Democratic Republic of the Congo

MINISTRY OF PUBLIC HEALTHEXPANDED PROGRAM ON IMMUNIZATION

Written with support from our partners

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PLAN OF ACTION FOR THE CAMPAIGN TO CONTROL TYPE A MENINGOCOCCAL MENINGITIS IN THE DRC IN 2015

Table of Contents

Error! Bookmark not defined.General considerations

I. Background

1.1 Geographic, demographic and sociopolitical context

With a surface area of 2,345,000 km² (905,355 sq mi), the Democratic Republic of the Congo is one of the largest countries in Africa. The population is estimated at 91,718,307 inhabitants in 2015, according to 2011 projections from the National Immunization Days database. Geographically, it is located in central Africa and straddles the Equator. The country shares a border with 9 countries: the Republic of the Congo to the west; the Central African Republic and the Republic of South Sudan to the north; Uganda, Rwanda, Burundi and Tanzania to the east; and Zambia and Angola to the south.

Administratively, the country is currently divided into 11 sub-divided Provinces. At the moment, the EPI includes 11 coordinating offices corresponding to the 11 provinces and 44 offices in the 48 administrative districts.

The security situation in the country is overall calm, although there are a few pockets of insecurity that make it difficult to implement activities in certain provinces in the east.

Human development-wise, the country was ranked 171st out of 176 in 2013, which highlights the seriousness of the situation.

1.2 HEALTH SITUATION

1.2.1 Organization of the health care system.

The health system consists of three (3) levels: the national level, intermediate level and peripheral level.The national levelThis level essentially has a prescriptive and strategic role. It includes the Minister’s Cabinet, the General Secretariat, 13 national departments and 52 specialized programs and services such as programs for the control of malaria, onchocerciasis, tuberculosis, HIV/AIDS and STIs; the National Nutrition Program; the National Program for Reproductive Health and the Expanded Program on Immunization. Disease control programs are placed under the coordination of the Department of Disease Control (4th Department).

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The intermediate levelThe role of this level is to provide technical and logistical support to the Health Zones. It is made up of 26 provincial health divisions (PHDs). Each provincial division includes offices corresponding to the normative departments of the national level and a hospital and laboratory of reference at the provincial level. Peripheral levelThe health zone is the operational level. It has a Health Zone Central Office (BCZS), a general hospital of reference and a network of health centers. The Health Zone is headed by the Chief Doctor for the Zone, who is supported by the members of the BCZS management team. The country currently had 516 Health Zones and 8,830 Health Centers.

1.2.2 Organization of the Expanded Program on Immunization

At the moment, the EPI includes 11 coordinating offices corresponding to the 11 provinces and 44 district offices in the 26 administrative districts. The coordinating offices and district offices are headed, respectively, by a coordinating doctor and a district office doctor who are each supported by a logistician in charge of vaccine management. These structures provide technical and logistical support to the Health Zones, which are the operational structures for implementing immunization activities. The health center is the smallest operational health unit.The EPI has just drawn up its 2015-2019 cMYP, which calls for a campaign to introduce MenAfriVac in provinces with an elevated incidence of meningitis.

1.2.3 Epidemiological situation

In the DRC, the surveillance of vaccine-preventable diseases is carried out in the global context of integrated disease surveillance and response. 35 diseases and health conditions are under surveillance, 20 of which are notified monthly and 15 are notified weekly. Of the 15 diseases with weekly notification, 8 are targeted by the EPI. These are poliomyelitis (AFP), measles, yellow fever, neonatal tetanus, diphtheria, pertussis, pneumonia and meningitis (in sentinel sites).It is appropriate to note that since 2000, the country has in place case-by-case surveillance of poliomyelitis (AFP), measles, yellow fever and neonatal tetanus. This case-by-case surveillance has been an opportunity to strengthen the integrated disease surveillance and response (IDSR). Moreover, since 2009, a system of surveillance has been in place in sentinel sites for bacterial meningitis in the pediatric environment to look for Haemophilus Influenza type b, Streptococcus pneumonia and Neisseria meningitidis infections coupled with Rotavirus enteritis infections. This most recent surveillance supports the introduction and monitoring of new vaccines. The country intends to implement a system of surveillance based on active screening of precancerous lesions of the cervix in order to test for the Human papilloma virus (HPV), another of the diseases that can be prevented through immunization.Support from the DRC’s partners in the framework of the initiative to eradicate poliomyelitis has enabled implementation of a decentralized system that covers the entire country and involves the teams from the central offices in the Health Zones in the surveillance of AFP and other diseases. The DRC has made progress in combatting certain vaccine-preventable diseases, which translates to halting the circulation of wild poliovirus for more than 3 years, reducing the number of health zones at risk for neonatal tetanus and a decrease in the incidence of measles. However, diseases for which the immunization system has just begun or has not yet begun present a threat to the population’s health, namely, meningococcal cerebrospinal meningitis, Rotavirus gastroenteritis and cervical cancer.

