Update on COVID-19 vaccination in Syria, 28 April 2021

Update on COVID-19 vaccination in Syria

On 22 April 2021, Syria received the first batch of 256,800 doses of COVID-19 vaccines facilitated through COVAX. This vaccine delivery (AstraZeneca vaccines from the Serum Institute of India, AZ SII) will be distributed to frontline health workers across Syria, including the northeast and northwest. The COVID-19 vaccines were delivered through two shipments: 203,000 doses arrived in Damascus for all governorates and additional 53,800 doses were delivered through Gaziantep for the crossborder shipment to the northwest. Vaccine distribution and administration will start in early May 2021. (for more information, read WHO Press Release on Vaccine Delivery)

COVAX is the vaccines pillar of the ACT-Accelerator, an instrument jointly convened by the Coalition for Epidemic Preparedness and Innovations (CEPI), WHO and the Vaccine Alliance (GAVI) to speed up the search for an effective vaccine for all countries; support the building of manufacturing capabilities; buy supply ahead of time so that two billion doses can be fairly distributed globally by the end of 2021.

Under the COVAX facility, Syria is one of the 92 countries eligible for advanced market distribution (AMD) of COVID-19 vaccines.

In coordination with GAVI; WHO and UNICEF are providing detailed technical assistance to the national health authority in Syria as well as the established committees such as the high-level National Coordination Committee (NCC), the National COVID-19 Technical Advisory Group (CTAG) and the Inter-Agency Coordination Committee (ICC).

Vaccine Request Form (VRF)

Part A of the COVAX COVID-19 vaccine application document was signed by the Syrian Minister of Health and sent to GAVI on 15 December 2020. On 27 January 2021, the Syrian Prime Minister declared the Syrian government’s approval of the COVAX vaccine initiative. Consequently, Part B of the vaccine application was signed and sent to GAVI on 3 February.

On 3 February 2021, GAVI acknowledged and expressed its intent to provide an initial 1 020 000 doses of AstraZeneca Serum Institute of India (AZ SII) vaccines to cover the first 3% of the population (targeted high-risk groups), including the population in Northeast Syria. An additional 336 000 doses are intended for northwest Syria.

On 15 February 2021, WHO granted Emergency Use Listing (EUL) for the AstraZeneca AZD1222 vaccine produced by the Serum Institute of India (AZ SII).

Later, the allocation of the AZ SII vaccine was confirmed by GAVI through May 2021 as 912 000 doses for Phase 1, in addition to 224 000 doses of the same vaccine to the Phase 1 vaccine administration in Northwest Syria (NWS). The month of June is not included in those allocations, which is the main reason that the quantities are less than the intended indicative allocation previously communicated.

This amount may only cover around 4% of the total population; indicative distribution is based on current communication of estimated vaccine availability from manufacturers. The distribution will likely need to be adjusted considering the unpredictable circumstances and constantly evolving variables.

The Indemnity and Liability agreement with the manufacturer was signed by the Ministry of Health and the corresponding manufacturer.

Since the beginning of 2021, regular daily meetings have been held by three vaccine-related committees: the NCC, the CTAG and the ICC (with WHO and UNICEF present at the ICC meetings). The WHO COVID-19 Vaccine Introduction Readiness Assessment Tool (VIRAT/VRAF 2.0) has been used to conduct monthly updates on the national readiness status; the most recent update was submitted on 23 February 2021.

Coordination framework

Since the end of January 2021, the NCC, the CTAG, the ICC as well as 10 technical sub-committees have been fully operational, with clear terms of reference.

1. National readiness assessment

The updated VIRAT/VRAF 2.0 includes assessment of planning and coordination, budgeting, regulatory measures, prioritization, targeting and surveillance, service delivery, training and supervision, monitoring and evaluation, vaccine cold chain, logistics, safety surveillance, and demand generation and communication. It covers a set of 50 key operational activities. Syria has been using this tool according to the following timetable:

The first update was submitted at end November 2020;
The second update was submitted on 14 January 2021;
The third update was endorsed by the Ministry of Health on 20 January 2021;
The fourth and final update was submitted on 23 February 2021.

2. Establishment of taskforces

To bridge the gaps in planning and implementation, and to ensure preparedness for key areas of vaccine introduction; 10 sub-committees have been formed as the technical part of the CTAG committee. These sub-committees, which include focal point from WHO and UNICEF, meet regularly to update the VIRAT/VRAF 2.0 work and prepare the necessary materials for the National Deployment and Vaccination Plan (NDVP). WHO and UNICEF are holding monthly coordination meetings.

