Desmond Maada Kangbai

Background: Mass azithromycin administration for infants is recommended in high mortality settings. There is a need to assess the impact of integrating age-based azithromycin with other child survival strategies delivered through the Expanded Program on Immunisation (EPI).Methods: In this individually randomized, placebo-controlled trial in Sierra Leone, 20 560 infants were randomized to receive either azithromycin (20 mg/kg) or placebo during routine immunization visits at 6 weeks, 9 and 15 months of age. All participants received up to six doses of Perennial Malaria Chemoprevention (PMC) during immunization contacts. The primary outcome was all-cause mortality up to 18 months of age.Findings: There were 425 deaths in the azithromycin group and 463 in the placebo group (adjusted hazard ratio, 0·93; 95% confidence interval [CI], 0·82-1·06; p=0·30). Azithromycin was associated with lower mortality within 30 days after the first dose (adjusted hazard ratio, 0·49; 95% CI, 0·26 – 0·91; p=0·02), with similar size but non-significant effects after subsequent doses. Azithromycin was associated with an 18% lower hazard of mortality up to 18 months of age among children who died at home (60% of all deaths) (subdistribution hazard ratio, 0·82; 95% CI, 0·69 – 0·97; p=0·02). Over 70% of children received all three azithromycin or placebo doses. Adverse events were similar in the two groups. Receiving all PMC doses corresponding to age was independently associated with a 37% reduction in mortality (p<0·0001).Interpretation: Three doses of azithromycin administered over the first 15 months of life did not significantly reduce all-cause mortality at 18 months. However, the reduction in early mortality supports that alternative azithromycin schedules in early infancy warrant further evaluation. The survival benefits associated with PMC, together with high intervention coverage through EPI delivery, highlight the potential of integrated platforms to deliver multiple child-survival interventions at scale in high-mortality settings.

Background: Despite high national childhood immunisation coverage in Sierra Leone, subnational disparities continue to leave communities at risk of under-immunisation and zero-dose status. Understanding the geographic distribution of immunisation risk and the health-system factors associated with these disparities is essential for designing targeted interventions. This study assessed the spatial clustering of facility-level immunisation risk and compared programme and health-system characteristics between hotspot and non-hotspot districts across Sierra Leone.Methods: A nationwide cross-sectional geospatial and health-systems analysis was conducted using supportive supervision data from 249 routine immunisation facilities across all 16 districts of Sierra Leone. A composite immunisation risk score (0-9) was constructed from three indicators of under-immunisation risk and categorised into low, medium, and high risk. Global Moran's I and Local Indicators of Spatial Association (LISA) identified spatial clustering and hotspot districts. Descriptive statistics summarised programme characteristics, while Pearson's Chi-square and Fisher's exact tests compared health-system indicators between hotspot and non-hotspot districts at a significance level of p<0.05.Results: Of the 249 facilities, 68.7% were classified as low risk, 18.1% as medium risk, and 13.3% as high risk. Immunisation risk demonstrated significant spatial clustering (Global Moran's I=0.223; permutation p=0.001). Western Area Urban (mean risk score=3.7; 46.7% high-risk facilities) and Bonthe (2.5; 43.8%) exhibited the highest risk, with Western Area Rural (2.1; 26.7%) also showing elevated risk. Hotspot districts had significantly higher availability of updated routine immunisation micro plans (48.4% vs. 13.3%, p<0.001), recent funding (90.3% vs. 69.7%, p<0.001), and supervisory visits (77.4% vs. 56.0%, p<0.001), but were more likely to report insufficient funding (96.4% vs. 85.5%, p=0.02) and lower community health worker assignment (83.9% vs. 95.0%, p=0.002).Conclusion: Immunisation risk in Sierra Leone is geographically clustered rather than randomly distributed, with distinct hotspots concentrated in Western Area Urban, Western Area Rural, and Bonthe. Integrating geospatial analysis into routine immunisation monitoring can facilitate precision public health approaches by enabling targeted resource allocation, strengthening community outreach, and reducing geographical inequities in immunisation coverage.