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II. Justification for the campaign

The DRC is one of 26 countries included in the “meningitis belt” where there is an increased risk of a type A meningococcal meningitis epidemic. Not all of the country, however, is included in the belt; the zones considered at risk are in the north and north-east of the country due to their climatic characteristics and their geographical proximity to other countries in the meningitis belt. Within the framework of IDSR, the data gathered over 6 years from 2009 to 2013 shows a total of 47,095 suspected cases of meningitis with 4,789 deaths, or a death rate of 10.2%, as indicated in the table below.

Table of meningitis cases and deaths in the DRC, 2009 to 2013

Cas Decès Cas Decès Cas Decès Cas Decès Cas DecèsBandundu 976 165 541 105 595 101 651 94 556 76 3319 541 16,3Bas congo 97 17 47 16 35 12 46 7 69 7 294 59 20,1Equateur 1142 141 1412 149 1926 186 2087 252 1571 130 8138 858 10,5Kasai Occ 445 55 441 51 312 30 301 44 875 91 2374 271 11,4Kasai Or 1049 156 1213 163 1098 120 924 105 1174 143 5458 687 12,6Katanga 1458 166 1390 112 1857 116 2319 120 1746 119 8770 633 7,2Kinshasa 810 108 656 61 919 86 834 70 0 0 3219 325 10,1Maniema 394 30 272 28 622 55 455 81 272 42 2015 236 11,7Nord Kivu 387 44 315 22 239 15 211 37 191 29 1343 147 10,9Prov Orientale 2260 191 1467 163 1716 142 2172 197 2741 178 10356 871 8,4Sud Kivu 358 32 363 30 386 34 398 34 304 31 1809 161 8,9Total RDC 9376 1105 8117 900 9705 897 10398 1041 9499 846 47095 4789 10,2

Cas Cumulés

Decès Létalité2009 2010 2011 2012 2013Provinces

Translation of French terms in table above:Provinces = ProvincesCas = CasesDécès = DeathsCas cumulés = Total deathsLétalité = Death rateTotal RDC = DRC Total

The incidence rate of meningitis based on suspected cases shows a predominance in the following provinces: Equateur, Orientale, Maniema, Kasaï oriental and Katanga. The absence of systematic confirmation at the laboratory, however, does not make it possible to attribute these elevated rates to a particular germ or serogroup.

Analysis of the data from the sentinel sites since 2009 highlights a point that only concerns a part of the country, but which is important: the three sentinel sites, in which confirmation at the laboratory is systematically carried out, are located in the provinces of Kinshasa and Katanga. The data points out a clear predominance of pneumococcus, the meningococcus being mainly group C. A single focal outbreak of type A was however detected in Katanga in 2012 by rapid diagnostic tests, but not confirmed by culture and PCR (see table). Serogroup A thus does not constitute a major problem in these two provinces and, as a result, they are not included in the first phase of a campaign strategy.

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Table: Results of the sentinel surveillance of meningitis confirmed in the laboratory, 2011-2014(all tests included)

2011 2012 2013 2014Pneumococcus

18 13 13 12

Hib 1 1 1 9MenC 4 1MenA 1Men Sp 1

The most important argument for determining priority locations for immunization was the review of confirmed and investigated epidemics with confirmation of the germ: deadly serogroup A epidemics were documented in the Orientale, Nord Kivu and Sud Kivu provinces. The Orientale province is also the province reporting the highest number of epidemic episodes between 1994 and 2011.

Based on this factual data, the country intends to plan a preventive campaign in these three provinces initially. This will make it possible to establish a southern boundary for the immunological front of the African Regional Strategy to eliminate meningococcal A epidemics.

It should be noted that the risk assessment conducted in 2012 in the DRC was not conclusive on where to locate a possible preventive campaign. Based on the data collected during this assessment, and after re-analyzing and updating the data, the EPI notes that the absence of data on laboratory confirmation remains a challenge to an optimal interpretation but still justifies the campaign in the priority zones due to the risk and high burden of the disease. This approach was approved by WHO during a consultation mission in January 2015.

It is therefore crucial that surveillance be reinforced, especially in the other non-eligible provinces, to find evidence of the presence of type A meningococcus. The EPI’s 2015-2019 cMYP intends to extend the sentinel sites to Kananga and Kisangani to provide a better representativeness of the data generated by the sites.

III. Objectives and target

3.1. Overall Objective

The overall objective of this campaign is to contribute to reducing morbidity and mortality linked to type A meningococcal meningitis.

3.2 Specific objectives

By April 2015, organize microplanning in the 149 Health Zones in the three provinces concerned; Reach at least 95% of the target during this campaign; Ensure quality campaign logistics by respecting the cold chain, effective vaccine management and

use of the controlled temperature chain (CTC) in 21 identified health zones and by destroying 100% of the waste produced by the campaign.

