Article Text
PDF
Abstract
Three months after the first shipment of RTS,S1/AS01 vaccines, Cameroon started, on 22 January 2024, to roll out malaria vaccines in 42 districts among the most at risk for malaria. Cameroon adopted and implemented the World Health Organization (WHO) malaria vaccine readiness assessment tool to monitor the implementation of preintroduction activities at the district and national levels. One week before the start of the vaccine rollout, overall readiness was estimated at 89% at a national level with two out of the five components of readiness assessment surpassing 95% of performance (vaccine, cold chain and logistics and training) and three components between 80% and 95% (planning, monitoring and supervision, and advocacy, social mobilisation and communication). ‘Vaccine, cold chain and logistics’ was the component with the highest number of districts recording below 80% readiness. The South-West and North-West, two regions with a high level of insecurity, were the regions with the highest number of districts that recorded a readiness performance below 80% in the five components. To monitor progress in vaccine rollout daily, Cameroon piloted a system for capturing immunisation data by vaccination session coupled with an interactive dashboard using the R Shiny platform. In addition to displaying data on vaccine uptake, this dashboard allows the generation of the monthly immunisation report for all antigens, ensuring linkage to the regular immunisation data system based on the end-of-month reporting through District Health Information Software 2. Such a hybrid system complies with the malaria vaccine rollout principle of full integration into routine immunisation coupled with strengthened management of operations.
- Malaria
- Vaccines
- Health systems
Data availability statement
Data are available upon reasonable request. Not applicable.
This is an open access article distributed under the terms of the Creative Commons Attribution IGO License (CC BY NC 3.0 IGO), which permits use, distribution,and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.
Statistics from Altmetric.com
Summary box
Successful introduction of a new vaccine into routine immunisation requires a high level of preparedness at national and subnational levels, especially in cold chain and logistics, training of health staff, monitoring and evaluation, and demand generation. Building on recent experiences in new vaccine introductions such as COVID-19 and the human papillomavirus vaccine, WHO has developed a malaria vaccine readiness assessment tool. This tool was adopted by the Cameroon Ministry of Health and used to monitor the implementation of preintroduction activities. In addition, setting up a data system that can allow for timely monitoring of progress in vaccine uptake is vital to informing and addressing operational issues that may arise from new vaccine introduction and rollout.
Cameroon was the first country to roll out malaria vaccines outside the three countries that piloted it. This study documents Cameroon’s experience in monitoring national and subnational readiness for the deployment of malaria vaccines and in setting up a system for collecting immunisation data by vaccination including those on malaria vaccine uptake and using them for decisions-making.
Other African countries could learn from Cameroon’s experience in preparing for malaria vaccine introduction and setting up a data system for malaria vaccine or any other new vaccine, fully integrated into the routine immunisation data system, allowing timely monitoring of progress in vaccine uptake to inform operational decisions.
Introduction
Malaria is a significant public health issue commonly affecting tropical settings.1 The highest disease burden disproportionately affects sub-Saharan African nations.2 The disease is the most widespread endemic disease in Cameroon and remains the leading cause of morbidity and mortality in children aged under 5 years.3 4 In 2022, Cameroon recorded 5.7 million suspected malaria cases, which included 3.3 million confirmed cases and 2481 related deaths.5 Cameroon is among the 11 countries most affected by malaria, globally.5 In 2020, malaria accounted for 29.1% of consultations and 17.2% of deaths recorded in health facilities.6 Plasmodium falciparum is the main parasite, accounting for 100% of the malaria cases reported in 2022.5
In addition to malarial curative medications, the malaria response interventions in Cameroon include vector control measures such as long-lasting insecticidal nets, intermittent preventive treatment administered to pregnant women since 2015, seasonal malaria chemoprevention implemented since 2017 in the Far North and the North Regions and perennial malaria chemoprevention rolled out in 2022.7–9
Following the prequalification of the first malaria vaccine by the World Health Organization (WHO),10 RTS,S/AS01 (known by its brand name ‘Mosquirix’), as an additional tool for the prevention of Plasmodium falciparum malaria in children living in areas of moderate to high malaria transmission10 and its successful pilot rollout in three countries (Ghana, Kenya and Malawi),11 the Cameroon Government decided to add malaria vaccine into the malaria control package. The country applied for RTS,S/AS01 allocations through the Gavi vaccine introduction grant. The first shipment of 331 200 doses (out of 701 211 doses required in 2024) was received in Cameroon on 21 November 2023.12 On 22 January 2024, Cameroon kicked off the malaria vaccine rollout in 42 health districts assessed as the most at risk for malaria.13 14
This paper summarises the system setup by the Cameroon Ministry of Health through its Expanded Programme on Immunization (EPI) to collect, analyse and use data on national and districts’ readiness for the deployment of malaria vaccines, as well as data on vaccine uptake, and completeness in reporting from health facilities.
