Implementation and Delivery of Oral Cholera Vaccination Campaigns in Humanitarian Crisis Settings among Rohingya Myanmar Nationals in Cox's Bazar, Bangladesh

"Based on this campaign experience, we can say that OCV delivery is feasible in complex refugee settings. The vaccine was well accepted, and a high level of coverage was achieved."

Over 700,000 Myanmar nationals known as the Rohingyas fled into Cox's Bazar, Bangladesh, in late 2017. Due to this huge displacement into unhygienic areas, these people became vulnerable to communicable diseases including cholera. Assessing the risk, the Government of Bangladesh (GoB), with the help of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and other international partners, decided to take preventive measures, one of which is the execution of oral cholera vaccination (OCV) campaigns. This paper describes the implementation and delivery of 7 rounds of OCV campaigns that were conducted between October 2017 and December 2021 in Bangladesh. The summary below highlights communication elements and lessons learned.

First- and second-round campaigns pursued a fixed site/mass campaign strategy, In this OCV delivery, 205 vaccination teams were deployed at the camp level (150 teams in Ukhiya and 55 in Teknaf Upazila. Each team had six members: 2 vaccinators, 2 mobilisers (who mobilised people from camps and maintained queues at the vaccination site), 1 record-keeper, and 2 person who marked the vaccine recipient's finger with gentian violet ink. Local Rohingya volunteers and a "Majhi" who acted as a leader (one member of the 6-member team) in camps were included in the micro-plan to make this campaign successful and acceptable to the community. The Majhi's role was to motivate and bring people to vaccination sites. They also actively participated in creating awareness in the community. Fixed sites for vaccine delivery to beneficiaries were established in a suitable place, such as the house of the Majhi, learning centres, and distribution points that were accessible to everyone; these sites were identified easily by the beneficiaries, as the Moni flag was placed in every vaccination site during the campaign days. One bar of soap for each beneficiary was distributed among the vaccine recipients. Along with OCV, the GoB administered oral polio vaccine (OPV) and measles and rubella (MR) vaccines during the second round. During the campaign, health education materials, such as banners and leaflets focusing on cholera control behaviours, were also distributed.

Conducted from May 6-13 2018, the third round of the OCV campaign involved 259 teams - again consisting of 6 members but this time with a Majhi instead of a finger-marker (there were no markings this time). A few team members went to a common gathering place, acting as a mobile team, to cover people who did not come to the fixed vaccination site. A vaccine card was introduced in this round, with two different colours for vaccine recipients: a white-coloured vaccine card for Rohingya Myanmar nationals and a yellow card for the host community (the host population of the area adjacent to the camps was also included in the round). A health education message was also circulated during the campaign, which focused on handwashing, food hygiene, and safe water.

In the fourth-round campaign, 70 mobile outreach teams (2 members in each team) and 46 fixed site teams were used to conduct the campaign and deliver OCV using a routine immunisation platform over 4 weeks. Each team consisted of 2 vaccinators and 2 volunteers. Majhis and Rohingya volunteers were enlisted to assist in mobilisation during the campaign. Vaccine cards were distributed to all OCV recipients.

The fifth- and sixth-round campaigns were based on a house-to-house strategy and reached people in the host community as well as Rohingya Myanmar nationals. In the house-to-house vaccination strategy, 50 mobile teams and 50 sweeping teams worked in each subdistrict. Each mobile team consisted of 5 people: 1 health education messenger, 1 vaccinator, 1 vaccine card writer, 1 tally marker, and 1 local mobiliser (who belongs to a specific community). A sticker was placed in every household during the campaigns, containing information about the total number of household members and the number of vaccinated members. The following day, a sweeping team composed of 1 volunteer and 1 local mobiliser attempted to administer the vaccine among those who remained unvaccinated on the previous day. Health education materials (leaflets and infographics) were used to build awareness about cholera control.

The seventh-round campaign involved a camp-by-camp rolling approach. A specific date for vaccination of each camp was shared with all participants before starting the campaign through loudspeaker announcements (miking), community health workers (CHWs), communication for development (C4D) volunteers, Majhis and religious leaders, posters, banners, and festoons. Parents and caregivers were encouraged to visit the nearest vaccination site along with their children to receive the vaccine. A total of 250 teams worked in this campaign: 200 for Ukhiya and 50 for Teknaf. Each team had 3 members: 1 vaccinator and 2 volunteers, 1 of whom was recruited from the Rohingya population. Each team was supported by a CHW and a Majhi.

Approximately 900,000 Rohingya Myanmar nationals and the host population (amounting to 528,297) received OCV across the 7 campaigns. In total, 4,661,187 doses of OCVs were administered. After the preemptive vaccination campaigns in Cox's Bazar camps, no cholera outbreaks were detected either in the Rohingya or host communities. According to the researchers, in addition to vaccination, water, sanitation, and hygiene (WASH) interventions, sustainable surveillance systems, and proper case management systems need to be established through a multisectoral approach to prevent cholera outbreaks in humanitarian crises, refugee camps, and surrounding host communities.