Strengthen the quality of meningitis surveillance; Immunize in the controlled temperature chain (CTC) in the 21 health zones identified; Ensure good surveillance and handling of cases of Adverse Events Following Immunization (AEFI); Ensure communication to promote the MenAfriVac campaign;

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Organize a post-campaign survey in the 3 months following the end of the campaign.

3.3 Campaign target

The target set for this campaign s 17,910,453 subjects aged 1 to 29 years, or 71% of the total population, with MenAfriVac.

Province # of district offices # of HZ Total population in 2015

MenAfriVac target population Quantity of vaccines necessary

NORD KIVU 2 32 7,724,367 5,484,301 6,093,670SUD KIVU 2 34 6,425,742 4,562,277 5,069,200Orientale province 6 83 11,082,980 7,868,916 8,743,240Total 10 149 25,233,089 17,915,493 19,906,880

IV. Links with other interventions

4.1 Coordination with other activities

The campaign is planned from 21 to 30 september 2015 in accordance with the EPI annual action plan. The period chosen is free of any other major activity and precedes the introduction of IPV scheduled for July 2015 in the provinces concerned.

4.2 Other interventions coupled with the campaign

This campaign offers the opportunity to integrate other interventions with a high impact on child, maternal and newborn health, notably Vitamin A supplements, deworming with Mebendazole, distribution of long-lasting insecticidal mosquito nets, logging children under one year of age on the register of births, etc.

4.3 Strengthening routine EPI

Routine EPI will directly benefit from purchases of new cold chain equipment and incinerators.

V. Cost and financing

The operating cost of the campaign comes to $US 11,581,465, which represents an operating cost of $US O.65 per immunized person. The entire budget (operating cost and vaccine purchase) is requested from GAVI and amounts to $US 23,692,930.

VI. Lessons learned from previous campaigns

An SIA of good quality necessitates good preparation based on innovations (best practices) that allows for improvement in the behavior of the stakeholders among other things: prospective missions; the deployment and timely availability of human, material and financial resources in the HZ; intersectoral collaboration; local supervision; and adequate community follow-up by Red Cross workers and/or local administrative authorities (APA).

VII. Support from partners

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The EPI partners support immunization activities on a technical, logistical and financial level in accordance with operating plans and cooperation agreements. The EPI’s main partners are WHO, UNICEF, GAVI, USAID, DFID, BMGF, the EU, the World Bank, the Rotary Club and IVS (Service Volontaire International).In order to reach the objectives set by the EPI, the partners rely on different strategies, notably:

1. Strengthening and revitalizing coordinating bodies. The bodies actively involved are the National Steering Committee for the Health Sector (NSC-HS) and the Provincial Steering Committee for the Health Sector (PSC-HS) with their various committees (Strategic Coordination Committee, Technical Coordination Committee and technical commissions).

The strategic Interagency Coordinating Committee for Immunization (ICC), headed by the Minister of Public Health, has approved the plan to introduce MenAfriVac with use of the CTC in certain targeted health zones.

The coordination committees for disease control established by the Ministry of Public Health at all levels of the health pyramid are, as part of their remit, in charge of coordinating mass activities. These committees are presided by the highest politico-administrative authorities. These are:

National coordinating committee for disease control (CNC) at the national level, Provincial coordinating committee for disease control (CPC) at the provincial level, District coordinating committee for disease control (CDC) at the district level, Local coordinating committee for disease control (CLC) at the health zone level.

Partners who are active in immunization are represented at these various committees at all levels.

2. Sustainability of program financing:

In order to enable sustainable and secure financing of immunization activities, the partners support the EPI in lobbying Governments, Parliament and Provincial Assemblies for the appropriation of immunization activities and an increase in the related budgets. Lobbying organized by the Network of Congolese MPs to Support Immunization (REPACAV) benefited from technical and financial support from the EPI and its partners. This lobbying included monitoring of the examination, vote and enactment of the law on immunization in Parliament.

3. Capacity building:

The partners support the EPI in building personnel capacity at all levels. Training at all levels will also receive support from the partners. Supervision will be organized with support from the partners in the pre-introduction phase, during the campaign and after the campaign.

Managers from the national and provincial levels, as well as workers in the health zones targeted for the CTC, will also receive special training on immunization with this new approach adapted for the MenAfriVac campaign.

4. Good governance and program management:

The program organizes internal and external audits at all levels as well as administrative and financial supervision. Two internal reviews of the Program are carried out during the year to ensure the evaluation of immunization activities.

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The partners support the EPI in mobilizing resources from donors and civil society organizations. They provide support by strengthening ties between healthcare services and the community and by strengthening coordination of the partners who act directly in the Health Zones to promote the EPI.

Technical and logistical support

The various partners provide support during all of the stages of planning, implementation and evaluation of the MenAfriVac campaign.