National and districts’ readiness for malaria vaccine deployment monitoring
In December 2024, the Cameroon Ministry of Health adapted the Malaria Vaccine Introduction Readiness Assessment Tool15 to its national context. The tool assesses the level of readiness at the national level and in each district in five components: (1) planning and coordination; (2) training; (3) monitoring and supervision; (4) vaccines, cold chain and logistics (VCCL); and (5) advocacy, social mobilisation and communication (ASMC) (table 1) .
Criteria used to assess readiness for malaria vaccine rollout at national and district levels
Table 1 summarises the readiness criteria by component of vaccine preparedness and rollout.
The tool was completed at different timeframes before launching the malaria vaccine introduction (namely, 2 months, 4 weeks, 2 weeks and 1 week before) by the Technical Working Group (TWG) setup to ensure the coordination of the vaccine introduction at the national level and by the subnational coordination teams at the district level. The tool was used as a self-assessment by each coordination body. The principle of all-or-one was used to assess each criterion. All the activities included in each criterion had to be fully completed for a criterion to be considered as met; otherwise, the criterion was regarded as unsatisfactory. The TWG created an online spreadsheet using Google Sheets for the national level and districts to report the results of their self-assessments within the defined timeframes. The TWG with support from the WHO Regional Office for Africa (WHO AFRO) developed a script in R statistical software, V.4.3.1,16 to merge the districts’ files for analysis. An interactive dashboard for monitoring readiness levels at the national level and in each district was developed and deployed using the R Shiny platform.17 For each component, the level of readiness was computed by dividing the number of criteria met by the total number of criteria and multiplying the result by 100 (figure 1).
The level of readiness at national level assessed 4 weeks, 2 weeks and 1 week before the beginning of the malaria vaccine introduction. The authors are the creator/owner of figure 2.
The readiness rate increased from 4 weeks to 1 week before the launching of the Malaria Vaccine Introduction (MVI) in all the components.
The overall performance one week before the launching of the MVI was 89% with three components that surpassed 80% but did not reach 95% of readiness: planning, monitoring and supervision, and ASMC. Two criteria out of six were not met in planning. These were related to the availability of guidance on catch-up strategies for missed malaria vaccine doses and to the confirmation and effective reporting to the Ministry of Health of the Gavi additional technical assistance provider. Health workers were trained on how to track and catch up with children missing doses; however, a written guidance strategy specific to the malaria vaccine is yet to be developed and integrated into the national policy on missed vaccination catch-up strategy. Dalberg, a global consulting firm, was confirmed as the additional technical assistance provider for Cameroon. Still, they are yet to formally report to the country and start supporting the malaria vaccine rollout. Regarding monitoring and supervision, the criteria related to preintroduction supervisory visits were not met out of the five criteria from this component. Similarly, the country did not meet one criterion out of six in the ASMC component. ASMC materials were not distributed to all health facilities, community leaders, communities and other key stakeholders in the 42 selected districts one week before the beginning of the vaccine rollout. This was finally done in the following days within the last week before the official launching date.
VCCL was the component with the highest number of districts recording a readiness level below 80%: nine compared with three in each of the remaining components. South-West and North-West were the regions with the highest number of districts recording a readiness performance below 80% in the five components: five districts in each region compared with four in littoral and one in centre. South-West and North-West are two regions with a high level of insecurity18 (figure 2). This may have hampered the implementation of preintroduction activities .
