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Background: The COVID-19 pandemic has highlighted the need for more effective immunization programs, including in limited resource settings. This paper presents outcomes and lessons learnt from a COVID-19 vaccination campaign (VC), which used a tailored adaptive strategy to optimise vaccine uptake in the Boeny region of Madagascar. Methods: Guided by the Dynamic Sustainability Framework (DSF), the VC implementation was regularly reviewed through multi-sectoral stakeholder feedback, key informant interviews, problem-solving meetings, and weekly monitoring of outcome indicators to identify and apply key adaptations. Qualitative data on processes were collected and analysed using a rapid assessment approach. Outcome indicators, including pre- and post-VC vaccine hesitancy and trends in vaccine doses administered, were analysed using generalized linear models. Additionally, vaccination coverage, geographic reach, and target population characteristics, and sustainability indicators, such as staff trained, facilities equipped, and degree of integration of operational and educational materials were also tracked. Results: Key strategy adaptations included using a proactive campaign approach, community-led awareness and outreach, particularly in remote areas, and addressing cold chain, waste management, vaccine transport, and information technology (IT) equipment gaps. Over six months, 24,888 COVID-19 vaccines were administered. The adapted strategy led to an 8% increase in doses administered weekly (RR = 1.08, CI 95%: 1.01-1.15). However, vaccine hesitancy among the unvaccinated population remained unchanged (∆ = 0.02, CI 95%: -0.04-0.08). In terms of sustainability, 340 staff were trained, and 10 primary healthcare facilities were equipped and refurbished. Conclusions: Implementing collaborative, multi-sectoral vaccination strategies that integrate healthcare services with proactive outreach and community-driven campaigns are effective in increasing vaccine coverage in resource-limited settings. It demonstrates how theory-based adaptive strategies can enhance vaccination rates, even if they do not significantly impact COVID-19 vaccine hesitancy within the community. More generally, this initiative has important implications for adult vaccination programmes other than those related to COVID-19. [ABSTRACT FROM AUTHOR]

Background: In the annals of public health, smallpox is a watershed, being the first disease eradicated by vaccination. Drawing parallels to contemporary pandemic control measures, we examined the first smallpox vaccination campaigns in early 19th-century northern Italy and the seminal work of Luigi Sacco. Our study delves into this under-explored historical landscape to elucidate lessons that resonate with modern public health dilemmas., Methods: We scrutinised primary sources from the Historical Civic Archive of Pavia, the State Archive of Pavia, and the State Archive of Milan. These archives provided exhaustive data on administrative decrees, local epidemiology, and university-health authority collaborations. Using period-specific keyword searches and expert consultations, we extensively reviewed correspondence, vaccination lists, and academic writings, including Luigi Sacco's seminal Trattato di vaccinazione. The epidemiological investigation focused on the pivotal period of 1816-1828 in Lombardy's 19th-century public health landscape., Results: Organisational reforms enacted in 1821 succeeded in doubling the number of vaccinations administered in Pavia, stabilising at elevated rates in subsequent years. Despite improvements, incongruities in epidemiological data and vaccinator remuneration persisted. Communication strategies pioneered by Sacco, encompassing academic and religious collaborations, demonstrated their efficacy. Epidemiological data revealed an initial surge in vaccination uptake in 1822, with a declining trend in the following years, notably impacted by logistical and data recording limitations., Conclusion: Our research underscores three salient dimensions pertinent to contemporary public health paradigms: first, the vital function of local administrative bodies as efficacious service providers, immunisation register keepers, and social safety nets; second, the equilibrium between mandatory vaccination policies and discretionary enforcement as a pragmatic framework for public compliance; lastly, the irrefutable importance of credible communication strategies in fighting vaccine hesitancy. These insights are not merely historical curiosities but cardinal principles for effectively managing modern epidemics and infectious disease threats., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)