Guidelines, user guides and training manuals for the MenAfriVac campaign are developed with technical support from all EPI partners.

UNICEF provides logistical support during the ordering of MenAfriVac vaccines and their transport to the country.

WHO and UNICEF have logisticians who are members of the Logistics Committee and who support the EPI at all levels – national, provincial, district and health zone – and in effective vaccine management, cold chain maintenance, correct implementation of the CTC and managing waste generated by the campaign.

WHO and UNIVEF will take part in the committees to manage any AEFI that might occur during the MenAfriVac campaign.

Social mobilization

The different partners who are members of the Task Force for Communication to promote immunization (UNICEF, WHO, PATH, the Rotary Club, SANRU, Red Cross and IVS), along with NGOs and CSOs, will provide support in mobilizing communities, parents, the media, educational institutions and community-based organizations by using suitable approaches to guarantee mobilizing those targeted to go to the immunization sites.

WHO, with the support of GAVI (SANRU, CNOS, Red Cross and Rotary), will contribute their past experiences in collaborating with local CSOs and NGOs to mobilize communities for a massive response in favor of immunization.

B. Rolling out activities

The country plans to conduct quality campaigns with the following characteristics:

Begin campaign preparation in a timely manner (at least 6 months in advance) Ensure timely training of high quality for workers at the intermediate and operational

levels (develop training modules, organize training from the national level to the operational level)

Make vaccines and injection materials permanently available Organize bottom-up microplanning from the country’s health centers with emphasis on

children who have not been reached or insufficiently reached (village-by-village microplanning approach)

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Consolidate microplans from the health centers in the health zones Approve base microplans and retro-information in time (at least 3 months) at all levels

and correctly adjust the budget if possible Develop and implement a detailed logistics plan and a reliable cold chain Use the CTC in certain targeted health zones Deploy logistical experts in a timely manner in the 3 coordinating offices and 10

district office in order to support the distribution of supplies At least 7 days before the campaign, deploy financial and human resources (supervisors

with a suitable profile and materials) in the health zones Have supervisors conduct rapid convenience sampling during the campaign Conduct a post-campaign survey with emphasis on the reasons for non-immunization of

targets Hold campaign evaluation meetings in the pools For this campaign, ensure good coordination and leadership at the national, provincial

and health zone levels well before the campaign, during the campaign and after the campaign.

Obtain the commitment of local politico-administrative authorities and community leaders to social mobilization activities before the activities begin.

1. Pre-campaign activities

1. Planning campaign activities

Planning will be in stages and will begin with a briefing of national and provincial supervisors on the specificities of the microplanning and all of the components of the program (technical, logistical and social mobilization) and implementing the campaign. These briefings will be carried out at all levels by multisectoral teams.

Microplans will be updated in the health centers and consolidated in the central offices of the health zones (BCZS).

The microplans will then be validated in each pool. This defense will receive technical support from the national and provincial teams.

For the campaigns, each HZ will develop a map that clearly represents the essential planning elements: storage sites, immunization sites, supervision axes and freezing points of the ice packs, points of passage for cross-border populations and locations of special populations. For routine immunization activities, identifying populations who have difficult access, messages on using immunization services and strategies for reaching them will be discussed and planned.

Technical and logistical data will also be collected at this level in order to identify the health zones where the CTC will be used during this campaign.

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2. Communication and advocacy to mobilize additional resources

a. Advocacy for the mobilization of local resources

The EPI National Coordinating Committee (NCC) will be in charge of holding advocacy sessions with the Government to obtain its financial contributions towards strengthening activities for meningitis control (surveillance). In addition, taking into account the positive experience in mobilizing local resources during the control of poliomyelitis epidemics and the measles follow-up campaigns in 2014, partners and potential local donors will be approached by members of the NCC and asked for contributions.

b. Communication to support the immunization campaign

Communication to support the immunization campaign against meningitis will be structured around the following four strategic axes: advocacy, social mobilization, Communication to Change Behavior and community follow-up of targeted persons.

To accomplish this, advocacy will target all of the politico-administrative, religious and other decision-makers in order to obtain their support for the campaign. The focus will be placed on religious leaders and leaders of factions who are hostile to immunization as well as leaders of so-called “special” groups. In zones where there is political insecurity, actions aimed at leaders of armed groups will be considered to support the transportation of campaign supplies, effective immunization organization and access to all populations, particularly displaced populations.

Alliances will also be formed with important social networks at all levels, in particular with the main religious denominations (Catholic, Kimbanguist, Protestant, Islamic, Revivalist, etc.), major community associations, the Red Cross and local radio and television stations as well as the school network (preschools, primary and secondary schools) that can mobilize parents at the local level in favor of the immunization campaign. With regard to Behavior Change Communication (BCC), emphasis will be placed on interpersonal communication. To do this, messages will talk about dates, strategy, interventions to be led, targets, responses to major questions from parents that are often behind rumors and resistance to immunization, and the necessity of continuing routine immunization of children under the age of 1 year. Local communication actions will essentially be aimed at targeted people in the 1- to 29-year age range, in particular those who are opposed to immunization, especially members of sects, school leaders, politico-administrative authorities and leaders of special groups.

