Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024

Ismail Aladani; Abdulaziz Adam; Abdelrahim Babakir; Nada Mohamed Ali Alnair; Nadir Hammad; Sahar Abd Elmoniem Alrayah; Nassir Gobara; Ekhlas Elgeli; Mohammed Elhussien; Ali Babiker Habour; Elfatih Mohamed Malik

doi:doi:10.11648/j.sjph.20251305.14

Case Report |

Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024

Ismail Aladani, Abdulaziz Adam, Abdelrahim Babakir, Nada Mohamed Ali Alnair, Nadir Hammad, Sahar Abd Elmoniem Alrayah^*, Nassir Gobara, Ekhlas Elgeli, Mohammed Elhussien, Ali Babiker Habour, Elfatih Mohamed Malik

Published in Science Journal of Public Health (Volume 13, Issue 5)

Received: 3 June 2025 Accepted: 27 June 2025 Published: 10 October 2025

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Abstract

Background: Immunization is known to be a cost-effective intervention; addressing more than (20) diseases. The Expanded Program on Immunization (EPI) was established to ensure target population, especially children, benefit from life-saving immunization services. Securing resources, establishing systems, and demand generation are crucial for successful immunization programs. The ongoing conflict in Sudan, resulting in displacement of over 10 million people, had severely affected country’s immunization services. This study explores the impact of the conflict on Sudan’s EPI and examines the strategies employed to mitigate these challenges. Methods: A qualitative synthesis and desk review were conducted to explore the best practices, innovations, challenges, and lessons learned from June 2023- to December 2024. Five of the authors collaborated to identify sources and extracted data from the EPI reports and records. Two other authors verified the outcomes and complemented it using meeting memos. Compiled findings were shared with other authors for review and feedback. Data was manually organized and analyzed using a thematic analysis. Key themes reflected the situation of EPI program before the conflict, the impact of war on the program, and the response of EPI program. Thematic areas encompassed human resources, cold chain, routine immunization, supplementary immunization activities, surveillance and outbreak investigation. Results: By the end of 2024, the EPI in Sudan started to reverse the decline in immunization services’ coverage and accessibility resulting from war. Modification of service delivery strategies; contemplating the security status district by district was key success factor. Furthermore, program’s resilience was supported by a dedicated, committed, and responsive EPI teams at national and sub-national levels, operating in collaboration and coordination with partners, motivated by a unified vision encapsulated in the slogan “Despite what is happening, vaccination must continue”. Conclusions: To sustain the immunization services in Sudan, the EPI prioritized the cohesion and solidarity of the team, adopting a collaborative approach. This durable essence of unity was especially evident is expanding partnership in security compromised states.

Published in	Science Journal of Public Health (Volume 13, Issue 5)
DOI	10.11648/j.sjph.20251305.14
Page(s)	283-295
Creative Commons	This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
Copyright	Copyright © The Author(s), 2025. Published by Science Publishing Group

Keywords

Immunization, Sudan, Conflict, Acheivement, Lesson Leant

1. Introduction

Immunization is a cost-effective investment to the prevention and control of more than 20 vaccine preventable diseases (VPDs)

[1]

. Immunization has significantly reduced infectious diseases’ morbidity and mortality. Childhood vaccines are estimated to save 4 to 5 million lives every year and have positively impact cognitive development, schooling, and economic productivity

[2].

That is why the immunization agenda for 2030 stresses expanding equitable access to immunization services for all ages, across life-course .

The EPI, established in 1974, ensures that all children and adults worldwide, benefit from life-saving vaccines. Countries implement their own EPI programs; initially prioritizing 6 diseases (Bacillus Calmette-Guérin (BCG), diphtheria, pertussis, tetanus, poliomyelitis, and measles). Overtime, priority disease has expanded, and the World Health Organization (WHO) now recommends 13 vaccines (antigens) for national EPI programs’ schedules. National health priorities, disease burden and local contexts guide selection of antigens for national schedules, spanning entire life course, providing protection from infancy through childhood, adolescence, and into older adulthood. To achieve EPI objectives and set targets, countries must establish basic program elements. These include adequate human resources at all levels, proper supply and logistics management system, suitable service delivery strategies, system for monitoring immunization coverage and adverse events following immunization (AEFIs), disease surveillance and demand generation interventions.

[3]

Moreover, countries must ensure that the vaccine supply and service delivery are adequately integrated in the existing health system and that the health care providers advocate for immunization at all levels.

[4]

Conflicts affect immunization coverage by damaging infrastructure and interruption of supply and service delivery systems at the PHC level including EPI. The risk of VPDs outbreak increases as conflicts create conditions favoring disease transmission such as population displacement, malnutrition and over-crowding

[5]

Considerable percentage - may be up to 40% - of under-vaccinated children live in areas that are either partially or entirely affected by conflicts

[6-8]

In Pakistan, the EPI faces several challenges in conflict affected areas such as lack of clarity about the delivery strategy - whether fixed centres, outreach or mobile teams, scarcity of human resource, inaccurate target calculations, logistical and financial obstacles, lack of political commitment, and community misconceptions about vaccines

[9]

. In Ethiopia, the immunization program had seriously deteriorated during and after the conflict due to security challenges, displacement of health workers, destruction of health infrastructures, integration of the displaced community in the host community, and weak coordination among stakeholders and partners .

