29 March 2021 – On 25 March 2021, the COVAX Facility informed that deliveries of doses from the Serum Institute of India (SII) to Syria, including northwest Syria, will be delayed in March and April, and that the closest delivery date may be in May 2021. Delays in securing supplies of SII-produced COVID-19 vaccine doses to Syria as well as to several other countries are due to the increased demand for COVID-19 vaccines in India.

COVAX is the vaccines pillar of the ACT-Accelerator [1], 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; and buy supply ahead of time so that 2 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 and 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. Part B of the vaccine application was signed and sent to GAVI on 3 February.

On 3 February 2021 GAVI acknowledged and expressed the intent to provide initially 1,020,000 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 northeast Syria. Additional 336,000 doses were 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 vaccine (SII-AZ).

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 the northwest. The month of June is not included in these 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. It is likely that distribution will need to be adjusted in light of circumstances that are difficult to anticipate and variables that are constantly evolving.

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

Regular daily meetings have been held since the beginning of 2021 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 update national readiness status on a monthly basis, with the most recent update submitted on 23 February 2021.

Coordination framework

The NCC, the CTAG, the ICC and 10 technical sub-committees have been fully operational, with clear terms of reference, since the end of January 2021.

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 gaps in capacity and 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 include WHO and UNICEF focal points, and meet regularly to update the VIRAT/VRAF 2.0 work and prepare necessary materials for the NDVP.

WHO and UNICEF are holding monthly coordination meetings, the first of which took place on 14 February 2021.

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 SAGE values framework and 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.

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

As decided in a meeting on 7 February 2021, the vaccination of the first 20% of the population will be carried out in three phases as outlined below, with doses 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
	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 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 PHC centres) and 105 mobile teams. Formal and informal settlements will be targeted in the same way. Microplanning will also cover the populations of 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 transport of the vaccine inside Syria, including to northeast Syria, and coordinate mobile activities with different stakeholders based on existing operations.

6. Monitoring and evaluation

Currently, for the national immunization programme, the Ministry of Health is using 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 that covers the pre-, intra and post- implementation of the vaccination activity at the field level, including assigning a third party for independent M&E is planned by WHO, UNICEF and MOH.

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

• provide proof of vaccination for individual’s travel, educational or occupational purposes;
• establish vaccination status in coverage surveys;
• provide vaccination information in case of an AEFI or in case of a positive COVID-19 test; and
• provide a useful vaccination card for adults and older adults to which COVID-19 vaccines and other recommended vaccines can be added and guidance on any doses required to complete vaccination course can be found.

During the vaccination campaigns, monitoring activities are conducted through different strata of supervision from the central, governorate, district team supervisors.

For the COVID-19 vaccination, a team consisting of representatives from MOH, WHO and UNICEF is formed and working on a monitoring and evaluation plan for government-controlled areas and northeast Syria. The WHO monitoring guide for COVID-19 vaccination has highlighted the potential sources for COVID-19 vaccination data through Health Information System, facility reports, electronic immunization registers and surveillance data for AEFI/AESI.

In nortwest Syria, WHO in partnership with UNICEF and COVID-19 taskforce is updating 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 are working 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 entails the development of a full media package (TV and radio spots, social media messages, billboards, posters, flyers, etc.) to be implemented nationally.

Based on learnings from previous COVID-19 prevention and response interventions, five strategies will guide the introduction of COVID-19 vaccines at national and state level. These are as follows:

• advocacy to gain commitment and garner support for rollout the new COVID-19 vaccine;
• capacity building to enhance communication and community mobilization skills of target workers (including heath 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; providing prompt, simple, focused communication to communities in order to manage expectations and hesitancy concerns; and
• crisis communication, including around adverse events following immunization (AEFI). Rapid responses will be prepared to manage crisis situations 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 implementation of COVID-19 vaccinations based on the existing immunization programme in northwest Syria.

As previously mentioned, northwest Syria has been allocated 224 000 doses of the AstraZeneca AZD1222 vaccine through May 2021. With the current changes in the delivery dates, Northwest Syria will also experience delays in vaccine deployment.  

Target groups were prioritized based on a series of discussions between involved parties, and 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 those with 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 the 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 on 16 February 2021.
• The Vaccine Introduction Readiness Assessment Tool (VIRAT) was updated during the week of 22 March 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, with the aim of improving 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 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 and possible mechanisms through which to reach them, based on experience and learning from the 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 the targeted populations and which vaccination point will cover them; identifying high-risk groups and ways and mechanisms to reach them; and agreeing the number of vaccination days for each team and the number of team members and staff included at each level.

The development of guidelines, protocols, checklists, and reporting forms will then be finalized, and planning will be done 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 begin, with the goal of vaccine rollout using a whole-of-Syria approach.

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

1. Training of trainers (TOT) for microplanning for all governorates took place (in 2 groups) on 17–20 March 2021.
2. TOT for service delivery professionals for all governorates took place on 23–24 March 2021.
3. TOT on vaccination communication for all governorates was organized on 23–24 March 2021.
4. An orientation meeting was organized at the Ministry of Health for media professionals on 25 March 2021.
5. Field training in all governorates will begin on the week of 28 March 2021.

Throughout this process WHO and UNICEF will continue to work closely with the Ministry of Health in Syria.

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 global level to avail a “humanitarian buffer” of vaccines, which can remain contingent once made available.

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

• unpredictable manufacturing and global vaccine availability: the exact arrival date of the first batch of vaccine allocated to Syria is still not defined; it became known that the manufacturer – Serum Institute of India – will redirect its vaccine production to domestic Indian needs, thus delaying the delivery to vaccines to Syria until May 2021.
• 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 (WHO has sent samples for sequencing at the WHO Regional Reference Labs, so this may improve);
• uncertain and unpredictable availability of funding to support rollout of COVID-19 vaccination;
• the fact that continuity of cross-border operations in northwest Syria depends heavily on a UN Security Council Resolution that currently only lasts until July 2021; and
• the need for contingency planning to ensure continuity of care for Q3 and Q4 of 2021 with COVAX vaccination.

14. Vaccine introduction costs

The estimated operational 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 operational cost of vaccinating 20% of the population in government controlled areas and northeast Syria, and the agreed cost sharing between WHO and UNICEF.

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
	Cost be covered by WHO CO	Cost to be covered by UNICEF	Cost to be covered by WHO	Cost to be covered by UNICEF
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