Mobilizers will be recruited from among community relays and community figures, notably Red Cross activists and community leaders. Immunizers will also play a key role in communication promoting the campaign. After administering the vaccine, they will communicate with the targets, especially on what to do in case of AEFI.

Local radio stations will be called upon to ensure that appropriate information about the campaign is broadcast to households.

Furthermore, in each health center, a system of follow-up and recovery of non-immunized people by community leaders will be put in place. These are notably the Nyumbakumi (a local person in charge of a group of 10 houses) and the Kapita (a traditional village leader) who, along with community relays, must work with health workers to identify and recover non-immunized people. In order to strengthen routine immunization, communication

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materials such as TV ads and other microprograms will also include messages to promote routine immunization. The vest will be the distinguishing sign and must be worn by all personnel involved in the immunization campaign.

3. Implementation of the logistics improvement plan

Logistics strengthening will take place through new purchases of cold chain materials (204 solar fridges and 19 cold rooms) financed by the World Bank; the last reception was in May 2013.

The country’s requirements in cold chain materials are: 4,064 refrigerators, 513 freezers, 4,104 ice boxes, 97,628 vaccine carriers and 472,592 ice packs. There exist already: 3,180 refrigerators, 448 freezers, 2,039 ice boxes, 31,591 vaccine carriers and 37,029 ice packs (however, during the various microplanning workshops, the actual requirements will be expressed).

The deficit is therefore: 985 refrigerators, 65 freezers, 2,565 ice boxes, 66,037 vaccine carriers and 435,563 ice packs.

Of this deficit, 515 refrigerators will come from the present GAVI project and 200 from the World Bank. However, 210 refrigerators, 106 freezers, 64,037 vaccine carriers, 1,665 ice boxes and 435,563 ice packs will need to be made up for by reassigning the available GAVI-HSS funds in the country.

Vaccine, cold chain and transportation management

An estimated 19,906,100 doses are required for the campaign, which will take up 51,756 liters of space in the cold chain.

Thus, vaccines will be stored at the national level in EPI cold rooms before being transported to the provinces at least 2 weeks before the campaign begins. The necessary dispositions will be taken at these levels to strengthen the capacities and quality of the cold chain and its monitoring in order to guarantee adequate storage of supplies. Storage of vaccine materials (syringes, safety boxes) will require approximately 1,414.22 m3 of space. Logistical support in the coordinating offices and district offices provisioned directly by the national levelThe EPI coordinating offices must provision the health zones at least one week before the campaign to ensure the availability of vaccines in the health centers 48 hours before the campaign and thus guarantee the availability of the vaccines in the immunization sites.

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Likewise, management tools and financial resources for vaccine management (transportation, fuel and refrigerator rental) must be made available to coordinating offices and district offices two weeks before the campaign in order to ensure that the vaccines are stored in optimal conditions.

Stock will be taken daily in each immunization site on the vaccine doses used, cold chin compliance (monitoring), the enforcement of and observations on the controlled temperature chain (CTC) that will be applied in the Zones and health centers with low cold chain coverage, and on any wastage. To minimize this wastage and to guarantee the quality of the vaccines administered, the immunization personnel will be trained and supervised on these aspects, among others. Emphasis will be placed on cold chain compliance from the national level down to the immunization site.

Cold chain:

Analysis of vaccine storage capacity by supply chain level

1. National level:

Level Existing net storage capacity in

liters

Volume (+) occupied routine vaccines in liters

Volume (+) required campaign in liters

Deficit in liters

National 142 ,00 127,356 51,758 -36 614

Taking into account the available capacity and storage volume requirements for routine vaccines during the supply period, the deficit of 36,614 liters can be filled by using the cold chain equipment available in the city-province of Kinshasa.Provisioning of the Provinces will take place by chartering planes depending on the volume of vaccines and other supplies to be transported.

2. Intermediate level: Provincial Coordinating Offices

Provincial storage facilitiesVolume in liters

Required MenA Routine Availabl

e Deficit

NORD KIVU 15,844 7,118 5,000 -17,962SUD KIVU 13,180 5,000 5,000 -13,180Orientale province 22,734 10,528 7,500 -25,762

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An insufficiency in vaccine storage capacity is noted at the provincial coordinating offices, which should be served directly by Kinshasa.

In light of this insufficiency in storage capacity, some coordinating offices will use the cold rooms at the district offices (Sud Kivu and Orientale province).

Moreover, given the geographical context of the country and the availability of certain provisioning opportunities from Kinshasa, some coordinating offices and district offices will be provisioned directly by the national level.

