Between Seas & Mangroves, health workers brave odds to vaccinate fishermen communities.

With a pair of rain boots on his legs and a megaphone in hand, Mbi Mathew sets out of a makeshift building through the marsh of Cap Cameroon on a routine tour announcing the commencement of vaccinations. "Cap" as locals call it, is one of the 47 islets making up the archipelagic Manoka Islands of the 6th Division of the Littoral Region of Cameroon.

On its beautiful shores, fishermen are fixing their boats and fishing nets, children play football on the sand beach while echoes of the megaphone of Mbi Mathew, who also nicknamed "Docta" is heard kilometers away saying a campaign has been announced by government to vaccinate against the Cholera – an infectious and often fatal bacterial disease of the small intestine, typically contracted from infected water supplies and causing severe vomiting and diarrhoea.

Estimates by health officials show that Cholera causes severe diarrhoea and if left untreated can lead to severe dehydration and death. It kills tens of thousands of people worldwide every year.

Mbi Mathew has been living in Cap Cameroon for over 15 years. He works there as a community health worker and special secretary to the Chief. His health mission consist mostly engaging local communities before campaigns and assist the team deployed from the urban area during vaccination rollout plans.

Manoka is Cameroon's largest island, located 35 minutes by boat from the small mainland fishing port of Youpwé, at the fringe of the city of Douala. The island's indigenous people are mainly fishermen called the Malimba. But 75% of the locals, a population totaling a little below 20,000, are immigrants, from neighboring Nigeria, Ghana and Niger. The Island is landlocked area facing an extreme supply availability and logistics  

As the existing local health centre, located in Manoka town cannot provide high-quality primary health care services to local community, severe cases are referred to neighboring urban hospital in Douala. 

However, fatalities caused by constraints linked with ferrying patients from Cap to the Centre in Manoka has pushed authorities to establish a temporary integrated health facility in Cap Cameroon

If you want to reach to the health centre from the furthest of the 47 islets, a trip could be accomplished in about two days on high sea. Most of patients often die before they could reach the health centre.

When news of Cholera outbreak broke out in Cap Cameroon way back in 2020, health workers had the daunting task to provide a fast mitigating response to the pandemic. 

Officials of the Littoral Regional Delegation for Public Health said, "getting to the Island is one of their most difficult challenges". Notwithstanding, they had to ensure that lives are saved through vaccines against all odds 

Cholera in Cameroon 

Since 1971, Cameroon has been facing an ever-growing outbreak of cholera epidemics; despite all the efforts made by the government to address the substantial public health problem. 

In 2020, in addition to the COVID-19 pandemic, Cameroon recorded a high cholera case fatality rate of 5.3% following epidemics noted predominantly in the Littoral, and South West regions which is far higher than the 1% World Health Organisation acceptable rate. 

The Manoka Islands had recorded 5 cases and three people died at the time of the pandemic. The Littoral Region of Cameroon and particularly the town of Douala is one of the commonly affected region by cholera in the country.

Of the cumulative recorded figures, high morbidity and consequent mortality caused by cholera have been attributable to several factors, including lack of clean drinking water, poor sanitation, poor hygiene practices and poor sanitation. 

Controlling cholera in the region, according to health officials, remains a significant challenge as many people still live in unclean places with limited access to drinkable water. In 2020, the region registered 979 suspected cases with 49 deaths. Out of these cases, only 538 were analysed, while 185 were positive. 

Estimates by the World Health Organisation (WHO) show that, since October 2021 cholera epidemic has killed at least 62 people and infected some 2,097 in Cameroon, six of the country’s ten regions – Centre, Littoral, Far North, North, South, and South West regions – reported at least one case amid daily increases in the incidence rate. The figures have witnessed a significant increase as new cases were reported recently the political capital, Yaoundé 

The daily rise in the number of cholera cases triggered a rush for cholera vaccines in the country. Over two million doses were approved from the Gavi-funded oral cholera vaccine (OCV) global stockpile to tackle the outbreak, enough to vaccinate more than a million people.

Three other oral cholera vaccines have been prequalified by the World Health Organisation (WHO) including Dukoral, ShanChol and Euvichol-Plus/Euvichol. All these vaccines are currently available for mass vaccination campaigns.

Cameroon's international partners in the fight against cholera including organisations such as WHO, UNICEF, Doctors Without Borders, the Norwegian Refugee Council, and other non-government organisations have embarked on sensitisation of the people on general cholera prevention.