Background: The 2025 EPI Managers’ Meeting for West African countries in Guinea was a critical platform for EPI managers to make an in-depth analysis of immunization programmes. We present a structured analysis of immunization status in West Africa using a WHO Health System model to move beyond descriptive reporting toward systemic analysis for actionable solutions. Methods: The meeting convened EPI managers from 14 of the 17 West African countries and partners supporting the immunization program. Country and regional presentations, immunization and surveillance data and meeting discussions were analysed through a framework identifying (1) core problems, (2) systemic barriers using WHO health systems building blocks and (3) actionable recommendations or call for action. Results: Analysis revealed stagnating immunization coverage. Recovery from COVID-19 pandemic disruptions remained limited, with persistent outbreaks of vaccine-preventable diseases (VPD). Among the five Immunization Agenda 2030 objectives assessed, only Maternal and Neonatal Tetanus (MNT) elimination was on track. Four critical challenges emerged: (1) Routine immunization stagnation with DTP3 median coverage of 76%. This was associated with challenges related to poor data quality, weak implementation of innovative vaccination strategies and donor dependency, as 88.2% of countries financed less than 50% of routine vaccine costs domestically. (2) Sub-optimal progress in Big Catch-Up (BCU) implementation in some countries, revealing poor health system resilience. (3) Inability to sustain high coverage for new vaccine introductions despite significant progress, highlighting demand and service delivery gaps. (4) Persistent VPD outbreaks with geographical expansion and the resurgence of diphtheria epidemics since 2023. Conclusions: Persistent immunization challenges in West Africa appear to reflect interconnected systemic challenges, suggesting the need for a fundamental shift toward subnational strategies, integration of immunization services within primary health care (PHC) and improved data quality. Sustainable financing of the national EPI and acceleration of local vaccine manufacturing is essential to achieve immunization sovereignty in West Africa. Country Call for Action provides strategic guidance to reverse the trend toward the Immunization Agenda 2030 targets.

Background: Accurate and timely immunisation data are critical for vaccine program planning, monitoring, and decision-making. In Sierra Leone, reported high vaccination coverage has not always aligned with observed disease trends, raising concerns about the reliability of routine immunisation data. This study assessed the quality of routine immunisation data across five diverse districts using a standardised WHO tool.Methods: A descriptive cross-sectional study was conducted between January and March 2025, reviewing immunisation records from 25 health facilities across five districts in Sierra Leone. Data from primary source registers were compared with monthly summary reports and entries in the national DHIS2 system for seven antigens (BCG, Penta1, Penta3, MR1, MV1, MV3, and HPV). The WHO Data Quality Self-Assessment (DQS) tool was adapted to calculate accuracy ratios and consistency levels. Descriptive analysis was used, and discrepancies were analysed by district and vaccine.Results: None of the assessed facilities achieved complete accuracy and consistency across all seven vaccines. Significant discrepancies were observed, particularly for MR1 (29%), Penta1 (16%), and HPV (12%). Underreporting was common for MV1 and MV3, while overreporting was most prominent for MR1 and HPV. Variations were observed across districts, with Port Loko showing the highest reporting inflation and Western Area Rural the greatest overreporting. Factors contributing to poor data quality included inconsistent use of tools, arithmetic errors, and a lack of trained staff.Conclusion: Routine immunisation data in Sierra Leone are affected by both systemic and local-level reporting inconsistencies, which undermine the accuracy of coverage estimates. Strengthening data systems, workers and frontline health workers, and institutionalising regular data quality audits are essential to improve immunisation program performance and accountability.

