Meningitis: Challenges of launching mass vaccination campaigns

"In a massive vaccination campaign like in Nigeria, you even have to think about what pens you will use" - Daniela Muñoz, MSF logistics coordinator

Thursday, June 1, 2017 — Nigeria

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.

A community elder from Damaturu, Nigeria, talks to MSF staff during the course of a meningitis vaccination campaign. Photographer: Igor Barbero/MSF
An MSF worker prepares a dose for the injection of a vaccine against meningitis in Damaturu, Yobe state, Nigeria. Photographer: Igor Barbero/MSF
A woman receives her MSF vaccination certificate after having been vaccinated against meningitis in Damaturu, in the Nigerian state of Yobe. Photographer: Igor Barbero/MSF
A child waits in the queue for a meningitis vaccination in Damaturu town, in the north-eastern Nigerian state of Yobe. Photographer: Igor Barbero/MSF
Daniela Muñoz, logistics coordinator with MSF. “Every single last detail must be controlled when you organise mass vaccination campaigns such as the meningitis intervention in Yobe. Successfully vaccinating tens of thousands of 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 is maintaining the cold chain: that is, keeping the vaccines at a constant temperature of between 2 and 8 degrees. Otherwise the vaccination loses its full effect.” Photographer: Igor Barbero/MSF
MSF teams coordinate the distribution of vaccines that will be used on a meningitis vaccination campaign in the Nigerian northern state of Yobe. Photographer: Igor Barbero/MSF
A child is vaccinated against meningitis in Damaturu, Nigeria. Photographer: Igor Barbero/MSF
A small girl holds her MSF vaccination card in Damaturu town, in the north-eastern Nigerian state of Yobe. Photographer: Igor Barbero/MSF
Hamza Hassan, MSF health promotion supervisor in Damaturu meningitis vaccination campaign, 38 years old. “We started our health promotion at least three days before the implementation of the campaign with a great number of community mobilisers going from house to house, meeting community leaders, religious leaders, women groups, youth groups, union workers, to inform them about this deadly disease so that people become aware that meningitis can kill, it can cause disabilities. This disease is a very deadly disease, so the people want this vaccination as a way to prevent meningitis.” Photographer: Igor Barbero/MSF
Baba Makintu, community elder from Damaturu town (Yobe state, northern Nigeria), 92 years old. “When I was younger, at around 25 years of age, I got meningitis. It affected my vision. For a while I couldn’t see anymore. It also deformed one of my legs. It is now very weak. This disease has hit many of my family members in Damaturu. I have seen people die because of it, creating havoc in many families. This is why I think it is so important to get vaccinated. We encourage everyone to carry out such interventions.” Photographer: Igor Barbero/MSF
Two girls hold their MSF vaccination cards in Damaturu town, in the north-eastern Nigerian state of Yobe. Photographer: Igor Barbero/MSF
Mustafa Ibrahim, student from Damaturu (northern Nigeria), 15 years old.<br/>“There are ten of us in my family and we earn our living by selling goods in the market. I have come here with some of my brothers and sisters. Our father has encouraged us to get vaccinated against meningitis as this disease can create lots of problems. We don’t have to be afraid if we get protected.” Photographer: Igor Barbero/MSF
MSF teams complete the vaccination certificates of people taking part in a vaccination campaign in the town of Damaturu, in the north-eastern Nigerian state of Yobe. Photographer: Igor Barbero/MSF
Solomon Jakob, an unemployed health officer, 25 years old, in Damaturu, capital of the Nigerian northern state of Yobe. “It is good to be vaccinated against meningitis, because it will prevent you from developing a handicap, a disability, a deformity, becoming deaf or blind.” Photographer: Igor Barbero/MSF