • Innovate: Medair conducted an OCV campaign alongside a WFP headcount enabling them to undertake a mass cholera vaccination campaign in a particularly difficult-to-access area during a short window of opportunity. 
  • Mobile vaccination teams: Following the campaign, Medair learned that for headcounts in such insecure settings, WFP counts beforehand the ‘vulnerable’ population unable to attend in person – which meant that a number of people were not present to receive the vaccine. Mobile vaccination teams may be deployed to reach these people for future interventions in similar locations.
Author: Ella Glass, Emergency Response Team Health Manager, Medair