The Ministries of Health in conflict affected areas usually seek the help of UN agencies and Non-Governmental Organization (NGOs). UNICEF is known to play an important role, negotiating corridors of peace and days of tranquility with armed groups that allow vaccinators to deliver immunization. Moreover, it supports resilient system strengthening and capacity building, ensuring uninterrupted supply of vaccines, improved risk communication and community engagement and tailored integrated outreach strategies

[7]

In Sudan, the challenges faced by the immunization program are not markedly different from those observed in other conflict-affected settings. Recent published reports underscore the complexity of vaccinating target groups in Sudan amidst the current war, highlighting the need for innovative funding mechanisms and adaptive service delivery strategies.

[11]

This study aims to present how the EPI program in Sudan has addressed the consequences of war on immunization services. Main challenges encountered, approaches adopted, key achievements, lessons learned are examined, proposing the way forward.

2. Methodology

Study area: The Republic of the Sudan lies in Sub-Saharan Africa, and is the third largest country in the continent, with a land area of 1,886,068 square kilometres. As of 2019, Sudan’s population is estimated at 42,596,5891. The country has a coastal line along the Red Sea and shares borders with seven countries: Egypt, Eritrea, Ethiopia, South Sudan, the Central African Republic, Chad, and Libya, most of these are elevated risk countries for VPDS. Sudan is a multiracial, multicultural nation distributed along eighteen states and 189 localities.

Setting: As of April 15^th, Sudan has been enduring an armed conflict affecting Khartoum - the capital and Darfur and Kordofan zones, rapidly expanding to reach central states, Gezira, Sennar, White Nile and Blue Nile, by the end of 2024. This widespread conflict resulted in a mass displacement with over 10 million displaced people, out of which 1.5 million crossed borders with neighboring countries.

EPI program in Sudan is a cornerstone of PHC, delivering one of the most effective preventive health interventions. One of the most notable achievements of the program is its expansion of immunization schedule. reflecting on a life course approach. The program started with 6 antigens and reached 11 antigens by the end of 2024, including introduction of Meningococcal A (MenA), Pneumococcal Conjugate Vaccine (PCV), Inactivated Polio Vaccine (IPV), Yellow Fever (YF), and a second dose of Measles Vaccine (MV2). Sudan is free of poliomyelitis for 16 years and succeeded to contain of circulating vaccine-derived poliovirus type 2 (cVDPV2). Major achievement also includes mitigation of measles risk, and reduction of other VPDs in addition to rapid to cholera outbreaks.

Design: In this retrospective description, a qualitative synthesis and desk review of the EPI during the emergency period from June 2023 to December 2024 was conducted; aiming to identify the best practices, innovations, challenges, and lessons learned to inform future programming.

Data collection and analysis: five of the authors identified relevant sources and extracted data from the EPI reports and records. The outcome was verified by two additional authors, using their meeting memos. The team shared their findings with the broader author team for review and feedback. All comments were compiled and integrated in the final analysis. Data was manually organized and analyzed using a thematic analysis approach.

Ethical consideration: As the data used in this study was collected from a public health program, including aggregated reports and documents, ethical clearance was not required. Permission to use the data was obtained from PHC General Directorate at Federal Ministry of Health (FMOH) in Sudan

[12]

Also, consent was not specifically sought for this study, as the analysis was based on anonymized data and all personally identifiable information were removed prior to reporting.

3. Results

The findings of this study highlight the situation of Sudan’s EPI program prior to the conflict, the consequences of war on the program, and the response strategies implemented. The analysis is structured around key components including the human resources, cold chain, routine immunization (RI) and supplementary immunization activities (SIAs), and vaccine preventable diseases (VPDs) surveillance and response. The conflict resulted in a very dynamic situation and unstable environment characterized by challenging security and political conditions with subsequent consequences on human resources, service accessibility, and health infrastructure.

3.1. Human Resources - The EPI Team

Before the conflict EPI in Sudan was operated under a robust encompassing a national team and 18 sub-national teams. While the national EPI team included 85 personnel, state level teams were composed of EPI managers and officers responsible for RI, SIAs, cold chain logistics, and disease surveillance. In addition, there are vaccinators whose immunization is the primary role, reflecting a strong human resources component of the program (EPI micro-plan 2024).

The EPI program is further supported by national independent advisory and oversight committees such as the National Immunization Technical Advisory Group (NITAG), the National Certification Committee (NCC), the Adverse Event Following Immunization (AEFI) committee, the National Expert Committee (NEC), and the National Containment Committee.

Like the general population, the EPI teams at national and states levels were directly affected by war. Tragically, at least three EPI personnel lost their lives, many others were not able to reach their working stations or were preoccupied by their own selves’ and families’ safety. Others run short of vaccines to sustain services. In addition, government instability adversely affected the operation of the program.

This was further aggravated by the destruction and looting of the state’s EPI offices, stores and vehicles. The program lost more than 57 vehicles including vaccine trucks. Moreover, 11 states were totally inaccessible or hard to reach with 51 localities (districts) partially accessible and 22 totally inaccessible (Figure 1). This directly affected EPI managerial and vaccinators teams.

Download: Download full-size image

Figure 1. Accessibility status of states and localities, Sudan EPI, 2024.

