Breaking new ground in COVID-19 vaccine delivery

In May 2021, Malawi became the first African nation to burn expired COVID-19 vaccines. As smoke wafted from the incinerator, murmurs were rising that no more doses needed to perish while most at-risk persons remain unprotected from the pandemic.

In a fightback, the country ultilised 714 000 doses within two months, saving them from expiring and doubling vaccine uptake to 6.5 per cent.

To achieve this, the government and its partners deployed community health workers in branded vans, ambulances, boats, motorcycles and bicycles to put vaccines closer to people who need them.

The fast-track teams have been on the move for 60 days, delivering COVID-19 vaccines beyond the 160 health facilities nationwide. They pitched in shopping malls, outside prayer houses and at busy rural markets to put doses to good use before their expiry dates.

The inroads excite Gervasio and Kilness Ludzu. The couple took their first AstraZeneca shots when a COVID-19 express vaccination van stopped near their home in Boyole Village, almost 25km north of Kasungu Town in central Malawi.

“We feel lucky to get vaccinated closer to home,” said the father of nine after the jab. “We have been hearing about COVID-19 vaccination for almost 10 months, but were dreading walking nearly five kilometres to Dwangwa health centre."

A motorcycle ride to the health facility, their nearest vaccination point before the van arrived, costs K2 000 (just over $2). “This is enough buy fish for lunch and supper,” says Kilness

“COVID-19 is killing people, so everyone needs to protect themselves and their communities. After all, the vaccines are coming home. This saves us time and money,” says Kilness.

There are similar stories across the country, with people vaccinated either at work or on the move. Some have been seen receiving the jab while digging graves or clad in gule wamkulu masks (traditional dance costume) while others working in  their crop fields, moulding bricks, selling or buying goods in busy trading centres.

Increasing Access

Malawi's Ministry of Health deployed 30 vans in all districts with support from Gavi and UNICEF.

The express vaccination initiative was a race against time to deliver perishable vaccines right where people live, meet or work. Each carried vaccinators, health promoters, dramatists and a public address system for rallying people while sharing facts about the jab

Clad in sky-blue uniforms, the health surveillance assistants (HSAs) worked with community leaders to mobilise community members to get vaccinated without worrying about long travels or transport costs. They also tackled myths and misinformation long blamed for vaccine hesitancy worldwide.

Before getting vaccinated, Kilness whispered a question or two to HSA Mercy Tchale, verifying what she learned from her vaccine-shy neighbours and the social media.

“Widespread rumours made my husband and I fear for our lives, but the HSA assured us that the vaccine is so safe that even President Lazarus Chakwera took two jabs. We don’t want our children to become COVID-19 orphans,” Kilness states.

The image of President Chakwera publicly receiving the first dose on 11 March 2011 drapes the vans that delivered the fragile doses against the odds.

Dr Mike Chisema, the Head of Malawi's Expanded Programme on Immunisation (EPI), hails the 60-day initiative for increasing the daily vaccination figures from 1 000 to 29 000.

"This helped us ultilise 130 000 AstraZeneca doses that were expected to expire by 30 November 2021 and 584 000 by 31 December 2021," he says.

Chisema admittedly feels heartbroken when a dose expires, "knowing what it takes to bring vaccines into the country and how it would have protected someone".

“The express vaccination exercise  is a game-changer. It turned around the uptake of the vaccine and all districts want to emulate this for distribution of subsequent vaccines,” he states.

“For the teams involved, there was no day to rest--thanks to their dedication and appreciation of the importance of vaccines as first-line against contagious diseases that slow progress in developing countries,” says Chisema.

“With the support from our teams, community leaders and partners, we have been able to utilise vaccines that would have expired and taken them to places rarely reached by routine immunisation. They worked through the  weekend delivering COVID-19 vaccines that were previously only accessible Monday to Friday," Chisema explains.

John Kuwanda, District EPI Coordinator in Rumphi challenged every HSA to finish a vial--a bottle containing doses for 10 people--to receive a K5 000 ($6) lunch allowance as an incentive.

“Our express vaccination crews worked even on Christmas to ensure no dose expired in our district vaccine store by the New Year,” he says.

