Photo credit: WHO/Syria

1 March 2021 - COVAX is the vaccines pillar of the ACT-Accelerator [1], convened by the Coalition  for Epidemic Preparedness and Innovations (CEPI), GAVI - the Vaccine Alliance (GAVI) and WHO. Syria is one of the 92 countries eligible for Advanced Market Distribution (AMD) of COVID-19 vaccines under the COVAX facility, a partnership between the World Health Organization (WHO), the Coalition for Epidemic Preparedness Innovations (CEPI), and the Global Alliance for Vaccines and Immunization (GAVI). 

In coordination with GAVI, WHO and UNICEF continue providing detailed technical assistance to and sharing guidelines with the national health authority and established committees, such as the high level National Coordination Committee, CTAG-national COVID-19 Technical Advisory Group and Inter-agency Coordination Committee. 

Vaccine Request Form (VRF) - Part A of the COVID-19 Vaccine Application document was signed by the Minister of Health and sent to GAVI on 15 December 2020. On 27 January 2021, the Syrian Prime Minister declared the Government’s approval of the vaccine initiative through the COVAX facility. Part B was signed on 3 February and sent to GAVI. 

GAVI, in return, on 3 February 2021 has acknowledged and expressed the intent to provide initially one million twenty thousand doses of Astra Zenica Serum Institute of India (AZ SII) vaccines, to cover the first 3% of the population (targeted high-risk groups), including the population in the north-east.

The National Deployment and Vaccination Plan (NDVP) was submitted on 9 February 2021, and re-submitted, after review, on 16 February, and approved on 19 February 2021. Cold chain application is submitted on 21 February 2021. 

As per GAVI, the first allocation of vaccines is anticipated by the end of the first quarter or within the second quarter 2021 at the latest, after signing of the indemnity document with the manufacturer and confirming operational readiness. 

Regular daily meetings are held in the past weeks since the beginning of 2021 by the 3 vaccine-related committees NCC, CTAG and ICC, the meetings of the latter being attended by WHO and UNICEF. 

The Vaccine Introduction Readiness Assessment Tool (VIRAT tool) has been used to update the readiness status on a monthly basis, the final update submitted on 23 February 2021. 

1. Coordination framework established

The following coordination committees are in existence, with clear TORs (terms of reference) and fully operational since end of January 2021, along with 10 technical sub-committees:

1. NCC - National Coordination Committee,
2. CTAG - COVID-19 Technical Advisory Group and
3. ICC - Inter-Agency Coordination Committee

2. National readiness assessment

VIRAT/VRAF version updated tool includes planning and coordination, budgeting, regulatory, prioritization, targeting and surveillance, service delivery, training and supervision, monitoring and evaluation, vaccine cold-chain, logistics, safety surveillance, and demand generation and communication – a set of 50 key operational activities: 

• First update was submitted at the end of November 2020.
• Second update was submitted on 14 January 2021.
• Third update was endorsed by the Ministry of Health on 20 January 2021.
• Fourth and final update was submitted on 23 February 2021.

3. Establishment of taskforces

To bridge capacity and planning and implementation gaps and to ensure preparedness regarding key areas of vaccine introduction, 10 sub-committees were formed as the technical part of the cTAG committee (WHO and UNICEF as focal points are included). Meetings take place regularly to update the VIRAT and to prepare the needed materials for the national vaccine deployment plan. 

WHO and UNICEF also instituted monthly coordination meetings with the first meeting held on 14 February 2021. 

4. Population prioritization

The priority categories identified in Part A are based on the National Technical Advisory Group recommendation, SAGE values framework and the COVAX facility fair allocation (prioritization roadmap). The following high-risk groups were agreed upon as a target under COVAX:  

• Health workforce (including front line social workers and teachers) - 3% of population;
• Older adults >55-year population - about 13% of population;
• People with chronic diseases - 5% of population. 

