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Abstract

Cholera remains a major healthcare issue in the Democratic Republic of the Congo with recurrent cholera outbreaks in its eastern provinces since 1994. Cholera cases and deaths increased from 18 403 and 302 in 2022 to 52 570 and 470 in 2023. From October 1st to December 31st, 2022, we conducted a mixed descriptive study to analyze the management process underpinning the cholera vaccination campaign in the Katana health district, South Kivu province, DRC. The survey targeted households (n = 404) with 1 adult person per household responding on behalf of all the members of the household and key informants (KI) who were health workers (n = 6) in 5 health areas of the Katana health district. The overall cholera prevalence in the surveyed households was 4.7% (95% CI 2.9-7.3), and the overall vaccination rate was 25.0% (95% CI 20.9-29.5). Most interviewed household respondents (54.5%) were eager for their household members to get vaccinated, and 61% had to walk for more than 1 hour to reach the vaccination center. Cholera vaccine for children under 2 years was available in all the 5 health areas investigated, only 2 out of 5 health areas had enough vaccine stockpiles. Only 33.3% of KI administering vaccines were trained at least once during the past 3 years. All the KI (100%) complained about delays or absence of payment for their services which negatively impacted their implication. Our findings highlight weaknesses in the planning of the last cholera vaccination campaign in the health district of Katana.

Keywords

Vaccination cholera planning Katana DRC

Introduction

Cholera is a gastrointestinal infection caused by Vibrio cholerae (V. cholerae), a Gram-negative comma-shaped rod bacterium.¹ Cholera remains a major public health concern in the world and is a heavy burden for populations in developing countries, with cases estimates and deaths of up to 4.3 million cases and more than 100 000 deaths annually.^1-3

Sub-Saharan Africa is the most affected region with cholera in the world, with large-scale cholera outbreaks reported frequently, in a context of complex crises such as famines and civil/military conflicts.⁴

The Democratic Republic of Congo (DRC) is among the leading countries for cholera cases in the World, contributing 5% to 14% of the global case count annually.⁵ In 2020, and 2022, DRC reported 19 789, and 18 403 suspected cholera cases respectively making it the most affected country in Central and West African, and second only to Nigeria in 2021 in that region.⁶

Data from 2023 indicate a deepening cholera crisis in the country with 52 570 cases and 470 deaths, representing 83% of cholera cases and 59% of deaths reported throughout the central and western African region.⁷

Cholera is endemic in the eastern DRC provinces (North-Kivu, South-Kivu, Tanganyika) which are part of the Great Lakes Region (GLR), with recurring outbreaks throughout the past 30 years.^8,9 Indeed, cholera was introduced in the country in the seventies but remained a somewhat low-profile disease characterized by small outbreaks alternating with long lull periods.¹⁰ However, in 1994, huge cholera outbreaks occurred in the country, particularly in and around the city of Goma following the massive influx of Rwandan refugees in DRC during the Rwandan Genocide. These resulted in the deaths of over 50 000 refugees.¹¹ From then on, recurrent cholera outbreaks have been reported regularly around Lakes Kivu and Tanganyika in DRC, a region that has been marred by protracted civil war for the past 30 years, with hundreds of thousands of internally displaced people.

In late 2022, a global surge of new cases and cholera cases and deaths following the renewed fighting in the North-Kivu province and the subsequent severe humanitarian crisis resulting from the displacement of hundreds of thousands of people fleeing their homes in the districts of Rutshuru and Masisi districts. By February 4th, 2023, a total of 4386 cholera cases, with 16 deaths (CFR 0.4%) had been reported¹⁰ and many of them lived near contaminated water sources.¹²

Previous studies have identified the areas around lakes in the GLR of eastern DRC as potential sources of cholera outbreaks, from where the intermittently spreads outside the GLR to central and western provinces of the country.¹³ Recent data on genomic characterization of V. cholerae associated with cholera outbreaks in eastern DRC has shown an enduring persistence of a lineage that was introduced in the country during the 1994 influx of Rwandan refugees.^8,9,14

The Katana health district, an area in the vicinity of Lake Kivu (west coast of this Lake) is one of the districts most affected by recurrent cholera outbreaks since 1994. Recently in 2023, the district recorded week 4 in week 8, 40 cases of cholera,¹⁵ despite the support of several national and international stakeholders in the fight against the cholera scourge in this environment.

