# Allocation of Oral Cholera Vaccines in Africa

## TL;DR

This study analyzes how oral cholera vaccines are distributed in 25 African countries, finding that most allocations are reactive and delayed, with institutional strength and geographic location influencing access.

## Contribution

The study introduces a 'cholera risk index' as an instrumental variable to evaluate vaccine allocation dynamics and highlights delays and inequities in vaccine distribution.

## Key findings

- 77.4% of OCV allocations were reactive, with governments taking 299.6 days to request doses.
- Countries with strong institutions and central African regions were more likely to receive vaccines.
- Reactive allocation was 48.4 percentage points more probable than preventive allocation.

## Abstract

Objectives: In this study, we examine the allocation of oral cholera vaccines (OCVs) across 25 African countries between 2013 and 2019. Methods: We constructed a dataset combining cholera outbreaks and requests, decisions, and deliveries of OCVs from the Global Task Force on Cholera Control, alongside additional covariates. Using machine learning algorithms, we assess the relative importance of socio-demographic, governance, and weather variables in predicting cholera outbreaks. We constructed and used an “index of cholera risk” as an instrumental variable to predict the likelihood of suspected cases and estimate the impact of cholera outbreaks on OCV allocation. Results: The majority of OCVs (77.4%) were allocated reactively. Governments took an average of 299.6 days to request doses, international agencies took 10.4 days to decide, and it took 84 days for vaccines to be delivered. Countries experiencing a cholera outbreak were 31.7 and 36.5 percentage points more likely to request and receive a vaccine delivery in the same month as the outbreak, respectively. We confirmed that the probability of obtaining vaccines through a reactive mechanism was 48.4 percentage points higher compared to preventive allocation. When exploring the heterogeneity of impacts, OCVs were more likely to be requested, allocated, and delivered in countries with strong institutions and those not facing crisis situations. OCVs were also more likely to be allocated in the central parts of the continent. Conclusions: While OCV allocation is responsive to cholera outbreaks, addressing delays, particularly in high-risk countries, could improve their distribution and mitigate the impact of cholera outbreaks. This study highlights the need for targeted strategies to ensure vaccine access in fragile and conflict-affected settings, where institutional capacity is weaker.