Suboptimal uptake of the malaria vaccine in Sudan: what's behind the blinds?

Malaria is a public health problem in Sudan, with more than 89% of cases caused by Plasmodium falciparum. In 2024 Sudan introduced R21/Matrix-M malaria vaccine in two states through routine immunization system. This study aimed to determine and identify the factors affecting the utilization of the vaccine.

A cross-sectional mixed -methods study was conducted in Gedarif and Blue Nile States of Sudan. Quantitative data were collected through pre-tested, pre-coded, structured questionnaire from samples of mothers or caregivers of children under the age of five. Additionally, Focus Group Discussions (FGDs) with school teachers and in-depth interviews with key Informants (KIIs) were conducted. Quantitative data were analyzed using SPSS, where univariate and multivariate analyses were performed. Qualitative thematic analysis was undertaken to identify barriers and drivers for each target group's behavior related to the malaria vaccine.

A total of 416 mothers or caregivers (with a 99.0% response rate) who had children under the age of five were interviewed. The median age was 27.0 years. Of 256 children eligible for the malaria vaccine, only 36.7%, 95% CI 31.1-42.8% or 94 received it, with no difference between states or residence. Attitudes towards vaccination were generally positive. Perceptions of malaria and awareness of the vaccine were low: 53.1% of mothers perceive malaria as not a significant health problem; 57.7% were aware of the malaria vaccine; 36.7% knew the number of required doses; 25.7% knew the recommended starting dose age. FGDs and KIIs highlighted vaccine stockouts and geographic access as additional barriers, indicating the importance of sustaining supply chains.

The suboptimal uptake of the malaria vaccine was not attributed to vaccine hesitancy or behavioral and social determinants, but rather to limited educational efforts and a lack of focus on the malaria vaccine as a new intervention. Reviewing the communication strategy and addressing health system barriers might help achieve the vaccine targets set by the Ministry of Health. Furthermore, assessing vaccine acceptability and identifying the enabling and inhibiting factors for vaccination before introducing the malaria vaccine in addition to engagement of higher authorities will lead to better vaccine uptake. Further research to test the effectiveness of culturally tailored communication interventions and the use of reminders or small incentives to raise the uptake is highly needed.