The current cholera response arsenal includes the provision of potable water, sanitation, and hygiene (WASH), surveillance, and case management.¹⁶ Over 80% of cholera patients can be treated with Oral Rehydration Serum (ORS) alone, although during cholera outbreaks there is often a sizeable gap in access to ORS.^17,18 Cholera vaccination has been recommended by WHO as an additional public health tool, along with WASH measures in cholera-endemic countries and areas at risk for outbreaks.¹⁹ Oral killed vaccines (kOCV) are safe and protect against cholera for at least 3 years when given in 2 doses.²⁰ A recent study on the efficiency of vaccination against cholera in a cholera-endemic health district showed that a single dose kOVC provided substantial protection against cholera for at least 36 months after vaccination.²¹ Accordingly, the cholera oral vaccine Rotasiil^® has been integrated into the panel of essential infant vaccines in the Katana health district and is administered along with vaccines against frequent preventable diseases, namely tetanus, diphtheria, pertussis, and measles.

In 2021, cholera vaccination campaigns which targeted a total of 3 366 039 people at risk of cholera took place in 4 DRC provinces (Haut-Katanga, Haut-Lomami, Sud-Kivu, and Tanganyika provinces).²² Whereas the real impact of these cholera vaccination campaigns on the reduction of cholera burden in DRC is yet to be assessed, especially in the light of the steady progression of cholera in those targeted areas,⁷ organizational issues during the cholera vaccination campaigns which might have impacted negatively the cholera vaccination coverage cannot be ruled out. Accordingly, this work aimed to analyze the management process underpinning the cholera vaccination campaign during 2021 to 2022 in the Katana health district, South Kivu province, DRC.

Materials and Methods

A mixed qualitative and quantitative study was conducted in the health district of Katana in the South Kivu province between October 1st and December 31st, 2022, to analyze the planning factors potentially impacting cholera vaccination coverage during 2021 to 2022 in this district. The population of the health district of Katana which was estimated at 251 907 in 2022 is distributed in 18 health areas (Figure 1).^23-25 For the survey, 5 health areas were drawn randomly out of the 18 health areas of the health district representing a total population of 80 319 individuals (31.9% of the total population of the district) distributed in a total of 11 475 households (approximately 7 individuals per household) were included in the survey. This percentage is robust and sufficient to achieve a statistical inference: the margin of error was (5%), and we used the confidence level of (95%) recommended for a larger sample. The survey was carried out in a well-defined and homogeneous environment. Our sample was collected randomly and stratified.²⁶ Noteworthy, individuals living in these selected health areas shared the same socio-cultural characteristics as those of the whole health district of Katana (ie, they all belonged to the same tribe and chiefdom, and shared the same languages, customs and beliefs). The sample size (n) from these 11 475 households was calculated using the SCHWART formula (n = Z²p(1 − p)/d²),^27,28 based on the following assumptions: (i) a confidence interval limit of 95% corresponding to Z = 1.96, (ii) an arbitrarily assigned prevalence of the problem at 50% given that we had no idea whatsoever of the prevalence of the problems related to the management of the cholera vaccination through the Katana population perspective, and (iii) a desired precision (d) of 5%. The sample size was increased by 5% to compensate for non-responsive participants and registration errors. Thus, the total of households to be surveyed was established at 404 households in the 5 health areas randomly selected out of a total of 18, which represents a total of 81 households per health area under study (Figure 2).

Figure 1.

Map of the health district of Katana. The red lines indicate the external boundaries of the health district whereas the black lines indicate the boundaries of the health areas within the health district. The health areas which were selected randomly for the study are indicated by red crosses.

Figure 2.