3. Population prioritization

The priority categories identified in Part A of the COVID-19 vaccine application document are based on the CTAG’s recommendations, the Strategic Advisory Group of Experts on Immunization (SAGE) values framework as well as the COVAX facility fair allocation prioritization roadmap. For Syria, the following high-risk groups were agreed upon as targets under COVAX:

The health workforce (including frontline social workers and teachers); 3% of the population.

Older adults (>55 years); approximately 13% of the population.

People with chronic diseases; 5% of the population.

The national authorities have collected and consolidated population data at the national and governmental levels (including from the Ministry of Planning, the Central Statistics Office and the Syndicate of Doctors and Health Workers). This data involves all 14 Syrian governorates, including Northwest and Northeast Syria. The Ministry of Health greatly relies on existing mechanisms and modalities related to previous experiences of successful routine immunization activities across these governorates.

As decided in a meeting on 7 February 2021, the vaccination of the first 20% of the population will be carried out at three phases as outlined in the table below. The doses could be adjusted according to quantities made available by COVAX and updates to population figures.

Phase	Groups	Estimated number of people vaccinated* to be adjusted as per available vaccine allocation
Phase One	All health workers	190 000
Phase One	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

4. Pre-registration mechanism

In collaboration with the committees, WHO is supporting the development and introduction of an automated pre-registration platform and reporting mechanism. Pre-registration will help identify target groups and aid vaccine distribution. This approach will not, however, be the only method for pre-registration, and exemptions are being factored in for some cases.

5. Service delivery mechanisms

Under the current plans, 76 hospitals will be used as service delivery points to provide vaccinations, along with 101 primary health care facilities all over the country. Services will be provided by trained hospital teams and routine immunization personnel in mobile teams. This number of facilities and associated teams is preliminary and subject to change based on ongoing microplanning. Each hospital will have three or more teams assigned to microplanning for each phase of the campaign.

Implementation across Northeast Syria will follow the current experiences of the Expanded Programme on Immunization (EPI) microplanning through 17 fixed facilities (hospitals and primary healthcare centres) and 105 mobile teams. Formal and informal settlements will be targeted in the same way. Microplanning will also cover camps across Northeast Syria. The first batch of vaccines will target eligible high-risk members of the health workforce and frontline humanitarian workers regardless of location. WHO will support the transport of the vaccine inside Syria, including Northeast Syria, and coordinate mobile activities with different stakeholders based on existing operations.

Following the COVID-19 vaccine arrival on 22 April through COVAX, the Ministry of Health is preparing to launch the vaccination campaign in early May 2021. WHO has supported the Ministry by printing and deploying vaccination cards, vaccination certificates, consent forms and other materials to all designated vaccination centres in Syria.

Based on the arrival of the limited doses of vaccines, 118 611 health workers will be vaccinated in the first cohort in 72 hospitals, 90 primary healthcare facilities, and 100 mobile teams.

In Northeast Syria, there are an estimated 14 000 health workers who will be eligible for the first cohort vaccination, which will be executed in 5 hospitals and 12 primary healthcare centres and 30 mobile teams.

6. Monitoring and evaluation

Currently, for the national immunization programme, the Ministry of Health is using an aggregate reporting system where administered doses are recorded by age and gender, tallied along key dimensions, and reported up the health system, often using a mix of digital and paper tools. A similar approach is being used also by the Syria Immunization Group in Northwest Syria.

After the immunization campaign concludes, independent monitors from universities, health colleagues and national NGO partners will be deployed to ensure the vaccination campaign coverage. This approach will be used for the COVID-19 vaccination. Furthermore, a more active form of monitoring and evaluation is planned by WHO, UNICEF and MOH. This form would cover the pre-, intra-, and post-implementation of the vaccination activity at the field level, including assigning a third party for independent M&E.

Paper-based records will be updated to reflect COVID-19 vaccination status to:

provide proof of vaccination for individuals’ travel, educational or occupational purposes;

establish vaccination status in coverage surveys;

provide vaccination information in case of an Adverse Event Following Immunization (AEFI) or a positive COVID-19 test; and

provide a useful vaccination card to which COVID-19 vaccines and other recommended vaccines can be added, as well as guidance on any doses required to complete the vaccination course.

During the vaccination campaigns, monitoring activities are conducted at different strata by central, governorate, district team supervisors.

For the COVID-19 vaccination, a team consisting of representatives from MOH, WHO and UNICEF has been formed and is working on the monitoring and evaluation plan for government-controlled areas as well as Northeast Syria. The WHO monitoring guide for COVID-19 vaccination has highlighted the potential sources for COVID-19 vaccination data through the health information system, facility reports, electronic immunization registers and surveillance data for Adverse Effect Following Immunization (AEFI) and Adverse Event of Special Interest (AESI).

