One of the main objectives of the MVIP pilot program was to assess the feasibility of administering the recommended 4 doses of the RTS,S malaria vaccine to young children for routine use in Africa. When pilot introductions began in Ghana, Kenya and Malawi in 2019, there had never been a childhood malaria vaccine, and administering it would require caregivers to bring their children to vaccination clinics for vaccination visits. additional vaccines, including one almost 2 years old, later than for other childhood vaccines.
More than 3 years after the launch of the malaria vaccine in pilot implementations, the evidence and experience gained in the pilots has confirmed that the vaccine is safe, lifesaving and possible to administer. The pilots also provided an opportunity to learn how to overcome the challenges of administering the 4-dose vaccination schedule to achieve good uptake and community acceptance.
In all 3 countries, the challenges with the dosing regimen were similar, as were some of the interventions put in place to address them. In this article, Expanded Program on Immunization (EPI) officials from each country share their thoughts.
1. Supportive supervision visits identified challenges early on.
The 3 countries share similarities when it comes to identifying missed opportunities for vaccination and resolving misunderstandings among health workers regarding the vaccination schedule. Overall, visits to health facilities by EPI workers to witness vaccination in action and provide on-site training to health workers – known as supportive supervision – identified challenges and ways to solve them.
“Early on, we saw poor uptake of the vaccine in some facilities. When we went deeper into supportive supervision and discussed scenarios with health workers about what they do if a child reaches a certain age [outside of the formal vaccination schedule]we discovered a lot of misunderstood information, so we had to go in and intervene,” said M Thomas Mavuto, Ministry of Health (MoH), Malawi.
2. Health workers need clear guidelines on what to do when children do not come to the clinic on time.
In all countries, health workers struggled to care for children who did not present for vaccination on schedule: 5, 6, 7 and 22 months in Malawi; and 6, 7, 9 and 24 months in Ghana and Kenya. During the first few months of introduction, health workers often did not know whether to vaccinate children who arrived late for their 1st dose, or for subsequent doses.
“There have been missed opportunities for vaccination. In some areas, when a child arrived and was 7 months old, health workers would not give the vaccine,” said Dr Kwame Amponsa-Achiano, Ghana Ministry of Health.
One reason for the confusion was that countries initially adopted schedules that emphasized specific ages for each dose. During the trainings, the health workers were instructed to vaccinate children who correspond to specified age groups. One of the reasons for emphasizing specific ages for vaccination was concern about the supply of vaccines available in the early months: the fear was that if all children under 1 were eligible for 1st dose, there would not be enough vaccines to meet demand. As this was the first real-world implementation of a vaccine, countries were unsure how far to deviate from the recommended schedule. The result was that health workers were less confident about scenarios requiring flexibility. In response, countries reviewed and revised communication and training materials for health workers to clarify guidance (see number 4 below).
Shortly after becoming aware of a misunderstanding over the timeline, countries went back to the drawing board to ensure that information products, checklists and health messages for caregivers were as clear as possible.
3. Changing the vaccination schedule can add confusion.
In Kenya, when the pilot introduction was launched, the recommended schedule for dose 1 was 6 months. When it was decided to “soften up” eligibility and offer the 1st dose to children up to 1 year old, it took some time for health workers to become familiar with the change and implement it.
“When we first trained the health workers, we told them the timeline was 6, 7, 9, and 24 months. But during implementation, after noticing missed opportunities for vaccination, we expanded eligibility for the first dose from 6 months to before the child turns 1st birthday. The change introduced a few issues,” said Dr Rose Jalang’o, Kenya Ministry of Health.
With any new vaccine, health workers and caregivers have to get used to a new schedule. Countries should adopt clear messaging on the recommended schedule from the start and communicate consistently on how to catch up on missed doses along the way, for example that the malaria vaccine can be given with a minimum of 4 weeks between doses. “They should be as clear as possible,” added Dr Jalang’o.
In Kenya, the team decided to modify the vaccination stickers to further reduce confusion. While the child’s health book stickers to document receipt of doses were initially labeled 6, 7, 9 and 24 months, the team changed them to read dose 1, 2, 3 or 4, it n There was therefore no confusion if a child showed up late for vaccination.
Ghana and Malawi developed short educational videos for health workers that described the dosing regimen and how to handle scenarios that can arise when children arrive late. In Ghana, this included a virtual and interactive quiz distributed over messaging platforms that featured multiple situations and real-time feedback on the right way to answer. These remote tools have been particularly useful in the context of Covid-19 when trainings and community visits were limited or put on hold.
“We came up with tailored messages for health workers, especially those in charge of screening children for vaccination. The caregiver can bring the child to the clinic, but the health worker may not offer this 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 programs to ensure that health messages, leaflets and posters include facts about malaria and how to prevent it as well as the benefits of the new malaria vaccine.
“Both programs can leverage each other’s strengths in community engagements, communications efforts and media events. The malaria team can use the existing EPI infrastructure as much as possible,” said Dr. Jalang’o.
5. Countries will need plans to ensure that all children receive 4 doses of vaccine.
A major challenge in the 3 countries is the adoption of the 4e dose, which is due around age 2 and several months after children have completed other childhood immunizations.
“In Malawi the last vaccination visit… had been the 2n/a dose of the measles and rubella vaccine, which is given when the child is 15 months old. Caregivers were used to the last visit at this age, but now they had to come back when the child was almost 2,” said Mr Mavuto.
Today, WHO’s March 2022 position paper on malaria vaccine recommends that national immunization programs exercise flexibility in determining the malaria vaccination schedule so as to “optimize administration, for example, to align the 4th dose with other vaccines given during the 2n/a year of life. »
Following the WHO recommendation and based on the country’s experience, Ghana recently decided to redefine its schedule for the 4th dose of malaria vaccine at 18 months of age to coincide with the schedule country for dose 2 of the measles-rubella vaccine.
“Based on our experience, I think the first 3 doses will not be a challenge, but for the 4e dose, given that the 3 pilot countries are struggling to absorb the final dose, perhaps other countries could learn from our experience. If they can start 4e giving the dose from 18 months, which is an age when most countries have other vaccines, I think is best,” said Dr Kwame.
Kenya is considering a similar change to its immunization schedule. Malawi has decided to maintain its 22-month schedule for dose 4. Additionally, to promote increased uptake of all doses, Malawi has increased training of health workers to inform them that they should offer the vaccine to any child presenting for vaccination from the age of 5 months. of age and must maintain a minimum of 4 weeks between vaccine doses; in addition, the Ministry of Health plans to seize opportunities to inform caregivers about the vaccine and its schedule, including through community radio. Going forward, all pilot countries are considering ways to leverage additional malaria immunization visits to increase utilization of other child health services.
“We are working to make parents aware that apart from malaria vaccination, they need to come to the facility for normal growth monitoring and other services like vitamin A. We need to communicate this under package form,” added Dr. Mavuto.
6. Programming decisions and the most effective interventions are country-specific.
A key takeaway from this discussion with malaria immunization program experts was that countries should adapt the recommended immunization schedule and information, education and communication efforts to their context.
“Planning decisions should be based on achieving maximum impact. There are always pros and cons, and every timeline will have limitations or challenges, so it’s all 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 deal with potential challenges,” said Mr. Mavuto.
Thanks 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.