At present, the national authorities collect and consolidate population data (including from the Ministry of Planning, Central Statistics Office, Syndicate of Doctors and Health Workers at national and governate levels). The population data includes all 14 governorates of Syria, the north-west and north-east Syria. The Ministry of Health highly relies on the existing mechanisms and modalities related to the previous experience of the successful routine immunization activities across these governorates (see section 7 for more on north-west Syria). 

As per the meeting conducted on 7 February 2021, the vaccination of planned 20% of the population will be carried out in 3 phases as follows, with the doses adjusted as per quantities made available by COVAX and adjusted population figures: 

Phase	Groups	Estimated number of people vaccinated* to be adjusted as per available vaccine allocation
Phase One	All health workers	190 000
	Older group (55 years or more)	485 450
Phase Two	Rest of the older group	1 540 900
	Persons with comorbidities	1 125 750
	School teachers	302 827
	Other essential workers	858 073
Phase Three		To be determined

5. Pre-registration mechanism 

WHO is supporting the development and introduction of the pre-registration automated platform and reporting mechanism working together with the existing committees. The pre-registration will support in identifying target groups and vaccine distribution. However, this modality will not be the only way for the pre-registration and the exemptions are being factored in for some cases. 

6. Service delivery mechanisms

At this stage, 76 hospitals used as service delivery points are planned to provide vaccination, on top of 101 primary health care facilities all over the country. This number of facilities and teams is preliminary and is subject to change based on the ongoing microplanning. Each hospital will have 3 or more teams assigned to the microplanning for each phase of the campaign. Services will be provided by the trained hospital teams and by routine immunization personnel as part of the mobile teams. 

The implementation across the north-east will follow the current experience of the Expanded Programme on Immunization (EPI) microplanning through the 17 fixed facilities (hospitals and PHC centres) and 105 mobile teams. Formal and informal settlements will be targeted as well through the same modalities. The microplans will equally cover the population of camps across north-east Syria. The first batch of vaccines will target eligible high-risk health workforce and frontline humanitarian workers, regardless of the location. WHO will support the transport of the vaccine inside Syria including to the north-east Syria and coordinate the mobile activities on the ground with different stakeholders, based on the existing operations. 

7. Northwest Syria

WHO Syria maintains a direct day-to-day dialogue with WHO Turkey. WHO Gaziantep office, together with UNICEF, has submitted COVAX application relying on the implementation based on the currently existing immunization programme modality in northwest Syria (NWS). 

The target groups were prioritized based on series of discussions among the parties involved and include health care workers (3%), the elderly aged 60 and above (7.5%) and people in the age group 20-59 with special conditions such as immune-compromised persons and persons with chronic illnesses (9.5%). The GAVI letter received on 3 February 2021 expresses the intent to allocate vaccines to cover the initial 3% of the population with AZ SII vaccines (indicative, 336 000 doses). 

 The following activities were undertaken:

• The Technical assistance plan for COVAX was developed and submitted on 28 February 2021.
• The Vaccine Request Form (Plan A) was developed, submitted in 7 December 2020.  
• WHO and partners have finalized the first draft of the COVAX vaccination campaign plan and budget.
• WHO and partners finalized the development of the National Deployment and Vaccination Plan (NDVP) for north-west Syria; the plan was submitted in time and approved on 17 Febrary 2021.
• WHO and partners developed a cold chain equipment (CCE) application package submitted on 15 February 2021.
• Partners are developing SOPs, formats and channels of the vaccination campaign, reviewing training materials for the context of north-west Syria.
• Health cluster and partners support estimation of the priority health workers working in the field aiming to get better estimated numbers.

8. Development of the national deployment and vaccination plan

• NDVP (submitted on 9 February and re-submitted, after comments, on 19 February) was approved on 22 February.
• 2 trained WHO consultants (international, national) are currently supporting the work of the sub-committees at the Ministry of Health on microplanning.

9. Guidelines, forms, reporting materials

Work is ongoing to develop the following:

• Vaccination cards, vaccination registers, reporting forms;
• Monitoring and supervision checklist;
• AEFIs guidelines, checklist and reporting forms;
• Updating COVID-19 reporting forms to include vaccination;
• IPC and waste management protocols;
• Communication materials.

