Reducing the risk of cholera in South Sudan’s remote refugee camps

MSF teams have just completed a preventive cholera vaccination campaign in and around the refugee camps in Maban County, South Sudan. 105,000 refugees in four camps and 27,500 residents of the area were vaccinated, with the aim of preventing possible cholera cases.

With the cooperation of the South Sudan Ministry of Health, MSF launched the vaccination campaign as part of a cholera preparedness and prevention plan. The teams had already set up and pre-stocked cholera treatment facilities in the camps, in case of an outbreak. But the remoteness of the area and supply difficulties mean that a cholera outbreak would have the potential to be severe. So prevention is crucial alongside preparedness, and a vaccination campaign provides an extra layer 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.”

Gathered in four refugee camps located in an extremely harsh environment, around 110,000 refugees, who have fled the ongoing conflict in neighbouring Sudan’s Blue Nile State, are entirely dependent on humanitarian organisations. 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 innovative approach to cholera-prevention is justified in a situation where a population is exceptionally vulnerable and where the consequences of an outbreak would be particularly devastating.

The vaccine comes in the form of oral drops and was given to each person twice, with a gap of two to three weeks between doses. 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 GOAL, IOM, Medair, Relief International, Solidarités, 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 an oral administration, which assists in the ease of its administration, it comes in one dose per vial and must be kept in a cold chain, which 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 also must 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 strict cold chain would greatly improve the logistical challenges 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.”

While providing individuals vaccinated with significant immunity to cholera, this vaccine alone does not guarantee that there will be no outbreak. While the high vaccine coverage achieved will help to substantially limit the spread of any outbreak, all efforts possible 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.
South Sudan