Tikonko Chiefdom Malaria Vaccine Project Final Report

Sierra Leone has one of the highest malaria burdens in the world, with more than 2 million hospital admissions a year, half of which are among children aged under 5 years ‒ accounting for 20% of deaths in this age group. (WHO)

The Malaria Vaccine Project was designed to reduce malaria cases, hospitalizations and deaths from malaria in children by developing strategies to increase uptake of the RTS, S malaria vaccine among eligible children.

Community Need
In December 2023, Sierra Leone received 550,000 doses of the WHO-recommended malaria vaccine. Gavi approved 1.7 million doses for Sierra Leone between 2024 and 2025. The vaccine is effective at reducing clinical disease by 39%, severe malaria by 31.5%, and hospitalizations by 37.2%.

Mathematical modelling predicts a decrease of 1,774 malaria cases for every 1,000 doses of vaccine (European Medicines Agency, 2015). There were 913 births in 2023 at RHCI  (Rural Health Care Initiative) supported health centers. If 75% of these births received 4-doses of the malaria vaccine, there could be a reduction of 4,870 cases of malaria over a four-year follow-up period for infants vaccinated in the first year of distribution.

Studies evaluating the implementation of the vaccine concluded substantial operational challenges. The four-dose schedule was complex and aligned poorly with the childhood immunization schedule. There was low uptake on the fourth dose, low knowledge and support in communities. Insufficient resources were noted as obstacles. Recommendations included: having strong defaulter tracing programs, community sensitization, and intensive staff training (Lancet, February 28, 2024).

The Bo District Medical Office requested support for the malaria vaccine campaign. Vehicles and fuel are needed for distribution. Financial resources are needed to support the vaccine cold-chain requirements, training and materials, and updated immunization cards. RHCI will increase support for the defaulter tracing program. Education will be provided for community health workers and village stakeholders to support vaccine messaging.

RHCI supports a robust defaulter tracing program. In 2023, 2,375 children were updated in their home village for immunizations. RHCI is in a strong position to support the malaria vaccine campaign that will reduce malaria cases, severe illness and hospitalizations with this grant.

Project Activities

Three main activities were implemented in this project:   

• 1. Support the Bo District Health Management Team with vaccine distribution to health facilities.
  2. Provide cold chain storage maintenance
  3. Vaccinate eligible children and support the Expanded Program for Immunization (EPI) to increase uptake of the malaria vaccine

The Bo Rotary Club participated in supervision visits at multiple locations with the EPI nurses to document activities and impact of the malaria vaccine program in remote hard-to-reach locations.

Saffie Kornya Jusu, Gondama CHC
Lead Vaccine Nurse
Lembema II village. Saffie, Adella and two community health workers

Supporting Vaccine Distribution

Activity Description:  Sierra Leone began distribution the RTS, S malaria vaccine in April of 2024.  The initial supply of vaccine was low and there were very narrow age eligibility requirements for children.

This grant began in January of 2025 with two experienced EPI nurses that supported the malaria vaccine and EPI protocol previously for the implementing partner.  These two nurses served as training  mentors for the five new EPI nurses.  The vaccine supply was readily available at the start of this project and the eligibility requirements for children expanded and included a protocol to catch-up children that did not meet the initial eligibility requirements. 

Training for all seven nurses included formal classroom training on the malaria vaccine including the catch-up protocol and the full Expanded Program of Immunization curriculum.  The implementing partner trained the nurses on the use of the mobile phone for data collection and submission, the activity protocol including engagement with village community health workers, and coordination with contracted motorbike drivers to facilitate transportation to the villages. 

January, 2025 was considered a mentored training month for the five new nurses. Activity during the training month is documented in this report.  Two additional trainings were completed during the grant where topics for improvement were identified in quality improvement reviews.

Nurses with the support of a motorbike rider travelled to villages two days a week.  Village visits were coordinated with community health workers who notified caregivers of the nurse visit.  Stakeholders in villages were identified and trained to support vaccine knowledge and supported community members and nurses when caregivers were hesitant to vaccinate their children. 

During the village visit, the community health worker brought the nurse to the homes of children eligible for vaccines.  All immunization records were reviewed by the nurse.  Children eligible for any vaccine or preventative treatment were updated.  One day each week, the nurse was required to attend their scheduled motorbike outreach clinic.  Children’s immunization records and immunizations were provided as appropriate.  ntil the fourth dose at 18-months.  Breakthrough infections were identified at the interim report and were communicated to the District Health Management Team.  The final data reinforces this trend.  In February, 2026, the Sierra Leone Ministry of Health updated the protocol requiring the fourth dose at 15-months to overcome the high dropout rate between doses three and four.  This schedule change may or may not decrease the cases of severe malaria between the last two doses.  Data from this project show two of five hospitalizations for malaria among children who had received the first three doses may be prevented by the new vaccine schedule.  Most hospitalizations for malaria among children receiving any vaccine occurred in younger infants, six to eight months of age and between the first two vaccine doses.  June had the highest number of hospitalizations among children receiving any dose of vaccine.  The Ministry of Health does not have a system that links vaccination status to hospitalizations, so partners like RHCI will be instrumental in informing government partners regarding trends identified.

