Suboptimal uptake of the Malaria Vaccine in Sudan: What's Behind the Blinds?

Background Malaria is a public health problem in Sudan, with more than 89% of cases caused by P. falciparum . In November 2024, Sudan introduced the R21/Matrix-M malaria vaccine in two states, to be administered in a four-dose schedule through the existing EPI system. This study aimed to determine and identify the factors affecting the utilization of the vaccine. Methods A cross-sectional study was conducted in Gedarif and Blue Nile States, using a mixed-methods approach that triangulated quantitative and qualitative data. A pre-tested, pre-coded, structured KoBo questionnaire was used to collect data from mothers/caregivers of children under the age of five. Focus Group Discussions (FGDs) with school teachers using a focus group discussion guide and in-depth interviews with key Informants (KIs) were conducted in the two states. Quantitative data were analyzed using SPSS for Windows, where univariate and multivariate analysis was performed. Qualitative data in the form of participants' words, statements, and ideas were thematically organized to identify barriers and drivers for each target group's malaria vaccine-related behaviour. Results A total of 416 mothers/ caregivers (with a 99.0% response rate) who had children under the age of 5 were interviewed. The median (IQR) age was 27.0 (24.0, 32.0) years. Of 256 children eligible for the malaria vaccine (age-wise), only 94 received it (36.7%; 95% CI: 31.1%- 42.8%), with no difference between states or residence. Attitudes towards vaccination were generally positive, and overall routine vaccine coverage was relatively high, similar to that reported by the EPI programme. Perceptions of malaria and awareness of the vaccine were low: 53.1% of mothers did not perceive malaria as a significant health problem; 57.7% were aware of the malaria vaccine; 36.7% knew the number of required doses; and 25.7% knew the recommended age to start the first dose. FGDs and KIs highlighted vaccine stockouts and geographic access as additional barriers. Multivariate logistic analysis showed that child age in months was the only factor associated with vaccination status (AOR = 0.852, 95% CI: 0.770, 0.942). Conclusions and recommendations The suboptimal uptake of the malaria vaccine was not attributed to vaccine hesitancy or behavioural and social determinants, but rather to limited education efforts and a lack of focus on the malaria vaccine as a newly introduced vaccine. Reviewing the communication strategy and addressing health system barriers might help achieve the targets set by the Ministry of Health and the WHO for the malaria vaccine. Furthermore, assessing acceptability and identifying the enabling and inhibiting factors for vaccination before the introduction of the malaria vaccine in any area will lead to better vaccine uptake.