A Scoping Review of Facilitators and Barriers Influencing the Implementation of Surveillance and Oral Cholera Vaccine Interventions for Cholera Control in Lower- and Middle-Income Countries

"A key finding of this review is the importance of accurate and timely information on cholera and OCV delivery from a trusted information source to the community."

Cholera disproportionately affects people in poverty and exacerbates their vulnerability; 47 lower- and middle-income countries (LMICs), particularly in sub-Saharan Africa and South Asia, contribute most of the cases. In these areas, surveillance informs planning of other interventions, such as oral cholera vaccine (OCV). This scoping review is driven by these questions: (i) What facilitators influence the implementation of surveillance and OCVs for cholera control in LMICs? (ii) What barriers hinder the implementation of surveillance and OCVs for cholera control in LMICs?

Database searches were conducted on February 12 2021, and a Google search was conducted on April 2 and 5 2021. Documents in the topic area(s) of interest were eligible if they concerned LMICs, were written in English language, were quantitative and/or qualitative in nature, and were peer-reviewed. The timeline was originally set to anytime in 1990 to February 2021 and later changed to 2011 to February 2021.

A total of 8,136 documents were originally identified, of which 48 documents were read in full, and 36 met the inclusion criteria. The characteristics of these studies are summarised in Table 2 of the paper. Of the 36 documents, more than half (67%) were published between 2016 and 2021. Most of the documents (56%) focused on cholera in an epidemic context. Haiti was the most studied country, with four (11%) studies among the selected documents.

There were two themes identified regarding the implementation of surveillance: (i) timeliness and reporting (e.g., poor knowledge of cholera surveillance systems on a local level, combined with weak local-level collaboration, such as weak communication between neighbouring communities, created barriers); and (ii) resources and laboratory capabilities. As for OCVs, there were four themes identified:

• Information and awareness: Community members' awareness of the seriousness and symptoms of cholera contributed to their motivation to receive OCV during OCV campaigns. Providing clear communication on the key messages of an OCV campaign was crucial in Nampula, Mozambique, as was correct information around self-administration of a second dose in Lake Chilwa, Malawi. Lack of knowledge of OCV, however, acted as a barrier to its implementation, an issue that was often characterised by misconceptions, vaccine hesitancy, and refusal. People in Lusaka, Zambia, lacked information on potential OCV side effects, intended population, and duration of protection. Consequently, observing side effects among community members became a credible rationale for spreading rumours of OCV being unsafe.
• Community acceptance and trusted community leaders: In several study contexts, a high level of acceptance of OCV was mediated by preexisting positive attitudes towards and willingness to receive the vaccine by community members. Another facilitator of OCV campaigns was having well-trained community leaders and having informed and engaged community stakeholders. Further aspects aiding OCV interventions were community members' increased trust in vaccine providers and the use of accepted community volunteers and leaders who could conduct OCV campaigning amidst insecurity challenges. The most common OCV information sources were: messages through megaphones, local criers, healthcare workers, family, and friends; community sensitisation in school, at church, or during home visits; social networks; word of mouth from neighbours; trusted healthcare organisations; and announcements inside internally displaced persons (IDP) camps.
• Planning and coordination: Adapting to local contexts included conducting vaccination on weekends, leveraging mobile vaccination teams, carrying out door-to-door vaccination, using fixed sites, and starting vaccination early and/or finishing late in the evening - all to reach as many persons as possible in as wide an area as possible.
• Resources and logistics: A variety of resources facilitated successful implementation of OCV campaigns, such as, for example: use of vaccination cards during vaccine distribution; mHealth solutions for vaccine registers to minimise printing and manual paperwork; and well-trained, experienced, and committed human resources.

At the interface between surveillance and oral cholera vaccines are facilitators such as having proper cholera surveillance to evaluate OCV campaigns or conducting daily and/or nightly reviews of vaccination data and subsequent case-finding. An example of a barrier is lack of an accurate map of a planned vaccination area, which can hinder the possibility of an exhaustive door-to-door OCV campaign.

Thus: "Findings suggest that adequate and sustainable resources are crucial for timely and accurate cholera surveillance and that oral cholera vaccine implementation would benefit from increased community awareness and engagement of community leaders....A bottom-up approach using local information providers is crucial to creating trust in the affected community and conducting a successful OCV campaign."

According to the researchers, "[t]he results presented on the importance of clearly communicating OCV information to communities can inform future research on how to develop and adapt specific cholera and OCV information campaigns tailored to local contexts. For instance, there is a need for further studies on what information should be provided and how to get messages across to populations affected by cholera. The scoping review also supports the need for research on vaccine hesitancy....Together with other studies on communicable diseases and their vaccines, there is an opportunity to share knowledge on how to prevent vaccine hesitancy and establish what mechanisms enable vaccine acceptance. Further research on cholera surveillance could also draw from facilitators and barriers found in this article....For example, since mHealth was found to be a facilitator under resources and logistics, there should be more implementation of and research on digital health solutions for surveillance and innovative OCV delivery strategies."

Recommendations for the betterment of cholera surveillance efforts, based on the results of this article, include:

• Putting into place detailed and structured record-keeping and reporting, having proper tools and know-how to analyse surveillance data, potentially using global positioning system (GPS) to pinpoint accurate locations of cholera cases, and showing flexibility and providing generous hours for vaccine campaigns;
• Improving communication between neighbouring communities in order to strenghthen local-level collaboration, such as by focusing on low-cost mHealth interventions (e.g., using designated cholera mobile phones in order to communicate new cases between neighbouring communities and to share and provide information and assistance; and
• Fostering collaboration between community members, cholera stakeholders, and representatives from government bodies and non-governmental organisations (NGOs) to further surveillance and OCV campaign activities. "National policymakers should also actively include trusted community members and leaders in policy decisions on cholera control, as they have a direct connection the community."