Presentation of samples by strata. The health areas selected for the survey are highlighted in beige. The number in each beige rectangle represent the total households in each surveyed health area. The number in each blue ellipse represent the number of households surveyed from each selected health area.

This was a disproportionate stratified random sampling, where we considered health areas as strata. The research team (constituted of the principal investigator and 4 assistants) was dispatched to the 5 health areas under study and conducted door-to-door interviews. All the selected participants (the head of the household or any adult from the household when the head of the household was unavailable) were interviewed face-to-face by trained research assistants using the local language. In addition, KI in the health district of Katana (ie, the district chief medical officer and 5 head nurses from the 5 health areas under study) were also interviewed using a different questionnaire, this one focusing on management aspects such as the availability of vaccines, the training of KI before the vaccination campaign, the alignment of partners with the priorities of the health district and the payoff of KI, reflected by the effective remuneration for the tasks accomplished before and during the vaccination campaign (see Annexes 1 and 2). The questionnaires used for our survey were designed based on a similar questionnaire in survey on cholera vaccination,²⁹ and on a similar study in a somewhat similar setting³⁰ and adapted following to achieve the objectives of the study.

Before the survey, the questionnaire was pre-tested in the Miti-Murhesa health district. This health district is very similar to our investigation area (geography, population structure, languages spoken, and customs as both districts belong to the same tribe and chiefdom). A total of 40 households from the Miti-Murhesa health district (approximately 10% of the size of our sample) were interviewed during this pre-test. This pre-test allowed us to readjust the questions and correct obvious inconsistencies.

The inclusion criteria for household participants were: (1) Any head of family or his representative (responsible adult) whose age was between 19 and 70 years old, (2) the people to be surveyed must have lived in the area for at least the 6 past months. The exclusion criteria for household participants were people seemingly confused and incoherent (apparently drunk or having mental health disorders). For KIs, the inclusion criterium was to have been working for the Katana health district for the past 3 years, while the exclusion criteria for KI was to be on leave during the investigation period, in addition to not having totalized 3 years working in the Katana health district. Assessed variables for household participants included: (i) socio-demographic data, geographic and cultural data, knowledge and attitudes toward cholera vaccination, getting information on cholera vaccination dates, and assessment of the implication of the national government. For KI, factors recorded included: (i) the availability of cholera vaccines during the cholera vaccination campaign, (ii) the training of healthcare personnel before the cholera vaccination campaign, (iii) the alignment of stakeholders with the priorities defined by the leadership of the healthcare, and (iv) the trustworthiness of stakeholders (national and international) concerning delivering on their pledges of paying salaries of healthcare personnel involved in the cholera vaccination campaign. Some of these questions were inspired by certain documents on cholera (see socio-demographic characteristics and aspects of vaccination).

Data were collected using the Kobo Collect application tool version v2021.2.4³¹ by aides who had been trained on how to use this application tool and analyzed using SPSS statistical package release 16.0 for Windows 16.0 (Chicago, SPSS Inc), with a P-value <.05 considered significant.

This study was reviewed and approved by the Ethical Review Committee of the Institut Supérieur des Techniques Médicales de Bukavu (ISTM/Bukavu; number ISTM-BKV/CRPS/CIES/ML/018/2023). All participants or their guardians (in the case of minors) provided written consent before enrollment.

Results

The study enrolled a total of 404 households (1 adult participant per household) for a total number of 2831 individuals and 6 key informants (KI). Socio-demographic characteristics and data on cholera vaccination of the 404 respondents are shown in Table 1.

Table 1.

Socio-demographic characteristics of respondents and aspects of vaccination coverage (n = 404).