Dr Jean de Dieu Iragena, Cholera Incident Manager, WHO Cameroon Office explained that during the campaign, the UN agency has assisted the Ministry of Health to establish the Incident Management System Team and also provided technical and financial support across five main pillars of the response; coordination of partners, health operations, planification and surveillance, operational support logistics and administration as well as finance,” says 

Dr Iragena, however, feels that Cameroon’s cholera response plan needs to be supported by more partners "to quickly reverse the incidence and mortality”. He said double efforts is needed together with the Ministry of Public Health and other partners.

His view went in line with that of the Country Representative Habimana Phanuel. Speaking to collaborators via videoconference from Yaounde at a crisis response evaluation meeting in Douala, Habimana called for more momentum to end the cholera epidemic and put Cameroon on the path towards complete eradication by the year 2030. He upheld the role health workers play in the global fight against the desease 

Gavi started funding the global cholera vaccine stockpile in 2013. Since the stockpile was launched, millions of doses every year have helped tackle outbreaks across the globe. In the 15 years between 1997 and 2012, just 1.5 million doses of oral cholera vaccine were used worldwide. In 2021 alone, the stockpile provided 29 million doses for emergency and preventive use across the globe.

As government and partners led vaccination campaign on mainland and sealand, community health workers were at the center of response. The case of the Manoka Islands remains perculiar as locals depend on rains as source for drinkable water. 

Mbi Mathew says, thanks to the Doctors without Borders, they were provided with Aquataps to purify water they use to drink. Ensuring water safety, was one of the many ways health workers managed to curb the spread of cholera aside vaccines.

Braving the odds

Community Health workers play an important role in every vaccination to keep people safe from dangerous preventable diseases said Dr Sangwe Clovis Nchinjoh,  a physician and public health researcher – an Associate for Routine Immunization in Missed Communities with the Clinton Health Access Initiative (CHAI). According to a study he led, which was co-funded by Gavi vaccines alliance and CHAI in 2022, 91.7% of children under two in the district have not received a single vaccination.

Dr Nchinjoh described the logistical woes, the hard-to-track mobile population, the frequent flooding, dangerous sea waves, language barrier, few trained personnel, misconception of vaccines as some of the challenges they had to overcome in their fight to get poeple vaccinated 

The situation is exacerbated by social and cultural factors, including religious beliefs and stigmatisation, as locals believe in the use of herbs for treatment. 

Going by Mbi Mathew, when the population in Cap Cameroon first came in contact with Cholera, they had never heard of it, neither were they of knowledge that adults could take vaccines.

"Most of them believe in what soothsayers tell them, some do not understand the English language nor French, we have to speak to them in the language, terms that they will best understand," he said

"Also, the difficult terrain, recurrent floods making it difficult to provide the necessary facilities like potable water and decent sanitary conditions. There are situations where we end up with faeces in the rivers where people also fetch water to bathe from,” adds Mbi Mathew.

Mbi Mathew and Dr Nchinjoh had worked together for long with the Dr Nchinjoh founded organisation, "Rural Doctors". They best understand the ordeals with reaching isolated communities. But as Mbi says, his love for mankind inspires him to work even with little pay.

Live-saving strides amidst challenges

The OCV was first used in March 2020 to respond to the cholera outbreak in the Manoka health district, with a very successful result. Speaking with Poeple in Cap-Cameroon and Littoral region in general, they would tell you that conception with regards to vaccines have changed. 

A report published by Adidja Amani, Sub-Directorate of Vaccination, Directorate of Family Health, Ministry of Public Health, Cameroon and Co, revealed great strides recorded in the region despite challenges.

Worth noting is the fact that, the vaccines took place when Cameroon was babbling with COVID-19 and other humanitarian crisis. Viral misconceived information went about social media telling people not to take vaccines as the government had derived a means to affect them with another form of "whiteman disease"

"We made efforts to educate parents on the importance of vaccines, some will still decline and ask government should provide other amenities than vaccines which would not benefit them in any way," Addja Amani said.

These misconception had affected the reach of vaccines in the Littoral greatly.  In the first round of the Vaccines in 2020, they had 64 % coverage but the second round later that year, they recorded 80.4% overall vaccines coverage 

According to the report, the success can be explained by the fact that the population had already had the first dose and, as such, were more confident of receiving the second dose. The second rollout had taken place in better climatic conditions than the first, enabling a better field implementation. 

There more significant media visibility and messages done and broadcast in the local languages of the people. There was 16% increase in coverage, specifically in littoral and south regions, which saw a leap from 38.61% to 53.95% and 72.74% to 94.07% - owning to the fact that the level of misconception and misinformation concerning vaccinations was not high.