Even though, the war in Sudan compromised the life of everyone in Khartoum, the national EPI team, supported by PHC management responded swiftly. On the first day of the tragedy, the EPI team in collaboration with partners formulated a small crisis management group to assess the feasibility of evacuating the supplies from the national vaccine store in Khartoum anticipating challenges in electricity supply maintenance. Subsequently in June 2023, a core team was formed in Wad Madani, a safe city at that time, initially composed of 9 personnels and later the team expanded to 19 experts. Driven with a sound and easy to share slogan “Despite what is happening, vaccination must continue”, the national team initiated and maintained communication with states teams and partners and proved its resilience and capacity to respond rapidly to emerging issues.

3.2. The Cold Chain

The documented success of EPI in Sudan since its establishment is largely attributed to sustaining an efficient cold chain and supply system. In addition to the central cold chain unit in Khartoum, there were 21 units at state levels. Each designed to meet the vaccination needs of the target population, including the routine service and supplementary immunization activities.

Due to widespread looting and the complete or partial destruction of facilities and equipment, the program lost its main vaccine stores representing about 42% of total capacity. The first store affected was the central store which is located south of Greater Khartoum, near where the fighting first erupted. The teams on duty were not able to rotate shifts due to the security situation.

Standby generators were used due to electricity instability; however, this was challenged by a shortage of fuel. Over time, worries about losing vaccines was a reality. The cold chain unit in Khartoum State was the second to be affected followed by the unit in South Darfur state. As the conflict progressed, more units were affected across Darfur, Kordofan, and central Sudan regions, extending to reach facility level. As a result, approximately 315 pieces of equipment were lost, leading to disruption of vaccine supply system from central to state to locality and health facility levels.

Despite the active military operations in Khartoum State, the EPI team in collaboration with partners succeeded to evacuate the vaccines. A total of 6.9 million doses of routine immunization vaccines and 6 million doses of measles-rubella (MR) vaccines were evacuated safely from the central store to a newly established store in Wad Madani and subsequently distributed to other states. Concurrently, the EPI team and its partners exerted tremendous efforts to maintain the integrity of the cold chain across all states, particularly in security compromised states. These efforts included the establishment of 5 new cold chain units.

During the study period, the cold chain succeeded to distribute 16 million doses of RI vaccines to the states. In addition, 5 million doses of Oral Cholera Vaccine (OCV) were supplied to control cholera outbreaks across six states. Furthermore, 14.5 million doses of MR vaccine availed for MR campaigns and for MR routine immunization. The efforts prioritized supplies to most vulnerable, and conflict affected areas such as Khartoum, Kordofan and Darfur (Figure 2). A joint convoy transported RI supplies from Kosti to Kordofan and to Darfur.

Download: Download full-size image

Figure 2. Pictures reflecting the efforts of the core team (left) and the vaccinators.

3.3. The Routine (RI) and Supplementary Immunizations Activities (SIA)

Over the past two decades, Sudan had sustained high RI coverage due to staff dedication, political commitment, coordination, and support from key partners including Global Alliance for Vaccine and Immunization (GAVI), UNICEF, WHO, and NGOs. Service delivery strategies including fixed, outreach, and mobile sites were used simultaneously. Alongside, efforts to maintain population immunity through SIAs are ongoing with plans targeting poliomyelitis, measles, and COVID-19.

Due to security situation, connectivity challenges, loss of assets - such as looted vehicles - and vaccines stock outs, only 62% (4,648) of vaccination centers remained functional, with only 33% of RI reports collected. The situation further deteriorated due to delayed disbursement of funds of operational costs of the RI activities resulting from difficulties in cash transfer.

Furthermore, the widespread population displacement has made it difficult to estimate population targets eligible for vaccination. This coupled was with families’ priorities shifting towards shelter and food, deprioritizing immunization. An extensive disruption in the implementation of the RI sessions was reported, with the coverage by different antigens declining dramatically (Table 1). Furthermore, The SIAs were not implemented as planned.

Based on comprehensive assessment of the security situation and health system status, the EPI team and its partners classified the states into two groups according to the accessibility level. Group A (accessible states) includes Northern, River Nile, Blue Nile, White Nile, Gedarif, Kassala, and Red Sea States and Group B are hard to reach states that include Khartoum, Gezira, Sennar, North Kordofan, South Kordofan, West Kordofan, North Darfur, South Darfur, Central Darfur, East Darfur, and West Darfur (see Figure 1). Further classification - left map on Figure 1 - categorized Sudan’s 186 localities to accessible (113 localities), partially accessible (51 localities), and inaccessible (22 localities). It is important to note that the accessibility status of states and localities is being continuously monitored. Due to the dynamic nature of the situation, classifications are subject to change over time as conditions evolve on the ground.

Table 1. Coverage with Penta 1 and Penta 3 per state, Sudan EPI, Dec 2024.

