A primary objective of the MVIP pilot programme was to assess the feasibility of administering the recommended 4 doses of the RTS,S malaria vaccine to young children in routine use in African settings. When pilot introductions started in Ghana, Kenya and Malawi in 2019 there had never been a childhood vaccine for malaria, and its administration would require caregivers to bring their children to vaccination clinics for extra vaccine visits, with one near 2 years of age, later than for other childhood vaccines.
More than 3 years after the launch of the malaria vaccine in pilot implementations, evidence and experience gained in the pilots have confirmed that the vaccine is safe, life-saving and feasible to deliver. The pilots also provided the opportunity to learn how to overcome challenges administering the 4-dose vaccination schedule to achieve good uptake and community acceptance.
Across the 3 countries, challenges around the dosing schedule were similar, as were some of the interventions put in place to tackle them. In this article, Expanded Programme on Immunization (EPI) officers from each of the countries share their reflections.
1. Supportive supervision visits identified challenges early on.
The 3 countries shared similarities when it came to identifying missed opportunities for vaccination and tackling misunderstandings among health workers about the vaccination schedule. Across the board, visits to health facilities by EPI officers to witness vaccination in action and provide on-site training to health workers – known as supportive supervision—identified challenges and ways to rectify them.
“Early on, we noted poor uptake of the vaccine in some facilities. When we went deeper through supportive supervision, and we went through scenarios with health workers of what they do if a child comes at a certain age [outside of the formal vaccination schedule], we uncovered a lot of misunderstood information, so we had to come in and intervene,” said Mr Thomas Mavuto, Ministry of Health (MoH), Malawi.
2. Health workers need clear guidance on actions to take when children do not come to the clinic on schedule.
Across the countries, health workers experienced challenges handling children who did not show up for vaccination on the expected schedule: 5, 6, 7 and 22 months in Malawi; and 6, 7, 9 and 24 months in Ghana and Kenya. In the first few months of introduction, health workers were often unsure whether to vaccinate children coming late for their 1st dose, or for subsequent doses.
“There were missed opportunities for vaccination. In some areas, when a child came and was age 7 months, health workers would not give the vaccine,” said Dr Kwame Amponsa-Achiano, MoH Ghana.
One reason for the confusion was that countries initially adopted schedules that emphasized specific ages for each dose. In trainings, health workers were instructed to vaccinate children who fit specified age brackets. One reason for emphasizing specific ages for vaccination was concern about available vaccine supply in the initial months: the fear was that if all children under age 1 were eligible for the 1st dose there would not be enough vaccine to meet demand. As this was the first real-world vaccine implementation, countries were unsure how much to deviate from the recommended schedule. The result was that health workers were less confident handling scenarios that called for flexibility. In response, the countries reviewed and revised communications and training materials for health workers to clarify guidance (see number 4 below).
Shortly after becoming aware of some misunderstanding on the schedule, countries went back to the drawing board to ensure that information products, job aids and health messages for caregivers were as clear as possible.
3. Changing the vaccination schedule can add confusion.
In Kenya, at the launch of pilot introduction, the recommended schedule for dose 1 was age 6 months. When decisions were made to ‘relax’ the eligibility and offer the 1st dose to children up to 1 year of age, it took some time for health workers to become familiar with the change and implement it.
“When we first trained health workers, we told them the schedule was 6, 7, 9 and 24 months. But during implementation, after noticing missed opportunities for vaccination, we expanded the eligibility for the first dose from 6 months to before the child celebrates their 1st birthday. The change introduced some problems,” said Dr Rose Jalang'o, MoH Kenya.
With any new vaccine, health workers and caregivers need to get used to a new schedule. Countries should adopt clear messaging about the recommended schedule from the start and communicate consistently on how to catch up on any missed doses along the way, for example, that the malaria vaccine could be provided with a minimum of 4 weeks between doses. “They need to be as clear as possible,” added Dr Jalang'o. In Kenya, the team decided to modify vaccination stickers to further reduce confusion. While child health book stickers to document receipt of doses initially were labelled 6, 7, 9 and 24 months, the team changed those to read dose 1, 2, 3 or 4, so there wasn’t any confusion if a child presented late for vaccination.
