How Rising Star Awardee Dr. Sangwe Clovis Nchinjoh is Transforming Vaccine Outreach in Remote Cameroon

With his 2023 Sabin Rising Star Award barely in the rear-view mirror, Cameroon public health physician Sangwe Clovis Nchinjoh is once again generating notice as the lead author of an implementation study in Vaccine that showcases impactful results from his on-the-ground vaccination work in the country’s remote Manoka Health District (MHD) fishing villages. In two previous studies, Nchinjoh quantified,  characterized and explained the reasons for the district’s high number of zero-dose children (91.7% of the under-2 population). In the new study, he shows how he generated vaccine demand by implementing a community-oriented primary healthcare (COPC) model, which builds trust by incorporating existing resources and providing care relevant to the community. We caught up with him in Nigeria, where he now works as a manager for the Clinton Health Access Initiative’s vaccine program, to talk about the study and his life since winning the award. 

What was the tool you used to overcome the many barriers to vaccination you found when looking for the zero-dose children in Cameroon’s Manoka district?

High disease burdens such as malaria and water-borne diseases in these settlements, which are accessible only by boat at high tide, have forced the population to depend on herbalists and roadside drug vendors, eroding trust in the primary healthcare system and worsening vaccine hesitancy. We looked at how we might generate vaccine demand by using an integrated community health worker service delivery package designed based on the community-oriented primary healthcare (COPC) model. 

It gives you a systematic approach to combining your routine curative service delivery with community medicine. So, instead of treating the midwives and herbalists like two different systems, it allows you to integrate them.  

How does that integration happen? 

In most settings, when we are designing interventions, people think the zero-dose population is hesitant, they don’t want vaccines, they prefer to deliver at home. In reality, everyone really wants to be taken care of and everyone wants good health. But now if you find yourself in a setting where you don’t have access to health services for one reason or the other, you need to design a coping mechanism. That becomes either a relative who will help you conduct that delivery or a traditional attendant, or you use a herbalist for your fever.  There are consequences to this, but they feel that this is their best option. 

Now imagine if the only way vaccines are being delivered is through a campaign that comes to these communities maybe twice or three times a year just to deliver vaccines and leave. Of course, there are bound to be hesitancies. They cannot trust you because you are never there, but they can trust the herbalist or their relatives because they are always there. 

What is special about the COPC model is that it gives you a systematic approach of combining your routine, essential service delivery with community medicine. You work with the communities to prioritize what solutions you know should be implemented. Since in this specific health area there were no functional health facilities, we worked with community health workers, training the people selected by the community themselves, and then work with them to deliver some service packages that the World Health Organization has validated that community health workers can actually offer, such as treating local diseases and education.  

Do the community health workers actually provide vaccines? 

No, but when we included vaccination services as part of the package, you know, saying community workers need to do counseling on vaccination, screen if a child is vaccinated, then refer them to a health facility where vaccinations are provided or arrange an outreach to receive the vaccination at home, we were able to mobilize patients. This had the effect of building trust over time. It empowered those community health workers to be able to talk about important parts of the health system. And people listen to them. 

Were you surprised that you were able to vaccinate 64% of the zero-dose children? 

Yes, absolutely. When we started the project, we expected to move the needle just a little bit. Quite frankly, at the beginning it was a little disappointing because we trained workers to refer children for vaccination services, but they didn’t go. So, we came back and met with the community health workers again to re-emphasize the importance. We realized that the more we kept on having these community health workers go through these households, deliver services that meant a lot to the community, and talk about vaccines, then gradually the community started listening and trusting that this would be useful for their child. But it had to be tied to helping with malaria or things that were important to them. It became apparent that building trust was very important and led to the kind of result we did not expect. 

Is this model something that can be utilized in other communities?  

That’s a very good question. We’ve been able to do this in a very small setting, and it has shown its potential. Can we now get the support to do this on a larger scale? It would need the government to provide the resources to run this kind of implementation study for HPV vaccines, for malaria vaccines, and things like that. Hopefully these studies will guide more stakeholders to use more systematic approaches to thinking about how vaccines are rolled out. Because probably what has handicapped our successes in generating vaccine demand and improving service delivery is the method that we’re using. Maybe the method has just too many limitations when it comes to addressing the situation on the ground, or maybe it’s working a little, but this kind of model would provide more productive results. 

Cameroon introduced the new RTS,S malaria vaccine this year. Is there more acceptance of a vaccine for a disease that affects so many in the country? 

I would like to call it a huge success because the target was around 50 percent, but they had 57 percent vaccination coverage (first dose) in the pilot districts. And there was a huge acceptance rate, close to 90 percent, based on a survey conducted prior to the initial roll out. But the difficulty is that there are four doses for this vaccine, and by the second dose the rate dropped to 44%. There are several reasons. In Cameroon, the vaccine is given at six months, seven months, nine months and 24 months so it is not exactly same as the routine schedule that we are very conversant with. So it is putting a strain on households because it requires that they go back to get the vaccine several times. We are just beginning to see that happen. Also, apart from that, this introduction was done just post-COVID. People are still trying to heal from the hesitancies, the spillover effect of those COVID vaccinations and so on. I think everyone is learning from the experience in Cameroon. 

Are you still working to support communities like Manoka? 

Although the program in Manoka came to an end, Rural Doctors, the non-profit I started, is still supporting similar communities, and I currently sit on the Board. Rural Doctors is setting up like a community health research hub, focused on partnering with educational institutions and relevant partners to optimize the quality of community-related research. We realized there is so much need in terms of how we interpret, how we conduct research at a community level. We want the research hub to build the capacity of young people on how to go about this kind of research and also to actively participate in generating this kind of interesting evidence that will help to catalyze how interventions are rolled out, especially with respect to access and utilization of primary health care services.  

Are you doing more COPC research? 

I’ve commenced a PhD program at the University of the Free State in Bloemfontein, South Africa. The study that I’m currently conducting, which is part of my PhD thesis, is about developing a pandemic resilience framework to optimize routine immunization and maternal neonatal child health services in sub-Saharan Africa, especially post-COVID-19. Recall that in Cameroon or in sub-Saharan Africa in general, we record some of the highest mortalities when it comes to under-five mortality and maternal mortality. Then COVID -19 came in and further stretched the inequalities that already existed.  

Being able to come up with, you know, a framework which countries can use to take actions, to decide, based on this experience with COVID, how can we use this framework to optimize how our maternal neonatal child services and routine immunization is rolled out such that even if we have a pandemic of similar magnitude, the effect will not be as grievous as the last time.