States	2022		2023		2024
States	Penta 1	Penta 3	Penta 1	Penta 1	Penta 1	Penta 3
Northern	101	99	107	101	108	107
River Nile	99	95	104	99	112	107
Red Sea	82	69	100	95	104	96
Kassala	92	81	88	83	97	89
Gedarif	100	94	87	82	117	106
Blue Nile	96	81	91	67	85	63
White Nile	96	85	93	79	85	69
Sennar	100	94	94	64	81	69
Gezira	92	81	96	93	27	24
Khartoum	96	85	28	25	17	14
N. Kordofan	88	84	49	39	36	23
S. Kordofan	95	96	56	46	56	58
W. Kordofan	109	92	53	47	8	5
N. Darfur	100	94	38	29	19	11
S. Darfur	99	89	14	8	32	8
W. Darfur	100	91	44	34	45	38
E. Darfur	82	69	25	31	36	21
C. Darfur	92	80	28	23	26	17
Sudan	94	84	57	51	48	39

The team finalized an emergency plan adopting a differentiated approach and customized strategies to counteract the challenges imposed by the new situation. The plan aims to increase demand for EPI services, ensure adequate supplies, and build capacity of program’s personnel. Additionally, Context-specific delivery strategies were adopted for each state and locality. (Table 2).

Table 2. Health system readiness, target population, challenges and adapted vaccination strategies according to accessibility classes, Sudan, 2024.

Class and access level	Health system readiness	Target	Key challenges	Adapted strategies
States
Group A (Accessible states)	High	491,559	IDPs, rainy season, change of the target population	Regular outreach Fixed site services maintained PIRI
Group B (Hard-to-reach states)	Moderate/ low	1,364,814	Intermittent access, security threats, severe conflict, supply chain disruptions, change of the target population	Mobile health units Community-led campaigns Temporary vaccination posts Use of local mediators  Hit and Run PIRI
Localities
Accessible	High	842,089	IDPs, rainy season, change of the target population	Regular outreach Fixed site services maintained
Partially accessible	Moderate	660,372	Intermittent access, security threats, IDPs, rainy season, change of the target population	Mobile health units Community-led campaigns
Inaccessible	Low	327,854	Severe conflict, supply chain disruptions, change of the target population	Temporary vaccination posts Use of local mediators Hit and run

Following the initiation of the implementation of the emergency plan, the RI was restored and SIAs started to progress. By December 2024, the coverage with BCG, Penta 1, Penta 3, Measles Containing Vaccine (MCV)/MR1, and MCV/MR2 significantly increased in Group A states (accessible), however, for Group B states (hard-to-reach) it remained below target. During the annual review meeting, the EPI teams at national and states levels decided to engage more partners to overcome the persistent challenges in hard-to-reach states. By the end of December 2024, the coverage for Penta 1 and Penta 3 started to reverse the down-going trend (Figure 3) in many states. Concurrently, more than 3 million under 5 children were vaccinated against poliomyelitis in 8 states. Moreover, more than 5.7 children were vaccinated against measles and rubella, which was facilitated introduction of MR vaccine in RI in 8 states.

In response to the cholera outbreak that began in August 2023 and affected 37 localities across 7 states by the end of 2024, the EPI program in collaboration with the Health Emergency and Epidemic Control General Directorate, implemented a series of vaccination campaigns to control the outbreak aimed at controlling the outbreak. The response campaign was organized into 9 phases: each covering a target geographical area. In total, 11.96 million people were vaccinated (with a coverage rate of 93.4%) in Gedarif, Gezira, Khartoum, Red Sea, Kassala, White Nile, River Nile, Sennar, and Northern States.

A breakthrough and outstanding achievement were the introduction of two new vaccines; measles-rubella (MR) and malaria vaccine. The roll out of MR vaccine was introduced in phases considering the security situation in Sudan. In phase one, eight states were targeted: River Nile, Northern, Red Sea, Kassala, Gedarif, Blue Nile, Sennar and White Nile states. A total of 6,851,121 children aged 9 months to less than 15 years were vaccinated (a coverage rate of 102%). Phased two focused on partially accessible states. Karrari locality in Khartoum states and two localities in Gezira state were covered with a total of 470,647 individuals vaccinated with a coverage rate of 94.3% and 801,013 individual vaccinated with a coverage rate of 98%, respectively.

The EPI program in collaboration with the national malaria control program and partners succeeded to introduce malaria vaccine (R21/Matrix-M vaccine) into RI services, targeting children under one year. The vaccine was used in phased manner which was guided by the burden of malaria at locality level. As part of phase one, the vaccine introduction was launched on November 4^th, 2024, in Gedarif and Blue Nile states targeting 16 localities. Phase two aims to expand to 147 priority localities by the end of 2026.

Other vaccine introduction efforts aim to introduce Hep-B Birth Dose targeting Infants 0 - 14 days).

Download: Download full-size image

Figure 3. Coverage with Penta 1 and Penta 3 per state, Sudan EPI, 2022 - 2024.

3.4. The VPDs Surveillance and Response to Outbreaks

Sudan’s EPI has a strong vaccine-preventable diseases (VPDs) surveillance system. The system is based on reports from 963 sentinel sites across the country. To fill the identified surveillance gap in some states, a newly established community-based surveillance (CBS) trained 568 community volunteers. Additionally, there is a well-established central laboratory unit within the National Public Health Laboratory (NPHL) which is equipped with sampling kits and clear protocols for samples collection and transportation. The effectiveness of the system is reinforced by strong stakeholder engagement, including active participation from pediatricians, healthcare providers, facility-level focal persons, and EPI surveillance officers at all administrative levels.