This involves: The Isiro district office The Bunia office and Aru via Bunia in the Orientale province The Butembo office via Beni in the Nord-Kivu province The Goma district office The Sud-Kivu coordinating office

Therefore, the situation of the storage capacity by storage facility served by the national level appears as follows:

a) Orientale Province storage facilities

Analysis of cold storage capacityFacilities Volume in liters

required MenA

Routine

Available

Deficit

ARU 4,596 2,066 2,500 -4,16

2BUNIA 6,156 2,851 8,124 -883ISIRO 3,960 1,780 5,282 -458Orientale Province coordinating office

8,021 10,528

12,500

-6,04

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b) Sud-Kivu Province storage facilities

Analysis of cold storage capacity

FacilitiesVolume in liters

required MenA

Routine

Available

Deficit

Sud-Kivu coordinating office 13,180

5,000 17,500 -680

The cold rooms in the district offices will be used to store vaccines from the Province and logistical dispositions will be taken to provision the Uvira district office within the deadline and this will ease the strain on the provincial coordinating office.

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c) Nord-Kivu Province storage facilities

Analysis of cold storage capacity

FacilitiesVolume in liters

required MenA

Routine

Available

Deficit

Butembo district office 7,750

3,475 7,500

-3,725

Nord-Kivu coordinating office 8,093

7,118 5,000

-10,21

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The deficits noted above will be compensated with the purchase of new cold chain equipment planned by the RSS2 and other partners.

3. Intermediate level: District office storage facilities

a) Sud-Kivu Province district offices

Analysis of cold storage capacity

District office storage facilities

Volume in litersrequire

d MenA

Routine

Available

Deficit

BUKAVU 9,8024,40

817,50

0 3,290UVIRA 3,378

1,519 5,312 415

The two district offices have sufficient storage capacity to ensure storage of the vaccines for the campaign.

b) Orientale Province district offices

Analysis of cold storage capacity

District office storage facilities

Volume in litersrequire

d MenA

Routine

Available

Deficit

ARU 4,5962,06

6 2,500-

4,162BUNIA 6,156

2,851 8,124 -884

BUTA 1,957 880 5,455 2,619ISIRO 3,960

1,780 5,282 -458

KISANGANI 4,3351,94

912,50

0 6,216LOKUTU 1,730 778 5,282 2,774

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The district offices in Buta, Kisangani and Lokutu have sufficient cold storage capacity to ensure storage of the vaccines for the campaign.

c) Nord-Kivu Province district offices

Analysis of cold storage capacityDistrict office storage

facilitiesVolume in liters

required MenA

Routine Available Defic

itButembo district office 7,750 3,475 7,500

-3,72

5 Goma district office 8,093 3,642 5,000

-6,73

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4. Operational level: Health zones and health centers:

At this point, each health zone has at least one functional refrigerator with a capacity of more than 100 liters.The country is in the process of improving the cold chain through the purchase of refrigerators for the operational level. With GAVI-HSS2, more than 4,000 refrigerators will be acquired this year.

In some health zones with low cold chain coverage, the CTC will be applied in order to resolve certain logistical difficulties.This campaign will need high mobilization of considerable means of transportation and a significant amount of technical and logistical support with the application of the controlled temperature chain in certain targeted health zones.

Table: Requirements in minor cold chain equipment and for the MenAfriVac campaign

Required equipment and spare parts

Ice boxes BI Wick

#8Wick #23

Wick #32

Burner 8

Burner 23

Burner 32

Glass #23

Glass #32

SUD KIVU 850 3,475 50 100 200 50 100 100 100 100NORD KIVU 706 2,886 65 130 260 65 130 130 130 130

ORIENTALE Prov 1,218 4,982 100 200 400 100 200 200 200 200TOTAL 2,774 11,343 215 430 860 215 430 430 430 430

Table: Requirements in monitoring materials and markers for the CTC during the MenAfriVac campaign

Province District office

Health zone Target population MenAfriVac

#immunization teams

#temp threshold indicators

#markers(Districts)

ORIENTALE

Isiro Aba 91,036 58 174 116Isiro Boma

Mangbetu77,463 49 147 98

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Isiro Doruma 49,047 31 93 62Isiro Dungu 88,655 56 168 112Isiro Faradje 79,086 50 150 100Isiro Gombari 79,241 50 150 100Isiro Isiro 174,551 111 333 222Isiro Makoro 86,323 55 165 110Isiro Niangara 78,400 50 150 100Isiro Pawa 118,754 75 225 150Isiro Poko 86,231 55 165 110Isiro Rungu 73,151 46 138 92Isiro Viadana 74,847 47 141 94Isiro Wamba 93,578 59 177 118Isiro Watsa 120,252 76 228 152Total ISIRO 1,370,615 868 2,604 1,736Lokutu Basali 60,157 38 114 76Lokutu Basoko 111,076 70 210 140Lokutu Isangi 111,309 70 210 140Lokutu Yabaondo 116,829 74 222 148Lokutu Yahuma 129,007 82 246 164Lokutu Yalimbongo 70,354 45 135 90Total LOKUTU 598,732 379 1,137 758