Variables	n (%)	P-value	Median/IIQ
	Age (y)
19-39	242 (59.9)		32 (28-58)
⩾40	162 (40.1)
	Gender
Male	148 (36.6)	<.05
Female	256 (63.4)
	Occurence of cholera disease during the 3 mo preceding the start of the vaccination campaign
Experienced cholera	19 (4.7)
Did not experience cholera	385 (95.3)
	Cholera vaccination status
Total of vaccinated (%)	101 (25.0)
• Partial vaccination (received one dose of the cholera vaccine)	70 (17.3)
• Full vaccination (two doses of the cholera vaccine)	31 (7.7)
Not vaccinated (zero dose)	303 (75.0)
	Distance to the vaccination center
⩽5 km	194 (48.0)
Over 5 km	210 (52.0)
	Eagerness to be vaccinated against cholera
Eager	220 (54.4)
Not eager	184 (45.6)
	Reasons for not having been vaccinated
Lack of information and/or guidance	121 (61.0)
Had the appropriate information but could not get vaccinated due to distance to the vaccination center	169 (55.8)
Had the appropriate information but did not get vaccinated for undisclosed reasons	13 (4.3%)
	Information sources on the last cholera vaccination campaign
Community relays	238 (58.9)
Media	77 (19.1)
Health structure	89 (22.0)

Women and men constituted 63.4%, (n = 256) and 36.6% (n = 148) respectively (chi-square, P < .05). The median age of surveyed participants was 32 years.

The overall prevalence of cholera in the 5 health areas under study was calculated at 4.7%. The vaccination rate in the households during the vaccination campaign was low with only 25% of households having received at least 1 vaccine dose. Indeed, 17.3% and 7.7% of households received 1 and 2 doses of the cholera vaccine respectively. Noteworthy, the availability of the cholera vaccine during the 2 vaccination campaigns of 2021 and 2022 was uneven in the 18 health areas of the Katana health district, due to insufficient vaccine stockpiles. Interviewed KI put the estimate at around 7 out of 18 health areas (38.9%) of the Katana district.

Analysis of socio-demographic characteristics and the vaccination status showed that young households (19-39 years) had a low ratio of vaccinated versus unvaccinated respondents (31/209) compared to >40 years households (70/94), (odds ratio = 5.0; P < .05). These data are presented in Table 2. Among other reasons put forward by unvaccinated participants for not attending the vaccination campaign, they cited: (i) the distance to the vaccination center (61.0% of respondents). Indeed, the ratio of the vaccinated households versus the unvaccinated households was 0.8 in the group of participants who walked less than 5 km (1 hour), but fell sharply to 0.08 in the group of participants who worked more than 5 km (odds ratio = 10.3, P < .05); (ii) the lack of information on the cholera vaccination campaign (39% of respondents). These factors are summarized in Table 2.

Table 2.

Bi-variate analysis: association between age, distance and cholera vaccination status.

	Cholera vaccination status
Variables	Vaccinated	No vaccinated	Odds ratio (IC 95%)	P-value
Age (y)
19-39	31	209
>40	70	94	5.0 (3.1-8.2)	<.05
Distance (km)
<5	15	195
⩾5	86	108	10.4 (5.7-18.8)	<.05

Our survey also showed that the community relays were the most frequently used communication mean by the households when it comes to seeking information regarding the vaccination campaigns (58.9%), with media and the health district accounting for 19.1% and 22% respectively.

Only 33.3% of KI were trained on how to administer the cholera vaccine before the vaccination campaign. KI reported receiving their remuneration long after the vaccination campaign, or not at all (Table 3).

Table 3.

Management of the vaccination campaign as viewed by Key Informants (KI; n = 6).

Availability of vaccines in health areas of the Katana health district (%)	Yes	Not
Dukoral^®	38.9	61.1
Rotasiil^®	100.0	0.0
Training of Key Informants prior to the start of the vaccination campaign (%)
	33.3	66.7
Stakeholders (national and international) align with the planning established by the Katana health district (%)
	0.0	100.0
Stakeholders (national and international) are trustworthy concerning delivering on their pledges of paying salaries of healthcare personnel involved in the cholera vaccination campaign (%)
	0.0	100.0

This table shows that 4.7% of our respondents had contracted cholera during the last 3 months preceding the start of the vaccination, 75% of our respondents have not been vaccinated against cholera and for those who have been vaccinated (25%), 70 out of 101 vaccinated people (69.3%) received a single dose of vaccine.

A statistically significant association between age, distance traveled and cholera vaccination status.