10. Cold chain

• Nationwide cold chain inventory was finalized and gaps for different scenarios were identified.
• UNICEF contracted two consultants to review and enhance this component. The cold chain application is submitted on 21 February 2021.
• WHO Gaziantep and partners developed the cold chain equipment (CCE) application for north-west Syria, which was submitted on 15 February 2021.

11. Vaccination in high-risk areas 

• The Ministy of Health decided to use a combination of fixed facilities and mobile teams to vaccinate health workers in hard-to-reach areas.
• The micro plans will include the high-risk groups and high-risk areas and the possible mechanism to reach them (as per EPI experience).
• Population figures of camps and settlements are collected regardless of the areas of control (including in north-east Syria) for the review and the necessary endorsement. 

Next steps and key areas

• cTAG meetings to approve what was agreed by sub-committees.
• Finalize microplanning which includes:

identifying the targeted population and by which vaccination point they will be covered.

identifying high-risk groups, ways and the mechanisms of reaching them.

agreeing on the number of vaccination days by each team.

agreeing on the number of team members and staff included at each level.

• Finalize the developments of guidelines, protocols, checklists, reporting forms for printing.
• Plan for an electronic reporting system to report on vaccinations and AEFI cases (ongoing discussion between MOH and WHO to streamline support).
• Develop the needed operational cost, cost of vaccine supplies and the possible source of funds using costing tool.
• Set a timeline for all the planned activities before the vaccine introduction.
• Coordinate at the high-level coordination and have a dialogue to continue planning and vaccine roll out using Whole of Syria approach.
• Get the Indemnity and Liability agreementsigned between the government and the manufacturer. 

WHO and UNICEF continue to work closely with the Ministry of Health in Syria.  

12. Challenges

While we are committed and put our efforts to combat COVID-19 and make vaccines available to the Syrian people, there are many ‘unknowns’ as we move forward. It is important to know that at present COVAX allocation is our best enabler to secure vaccines across Syria. There are discussions at the global level to avail ‘humanitarian buffer’ of vaccines, which can remain contingent once made available.

The “unknowns” that may influence vaccine deployment include:

1. Manufacturing and global vaccine availability – the arrival of the first batch of vaccine allocated to Syria is still not defined;
2. The security situation on the ground;
3. COVAX commitment beyond the initial 3% is not ensured;
4. Options to secure the vaccines, in the long run, may be limited resulting in increased humanitarian needs;
5. The current mutations and variants of the COVID-19 virus circulating in Syria are not known, making it difficult to prove the efficacy of the introduced vaccines (*however, WHO has sent samples for sequencing at the WHO Regional Reference Labs);
6. Availability of funding for COVAX Vaccine to support the roll out of COVID-19 vaccination;
7. Continuity of the cross-border operations in north-west Syria heavily depends on the UN Security Council Resolution (scheduled July 2021) and contingency planning to ensure continuity of care for Q3 and Q4 of 2021 with COVAX vaccination. 

13. Vaccine introduction costs

Estimates for the operational costs for the first phase of the vaccine roll-out under COVAX, targeting 3% of the population (front-line health workers and social workers), during the first and second quarter: US$ 7 000 000 (US$ 4.5 million for the areas under the control of Government of Syria and the north-east Syria, and US$ 2.5 million for northwest Syria areas).  

The second phase of the vaccine roll-out will target the next 17% of the population and include the elderly and those with chronic diseases; it will take place in the third and fourth quarter. Estimated gaps in operational costs: US$ 32 000 000 (US$ 24.3 million for areas under the control of Government of Syria and northeast Syria, and US$ 7.5 million for northwest Syria.

Previous updates

Update on COVID-19 vccination in Syria, 16 February 2021

Update on COVID-19 vaccination in Syria, 9 February 2021

Update on COVID-19 vaccination in Syria, 26 January 2021