The ongoing conflict has severely affected the immediate and weekly reporting due to disruption of the government system, staff displacement, and connectivity issues. At the time of the study, only 623 out of 963 (65%) sentinel sites 200 out of 577 (35%) community volunteers are reporting regularly. Reporting rates from hard-to-reach states was low averaging 40% (251 out of 577) in recent months.

The national laboratory unit at the NPHL was not functioning, and the stock of sample kits at states and facilities was depleted due to inaccessibility to the central store. These challenges have resulted in delayed detection and confirmation of suspected (and probable) cases of measles, whooping cough, diphtheria, cholera, and acute flaccid paralysis (AFP). Moreover, sample collection and transportation were discontinued. Thus, the timely response to the outbreak was jeopardized.

Efforts to enhance surveillance and early detection of VPDs include training of additional community volunteers and revitalization of sentinel sites in accessible and hard-to-reach states. One initiative in collaboration with EMPHNET is the Public Health Empowerment Program (PHEP) which targets EPI surveillance officers at locality level in 9 states. The program aims to build capacities in surveillance, outbreak investigation and project design, implementation and evaluation. Preliminarily, improvement in the overall reporting rates was observed (Table 3).

3.5. Social and Behavioral Communication (SBC)

Since establishment of the EPI in Sudan, efforts to increase demand for immunization, overcoming rumors, informing the caregivers, and to address behavioral and social determinants (BeSD) are continuing. The EPI program utilizes a wide range of communication channels such as radio, TV, newspapers, immunization ambassadors, vaccination friends’ groups, social media, health care providers, vaccinators among others.

However, the ongoing conflict in Sudan disrupted these efforts. Traditional and digital media channels have been affected safety concerns limit mobility of immunization teams. Moreover, The conflict shifted the families’ priorities towards safety, securing shelters and food at the expense of routine immunization.

In coordination with the Health Promotion Directorate, with support from UNICEF, several interventions were implemented to mobilize communities and maintain and increase demand for routine immunization in the accessible states. These include training EPI teams and health promotion officers on crisis on communication during conflict. Additionally, mobile theatres for displaced people and host communities, home visits, orientation of religious and community leaders, and awareness session for general population were implemented.

Table 3. Status of reporting as part of vaccine preventable diseases surveillance system, 2023-2024.

State	April 2023- June 2023					July 2023- December 2024
State	## of sites	## of functioning sites	% of functioning sites	## of reporting sites	% Reporting out of functioning	## of sites	## of functioning sites	% of functioning sites	## of reporting sites	% Reporting out of functioning
Northern	65	0	0	0	0	65	65	100	65	100
River Nile	84	0	0	0	0	84	84	100	84	100
Red sea	53	0	0	0	0	53	53	100	53	100
Kassala	43	0	0	0	0	43	43	100	43	100
Gedarif	56	0	0	0	0	56	56	100	56	100
Blue Nile	33	0	0	0	0	33	28	85	28	100
White Nile	53	0	0	0	0	53	53	100	49	92
Sennar	33	0	0	0	0	33	33	100	33	100
Gezira	102	0	0	0	0	102	80	78	80	100
Khartoum	108	0	0	0	0	108	22	20	22	100
N. Kordofan	64	0	0	0	0	64	56	88	56	100
S. Kordofan	32	0	0	0	0	32	27	84	27	100
W. Kordofan	42	0	0	0	0	42	22	52	22	100
N. Darfur	47	0	0	0	0	47	7	15	7	100
S. Darfur	52	0	0	0	0	52	52	100	52	100
W. Darfur	55	0	0	0	0	55	43	78	43	100
E. Darfur	30	0	0	0	0	30	30	100	30	100
C. Darfur	59	0	0	0	0	59	50	51	30	60
Sudan	1011	0	0	0.0	0	1011	804	77	780	97.0

3.6. Leadership and Management

Through the years, EPI in Sudan established a strong partnership with many organizations with clear definition of roles. While UNICEF is supporting cold chain, supply transportation, service delivery, monitoring, supervision, and SBC; WHO provides support for VPDs surveillance, outbreak investigation, response, and human resources for immunization. Save Children International (SCI) contributes to RI delivery, SBC, and supervision, while EMPHNET is active in capacity building. International Medical Corps (IMC) and AIGHT provide support in RI, integrated VPD services, SBC, cold chain (CC), and monitoring and evaluation (M&E), particularly in the Kordofan and Darfur regions. All partners provide continuous support for vaccination campaigns (MR, OCV, Polio, and response campaigns).

The EPI team strengthens the partnership with these organizations further with a clear shift towards emergency response. The EPI team actively involves the Minster of Health and the Director General of Primary Health Care in high-level communication within partner organizations and facilitate government-related processes.

Despite the challenges posed by the ongoing conflict, the EPI in Sudan has continued to operate through pre-existing coordination mechanisms that were well-established prior to the war. The Technical Working Group (TWG)—comprising representatives from WHO, UNICEF, SCI, Médecins Sans Frontières (MSF), EMPHNET, ACASUS, and the Project Management Unit (PMU)—has convened regularly to address emerging issues and guide programmatic decisions.