Total Provinces 1,969,347 1,247 3,741 2,494

Province District office

Health zone Target population MenAfriVac

#immunization teams

#temp threshold indicators

#markers(Districts)

ORIENTALE

Isiro Aba 91,036 58 174 116Isiro Boma

Mangbetu 77,463 49 147 98Isiro Doruma 49,047 31 93 62Isiro Dungu 88,655 56 168 112Isiro Faradje 79,086 50 150 100Isiro Gombari 79,241 50 150 100Isiro Isiro 174,551 111 333 222Isiro Makoro 86,323 55 165 110Isiro Niangara 78,400 50 150 100Isiro Pawa 118,754 75 225 150Isiro Poko 86,231 55 165 110Isiro Rungu 73,151 46 138 92Isiro Viadana 74,847 47 141 94Isiro Wamba 93,578 59 177 118Isiro Watsa 120,252 76 228 152Total ISIRO 1,370,615 868 2,604 1,736Lokutu Basali 60,157 38 114 76Lokutu Basoko 111,076 70 210 140Lokutu Isangi 111,309 70 210 140Lokutu Yabaondo 116,829 74 222 148Lokutu Yahuma 129,007 82 246 164Lokutu Yalimbongo 70,354 45 135 90

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Total LOKUTU 598,732 379 1,137 758

Total Province 1,969,347 1,247 3,741 2,494

4. Training

A technical manual will be developed for personnel training at all levels.

A 2-day training session at each level will cover all of the aspects of the campaign, namely: campaign organization, collection and management of waste, communications technique, cold chain management, AEFI surveillance, use of management tools, etc.

5. Coordination

At the national level, the National Coordinating Committee for disease control (NCC), coordinated by the Minister of Health and receiving technical support from the EPI Department, will be in charge of coordinating activities and monitoring the preparation, implementation and evaluation of the campaign.

At the provincial and peripheral levels, the existing coordinating committees (PCC and LCC) will be in charge of coordinating all campaign activities.

In particular, the collaboration with the sector on education and social affairs will be strengthened. This will mean including leaders from these sectors in the coordinating committees at all levels.

The NCC meetings will begin at least 4 months before the official launch of the immunization campaign to ensure regular monitoring of preparation and implementation.

PCC and LCC meetings will begin at least 1 month before the campaign launch.

The system of information exchange among the various levels will be strengthened and will enable regular monitoring of campaign preparation and implementation.

2. Activities during the campaign

II.1. Campaign launch and implementation

An official launch ceremony is planned, to be presided over by the highest official in the administrative district. The campaign launch must be prepared (identification and preparation of launch site, information to local officials, preparation of invitations, etc.).

II.2. Organizing immunization

The campaign will take place over a period of 10 days from 21 to 30 september 2015 at fixed sites, following the fixed and advanced strategy immunization approach.

However, in order to immunize all children in the target group, specific strategies will be developed for special populations (displaced and refugee populations, pygmies and other marginalized minority groups, border populations and/or those falling into two or more zones, fisherman and nomad populations, those living in hard-to-reach areas, schools, “street children,” etc.). In fact, motorized pirogues will be assigned to teams in order to immunize populations living along the river and itinerant populations living on boats,

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pirogues, etc. At various landing points and places where many people gather (train stations, markets, ports, etc.), teams will be put in place and will remain there throughout the campaign.

II.3. Vaccine dose to be administered and other interventions

Everyone from 1 to 29 years of age must be immunized, regardless of their previous immunization status, with a 0.5-ml intramuscular dose of MenAfriVac in the left arm.

An immunization card specific to this campaign will be given to each immunized person.

II.3.1. Team composition

Each immunization site team will be made up of 5 people: 2 immunizers, 1 mobilizer, 1 time-keeper and 1 person to keep order and sort people. The whole team will also be in charge of destroying waste.

NB: The immunizers are qualified healthcare workers who are very familiar with injection techniques (nurses and medical students).

The time-keeper will be recruited among people with an acceptable level of education (teachers, D6 or beyond).

The mobilizer and the person keeping order will be recruited within community organizations, notable the community relays, CODESA (Health Development Committee), CAC, CTE, Red Cross, etc.

Those chosen from the community will begin awareness-raising activities in their communities before and during the immunization campaign.

II.3.2. Targets to be immunized per day

Based on the country’s past experience and accessibility issues, each site will immunize on average:

- 300 people per day in urban areas - 150 people per day in rural areas

II.3.3. Purchase of vaccines / supplies, transportation and distribution

Required MenAfriVac items, AD syringes, dilution syringes, safety receptacles, cold chain materials, temperature threshold indicators for the CTC and other EPI supplies will be ordered through UNICEF. Vaccines and immunization materials must be available at the national level at least 2 months before the campaign launch. The vaccines will first be stored at the national EPI storage facility at temperatures between 2 and 8°C and away from light. Injection materials and other supplies will be stored in dry stores.