The district’s geographical distribution of readiness levels in each of the five components. Link: https://worldhealthorg.shinyapps.io/cameroon_vaccine_deployment_preparedness/
Malaria vaccine introduction data collection system
Integration into routine immunisation is the main strategy considered by the national authorities for introducing and rolling out the malaria vaccine. The vaccines were therefore administered to eligible children during fixed, outreach and mobile vaccination sessions. In routine immunisation, data on children vaccinated and doses used are collected during vaccination sessions in paper-based immunisation registers. Aggregated reports are prepared monthly and submitted by each health facility to the upper levels of the health pyramid through the District Health Information Software 2 (DHIS2), an open-source software platform used by the Cameroon Ministry of Health for collecting and storing health data. All the paper-based tools (registers, tally sheets, monthly immunisation report templates and vaccination cards) were revised to include malaria vaccines.
Given the need for monitoring progress in malaria vaccine uptake daily, at least during the first months of the vaccine introduction, the Ministry of Health decided to pilot a data reporting system by vaccination session using an electronic form shaped in IASO, an open-source geostructured data collection platform developed by Bluesquare,19 a global health information system and data management company active in low-income and middle-income countries. The digital form was designed to allow reporting on all antigens of the EPI, including malaria vaccines. Health workers in the 42 districts were trained on data reporting by vaccination session using IASO (figure 3). The IASO form was deployed in private Android phones belonging to one of the health workers involved in immunisation activities . No additional equipment was provided to health facilities for the purpose of IASO deployment. IASO allows offline recordings, with synchronisation carried out when the user has access to the internet.
The immunisation data flow following IASO piloting in 42 districts. The authors are the creator/owner of figure 3.
While the health facilities report immunisation data by vaccination session through IASO, they still have to submit monthly reports through DHIS2.
With the support of the WHO AFRO, the Ministry of Health has added a component on malaria vaccine uptake to the malaria vaccine introduction dashboard. The dashboard summarises vaccine uptake indicators at national, regional and district levels. The summary highlights elements such as the health facility reporting completeness, the cumulative and weekly number of children vaccinated disaggregated by gender and strategy, and immunisation coverage. In addition to malaria vaccine uptake outputs, the dashboard provides a monthly summary report on children immunised with all the EPI antigens, with the view to health facilities using the IASO summary to report into DHIS2 without performing additional calculations (figure 4).
Screenshot of the landing page of the malaria vaccine uptake module of the malaria vaccine introduction dashboard.
Comments
Cameroon experienced high vaccine hesitancy leading to low uptake during the recent introductions of human papillomavirus vaccines in 2019 and COVID-19 vaccines in 2021.20 21 Given the high burden of malaria in Africa and the expectations raised by the addition of malaria vaccines among response tools, considered a step forward towards malaria elimination, the malaria vaccine introduction attracted the attention of the media (figure 4). It was critical for the introduction in Cameroon, the first country to roll out malaria vaccines outside the three countries that piloted it, to succeed. Attaining this goal required robust preparedness and readiness monitoring systems at all levels. Adequate risk communication and community engagement, training of health workers, and supply and cold chain in health facilities are known to be the main facilitators of vaccine rollout.22 Agreeing on readiness criteria at national and subnational levels, covering planning, training, monitoring and supervision, VCCL and ASMC, as well as setting up systems for monitoring national and districts’ readiness, was key to a successful start of the MVI. This helped to identify and address issues related to the implementation of preintroduction activities.
Challenges in the completion of the readiness tool were mostly related to the use of Google Sheets with one sheet for each district and access to the full spreadsheet granted to each district. Some districts were completing the wrong sheet contributing to misleading the assessments. The TWG had then to save a version of the spreadsheet offline to be used for comparison. The criteria of completion of each preintroduction activity were not predefined. This may have tainted the objectivity of the assessments from one district to another. In addition, the tool did not allow to keep track of proposed actions to achieve the completion of activities from one period of assessment to another. The automation of merging of districts’ sheets contributed not only to saving time dedicated to data management by the monitoring and evaluation team within the TWG but also to minimising errors.