This table highlights weaknesses in the planning of the vaccination campaign as perceived by key informants. All KI (n = 6) 100% of KI said they were not enthusiastic to carry out vaccination tasks because the stakeholders were not trustworthy.

Discussion

Cholera elimination is a goal set by the WHO, and by the DRC government,³² therefore underscoring the political will to fight the cholera plight which has affected hundreds of people over the past 3 decades in the country, and vaccination against cholera represents an important asset in this fight.

One of the striking observations of our study was the low vaccination coverage in households of respondents (25% coverage for people aged more than 2 years old, and even only 7.7% received 2 doses). This rate is way too low to confer any significant herd immunity which is theoretically reached when vaccination coverage is between 50% and 70%.¹⁷

Whereas a handful of studies have shown the feasibility of cholera campaigns in DRC,^21,33 none of them has analyzed various management aspects of cholera vaccination in the country. Our study is the first in the country to analyze management aspects that play an important role in the success of the cholera vaccination rollout. Among them, the distance to the vaccination center is critical, as shown by our data. A study conducted by Amani et al³⁴ showed a high vaccination coverage in Mabeta (Limbe health district), which is a small health area of 6899 people, due to the ease of geographical access by road compared to health areas in the Tiko district, where it is sometimes necessary to take a canoe to reach certain health areas. Alternatively, mobile vaccination units that would move toward the households could be set up, although this would not be cost-effective, as it would need more staff and would require more equipment to maintain the cold chain. Regarding the planning of the 2021 to 2022 vaccination campaign in the Katana health district, interviewed KI feel that vaccination rollout by the DRC Ministry of health and its international partners did not take into consideration the health district’s planning and forecasting as reported by the interviewed providers, and point to this as one of the reasons for cholera vaccines shortage during the 2021 to 2022 cholera vaccination campaign.

Our study had several major limitations. The first limitation is the trans-sectional nature of our study, as there is no guarantee that some of the factors analyzed in this work which seem related to low vaccination coverage could not change over time. Future studies are required to confirm the role of these factors in the low vaccination coverage. The second limitation is the non-investigation of other factors which could impact vaccination coverage. These include, among others, vaccine chain supply, cultural factors, and vaccination hesitancy. No KI was eager to discuss questions related to the chain supply out of fear of losing his position if his comments were read by any government official or one of its international partners. Cultural factors and vaccine hesitancy were difficult to survey because answers given by household participants were not clear-cut. Vaccination hesitancy was also difficult to analyze, as participants who were against vaccination were unwilling to explain their opinions. Indeed, vaccination against COVID-19 has generated passionate debates in the world and the shockwaves are still felt in this African region rife with rumors about safety of covid-19 vaccines. Another important limitation of our study was the fact that whereas KIs had several insightful ideas, they refused that these be detailed and put as such put on record, out of fear of losing their jobs.

This is an illustration of top-bottom management in the DRC healthcare system, where local levels have no power to decide or suggest any improvements whatsoever.^34,35 The fact that KIs would not receive training before the organization of the vaccination campaign or complain about not being paid several months after the vaccination campaign is a clear indication of the underlying management issues in the Katana district healthcare. Such issues not only risk undermining the motivation and engagement of healthcare workers but also compromise the sustainability of future campaigns. Addressing these challenges through timely financial incentives, improved training programs, and enhanced logistical support could strengthen the effectiveness of vaccination initiatives in similar settings.

Accordingly, the Congolese Ministry of Health and its international partners should do their best to involve local stakeholders (from the province, the district, and the area) in the planning of vaccination campaigns. This entails involving them in the evaluation of vaccine stockpile needs, making sure all the staff participating in cholera are trained and in the selection of vaccination sites that are close to the targeted households, and scheduling vaccination campaigns during the dry season because people won’t be hindered by rain; but also, during the dry season, there are water shortages, which cause epidemic peaks in cholera cases. Noteworthy, Amani et al³⁴ also found that scheduling the campaign appropriately during a good climatic season was crucial to achieving good vaccine coverage. Entrusting the community relays in the planning and the rollout of the vaccination campaign is critical, as highlighted by our findings. The confidence they have built with the population over the years is well reflected in the survey as they are the main communication channel for households when it comes to participating in a cholera vaccination campaign. Also, making sure that the staff is paid as pledged before the vaccination campaign seems, in our opinion critical for the success of vaccination campaigns.