In Northwest Syria, WHO, in partnership with UNICEF and COVID-19 taskforce, has updated monitoring and evaluation tools and strategies for the COVID-19 vaccination campaigns. In Northwest Syria, the evaluation process will be implemented through third-party independent monitors who will be deployed to ensure the vaccination campaign process in 3 phases - pre, intra- and post-campaign monitoring.

7. Risk communication and demand generation

WHO and UNICEF has worked in close cooperation with the Ministry of Health to develop the COVID-19 vaccination media campaign, which includes capacity building workshops for journalists, health educators and community influencers. It also includes a full media package (TV and radio spots, social media messages, billboards, posters, flyers, etc.) to be implemented nationally.

The first batch of the social media key messages was developed and finalised to be launched on the different national media channels and platforms. It targets different aged groups including health workers, the elderly, parents, university students school children. Video and radio spots have been developed too.

In close cooperation with the Ministry of Health, in March 2021 WHO supported the first media workshop on the introduction of COVID-19 vaccination in Syria with the participation of more than 35 media professional representing different national media channels.

Based on learnings from previous COVID-19 prevention and response interventions, five strategies will guide the introduction of COVID-19 vaccines at the national and governmental level:

Advocacy to gain commitment and garner support for the rollout of the new COVID-19 vaccines.

Capacity building to enhance communication and community mobilization skills of target workers (including health care providers, health education officers, NGOs, etc.).

Media engagement and social media campaigns to promote balanced, evidence-based discourse on COVID-19 vaccines and the vaccination process (these campaigns will set out to manage demand and vaccine hesitancy, build trust and manage misinformation and rumours).

Community engagement by providing prompt, simple, and focused communication to communities to manage expectations and hesitancy concerns.

Crises communication related to adverse events following immunization (AEFI); rapid responses will be prepared to manage crises arising from demand and vaccine hesitancy.

8. Northwest Syria

WHO Syria maintains a direct day-to-day dialogue with the WHO hub in Gaziantep, Turkey. Together with UNICEF, the hub has submitted a COVAX application for the implementation of COVID-19 vaccinations based on the existing immunization programme in Northwest Syria.

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

The following activities have been undertaken in Northwest Syria:

WHO and partners have finalized the first draft of an estimated budget for thThe NDVP was submitted on 9 February 2021, resubmitted after comments on 19 February, and approved on 22 February. Two trained international and national WHO consultants are currently supporting the sub-committees involved with microplanning at the Ministry of Health. e COVAX vaccination campaign that covers different possible scenarios.

WHO and partners have finalized the development of the National Deployment and Vaccination Plan for Northwest Syria. This was submitted to the WHO Regional Office for the Eastern Mediterranean and presented to, and approved by, the Regional Review Committee (RRC) on 16 February 2021.

Vaccine Introduction Readiness Assessment Tool (VIRAT) was updated during the week of March 22, 2021.

Partners are developing standard operating procedures (SOPs), formats and channels for the vaccination campaign and reviewing training materials for the context of Northwest Syria.

The Health Cluster and partners are supporting estimations of the number of priority health workers in the field, to improve the accuracy of estimated numbers.

9. Development of the National Deployment and Vaccination Plan (NDVP)

The NDVP was submitted on 9 February, resubmitted after comments on 19 February, and approved on 22 February. Two trained WHO consultants (international, national) are currently supporting sub-committees at the Ministry of Health that are working on microplanning.

10. Guidelines, forms, reporting materials

Work is ongoing to develop the following resources:

vaccination cards, vaccination registers and reporting forms;
a monitoring and supervision checklist;
guidelines, checklists and reporting forms for AEFI;
updated COVID-19 reporting forms that include vaccination;
infection prevention and control (IPC) and waste management protocols; and
communication materials.

11. Cold chain

A nationwide cold chain inventory has been finalized and gaps for different scenarios have been identified. Training of trainers for cold chain and logistics officers has been conducted at the central level. UNICEF has contracted two consultants to review and enhance this component, and the cold chain application was submitted on 21 February 2021.

WHO’s Gaziantep hub and partners have developed the cold chain equipment (CCE) application for Northwest Syria, which was submitted on 15 February 2021.

12. Vaccination in high-risk areas

The Ministry of Health has decided to use a combination of fixed facilities and mobile teams to vaccinate health workers in hard-to-reach areas. Microplanning will include high-risk groups and high-risk areas as well as possible mechanisms through which to reach them, based on experiences and learnings from the Extended Program on Immunization (EPI). Population figures for camps and settlements are being collected for review and the necessary endorsement regardless of the areas of control (including in Northeast Syria).