The Mosqirix vaccine does not correlate well to the childhood immunization schedule.  The protocol requires doses and 6, 7, 8 and 18 months.  For children behind on the schedule, dose 4 can be completed up to 59 months of age.  The first three doses do not correlate with any other childhood vaccinations. 

One of the concerns identified during this project is the discrepancy in reporting malaria vaccine data between RHCI and the government.  RHCI had higher reports of vaccine administered than the government.  This is likely due to weekly follow-up by the data manager at RHCI with each nurse.  The nurse was required to have all data submitted to receive their monthly stiped for this project.  Discussions are occurring between RHCI and the EPI Focal Unit at the Bo District to design strategies to get quality and consistent data between the two partners.

The Head Sister I at the Bo DHMT is responsible for assigning EPI nurses to health facilities.  The implementing partner and the Chiefdom Supervisor who worked closely with this project did not have a role in assigning or reassigning nurses in the chiefdom.  This created a problem at two facilities during this grant period.  Both reassignments left at least a three-month gap at each facility in implementing the vaccine activities.  In the future, an attempt will be made to have the Head Sister I sign contracts for this work that will require nurses to be posted at a specific health facility for the duration of the project.

A high number of doses of malaria vaccine were administered in this project.  No stock-outs or shortages of the vaccine were reported.  Reporting for child hospitalizations was thorough and complete for four of the five health facilities.  In the interim report, there were four children hospitalized for malaria who had received any dose of malaria vaccine.  That number increased to thirteen children hospitalized at the end of the grant.  No child deaths were reported among children receiving the malaria vaccine.

The Sierra Leone Expanded Program for Immunization creates targets for the number of doses of each vaccine a health facility should administer based on their population of eligible children.  The target for the malaria vaccine at each health facility is 80% of the eligible population for each dose.  This grant provided a high level of support for the nurses including transportation, but the number of facilities meeting their target for each dose was low. 

This is in contrast to a paper published in Lancet that evaluated the vaccine roll-out in Sierra Leone (Lancet Prim Care; 1: 2025).  This article documents targets of 80% for dose 1 and 50% for dose 2 at roll out.  This article documented 71% coverage of dose 1 and 74% coverage of dose 2 among eligible children.  It is important to note, the roll-out period referenced in Lancet ended on December 31, 2024 and this grant began on January 1, 2025.  The table below is based on targets of 80% for each dose.  If the roll-out targets were used in this report, there would still be two facilities meeting the 80% target for dose 1, and four health facilities meeting the 50% target for dose 2.   

Malaria Vaccine Impact.  Data reported from 1/1/2025 – 1/30/2026.  The column “Number, Interim” was reported in the interim grant report with data through May 31, 2025.

The table below documents the number of each dose of malaria vaccine that was administered by each health facility supported in this grant.  Two facilities had two nurses that supported this grant five-days each week.  The remaining three facilities had one nurse supporting this project three-days a week.  One day each week was dedicated to supporting their motorbike outreach program, the remaining days were dedicated to work in the villages.  The Kassama health facility underperformed throughout the entire grant period.  They received many support visits from the implementing partner and did not meet their requirements for activity in the villages and outreach. 

This was primarily due to a leadership change at the health facility and a medical leave by the immunization nurse.  It took several months for these positions to be filled by the District Health Management Team in Bo.  Even prior to the medical leave, this facility was not going out on their visit schedule on a regular basis.  The Tikonko health facility lost their lead nurse in October which decreased their impact in the last several months of this project.  A new nurse was not identified until late December, 2025 but was not able to be trained to implement this program before the end of the grant,

Table 2.  Malaria Vaccine Administered by Health Facility, number of doses administered.  Data reported from 1/1/2025 – 1/30/2026.

This project had a strong focus on getting the malaria vaccine out into the villages and remote motorbike outreach posts.  Malaria vaccine provided at the health center were recorded for this project.  Some of the nurses collected immunization cards while they were in the villages for children needing vaccines.  They then instructed the caregiver to attend the immunization clinic at the health facility.   Some of the vaccines come in multiple dose vials and need to be discarded shortly after the vial is opened.  The malaria vaccine comes in a two-dose vial, so this is not a large concern, but other vaccines come in a 10dose vial.  If these vaccines were identified as needing updates, the child was more likely to be updated at the health center.  One health facility routinely implemented this procedure.  About 66% of all doses of the malaria vaccine were provided at a remote area (home village or motorbike outreach post).  This represents a significant success of this project.

