More than 105,000 refugees and 27,500 residents of Maban county, South Sudan, have been vaccinated against cholera. With the cooperation of South Sudan's Ministry of Health, Médecins Sans Frontières (MSF) launched the vaccination campaign as part of a cholera preparedness and prevention plan.
Teams had already set up and pre-stocked cholera treatment facilities in the camps, in case of an outbreak. However, the remoteness of the area and supply difficulties mean that the consequences of a cholera outbreak could be severe. Prevention is crucial alongside preparedness, and a vaccination campaign is just one extra method of prevention.
"The key for preventing cholera is to ensure sufficient access to clean drinking water, and to have appropriate sanitation and hygiene facilities," says Paul Critchley, MSF emergency coordinator in Maban county. "We are currently tackling an escalating hepatitis E outbreak in the camps, so we know that sanitation conditions here are not yet adequate. Hepatitis E is spread in similar ways to cholera, and this reinforces the need to do all we can to prevent cholera breaking out too."
Around 110,000 refugees who have fled the ongoing conflict in neighbouring Sudan's Blue Nile state are now gathered in four refugee camps, which are located in an extremely harsh environment. The refugees are entirely dependent on humanitarian organisations for food and medication. With no easy access routes, it was a challenge for MSF to bring in nineteen 200-litre fridges, the generators to keep them running and the 290,000 vials of vaccine. Despite the logistical challenges, the exceptionally vulnerable population and the potentially devastating consequences of an outbreak justify the implementation of a vaccination campaign.
The vaccine comes in the form of oral drops and each person received two doses, with a gap of two to three weeks between each dose. By deploying a substantial health promotion effort in advance, the teams were able to reach more than 132,000 people with both doses of the vaccine. The MSF teams were supported by staff from humanitarian organisations GOAL, Medair, Relief International and Solidarités, as well as the International Organization for Migration and the Ministry of Health.
"The logistical difficulty of this vaccination campaign highlights the need for further development of more field-adapted vaccines," says Dr Jennifer Cohn, medical director for MSF's Access Campaign. "While it is helpful that the vaccine is administered orally, it comes in one dose per vial and must be kept in a cold chain. This means the sheer bulk and logistics of supplying some 290,000 doses makes using this vaccine challenging in locations where it may have the greatest benefit. The vaccine must also be given in two doses, at least 14 days apart. Ensuring both doses are given is difficult in situations of disaster or with mobile populations."
"A formulation that can be packaged in multi-dose vials and can be used without a strict cold chain would greatly improve the logistics of such important vaccination activities. Further, the price is an issue. If the cost could be reduced, that would further increase the scope for widespread use of the vaccine." says Dr Cohn.
While providing individuals with significant immunity to cholera, this vaccine alone does not guarantee that there will be no further outbreak. While the high vaccine coverage achieved will help to substantially limit the spread of any outbreak, all possible efforts must still be made by the organisations working on water and sanitation in the camps, both to control the hepatitis E epidemic, and to limit the risk of a cholera outbreak.
MSF has worked in the refugee camps in Maban since November 2011 and is currently running three field hospitals and seven health posts, providing around 5,500 consultations per week across the four refugee camps in South Sudan.