Ghana and Malawi developed short educational videos for health workers that outlined the dosing schedule and how to handle scenarios that might arise when children came late. In Ghana, this included a virtual, interactive quiz distributed on messaging platforms that presented multiple situations and real-time feedback on the correct way to respond. These remote tools were particularly useful in the Covid-19 context when trainings and visits to communities were limited or put on hold.
“We came up with messages that are tailored for health workers, particularly those responsible for screening children for vaccination. The caregiver might bring the child to the clinic, but the health worker might not offer that service to a child if the vaccinator cannot determine if the child should receive the vaccine,” said Mr Mavuto.
Countries also noted the importance of collaboration between the EPI and national malaria control programmes to ensure that health messages, leaflets and posters include facts on malaria and how to prevent it as well as the benefits of the new malaria vaccine.
“The two programmes can leverage each other’s strengths during community engagements, communication efforts and media events. The malaria control team can use the existing EPI infrastructure as much as possible,” said Dr Jalang’o.
5. Countries will need plans to ensure all children receive 4 doses of the vaccine.
A key challenge across the 3 countries is uptake of the 4th dose, which is scheduled near age 2 years and several months after children would have finished other childhood vaccinations.
“In Malawi the last vaccination visit…had been the 2nd dose of the measles-rubella vaccine, which comes when the child is 15 months old. Caregivers were used to the last visit at that age, but now they had to come again when the child is almost 2 years old,” said Mr Mavuto.
Today, WHO’s March 2022 position paper on the malaria vaccine recommends flexibility for country immunization programmes to determine the malaria vaccine schedule in ways that “optimize delivery, for example, to align the 4th dose with other vaccines given in the 2nd year of life.”
Following the WHO recommendation, and based on the country’s experience, Ghana recently decided to re-set its schedule for the 4th dose of malaria vaccine to age 18 months to coincide with the country’s schedule for dose 2 of the measles-rubella vaccine.
“Based on our experience, I believe the first 3 doses won’t be a challenge, but for the 4th dose, given that all 3 pilot countries are struggling somewhat on uptake of the final dose, other countries may be able to learn from our experience. If they can start 4th dose administration from 18 months, or at an age at which most countries have other vaccines, I think that it’s better,” said Dr Kwame.
Kenya is considering a similar change to its vaccination schedule. Malawi has decided to retain its schedule of 22 months for dose 4. Additionally, to promote increased uptake of all doses, Malawi has increased training to health workers to inform them that they should offer the vaccine to any child who presents for vaccination from 5 months of age and should maintain a minimum of 4 weeks between vaccine doses; furthermore, the MoH plans to take opportunities to inform caregivers about the vaccine and its schedule, including via community-based radio. Looking forward, all of the pilot countries are considering ways to build on additional malaria vaccine visits to increase uptake of other child health services.
“We are working to make parents aware that apart from malaria vaccination, they should come to the facility for normal growth monitoring and other services like vitamin A. We need to communicate that as a package,” added Dr Mavuto.
6. The most effective scheduling decisions and interventions are country specific.
A key takeaway from this discussion with experts in the malaria vaccine programme was that countries should tailor the recommended vaccination schedule and information, education and communication efforts to their context.
“Scheduling decisions should be based on getting the maximum impact. There are always pros and cons, and every schedule will have some limitations, or some challenges, so it’s about making the decision based on what works best for your country,” said Dr Kwame.
“Countries should consider using the same traditional communication channels they use for other vaccines. They know how they do their own communications, how to communicate with communities, and that will help them tackle potential challenges,” said Mr Mavuto.
Thank you to Dr Kwame Amponsa-Achiano, Ghana Ministry of Health, Dr Rose Jalang'o, Kenya Ministry of Health, and Mr Thomas Mavuto, Malawi Ministry of Health for your contributions.