Voices from the field: Rolling out a COVID-19 vaccination campaign in the world’s largest refugee camp

Refugees of 55 years-old and above received last week the second dose of COVID-19 vaccine in the Rohingya refugee camps in Cox’s Bazar. A total of 33 386 people – 19 919 male and 13 467 female – completed the required doses of vaccination throughout a 6-day vaccine roll-out that, despite initial uncertainty and hesitancy, registered a high uptake among a population with a history of limited health seeking behavior.

WHO assisted the Government of Bangladesh through technical and operational support to ensure the effective roll-out of the vaccine among Rohingya refugees. WHO Bangladesh/ Irene Gavieiro Agud

In the early morning of 23 September, Nur Hossain was the first male refugee to arrive to the Gonoshasthaya Kendra (GK) Primary Health Care facility in camp 4 to receive his second dose of the vaccine. “I came with my wife. We have a long way back home and we wanted to make sure we received the vaccine”, he said. Few meters away, in the female waiting area, Soyoda Khatun was also waiting for her turn accompanied by other early riser women: “I want to get the vaccine so that I don’t get affected by the coronavirus”. In the future, she said, she would also like the younger members of her family to receive it and be protected.

Nur and Soyoda are the stark illustration of the good will extended among the eldest population group of the Rohingya community to receive the COVID-19 vaccine despite their initial fears.  

“We were very well aware that this was going to be a particular vaccination campaign. We were introducing  new vaccine among a population with low protection against vaccine-preventable diseases and many misconceptions and stigma around infectious diseases, so all our efforts focused on increasing their acceptance and confidence”, says Dr Md Zion, WHO Immunization and Vaccine Development (IVD) Coordinator.

Rohingya refugees waiting to submit their vaccination card at the entrance of the vaccination center. WHO Bangladesh/ Jubair Bin Iqbal

Preparations for the COVID-19 vaccination campaign started many months before the roll-out of the first round in August 10. In early 2021, coinciding with the national campaign roll-out, a micro-plan for COVID-19 vaccination in the Rohingya refugee camps was prepared under the leadership of Government health authorities with the involvement of multiple stakeholders, including WHO as chief technical advisor. Community Health Workers (CHWs) led by UNHCR and the Communication for Development (C4D) Working Group led by UNICEF also formed part of the initial consultations to ensure well-coordinated community outreach and mobilization throughout the campaign.

Aligned with the Bangladesh National Deployment and Vaccination Plan (NDVP) for COVID-19, the Operational Guidelines were adjusted to the context in the Rohingya refugee camps through a consultative process with the Civil Surgeon, the Ministry of Health and Family Welfare - Coordination Center (MoHFW-CC), the Refugee Relief and Repatriation Commissioner (RRRC) and key humanitarian partners.

A total of 56 health facilities were identified as vaccinations sites in the camps and 58 vaccination teams –comprising of two vaccinators and four trained volunteers– were formed. Additionally, every healthcare facility designed one supervisor, two Adverse Event Following Immunization (AEFI) focal persons and one verifier for better vaccine management and monitoring.  

First Rohingya refugee arriving to the vaccination center in camp 4, Janina Khatun, shows her vaccination card while she waits for her turn. WHO Bangladesh/ Irene Gavieiro Agud

Throughout the COVID-19 vaccine roll-out, every vaccination session in the Rohingya camps was closely monitored through online and offline mechanisms. A skilled workforce of 25 WHO Health Field Monitors (HFMs), along with health humanitarian partners and Government officials supervised vaccination through several monitoring checklist tools previously designed by WHO.

“These session monitoring checklists enable the systematic collection of data at vaccination sites, which WHO analyzes in real time for evidence-based decision-making during the campaign.  All the data is integrated into an interactive dashboard which allow us to identify any problems in the vaccination center and immediately take the necessary actions”, explains Md. Ahadur Rahman, Data Executive at WHO.

WHO Health Field Monitor, Dolna Dey, provided technical support to Government and humanitarian partners to ensure the safe and effective roll-out of the campaign. WHO Bangladesh/ Irene Gavieiro Agud

WHO also provided technical guidance to design the COVID-19 vaccine card, which involved written consent from the Rohingya people. “Unlike previous campaigns, due to the novelty of the vaccine, this is the first time that written consent from vaccine recipients has been needed, which has increased concerns among some of them”, explains Dr Jubayer Mumin, one of the WHO Surveillance & Immunization Monitoring Officers (SIMO), who has been responsible for monitoring the campaign in the eight camps located in Teknaf Upazila.