Table 3.  Location of patient contact where malaria vaccine was administered, percent of doses administered.  Data reported from 1/1/2025 – 1/30/2026.  The column “Percent of Doses, Interim” was reported in the interim grant report with data through May 31, 2025.

Challenges

Providing the malaria vaccine as a tool to decrease severe illness and deaths is the underlying goal of this project.  The vaccine is one strategy to address this goal, but was accompanied with strong nurse training, community health workers (CHWs) testing and treating malaria in some villages, CHW training, stakeholder engagement, support of insecticide treated nets, recent indoor residual spraying, and diligent support of intermittent prevention of malaria in infants. Multiple strategies will need to be continually employed to reduce malaria cases, severe illness and deaths in children.

Eight of the thirteen children hospitalized for malaria during the grant cycle had received three doses of malaria vaccine.  The dosing schedule requires monthly dosing for the first three doses, followed by a ten-month span until the fourth dose at 18-months.  Breakthrough infections were identified at the interim report and were communicated to the District Health Management Team.  The final data reinforces this trend.  In February, 2026, the Sierra Leone Ministry of Health updated the protocol requiring the fourth dose at 15-months to overcome the high dropout rate between doses three and four.  This schedule change may or may not decrease the cases of severe malaria between the last two doses.  Data from this project show two of five hospitalizations for malaria among children who had received the first three doses may be prevented by the new vaccine schedule.  Most hospitalizations for malaria among children receiving any vaccine occurred in younger infants, six to eight months of age and between the first two vaccine doses.  June had the highest number of hospitalizations among children receiving any dose of vaccine.  The Ministry of Health does not have a system that links vaccination status to hospitalizations, so partners like RHCI will be instrumental in informing government partners regarding trends identified.

The Mosqirix vaccine does not correlate well to the childhood immunization schedule.  The protocol requires doses and 6, 7, 8 and 18 months.  For children behind on the schedule, dose 4 can be completed up to 59 months of age.  The first three doses do not correlate with any other childhood vaccinations. 

One of the concerns identified during this project is the discrepancy in reporting malaria vaccine data between RHCI and the government.  RHCI had higher reports of vaccine administered than the government.  This is likely due to weekly follow-up by the data manager at RHCI with each nurse.  The nurse was required to have all data submitted to receive their monthly stiped for this project.  Discussions are occurring between RHCI and the EPI Focal Unit at the Bo District to design strategies to get quality and consistent data between the two partners.

The Head Sister I at the Bo DHMT is responsible for assigning EPI nurses to health facilities.  The implementing partner and the Chiefdom Supervisor who worked closely with this project did not have a role in assigning or reassigning nurses in the chiefdom.  This created a problem at two facilities during this grant period.  Both reassignments left at least a three-month gap at each facility in implementing the vaccine activities.  In the future, an attempt will be made to have the Head Sister I sign contracts for this work that will require nurses to be posted at a specific health facility for the duration of the project.

Cold Chain Storage Maintenance
Activity Description: In the context of the Expanded Program on Immunization (EPI), a cold chain is the system of storing and transporting vaccines at a consistent temperature range to keep them potent and effective. Cold chain preventive maintenance is the routine and scheduled upkeep of equipment used to keep temperature-sensitive products, like vaccines, within their required temperature range during storage and transport. This includes tasks such as regular cleaning and defrosting of refrigerators, checking and testing alarms, and ensuring that temperature monitoring devices are functioning correctly. The goal is to ensure the equipment works optimally, maintains product quality, and prevents costly waste and loss.

All fourteen health facilities in the Tikonko Chiefdom received preventative maintenance during the month of December. Two technicians and one supervisor, transportation and materials for cleaning, repairs and maintenance were provided in this grant.

Concluding Comments
Thank you for your support of the Tikonko Chiefdom Malaria Vaccine project. Almost 3,000 doses of the RTS, S vaccine were administered from this project. The immunization infrastructure has been improved through extensive training and monitoring of nurses responsible for administering the vaccine. Failures in the cold chain storage have not occurred due to monitoring of the systems and providing routine maintenance. Community and stakeholder meetings have developed strong trust with the vaccine program and a system was developed to provide knowledge and support for caregivers who were hesitant to vaccinate their children.

The intervention of the malaria vaccine in Sierra Leone is still in its infancy. The full impact of the vaccine has not been realized and long-term immunity has not been determined. In this short project, the outcome of zero deaths among partially and fully vaccinated children is promising.

Data and Reporting: Rural Health Care Initiative (RHCI), the implementing partner was responsible for collecting data on project activities. Training ledgers were maintained, an electronic record of each patient contact was collected, and photo documentation of cold chain maintenance was collected. A full description of the data collection, reporting and program implementation was provided in the interim report (July 20, 2025).