Muted success

To Dr John Phuka, from KUHES School of Public Health, the mobile vaccination campaign aptly personifies universal health coverage—a global agenda to ensure everyone gets quality health services without hardship.

He led the express vaccination mission since trials in Mzimba North, Zomba, Lilongwe and Blantyre in September 2021.

Dr Phuka, the pioneer co-leader of Malawi’s national COVID-19 response, recalls the media backlash against the potential loss of doses during a dramatic drop in COVID-19 vaccine demand.

He narrates: “On 29 September 2021, one newspaper reported that 27 000 doses would expire two days later, but early results were encouraging.

“We expanded the pilot to Phalombe and Mwanza districts before scaling up to all districts. With this effort, we saved all the [130 000 doses of Astrazeneca] doses that could have expired on September 31, but it took a while before the media realised that the big news they were expecting didn’t happen.”

The figures bring into question suggestions that Malawians weren’t getting vaccinated because of denial, dislike or disinformation.

“It had to be access,” Dr Phuka states. “Where were all these people? Surely, they needed the vaccine, but it wasn’t available where they live and work,” he says.

Since the roll-out of the COVID-19 vaccination exercise in Malawi in March 2021, UNICEF has facilitated the delivery of 2, 089, 790 doses of Astra Zeneza from the UK, France, African Union through the COVAX facility, 655, 200 doses of JJ vaccine from the US Government via the COVAX facility and 372, 060 doses of Pfizer from the United States Government. With funding from GAVI and the Government of Japan, UNICEF continues to support the Government of Malawi’s cold chain system to store and transport vaccines safely and on service delivery.

Mphatso Mtenje, EPI cold chain manager, says administering vaccines beyond health facilities’ walls reduced the pressure doses with short shelf lives exert on the national vaccine store.

He explains: “Vaccines are so sensitive they lose their efficacy if exposed to high temperatures. This is why every field team carries them in special cooling boxes stuffed with cool packs that keep them safe for eight hours.

 “As more people get vaccinated, we are protecting the nation while creating space for more vaccines to come. Without this outreach, vaccines would have been piling and expiring in the refrigerators.”

This would negatively affect both COVID-19 vaccination and routine immunisation, according to Mtenje.

The fast-track teams took the vaccines to remote areas, including the interiors of Lake Chilwa basin where islanders, shoreline communities and migrant fishers on floating huts live far from health facilities.

Kingsley Chisuse, senior HSA at Chisi Island health centre in the southeastern district of Zomba, leads a team of five that makes boat trips in Malawi’s second-largest lake and long walks on rocky islands to vaccinate the tricky populations.

“We’ve learnt that when you bring health services closer to people even in hard-to-reach areas, the uptake increases. Within five days before Christmas, we vaccinated about 107 people in Lake Chilwa, including over 20 of 30 migrant fishers we found in floating huts called zimbowera,” he says.

Zomba district environmental health officer Innocent Mvula attributes this to UNICEF “flexible support” which allows them to tweak the vaccination strategy to beat their unique barriers.

UNICEF support

UNICEF designed and funded the ambitious approach which has doubled the vaccine uptake to 6.5 per cent of about 11 million Malawians aged at least 18. However, only three in every 100 people are fully vaccinated.

Apart from fueling the vans, boats and motorcycles, UNICEF provides a lunch allowance to HSAs who finish a vial without losing a dose. Zomba district health office extended this incentive to every trained community leader who worked with HSA to mobilise 20 people and call for two vials.

To Dr Ghanashyam Sethy, UNICEF focal person for the COVID-19 vaccination programme, the campaign marked a shift  from doing business as usual.

He looks back: “When it became clear that the vans alone couldn’t distribute the doses Malawi received in October, we expanded the initiative to include boats, motorcycles and bicycles for hard-to-reach areas as well as incentives for HSAs who finished a vial.

We knew that the campaign would fail if we didn’t engage the traditional and religious leaders, so we put these influential community voices at the centre of the demand creation efforts as early as possible.”

By 30 December 2021, Malawi had distributed 2, 109,790 of over the 3.1 million AstraZeneca, Johnson & Johnson and Pfizer doses received.

UNICEF supported the EPI to establish an emergency call centre to track the daily vaccine uptake and stocks while redistributing the shots from districts with surplus to fast-consuming neighbours and health facilities.