Background: The 2013-2016 Ebola virus disease outbreak in West Africa profoundly affected Sierra Leone’s health financing, health delivery, health governance, and health workforce. The country becomes the first among those most severely affected ten years ago by the West Africa Ebola outbreak, to launch nationwide preventive Ebola vaccination, targeting 20,000 frontline workers who received a single dose of the Ebola Vaccine. Methods: A mixed-method study design that analysed administrative vaccination data, field supervision reports, and electronic records from all 16 districts in Sierra Leone was used. The following indicators were analysed: vaccination coverage and logistical regression. Qualitative information from stakeholder debriefings and community feedback complemented the findings from the quantitative analysis. Quantitative data were analysed using Statistical Package for the Social Sciences (SPSS) version 27. Results: A total of 17,454 (vaccine coverage= 84.5%) frontline workers and high-risk populations for EVD infection were vaccinated. Healthcare workers accounted for 35% of all vaccinations. Multivariate analysis showed that females had an AOR of 1.507 (95% CI: 1.293-1.756, P < 0.001) and individuals with tertiary education had an AOR of 1.900 (95% CI: 1.371-2.633, P < 0.001), were more likely to be vaccinated. Western and Southern regions achieved the highest coverage due to superior cold-chain readiness and community mobilisation. No serious adverse events following immunisation were reported. Conclusion: Sierra Leone’s decade-long journey from outbreak response to preventive vaccination demonstrates the transformative impact of sustained investment, multisectoral coordination, and community trust. High coverage and operational success affirm the feasibility of nationwide Ebola immunisation in resource-limited settings.

Background: Childhood vaccination coverage in Sierra Leone remains unsatisfactory despite multiple efforts made by health authorities to enhance collective immunity of the population, especially for children aged 12 to 23 months. This study aimed at identifying the factors associated with incomplete vaccination or non-vaccination among children aged 12 to 23 months in Sierra Leone in 2019. Methods: This was a cross-sectional study that used the 2019 Sierra Leone Demographic and Health Survey data. Descriptive statistics was performed to describe the sample, ascending hierarchical classification following a multiple correspondence analysis was employed to establish the profile of children with incomplete vaccination or non-vaccination status, and a binary logistic regression was used to identify the factors associated with incomplete vaccination or non-vaccination. Results: Of the 966 children aged 12 to 23 months involved in the study, 42.9% (95% CI[39.2; 46.6]) were incompletely vaccinated or unvaccinated, of which, 43.5% (95% CI[37.9; 49]) among male children and 42.4% (95% CI[37.3; 47.4]) among their female counterparts. The Northern (AOR 1.683, 95% CI[1.131; 2.503]) and the North Western (AOR 1.847, 95% CI[1.208; 2.825]) survey regions, delivery in a place other than a health facility (AOR 1.404, 95% CI[1.001; 2.042]), the mother’s age group 35 to 49 years (AOR 0.437, 95% CI[0.251; 0.762]) and the child’s birth order 7th or higher (AOR 2.640, 95% CI[1.452; 4.800]) turned out to be significant factors of incomplete vaccination or non-vaccination. Conclusion: Incomplete vaccination or non-vaccination among children was high in Sierra Leone in 2019. In order to increase childhood vaccine uptake, we recommend the development of initiatives geared towards optimizing facility-based service delivery, intensifying health education focusing more on vaccination, enhancing community engagement, addressing barriers to vaccine access, establishing and ensuring proper functioning of immunization defaulter tracking systems.

Background: A circulating Vaccine-Derived Poliovirus Type 2 (cVDPV2) was isolated in environmental samples collected at the Mabella Sawmill Bridge environmental surveillance site in March 2024. The Ministry of Health and its partners responded to the outbreak by conducting a novel oral poliovirus vaccine type 2 (nOPV2) nationwide vaccination campaign among children aged 0-59 months. This study explores Sierra Leone's experience in terms of gaps identified, successes, and outcomes of the campaigns. Methods: The study employed a descriptive secondary data analysis of the nOPV2 campaign, administrative, and Lot Quality Assessment Survey (LQAS) data collected during the first round of the nOPV2 campaign in Sierra Leone in May 2024. Administrative data was extracted from the national nOPV2 campaign database, while the LQAS data were requested from the WHO server. Stata version 18 and Power BI were used to analyse the administrative and LQAS data. Results: 1,590,769 children aged 0-59 months were vaccinated against the polio virus in Sierra Leone. The Supplementary Immunization Activity (SIA) coverage for the nOPV vaccination in Sierra Leone was 100% for the first round of the campaign. Also, of the sixteen districts selected for the LQAS survey, twelve districts 75% passed the survey, and four districts 25% failed the LQAS. Conclusion: The first round of the nOPV2 vaccination campaign in Sierra Leone demonstrated significant success in reaching the majority of the target population, with robust preparatory and implementation strategies contributing to this achievement.