In the tumbledown concrete room that has been commandeered as this sleepy African trading center, a battered freezer holds stacks of boxes with dozens of small glass vials.
There are four brands of Covid vaccines. The vaccine team gives Sinopharm to the healthiest people because they think it's the least effective of the vaccines. It is normally only for people with underlying medical conditions. The health workers in the town are rushing to use all of the shipment that is coming to an end soon. Johnson is given mostly to teachers.
Six shots of Pfizer, the most popular vaccine in the United States, are hidden in a corner of the freezer, in a salvaged carton that came in the last delivery. The only Covid vaccine authorized here for people under 18 is one that the health workers try to save for teenagers, but they also have to use up a vial once it is open, so sometimes Pfizer is for whoever walks in the door.
Mr. Conteh said that more will be coming.
The town's improvised distribution strategy is reflective of a new phase in the effort to vaccine the world against Covid. The supply in the lowest-income countries is growing more plentiful, but it is often unpredictable and difficult to plan for. Storage, personnel and transportation are needed to carry out broad vaccination campaigns.
Scientific understanding of what it takes to achieve full and strong protection against existing and new Covid-19 variant is continuously evolving. The United States and many wealthy countries have been pushing booster shots from Pfizer and Moderna, which use new technology seen as the gold-standard, in line with the latest thinking about the best chance for protection.
Many researchers believe that lower levels of protection are offered by products and dosing schedules that African countries still rely on. The World Health Organization does not like the regimen that many people are sticking with.
The W.H.O. recommended in December that the Johnson & Johnson vaccine should be given in two doses, but it is still being used as a single shot.
Austin Demby, Sierra Leone's health minister, said in an interview that one dose is better than zero. It's just unbelievable. Imagine trying to keep track of these vaccinations. It is a collection of protocols. It is a nightmare.
The Pfizer vaccine is being delivered here as a two-shot regimen, not a three-shot regimen, as it is in high-income countries. The W.H.O. recommended booster shots of Pfizer's vaccine for older people and health care workers.
The W.H.O. recommends a gap of eight to 12 weeks for the two doses of the shot, but it is difficult to track recipients in rural areas.
Sinopharm, the first Covid vaccine given to Sierra Leone, has been found to produce a minimal immune response against the Omicron variant, even when given as three doses. Sierra Leone is giving it two shots, with an unpredictable schedule.
Public health experts expect Africa to experience a fifth wave of the virus in the coming months, possibly from a new variant that could be more lethal. Dr. Demby acknowledged that the goal is to give 40 percent of the population primary immunizations by June. Almost no one has received a booster shot, and the figure is just 12 percent.
As in the rest of West Africa, a combination of poor reporting, limited testing and a younger population has led to relatively few Covid cases or deaths here. There was an apparent spike in cases but not a surge in hospitalizations or deaths. There is less of a sense of importance around vaccinations.
After months of shortages, the country now has a good stock of Covid vaccines, but most people are preoccupied with the challenges of daily life, according to the health minister.
The best way to get people to accept a shot is to take it right to them, at churches, mosques, football matches or doorsteps. That is expensive. Many here see anti-malaria efforts as equal or greater priorities, and it requires intensive staffing and diversion of other resources away from that.
Vaccine deliveries are coming to Africa quicker than vaccination programs can. Some African governments have asked manufacturers to stop shipments until they have enough. An African Union official said the bloc has stopped ordering more vaccines until countries can use a recent influx of donated doses from China and Covax.
Moderna and Pfizer are the two companies that have made a quarter of the Covid vaccines that African countries have received. The figure does not include instances in which the W.H.O. did not have data on which brand was delivered. Most of the donations expected from the United States and Europe will be for those two products.
There is a debate over whether the shots are optimal for the population being vaccine and for stopping the emergence of variant and ending the epidemic in Africa.
The shots from Pfizer and Moderna have been found to perform better than vaccines using older technology on different metrics. The strongest short-term protection against Omicron appears to be offered by mRNA. Researchers expect this to happen with future variants as well.
The shots that use traditional vaccine technologies are easier to store and transport, and a mounting body of evidence shows that several may offer especially long- lasting protection across new variant, while the protection against infection offered by the Pfizer and Moderna has been found to fade faster over time.
The chief executive of the main nonprofit behind Covax said in an interview that better means high efficacy and ease. It means cost effectiveness, duration of protection, and the ability to protect against different strains.
I don't want to say that they're not the best vaccines, but boy, do I not have any evidence.
The work on vaccines and immunizations is done by the W.H.O., and it is important for lower-income countries to have non-mRNA shots and single-dose regimen.
Many lower-income countries have opted for products that have been rejected by rich countries when given the option to choose which brand of donated vaccine they want. The top preference is often Johnson & Johnson, because of its ease of use as a single shot.
The W.H.O. called the push for boosters in rich countries morally indefensible when poor countries were facing severe supply shortages. The agency has recently recommended additional shots for certain populations, and last week it endorsed boosters more emphatically than ever before.
There are different forms of a booster shot. It could be a second shot of any brand for a person who received a single dose of Johnson & Johnson's vaccine. It could be a third shot for someone who had already received two shots.
Hilary Marston said that the most important thing is that we get people that baseline of protection, but also make boosters available for people that are eligible.
In most African countries, there is not much of a booster campaign for vaccines, equipment and trained people.
The health workers at the vaccine headquarters are trying to figure out how to use the supplies they have been given. The health minister said that the ministry never instructed health workers to give Pfizer to teens. The community came up with its own rubric. He said that many local officials were hesitant to try to increase demand in the public because they didn't know what shots they would get.
On a recent Tuesday, the vaccination team headed out with a small Styrofoam cooler of their mishmash of vaccines to the village of Kathantha Yimbo, about a 40 minute drive on a rough dirt track. An advance team went through with a motorcycle and a bullhorn in order to get people to come to the central square.
The cards of most people showed they already had two Sinopharm shots. They were sent away without any offers of boosters. The second shot for some people was six months later than the recommended eight to 12 weeks because they had one AstraZeneca.
The 35-year-old woman who was selling fry cakes in the market decided to get her first vaccine since the shots were right there. I saw that people die of Covid sometimes, so I will take this even though I am not sure what it will do.
She was given a blue card by Mr. Conteh and sent on her way. No one talked about when she might get a second.
Noah, Matina, Monika, and Apoorva contributed to the report.
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