In addition, the EPI team has maintained its weekly RI coordination meetings with key partners, including UNICEF, WHO, and SCI. Weekly surveillance coordination meetings with WHO and other stakeholders have also continued, alongside the ACASUS-led electronic supervision meetings.

At the regional level, the Gavi Coordination Group, which includes technical staff from the regional offices of WHO, UNICEF, and EMPHNET, meets weekly to align and coordinate their activities with the national EPI program. The NITAG—comprising pediatricians, epidemiologists, microbiologists, researchers, representatives from the National Regulatory Authority, and development partners—has sustained its regular meeting schedule, continuing to provide evidence-based guidance for immunization policy and strategy.

Furthermore, the EPI program actively engages health clusters, including OCHA, International Committee of the Red Cross (ICRC), MSF, and other humanitarian actors, to reach target populations in partially accessible and inaccessible areas. This coordination has extended to include collaboration with the Joint Military Forces in Darfur to facilitate the delivery of vaccines and supplies to areas under their control and beyond.

To strengthen subnational coordination, the EPI program has also established new coordination bodies at the state level, aimed at enhancing governance, accountability, and the effectiveness of immunization service delivery during emergencies.

Prior to the onset of the conflict, Sudan’s EPI operated a well-established M&E system. Data flowed systematically from the facility level to locality, then to state, and ultimately to the federal level, enabling comprehensive monitoring of immunization activities. Routine supervisory visits at all administrative levels complemented the reporting system, while periodic review meetings provided structured forums to assess performance, identify challenges, and implement corrective actions.

This monitoring framework was further supported by evaluation activities, including coverage surveys, post-campaign assessments, and operational research, which provided critical insights into program effectiveness and areas for improvement.

4. Discussion

The EPI program in Sudan has effectively reversed the decline in immunization coverage and improved access to services by adapting delivery strategies to the security context of each district. These efforts were supported by dedicated and responsive teams at both national and sub-national levels. The program’s success was further strengthened through strong collaboration with partners and a unified operational theme, encapsulated in the slogan: “Despite what is happening, vaccination must continue.” This collective effort was recognized through the awarding of the Medal of Achievement and Excellence by the Minister of Health and acknowledgment by the WHO Eastern Mediterranean Regional Office (EMRO).

Although the conflict in Sudan temporarily disrupted the M&E system of the Expanded Program on Immunization (EPI), the system has since been partially restored. The federal EPI team demonstrated resilience and commitment by successfully conducting national supervisory visits in 17 out of 18 states. Additionally, supervisory activities related to the introduction of the malaria vaccine were implemented, reinforcing the program’s capacity to adapt and maintain quality assurance during emergencies.

The ongoing conflict has significantly affected the immunization program by weakening public health infrastructure, diverting caregiver attention from preventive services, and prioritizing curative and emergency care.

[10]

As seen in other conflict-affected countries such as Afghanistan, the Democratic Republic of Congo, Somalia, and Angola, the long-term consequences of war often persist well beyond the cessation of hostilities.

[13]

Despite initial prioritization, rebuilding public health infrastructure, including immunization systems—rarely receives sustained investment.

[14]

To mitigate the impact of conflict, the EPI program in Sudan implemented governance reforms, delegating greater authority to state-level actors, particularly in the design and execution of implementation strategies. This hybrid approach—combining top-down guidance with bottom-up engagement—proved effectively in enhancing immunization coverage and promoting local ownership.

[14]

Evidence from similar settings supports the effectiveness of institutional support, public education campaigns, countering misinformation, and maintaining coverage among host populations.

[15]

Key strategies drawn from the Polio Eradication Initiative include:

[9]

1) Conducting security assessments and negotiations with key actors,

2) Utilizing geographic information systems (GIS) for planning and tracking,

3) Engaging communities closely,

4) Coordinating with humanitarian relief efforts,

5) Adopting flexible vaccine scheduling and dosing strategies.

These approaches require coordinated efforts from local, national, and international stakeholders, underpinned by strong leadership and governance structures. Coordination of stakeholders and strong leadership systems are crucial in maintaining optimum vaccination service delivery even at the time of conflict

[10]

WHO declared vaccine hesitancy as one of the world’s top 10 global health threats in 2019

[16]

Although vaccine hesitancy is not currently a widespread issue in Sudan, it remains a concern in contexts of migration and internal displacement. Among displaced populations, hesitancy has been linked to fear, misinformation, limited knowledge, and distrust.

[17]

This phenomenon has been observed in other countries and underscores the need for proactive communication and trust-building strategies.

[18]

The conflict has contributed to the resurgence of VPDs such as measles, diphtheria, cholera, and pertussis, as well as other infectious diseases like dengue fever and malaria. These outbreaks are driven by mass displacement, overcrowding, poor sanitation, lack of shelter, and malnutrition.

[19]

For example, Yemen experienced a fatal diphtheria epidemic in 2017 due to a significant drop in vaccine coverage.

[20]

Similarly, conflict in Afghanistan and subsequent displacement to Pakistan led to a rise in paralytic poliomyelitis cases, exacerbated by anti-vaccination propaganda and security threats.

[21]

In conflict-affected areas, public health surveillance is often hindered by inaccessibility, infrastructure damage, and security constraints. These challenges can be addressed through the recruitment of local community volunteers who can negotiate access with armed groups and advocate for the urgent need for immunization and disease surveillance. The use of GIS technology is essential for mapping coverage, identifying gaps, and estimating the size and location of inaccessible populations.