Additionally, as part of the innovations recently implemented in the COVID-19 vaccination for the Rohingya community, a digital verification system was introduced to confirm the identity of the vaccine recipient during the registration process. This brought along some initial challenges due to the difficulty in determining the exact number of beneficiaries, which was based on the block-wise population data collected by UNHCR.

Prior to the vaccine roll-out, WHO conducted several visits to health facilities to assess and map those that could support the COVID-19 vaccination campaign in the camps. WHO Bangladesh/ Irene Gavieiro Agud

One of the biggest concerns that arose when planning the COVID-19 vaccination roll-out in the world largest refugee camp was maintaining the cold chain during the whole distribution process to ensure the effectiveness and safety of the vaccines.

Due to the limited cold storage capacity in the camps, WHO also supported the logistics and vaccine transportation from the two Upazila Health Complexes (UHC) belonging to the Government, where the vaccine was stored in Ice-Lined Refrigerators after traveling from Dhaka, to the 56 vaccination centers in the camps. “The COVID-19 vaccine distribution process starts here every morning around 5.30 am”, says Dr Sujit Paul, WHO SIMO at the Ukhiya UHC. “We support the Government staff to prepare the vaccine carrier cases that will be distributed among the vaccination centers in the refugee camps. Every carrier case has four sets of ice packs that can maintain the vaccines for 24 hours”, Dr Sujit adds.

WHO monitored the transportation at the Upazila Health Complex to ensure the safe vaccine storage and proper cold chain requirements. WHO Bangladesh/ Irene Gavieiro Agud

Once the vaccines are ready to be transported, one of the WHO Health Field Monitors (HFMs) will be waiting at the vaccine distribution point at camp level to supervise the reception of the vaccine carrier cases by the vaccination center. “It is important to monitor and document the whole supply chain process to ensure that an appropriate number of vaccines reach the healthcare facility, and that not a single one of these vaccines is wasted”, says Dolna Dey, WHO HFM at Camp 4. “Once the vaccination session ends, we make sure that the vaccines that have not been used are sent back to the Upazila Health Complex for cold storage”, she says.

In the vaccination site, HFMs as Dolna work hand in hand with vaccination site supervisors, AEFI focal teams (doctor and nurses), vaccinators and volunteers to ensure smoothly and safe deployment of the vaccines. They also provide monitoring support to capture any adverse effects that may occur after vaccination, and work closely with Rohingya volunteers to better understand the perception and concerns of the target group . They are the last and fundamental gear within the vaccination process.

Rohingya volunteers helped the eldest members of their community reach the COVID-19 vaccination centers. WHO Bangladesh/ Jubair Bin Iqbal

Rohingya volunteers engaged as Community Health Workers (CHWs) are the keystone within an extensive communication and engagement campaign devised among UNHCR, UNICEF and WHO, under the leadership of the Government, to raise confidence, trust, and acceptance among the Rohingya refugees, and thus lead to better uptake of the COVID-19 vaccine.

They are trusted members of their community, as Md Ayatullah, and their mission is to share correct, up-to-date and appropriate health information to increase awareness around COVID-19 and vaccination. “Many people are happy to receive the vaccine, but others had much fear and thought that it will worsen their health condition. In this case, I explain them that vaccines strengthen their immune system and can protect us from many diseases”, he said.

Rohingya volunteers also played a key role helping elderly people with reduced mobility reach the vaccination centers from their homes, which in many cases was not an easy feat due to the rugged terrain in some camps.

The WHO IVD team has been working tirelessly to ensure that no refugee is left without a COVID-19 vaccine. WHO Bangladesh/ Jubair Bin Iqbal

“The high vaccination uptake in this first round of vaccination is the reflection of the strong commitment and hard work of the many actors involved in the campaign, who sacrificed sleeping hours in the last few days to ensure that no Rohingya refugee is left out of COVID-19 vaccination”, acknowledges Dr Kai von Harbou, Head of WHO Emergency Sub-Office in Cox’s Bazar. “I want to express my thanks and gratitude to the Government, health partners and in particular all the frontline workers in the camps for making this possible. Vaccine equity offers the best hope for slowing the coronavirus pandemic and save lives, and refugee populations should not be left behind of the global efforts”.