Every single last detail must be controlled when you organise mass vaccination campaigns such as the meningitis intervention that Doctors Without Borders (MSF) is undertaking in the northern Nigerian state of Yobe.
Successfully vaccinating 136,000 people in a week, in remote areas and with temperatures exceeding 40 degrees Celsius, requires thinking even about the pens that one will need. The most delicate and essential part of it all is maintaining the cold chain: that is, keeping the vaccines at a constant temperature of between 2 and 8 degrees Celsius. Otherwise the vaccines will spoil and be rendered ineffective. From the time the vaccines leave producers in Europe until vaccinators use them in the field in Nigeria there is a long journey, in which dozens of people participate, and we need to ensure the material is supervised at all times.
Once the vaccines are flown into the capital of Nigeria, Abuja, MSF officials organise a special reception at the customs office to prevent them from being kept for long. From there, they are transported in refrigerated trucks to a cold room in the Ministry of Health, where distribution to areas of Yobe state is organised. For this journey we use portable coolers loaded with the necessary ice-packs to last for a trip of several hours by road. When the vaccines reach the operational bases, they are stored in electric fridges that have been operating for at least two or three days before and have a stable temperature. From there the teams coordinate the dispatch to the districts affected by the outbreak. Often electricity is a service that is not available or is scarce in the places where we launch these interventions. It implies always having generators, an electrical installation and enough space to have all this material at hand.
Fuel is also required for the devices to operate 24 hours a day, which is not easy to come by in non-urban areas, affected by crises. Choosing the right transport is not easy either. For example, air traffic to northern Nigeria is limited because MSF can only use the United Nations or Red Cross flights that arrive at the nearest airport in Maiduguri. They are small aircrafts that only allow light cargos.
This forces us to transport the cargo to the bases in Yobe along main roads, which are in good condition and do not present security problems. However, the same does not apply at vaccination points. Some places are more than a two hour drive from our bases and there is no other option than traveling by car. We can’t risk walking because of the possible presence of members of the Boko Haram in the area.
Our logisticians have to manage and control the movements of the cars at all times as well as our telecommunications by radio, mobile and satellite telephones. Beyond all the logistical aspects of handling the cold chain, searching for cars and materials, houses, mattresses and even mosquito nets for our teams.
All MSF's efforts would be in vain if what is known as the microplan had not been developed: a detailed mapping of all the areas where we vaccinate. We need to know how far, up to the kilometre, the destinations are from the bases, the conditions of the routes, what happens if it rains or if it is sunny, the number of people who live in each place and the population type. This is fundamental, for example in Nigeria, where fulani people (nomadic herding tribes) live - so we have to do awareness raising among the communities with enough lead time so that on the day the vaccination begins, people are aware and accessible.
In the case of meningitis, the perception of the population is quite good because in general they fear the disease, but it is not always the case. Some vaccines that require a painful injection can deter people and it is hard to persuade them to attend the following rotations. No matter how much all the technical details are controlled and the vaccination teams are trained, unforeseen events can always arise. A road could be closed off for hours. A warning of an attack could force us to suspend gathering people in one place for the vaccination.
We have also found situations where teams who wanted to go faster, took the refrigerators without the vaccines in them, and two or three minutes after arriving at the destination they realised what had occurred. These are mistakes that can happen in a massive mobilisation involving more than fifty vehicles and teams; an intervention in which you even have to control up to the very last pen.