[22]

Two critical lessons emerged from the EPI program’s experience during the conflict:

1) The early adoption of a collaborative approach enabled sustained communication with partners and alignment of activities, even as the conflict evolved and displacement patterns shifted.

2) Maintaining team cohesion and solidarity was essential for ensuring continued service delivery, particularly in areas directly affected by the conflict.

The EPI program and its partners are committed to sustaining routine immunization services not only in accessible areas but also in hard-to-reach and conflict-affected regions. This includes expanding partnerships in security-compromised states and extending services to zero-dose children under five years of age. Strengthening the capacity of EPI surveillance officers and frontline personnel through the expansion of the Public Health Empowerment Program (PHEP) equivalent to the basic Field Epidemiology Training Program (FETP) is a key priority. The goal is to maintain a functional VPD surveillance system, including community-based surveillance, and to ensure timely investigation and response to outbreaks.

Addressing the broader health crisis in Sudan requires international collaboration to restore healthcare services, improve living conditions, and strengthen disease surveillance. Timely and coordinated responses are essential to mitigate health risks and protect public health security.

1. Limitation

To overcome the inherited pitfalls in such qualitative synthesis, we managed to strengthen the validity through triangulation of data and information from several sources including the program and partner documents.

Abbreviations

AEFIs	Adverse Events Following Immunization
AFP	Acute Flaccid Paralysis
CBS	Community-based Surveillance
EPI	Expanded Program on Immunization
EMRO	WHO Eastern Mediterranean Regional Office
FMoH	Federal Ministry of Health
GAVI	Global Alliance for Vaccines and Immunization
MCV	Measles Containing Vaccine
M&E	Monitoring and Evaluation
MR	Measles-rubella
MSF	Médecins Sans Frontières
NCC	The National Certification Committee
NEC	The National Expert Committee
NGOs	Non-governmental Organizations
NITAG	National Immunization Technical Advisory Group
NPHL	National Public Health Laboratory
OCV	Oral Cholera Vaccine
PHC	Primary Health Care
RI	Routine Immunization
SBC	Social and Behavioral Change
SCI	Save the Children International
SIAs	Supplementary Immunization Activities
VPDs	Vaccine Preventable Diseases
WHO	World Health Organization

Author Contributions

Ismail Aladani: Conceptualization, Supervision, Validation, Writing - original draft

Abdulaziz Adam: Conceptualization, Writing - original draft, Formal analysis

Abdelrahim Babakir: Conceptualization, Visualization, Writing - review and editing

Nada Mohamed Ali Alnair: Conceptualization, Writing - review and editing

Nadir Hammad: Conceptualization, Validation

Sahar Abd Elmoniem Alrayah: Conceptualization, Writing - review and editing

Nassir Gobara: Conceptualization, Validation

Ekhlas Elgeli: Conceptualization, Validation

Mohammed Elhussien: Conceptualization, Validation

Ali Babiker Habour: Conceptualization, Writing - original draft

Elfatih Mohamed Malik: Conceptualization, Supervision, Methodology, Writing - original draft, Writing - review and editing

Funding

This work is supported by EMPHNET.

Data Availability Statement

The data is available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

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Aladani, I., Adam, A., Babakir, A., Alnair, N. M. A., Hammad, N., et al. (2025). Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Science Journal of Public Health, 13(5), 283-295. https://doi.org/10.11648/j.sjph.20251305.14

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Aladani, I.; Adam, A.; Babakir, A.; Alnair, N. M. A.; Hammad, N., et al. Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Sci. J. Public Health 2025, 13(5), 283-295. doi: 10.11648/j.sjph.20251305.14

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Aladani I, Adam A, Babakir A, Alnair NMA, Hammad N, et al. Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Sci J Public Health. 2025;13(5):283-295. doi: 10.11648/j.sjph.20251305.14

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@article{10.11648/j.sjph.20251305.14,
author = {Ismail Aladani and Abdulaziz Adam and Abdelrahim Babakir and Nada Mohamed Ali Alnair and Nadir Hammad and Sahar Abd Elmoniem Alrayah and Nassir Gobara and Ekhlas Elgeli and Mohammed Elhussien and Ali Babiker Habour and Elfatih Mohamed Malik},
title = {Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024
},
journal = {Science Journal of Public Health},
volume = {13},
number = {5},
pages = {283-295},
doi = {10.11648/j.sjph.20251305.14},
url = {https://doi.org/10.11648/j.sjph.20251305.14},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.sjph.20251305.14},
abstract = {Background: Immunization is known to be a cost-effective intervention; addressing more than (20) diseases. The Expanded Program on Immunization (EPI) was established to ensure target population, especially children, benefit from life-saving immunization services. Securing resources, establishing systems, and demand generation are crucial for successful immunization programs. The ongoing conflict in Sudan, resulting in displacement of over 10 million people, had severely affected country’s immunization services. This study explores the impact of the conflict on Sudan’s EPI and examines the strategies employed to mitigate these challenges. Methods: A qualitative synthesis and desk review were conducted to explore the best practices, innovations, challenges, and lessons learned from June 2023- to December 2024. Five of the authors collaborated to identify sources and extracted data from the EPI reports and records. Two other authors verified the outcomes and complemented it using meeting memos. Compiled findings were shared with other authors for review and feedback. Data was manually organized and analyzed using a thematic analysis. Key themes reflected the situation of EPI program before the conflict, the impact of war on the program, and the response of EPI program. Thematic areas encompassed human resources, cold chain, routine immunization, supplementary immunization activities, surveillance and outbreak investigation. Results: By the end of 2024, the EPI in Sudan started to reverse the decline in immunization services’ coverage and accessibility resulting from war. Modification of service delivery strategies; contemplating the security status district by district was key success factor. Furthermore, program’s resilience was supported by a dedicated, committed, and responsive EPI teams at national and sub-national levels, operating in collaboration and coordination with partners, motivated by a unified vision encapsulated in the slogan “Despite what is happening, vaccination must continue”. Conclusions: To sustain the immunization services in Sudan, the EPI prioritized the cohesion and solidarity of the team, adopting a collaborative approach. This durable essence of unity was especially evident is expanding partnership in security compromised states.
},
year = {2025}
}

