South Sudan: Implementing a Vaccine Campaign During a Crisis
South Sudan became an independent nation in 2011, but ongoing civil unrest has hindered the progress of this new nation. An outbreak of armed conflict in the capital of Juba in December 2013 led to the displacement of approximately 2 million people and the creation of internally displaced person camps. Conditions inside the camps were poor, particularly in regards to sanitation and health. These deteriorating conditions alarmed local and international health organizations. Cholera is endemic in the country, which heightened concerns for a potential outbreak in the camps. In response to these concerns and as a preventative measure, the South Sudan Ministry of Health, World Health Organization (WHO), and other health organizations jointly decided to implement an oral cholera vaccine (OCV) campaign among people residing in the camps in January 2014, paving the way for additional campaigns in 2015.
 Abubakar, A., Azman, A. S., Rumunu, J., Ciglenecki, I., Helderman, T., West, H., ... & Legros, D. (2015). The first use of the global oral cholera vaccine emergency stockpile: lessons from South Sudan. PLoS Med, 12(11), e1001901.
- The South Sudan Ministry of Health in collaboration with the WHO conducted comprehensive cholera risk assessments in the displaced camps; one of the recommendations to prevent a potential cholera outbreak was the implementation of an OCV campaign targeting people residing in the camps.
- The South Sudan Ministry of Health submitted an application to the Global OCV stockpile in January 2014 and the request was approved for approximately 250,000 doses. The first delivery of vaccines arrived 30 days after the application was submitted.
- The vaccine was given to people who were over one year old and not pregnant who were residing in camps in the areas of Juba, Awerial, Bor, Rubkona, and Malakal. International organizations conducted an intensive social mobilization campaign in all camps 3-7 days before the vaccination campaign to raise awareness about the vaccine. A total of six camps received the vaccine, with two-dose coverage rates ranging from 64% to 95%. The time between first and second dose ranged from 12-56 days.
- A cholera outbreak was declared in Juba and then in displaced camps in Juba and Malakal approximately two months after the initiation of the vaccination campaign in the six camps. Researchers compared cholera cases in vaccinated camps and unvaccinated areas in two locations. The analysis indicated that cases were sporadic in Juba, Malakal and Awerial camps and little to no secondary transmission seemed to occur in the vaccinated camps, suggesting that the vaccine successfully reduced cholera transmission.
- Coordination: Many partnering agencies were involved in the decision to use the vaccine and implement the vaccination campaign, including the South Sudan Ministry of Health, WHO, and Medicins Sans Frontieres, among others. Each camp was overseen by one organization to lead and coordinate the vaccination campaign in that particular camp. While all of these organizations worked well together, when planning and implementing an OCV campaign, it is recommended that one organization coordinate everyone involved and that clear roles and responsibilities are set for each organization.
- Surveillance: Surveillance systems in South Sudan need to be strengthened to ensure the rapid confirmation of cholera cases. This will require investment in laboratory equipment, training laboratory staff, and routine processes for collecting and testing specimens throughout the country. Strengthening existing surveillance systems will contribute to improved response times to cholera outbreaks.
 For more information on cholera surveillance read Cholera Surveillance: Detecting and reporting Cases.
- Ease: The vaccine is one tool for the prevention of cholera that is relatively simple to use. The vaccine is safe, has few side effects, and is given orally. Health personnel with varying skill levels can administer the vaccine, such as community health workers and midwives. During the vaccination campaign in South Sudan, trained volunteers and community health workers helped administer the vaccine.
- Use: Determine ahead of time where to use the vaccine, keeping in mind where the vaccine may have the greatest impact. For example, target the use of the vaccine in areas where previous outbreaks have occurred, where the risk of cholera is high due to a humanitarian emergency, or where cholera is endemic.
Contributors: Abdinasir Abubakar, WHO; Andrew Azman, Johns Hopkins University DOVE Project; Francisco Luquero, Johns Hopkins University DOVE Project; David Sack, Johns Hopkins University DOVE Project; Naheed Ahmed, Johns Hopkins University DOVE Project.
 For more information read The Scenario Approach for Countries Considering the Addition of Oral Cholera Vaccination in Cholera Preparedness and Control Plans, published in The Lancet.