Update on COVID-19 vaccination in Syria

17 February 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 SII (AZ SII) vaccines [2], to cover the first 3% of the population (targeted high-risk groups), including the population in the north-east.

The National Vaccine Deployment Plan (NDVP) was submitted on 9 February 2021, to which comments were  provided on 16 February for further review and re-submission. 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, once the NDVP is endorsed after its technical review and signing of the indemnity document with the manufacturer.

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 next update is due on 21 February 2021.

1. Coordination framework established

The following coordination committees are in existence, with clear TORs and fully operational since end of January 2021:

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 update is due on 21 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 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) and 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% will be carried out in 3 phases as follows, with the doses adjusted as per quantities made available by COVAX and adjusted population figures:

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 22 fixed facilities (hospitals and PHC centres) and 108 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. North-west Syria

WHO Syria maintains a direct day-to-day dialogue with WHO Turkey. WHO Gaziantep office, together with UNICEF, has submitted COVAX applications relying, for the implementation, on the currently existing immunization programme modalities in north-west Syria. The Vaccine Request Form (Part A) envisaged to cover up to 20% of the Syrian population residing in north-west Syria. 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. More information will be provided at a later stage.  

8. Development of the national deployment vaccination plan

• Trained WHO and national staff and consultants on the tools and methodology.
• Deployed 2 trained WHO consultants (international, national), who are finalizing the NDVP together with ICC and the sub-committees.
• The final plan is to be submitted on 9 February and to be endorsed by end of February 2021.

Meanwhile the team is engaged in refining the costs for NDVP and resource mobilization to meet the needs for vaccine implementation to cover initial 3% of the population with 2 doses of AZ SII. As per preliminary estimates the cost per person may exceed US$ 7-10, which may vary.

8. Guidelines, forms, reporting materials

Work is ongoing to develop the following:

• Vaccination cards, vaccination registers, reporting forms;
• Monitoring and supervision checklist;
• Adverse events following immunization guideline, checklist and reporting forms;
• Updating COVID-19 reporting forms to include vaccination;
• Infection prevention and control and waste management protocols;
• Communication materials.

9. Cold chain

• A nationwide cold chain inventory is being carried out. UNICEF contracted 2 international consultants to review and enhance this component. 
• A desk review was conducted, the report is pending.
• A specific tool is being used to identify gaps and needs.

10. Vaccination in high-risk areas

• The national health authority took a decison to use a combimnation of fixed and mobile teams in the first phase to vaccinate all health workers, including those in hard-to-reach areas, private health facilities, humanitarian and UN frontline workforce.
• The micro plans will include the high-risk groups and high-risk areas and the possible mechanism to reach them (as per the national EPI programme experience).
• Population figures of camps and settlements are collected regardless of the areas of control (including north-east Syria) for the review and the necessary planning to include all high risk groups.
• All the above population figures and risk groups are being identified and quantified.

11. Next steps and key issues

• CTAG to review and approve recommendations from the sub-committees.
• Finalize microplanning for the vaccine introduction, which includes:

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

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

The number of vaccination days by each team.

The number of team members and staff included at each level.

• Finalize the developments of guidelines, protocols, checklists, reporting forms for printing.
• Plan roll out of training and distribution of forms, materials.
• Report and follow-up recommendations of the Quick Analysis of Cold Chain Inventory with the aim to capacitate beyond routine immunization program to meet the COVID-19 vaccine roll out requirements.
• Finalizing pre-registration automated platform and reporting mechanism to report on vaccinations and AEFI cases.
• Firm up the needed operation cost, cost of vaccine supplies and the sources of funds.
• Set a timeline for all the planned activities for vaccine introduction.
• High-level coordination to continue for proper planning and response across northwest Syria and northeast Syria, including WHO Syria and WHO Turkey.

12. Challenges

The vaccine introduction  efforts have to deal with many ‘unknowns’ and 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 which can remain contingency 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 definite;
2. security situation on the ground;
3. COVAX commitment beyond 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 not known, making it difficult to efficacy of the introduced vaccines (*however WHO is working to send samples for sequencing at the regional reference laboratories).

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.

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.

Previous updates

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

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

[1] ACT-Accelerator or The Access to COVID-19 Tools (ACT) Accelerator, is a groundbreaking global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines, more at https://www.who.int/initiatives/act-accelerator/

[2] AZ SII was approved by WHO and included in the Emergency Use Listing on 15 February 2021.