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TY - JOUR
T1 - Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024

AU - Ismail Aladani
AU - Abdulaziz Adam
AU - Abdelrahim Babakir
AU - Nada Mohamed Ali Alnair
AU - Nadir Hammad
AU - Sahar Abd Elmoniem Alrayah
AU - Nassir Gobara
AU - Ekhlas Elgeli
AU - Mohammed Elhussien
AU - Ali Babiker Habour
AU - Elfatih Mohamed Malik
Y1 - 2025/10/10
PY - 2025
N1 - https://doi.org/10.11648/j.sjph.20251305.14
DO - 10.11648/j.sjph.20251305.14
T2 - Science Journal of Public Health
JF - Science Journal of Public Health
JO - Science Journal of Public Health
SP - 283
EP - 295
PB - Science Publishing Group
SN - 2328-7950
UR - https://doi.org/10.11648/j.sjph.20251305.14
AB - Background: Immunization is known to be a cost-effective intervention; addressing more than (20) diseases. The Expanded Program on Immunization (EPI) was established to ensure target population, especially children, benefit from life-saving immunization services. Securing resources, establishing systems, and demand generation are crucial for successful immunization programs. The ongoing conflict in Sudan, resulting in displacement of over 10 million people, had severely affected country’s immunization services. This study explores the impact of the conflict on Sudan’s EPI and examines the strategies employed to mitigate these challenges. Methods: A qualitative synthesis and desk review were conducted to explore the best practices, innovations, challenges, and lessons learned from June 2023- to December 2024. Five of the authors collaborated to identify sources and extracted data from the EPI reports and records. Two other authors verified the outcomes and complemented it using meeting memos. Compiled findings were shared with other authors for review and feedback. Data was manually organized and analyzed using a thematic analysis. Key themes reflected the situation of EPI program before the conflict, the impact of war on the program, and the response of EPI program. Thematic areas encompassed human resources, cold chain, routine immunization, supplementary immunization activities, surveillance and outbreak investigation. Results: By the end of 2024, the EPI in Sudan started to reverse the decline in immunization services’ coverage and accessibility resulting from war. Modification of service delivery strategies; contemplating the security status district by district was key success factor. Furthermore, program’s resilience was supported by a dedicated, committed, and responsive EPI teams at national and sub-national levels, operating in collaboration and coordination with partners, motivated by a unified vision encapsulated in the slogan “Despite what is happening, vaccination must continue”. Conclusions: To sustain the immunization services in Sudan, the EPI prioritized the cohesion and solidarity of the team, adopting a collaborative approach. This durable essence of unity was especially evident is expanding partnership in security compromised states.

VL - 13
IS - 5
ER -

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Author Information

Ismail Aladani

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Abdulaziz Adam

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Abdelrahim Babakir

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Nada Mohamed Ali Alnair

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Nadir Hammad

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Sahar Abd Elmoniem Alrayah

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan

Contact Email
Nassir Gobara

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Ekhlas Elgeli

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Mohammed Elhussien

Expanded Program on Immunization, Federal Ministry of Health, Khartoum, Sudan
Ali Babiker Habour

Department of Pandemics, University of Gezira, Wad Madani, Sudan
Elfatih Mohamed Malik

Faculty of Medicine, University of Khartoum, Khartoum, Sudan

http://orcid.org/0000-0002-8071-8092

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Aladani, I., Adam, A., Babakir, A., Alnair, N. M. A., Hammad, N., et al. (2025). Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Science Journal of Public Health, 13(5), 283-295. https://doi.org/10.11648/j.sjph.20251305.14

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Aladani, I.; Adam, A.; Babakir, A.; Alnair, N. M. A.; Hammad, N., et al. Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Sci. J. Public Health 2025, 13(5), 283-295. doi: 10.11648/j.sjph.20251305.14

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Aladani I, Adam A, Babakir A, Alnair NMA, Hammad N, et al. Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024. Sci J Public Health. 2025;13(5):283-295. doi: 10.11648/j.sjph.20251305.14

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TY - JOUR
T1 - Sustaining Immunization Under the Roar of Cannons: Lessons Learned from Sudan, June 2023 to December 2024

VL - 13
IS - 5
ER -

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