Conclusion

Despite these limitations, our study highlighted the following management issues related to the cholera vaccination rollout in the Katana health district: (i) the lack of cholera vaccine stockpiles for adults, (ii) the insufficient training of the staff or lack thereof before vaccination campaign, (iii) the non-payment of salaries of the staff, (iv) the remoteness of vaccination sites, with most respondents having to walk for more than 1 hour to reach vaccination site, (v) the absence of concentration between the district level and the ministry of health and its international donors, and (vi) the lack of technical support for community relays before the cholera vaccination campaign.

Our findings call for similar studies in other provinces of the country.

Supplemental Material

sj-docx-1-his-10.1177_11786329251316675 – Supplemental material for Assessment of Management Factors Influencing Vaccination Against Cholera in the Health District of Katana, the Democratic Republic of the Congo

Supplemental material, sj-docx-1-his-10.1177_11786329251316675 for Assessment of Management Factors Influencing Vaccination Against Cholera in the Health District of Katana, the Democratic Republic of the Congo by Irène Ntererwa-Nsimire, Leonid M Irenge, Paulin B Mutombo, Eric M Mafuta, Jean-Luc Gala and Dosithée Ngo-Bebe in Health Services Insights

Footnotes

Acknowledgements

We would like to acknowledge the help of the personnel of the Public Health Department of the Université Officielle de Bukavu (UOB) for their implication throughout this study. We also extend our gratitude to Joël Muganguzi Chibasa and Louisette Wimba Kayange (Institut Supérieur des Techniques Medicales de Bukavu/Bukavu, DRC) for the administrative support.

Funding:

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Belgian Cooperation Agency of the ARES (Académie de Recherche et d’Enseignement Supérieur) [grant COOP-CONV-20-022]. The funder did not play any role in the study design, collection, analysis and interpretation of data, manuscript writing or the decision to submit the paper for publication.

Declaration of conflicting interests:

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions

Design of the study: Irène Ntererwa-Nsimire and Dosithée Ngo-Bebe. Analysis and curation of data: Irène Ntererwa-Nsimire, Leonid M. Irenge, Paulin B. Mutombo, Eric M. Mafuta, and Dosithée Ngo-Bebe. Drafting of the manuscript: Irène Nterewa-Nsimire and Leonid M. Irenge. Funding acquisition: Jean-Luc Gala and Leonid Irenge. Irène Ntererwa-Nsimire and Leonid M. Irenge have revised the manuscript before submission. All authors read and approved the final manuscript.

Ethical Approval

This study was reviewed and approved by the Ethical Review Committee of the Higher Institute of Medical Techniques/Bukavu (number ISTM-BKV/CRPS/CIES/ML/018/2022). All participants or their guardians (in the case of children) provided written consent before enrollment.

ORCID iD

Irène Ntererwa-Nsimire

Data Availability

All the data used and/or analyzed during the current study are available from the corresponding author upon request.

Supplemental Material

Supplemental material for this article is available online.

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, et al. Political analysis and strategies. In: Getting Health Reform Right. Oxford University Press; 2008:61-89.

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Assessment of Management Factors Influencing Vaccination Against Cholera in the Health District of Katana,the Democratic Republic of the Congo

Abstract

Keywords

Introduction

Materials and Methods

Results

Discussion

Conclusion

Supplemental Material

sj-docx-1-his-10.1177_11786329251316675 – Supplemental material for Assessment of Management Factors Influencing Vaccination Against Cholera in the Health District of Katana, the Democratic Republic of the Congo

Footnotes

Acknowledgements

Funding:

Declaration of conflicting interests:

Author Contributions

Ethical Approval

ORCID iD

Data Availability

Supplemental Material

References

Supplementary Material