The readiness module of the malaria vaccine introduction dashboard was designed so that each district could visualise progress in implementing readiness activities. Such readiness monitoring can only be useful if implemented few months before launching the introduction.
Visualising progress made through a national dashboard proved pivotal in engaging districts’ coordination teams and feeding into discussions during coordination meetings between national and district levels. However, using the all-or-none principle in assessing each readiness criterion did not allow capturing partially completed activities. Using three response options for each criterion (completed, ongoing and not yet started) instead of ‘yes or no’ would have allowed to capture criteria partially completed and better inform operational decisions.
In Cameroon and other African countries that do not use electronic immunisation registries, data on routine immunisation are collected monthly. Given the challenges in deploying immunisation registries in the African context (lack of equipment, limited access to the internet, high turnover of health staff, etc), Cameroon planned to set up a system that falls between case-based reporting and monthly reporting of aggregated data: data reporting by vaccination sessions. In this system, data reported are still aggregated but are reported at the end of each vaccination session. Such a reporting system allows better monitoring of health facilities’ activities and eases timely interventions to improve vaccination coverage and data quality. The associated dashboard allows generating the monthly summary data reported through DHIS2 and ensures linkage between the regular system, based on end-of-month reporting, and the vaccination session-based reporting system. The Cameroon EPI, with support from Bluesquare, developed this platform in November 2023 and used the malaria vaccine introduction as an opportunity to pilot it. The dashboard is focused on malaria vaccines. However, data on all routine immunisation antigens are being collected, contributing to strengthen overall routine immunisation data management, and are used to inform strategic and operational decisions. Ultimately, this system will also enable monitoring of the implementation of planned vaccination sessions in the immunisation microplans, to ensure that vaccination services reach all communities. A digitised GIS-enabled microplanning tool has been developed in the same IASO platform. No tablets or phones were provided to health facilities, who were urged to use their own Android phones to deploy the digital form, and internet fees for data synchronisation are covered by each health facility. This ensures the sustainability of the system.
Conclusion
Cameroon is the first country to pilot the readiness assessment tool developed by WHO. The country has also integrated the malaria vaccine into routine immunisation without intensifying routine immunisation activities and has set up a data collection system that facilitates daily progress monitoring of the malaria vaccine rollout.
The following lessons could be drawn from the Cameroon experience:
First, it is critical to adapt the WHO readiness assessment tool to the local context and start early monitoring of progress in completing readiness activities at national and subnational levels (at least 3 months before the launching of the introduction).
Second, developing a dashboard that can help visualise the readiness level by the TWG and the districts’ coordination teams serves as an incentive for conducting the self-assessment, completing the tool and addressing the activities not yet fully completed. In addition, the outputs displayed by the dashboard offer a basis for discussions within each coordination body and between the TWG and any district coordination team that may be lagging.
Third, given the high burden of malaria, increased risk of vaccine hesitancy and resulted in increased media attention around MVI, it is critical to monitor daily progress and provide evidence of malaria vaccine uptake to inform planning decisions and risk communication messages. As such, the system of collecting immunisation data by vaccination session in districts selected for the MVI, connected to the regular data system for routine immunisation, complies with the principle of full integration into routine immunisation combined with strengthened management of operations during the first months of introduction as set by the WHO AFRO initiative for accelerating malaria vaccine introduction and rollout in Africa.
Data availability statement
Data are available upon reasonable request. Not applicable.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors are thankful for the contribution of the health workers from the Cameroon Ministry of Health and the WHO country office in Cameroon involved in the Malaria vaccine introduction and rollout.
Footnotes
Handling editor Seye Abimbola
Contributors FM and STN led the conception and design of the study, data analysis and manuscript writing. RN and AN provided the data, ensured data cleaning and supported data analysis. BI and PH oversaw the conception of the project, the execution of the project and the development of the manuscript. SFB, AAN, JN-mB, MK, AA and BF critically reviewed the manuscript. All authors approved the final version and agreed to be accountable for all aspects of the work.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area of its authorities. This map is provided without any warranty of any kind, either expressed or implied.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.