Oral Cholera Vaccination Coverage in an Acute Emergency Setting in Somalia, 2017

"The Somalia experience has shown that large-scale OCV campaigns can be implemented in acute and protracted crisis and can have high levels of acceptance by the people even in areas that are perceived to be insecure."

During the 2016/17 drought season, a cholera outbreak was declared in 55 districts of Somalia as a result of depleted water sources and displacement of over 3 million Somalis to camps where access to safe water and proper sanitation was limited. In response, the Ministry of Health implemented an oral cholera vaccination (OCV) campaign between March and October 2017, with the aim of covering 1.1 million people 1 year of age and older with 2 doses of the OCV in 11 high-risk districts. Following the campaign, which the researchers say was a "first" in this country, a random sample survey was conducted in 9 out of 11 districts to evaluate coverage, awareness, reasons for non-vaccination, the water and sanitation status of households, and any resulting adverse events. The purpose of this paper is to present the findings of the OCV coverage survey.

After a microplanning exercise was done by different programmes within the Ministry of Health, along with the Polio Eradication Initiative (PEI) and various non-governmental organisations (NGOs), a mixed vaccination strategy of door-to-door campaign and fixed posts in health centres, schools, and other public places was used to implement OCV. Over 3,000 vaccinators, recorders, social mobilisers, cold-chain technicians, independent monitors, and supervisors were trained by the national trainers for 2 days before each OCV campaign.

The coverage surveys were conducted from May 14-30 2017 in the first 7 districts (Dharkenley, Hodan, Koshin, Xaawo Taako, Calanley, and Fanole) and from July 14-28 2017 in the second 2 districts (Baidoa and Jowhar). Of the 3,715 individuals interviewed from the 7 districts in the first campaign, 3,436 (92.5%) received 2 doses of OCV, and 7.0% received only 1 dose. In this OCV campaign, 32 people who were not vaccinated in the first 7 districts reported they were not home (42%). Other reasons were failure by the vaccinator to visit the home (26.0%) and being sick at the time of the vaccination (12.2%).

During the OCV campaigns, hand washing messages were the most received of the awareness efforts. Community health workers were the main source of information during the second OCV campaign in Baidoa and Jowhar districts (65.1%), closely followed by the radio (63.9%). In the first OCV campaign in the 7 districts, local NGOs were contracted for the social mobilisation, while in the second campaign, social mobilisation was done by community health workers under the Federal Ministry of Health.

"Despite the many challenges, the experience of the campaigns highlights the feasibility of implementing OCV campaigns in protracted complex emergencies that are compounded by an active cholera epidemic." The researchers explain the success by pointing to:

• The use of the existing national Expanded Programme on Immunization (EPI) and PEI structures to conduct house-to-house campaigns in all target districts, which had earlier contributed to high oral polio vaccine (OPV) coverage rates in similar districts;
• Strong political commitment from policymakers and effective collaboration and coordination between health authorities, local communities, and health and water, sanitation, and hygiene (WASH) partners;
• Implementation of the OCV campaign in a phased approach, whereby all vaccination teams concentrated on particular areas before moving to new locations; and
• Social mobilisation using the experienced polio mobilisers and local NGOs, which played an important role in communicating the need to receive 2 doses. (As observed in the Iraq OCV campaign in 2015 as well, community health workers and mobile radios were the most common sources of information during the campaign. This could be attributed to the extensive use of community health workers for mobilisation in previous polio campaigns in Somalia.)

Elaborating, the researchers say: "Being the first of its kind in Somalia, the teams acquired skills and confidence during the first few campaigns which were useful during subsequent campaigns. Even when insecurity may have been perceived as a major obstacle to implementation of the campaign in Somalia, the use of accepted community volunteers and community leaders within areas that were not accessible to humanitarian agencies, the vaccinators targeting IDP [internally displaced person] camps where majority of the target population lived having been displaced by drought, helped achieve the high coverage rates."