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The marathon of vaccinating children began on February 21, 2018, at 10:13 AM, with 4-year-old Golden becoming the first child in Africa to be enrolled in a typhoid conjugate vaccine study. The day of Golden’s vaccination was eventful, and all were uttering the same phrase, “27,999 children to be vaccinated by the end of September 2018,” our finish line. The Typhoid Vaccine Acceleration Consortium (TyVAC) is led by the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine, the Oxford Vaccine Group at the University of Oxford, and PATH. The TyphoidVaccineAccelerationConsortium is fundedby theBill &MelindaGatesFoundation. This study is part of the TyVAC, a partnership between the Center for Vaccine Development and Global Health at the University of Maryland School of Medicine, the Oxford, and PATH. This vaccine efficacy study is the biggest of its kind to ever be conducted in Blantyre, Malawi. Our team of doctors, nurses, and field workers were very enthusiastic to meet our goal, an ambitious target of 200 vaccinated children every day. We split ourselves into three vaccination teams. Each team was allocated a school where wevaccinated for a number of days, or evenweeks, until all the eligible children were enrolled; then, we would move to a new school. The vaccination areas thatwe set up varied depending on the spaceprovidedby theschool. Someprovided theentire school hall, some a classroom with desks, whereas others opengroundwherewewouldpitch tents. Each timewemoved to a new school, we had to set up newvaccination stations in a configuration that ensured smooth flow of children and matched the protocol and standard operating procedures. The first few weeks we targeted smaller schools, with populations of about 300, where we vaccinated about 100 children per day. Starting in smaller schools helped improve our time management and master the routine on screening, enrolling, andvaccinating thechildren in themost efficientway possible.Weused this experience in larger schools,which had up to 7,000 children. Parents learned about the project and opportunity to vaccinate their children through letters sent home from school the previous day.We also had a vanwith a loud speaker on the top that drove around the communities in the evening to spread the news of the study and inform people of the vaccination locations. Parents would bring their school-aged children along with their toddlers and preschool children for vaccination; on average, a mother would bring two to three children, which resulted in good vaccination coverage in all age groups. We started slow, but soon caught up to a good speed and were vaccinating our target of 200 children per day. However, our recruitment numbers substantially reduced in April when the schools closed down for vacation. We were allowed to continue with vaccination activities despite the holiday, but our means of inviting parents through letters was disrupted. During this period, we spread the news about the study, opportunity to vaccinate, and vaccination locations with our community engagement van. The use of a mobile van was advised by a member of the community advisory group who highlighted that, “the use of a mobile van with key messages would be effective in recruitment for the study. This is still a popular medium by which health, political, and commercial messages are delivered to mass audiences in Blantyre and TyVAC should take advantage of this.” It was a Monday morning in the second week of April, and like every other day, a fewof us reported to our homebases, at Malawi-Liverpool-Wellcome Trust to collect credo boxes containing the vaccine and tablets for recording data,whereas the rest directly reported to the vaccination site and started setting up the stations by arranging furniture stored on site. We drove out through the hills of Ndirande and Zingwangwa through very rocky and bumpy roads to reach the schools, not knowing what effect the van had caused on the turnup of mothers. As we drove onto the school premises, all of us said the same thing, “oh my,” when we saw the huge crowd of mothers. We found the vaccination sessions had already begun. Chrissy, a study nurse, had already given a health talk and explained the study to the mothers. We were all excited and jumped out of the car and took charge of our stations. Vaccinating children is not as simple as jabbing them one after the other. It involved a lengthy process where mothers who attended the group information session wouldmove with their children through a consent area. Once consented, the child would be assessed for eligibility by the study nurse. Those eligible were given an orange wristband and instructed to queue up at the vaccination station, which was typically a tent or corner of a classroom partitioned using hospital screens to maintain blinding. The final step was the electronic patient locator station where an electronic mapping tool was used to identify the geographical location, and children were served refreshments. Detailed aerial photographs of Ndirande and Zingwangwa were uploaded onto tablets, and mothers were asked to point to their house on themap. One of uswould help using common landmarks such as schools, churches, bars, markets, or mosques. These data enabled estimates of vaccine coverage in the two areas and effective follow-up of participants during the passive surveillance period. At the endof theday,wepackedawayall furniture andstored it on site, whereas tablets and vaccines were returned to the Malawi-Liverpool-Wellcome Trust. It was past 7 PM when we got back from the field, and some of us sighed in relief because “it is the end of the day.” For Robert, Cephas, and Innocent, * Address correspondence to Pratiksha Patel, Queen Elizabeth Central Hospital, P.O. Box 30096, Chichiri, Blantyre, Malawi. E-mails: pratikshadpatel5@gmail.com or priyankadpatel92@gmail.com

On the Ground in Malawi—First Typhoid Conjugate Vaccine Study in Africa