Introduction: The introduction of new interventions tends to place huge burdens on the health system. Context-specific factors often create barriers to uptake and implementation bottlenecks within the health system and at the community level. Identifying and targeting these factors is crucial to facilitate the adoption of those interventions.

Within the SAVING consortium, the Swiss Tropical and Public Health Institute (Swiss TPH) as the leader of WP5, is responsible for conducting a systematic review of the implementation of RTS,S in a country. The main purpose of this systematic review is to understand/identify the implementation challenges, applied solutions and lessons learnt regarding RTS,S deployment. The review aims to provide evidence to Ghanaian and international policymakers to take action concerning the malaria vaccine implementation.

Methods: As the SAVING project is expected to last until the end of 2025, this systematic review is a living systematic review, i.e. the literature will be re-checked regularly (around every eight months) to be able to include new publications in the analyses.

For this living systematic review, all published papers and documents in the grey literature that focus on the malaria vaccine implementation were and will be screened. Studies to be included are quantitative and qualitative studies focussing on implementation issues when introducing the malaria vaccine.

Search strategy: the search includes terms related to the study designs and the malaria vaccine, excluding experimental or quasi-experimental studies, laboratory studies and immunological and pre-clinical studies. There is no restriction on the dates of the documents to be searched. There is no restriction on the language of the documents.

Findings from the first round of reviews: As of June 2023, 542 documents were screened for relevance; 86 were judged relevant. Among them, the inclusion criteria led to including eight documents for data extraction. Findings were from Bangladesh and seven Sub-Saharan African countries.

The findings with high relevance for SAVING were as follows:

• While RTS,S is considered safe, cost-effective and clearly beneficial, side effects do occur. Therefore, tools like the Med Safety Mobile App are highly relevant.
• Critical appraisal of behavioural interventions following immunization should be part of RTS,S-related research efforts.
• Ensure that the introduction of RTS,S into national immunisation programmes does not negatively impact efforts to tackle other national health threats.
• Ghana will over the next two years receive through Gavi-UNICEF-WHO approximately 2 million doses of RTS,S. As a recent phase 3 study found, each fully vaccinated child can lead to 1.7 less malaria cases, and in settings of intense malaria transmission, this benefit is even higher. It is, therefore, important to carefully consider where to distribute the available RTS,S doses.

Conclusion/Projection: There is some indication that a malaria vaccine better than RTS,S will soon be available. Therefore, it is important that if this more effective vaccine becomes available, decision-makers change course accordingly in a rapid fashion.