Next steps and key areas

CTAG meetings will be held to approve the decisions of the technical sub-committees and finalize microplanning. This will include identifying targeted populations and vaccination points that will cover them; identifying high-risk groups including ways and mechanisms to reach them; agreeing on the number of vaccination days per team, the number of members per team and the staff included at each level.

The development of guidelines, protocols, checklists and reporting forms will then be finalized, and planning will be accomplished for an electronic reporting system to report vaccinations and AEFI cases (discussions on streamlining support for this system are ongoing between the Ministry of Health and WHO(.

A timeline for all planned activities will be set and ongoing high-level coordination will commence, with the goal of rollout the vaccines using a whole-of-Syria approach.

Training-of trainers, cascaded training and orientation meetings have started on 17 March 2021 and will continue at the governmental level. The following activities have been rolled out:

Training of Trainers (TOT) for microplanning for all governorates took place (in 2 groups) on 17-20 March 2021.

TOT for service delivery professionals for all governorates took place on 23-24 March 2021.

TOT on vaccination communication for all governorates was organized on 23-24 March 2021.

An orientation meeting was organized at the Ministry of Health for media professionals on 25 March 2021.

Field training on service delivery in all governorates were held from 28 March until 17 April 2021.

Vaccine deployment microplanning workshops took place in Damascus and governorates at the end of March 2021.

13. Challenges

WHO is committed to making every effort to combat COVID-19 in Syria and make vaccines available to the Syrian people. There are and will be, many “unknowns” as we move forward. It is important to know that while at present COVAX allocation is the best means of securing vaccines across Syria, there are also discussions at the global level to avail a “humanitarian buffer” of vaccines, which can remain contingent once made available.

The following issues are among the many unknowns that could influence vaccine deployment:

The instability of the security situation on the ground.

The fact that COVAX commitment is not currently ensured beyond the initial 3%.

The fact that options to secure vaccines may be limited in the long run, resulting in increased humanitarian needs.

The fact that current mutations and variants of the COVID-19 virus circulating in Syria are not known, making it difficult to predict or prove the efficacy of the introduced vaccines (However, WHO has sent samples for sequencing at the WHO Regional Reference Labs; so this point may improve).

Uncertain and unpredictable availability of funding to support the rollout of COVID-19 vaccination. While the first batch of vaccines arrived and are about to be administered, the operational costs will be covered by WHO and UNICEF. Special allocation of funding to support these costs is sought.

The fact that continuity of cross-border operations in Northwest Syria depends heavily on a UN Security Council Resolutions that currently only lasts until July 2021.

The need for contingency planning to ensure continuity of COVAX vaccination for the 3rd and 4th Quarters of 2021.

14. Vaccine introduction costs

The estimated operating cost of the first phase of vaccine rollout under COVAX, targeting 3% of the population (front-line health workers and social workers) during the first and second quarter of 2021, is US$7 million. This includes US$4.5 million for areas under the control of the Government of Syria and Northeast Syria and US$2.5 million for Northwest Syria.

The second phase of vaccine rollout will target the next 17% of the population and will include the elderly and those with chronic diseases. This will take place in the third and fourth quarter of 2021. The estimated gap in operational costs is US$32 million, including US$24.3 million for areas under the control of the Government of Syria and Northeast Syria, and US$7.5 million for Northwest Syria.

The table below outlines the estimated budget breakdown for vaccine introduction costs to cover 20% of the population by end of December 2021:

Estimated Budget Breakdown for Vaccine Introduction Costs to Cover 20% of the Population by end of December 2021

Budget summary for 2 Rounds	Damascus		Gaziantep (cross border)		Total
Budget summary for 2 Rounds	Cost be covered by WHO CO	Cost to be covered by UNICEF	Cost to be covered by WHO	Cost to be covered by UNICEF	Total
Human resources and incentives	$8,773,424.00	$1,066,317.00	$5,298,979.20	$0.00	$15,138,720.20
Training	$707,323.00	$99,523.00	$358,137.60	$0.00	$1,164,983.60
Meetings	$444,299.00	$0.00	$528,379.92	$0.00	$972,678.92
Cold chain, supplies and Logistic	$2,677,852.00	$2,903,453.00	$752,077.92	$0.00	$6,333,382.92
Transportation	$4,023,314.00		$1,526,804.40	$0.00	$5,550,118.40
Evaluation & Monitoring	$1,878,748.00	$0.00	$662,833.00	$0.00	$2,541,581.00
Social mobilization	$952,068.00	$5,317,619.00		$500,000.00	$6,769,687.00
Supporting management cost for contracted NGOs	$0.00	$0.00	$372,787.68	$0.00	$0.00
Grand Total	$19,457,028	$9,386,912	$9,499,999.72	$500,000	$38,843,941