As with routine vaccines, distribution of the vaccines throughout the country will be done mostly by air. River transport may be used for some provinces. At the local level, depending on the specificities of the terrain, local means of transportation will be used (vehicles, outboards, motorcycles, bicycles, pirogues and porters).

During the campaign, vaccines will be stored in health structures between 2 and 8°C and away from the light, except in health zones targeted for the CTC.

It should be noted that the zones selected for CTC immunization are subject to specific planning.

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A plan for distributing supplies will be developed at each level to ensure that operations proceed correctly.

A system of monitoring supplies will be set up to make it possible at all times to ensure the availability of the supplies at the various sites, identify bottlenecks and make any necessary adjustments.

II.3.4. Supervision and monitoring of campaign vaccine stocks/supplies and from other routine activities

Before the start of the campaign, prospective supervision will be carried out to assess the level of preparation and identify the support necessary to implement it.

Supervision will be done in collaboration with local partners. It will be organized in stages. First, the national teams will supervise the provincial and district teams, as well as the teams in problem health zones.

During the campaign, the BCZS teams (health zones) will supervise the immunization site supervisors. A site supervisor will have, on average, 3 sites to supervise in urban and rural areas.

Storage sites for vaccines and other supplies will be supervised (quantities of vaccines and supplies, vaccine quality, stock management and vaccine handling). Furthermore, the organization and techniques for immunization, documentation of immunizations carried out, the collection and elimination of waste, messages, etc. will be supervised at the immunization sites and in the community.

II.3.5. Identification and handling of AEFI

Communication will take place between healthcare professionals and parents on the subject of mild and serious AEFI. All AEFI, mild or serious, will be notified. Serious cases of AEFI will be handled in the fixed immunization sites.

II.3.6. Waste management

Each health zone will be provided with an incinerator during this campaign. A plan for waste collection will be drawn up in each health zone. All supervisors (national, provincial and health zone) will make sure that the different management steps are followed.

II.3.7. Holding daily monitoring meetings

During the campaign, at the end of each day, a monitoring & evaluation meeting will be held to assess and take stock of the campaign. The day’s weak points will be reviewed and corrective actions discussed in order to improve performance the next day.

Monitoring and Evaluation

Emphasis will be placed on local supervision. A rapid survey will be conducted in all health zones to help improve the quality of activities.

1. Monitoring

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A qualitative assessment will be done by using a checklist to assess logistical support (communication, cold chain materials, injection safety, waste elimination), surveillance and the response to AEFI.

Following supervision at all levels, the supervisors will write up a report on campaign preparation and implementation and propose corrective actions necessary for improving immunization activities.

Quantitative assessment: Rapid convenience sampling will be carried out by the supervisors in zones and localities where there are populations at high risk or who are poorly served, places where high-risk populations are located (displaced or refugee populations, hard-to-reach, political and economic problems). These assessments will make it possible to identify pockets of non-immunized people and take corrective action. It will involve visiting 20 houses and interviewing 20 people between the ages of 1 to 29 in order to guide the actions.

2. Campaign technical and financial reports

Technical and financial reports will be available at the national level 4 weeks after the end of the immunization campaign, at the latest.

3. Evaluation of the campaign results

a Administrative coverage

At the end of the campaign, the supervisors will organize a campaign evaluation meeting to estimate performance by looking at daily reports from the teams and comparing the number of people reached with the target number. These reports will be consolidated by zone and, in this way, estimate the immunization coverage reached.

Likewise, the process of organizing the campaign will be evaluated – strengths and weaknesses will be identified and discussed. Lessons learned will be shared and can be used to improve future campaigns.

b. Post-campaign surveys

Post-campaign evaluation through cluster sampling (survey of 30 clusters adapted following WHO/AFRO protocol) will enable:

a. Estimation of immunization coverage one month later after the immunization campaign,

b. Assessment of the process of implementing activities at all levels compared to expected results,

c. Assessment of immunization safety, d. Assessment of AEFI surveillance and the response to immunization-related

undesirable effects.

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4. CONTROLLED TEMPERATURE CHAIN

The strengths and weaknesses, as well as lessons learned from immunization with the CTC, will be documented.

5. Indicators

The following indicators will be collected and analyzed in order to allow for monitoring and evaluation of the campaign. The CTC indicators are described separately.

- Monitoring- Completeness of daily reports (by zone)- Completeness of supervision carried out (based on filled-in supervision checklists)

- Immunization coverage- Percentage of people immunized following administrative data- Percentage of people immunized with immunization card (survey)- Percentage of people immunized with immunization card and record- Percentage of people immunized by age group and by sex- Percentage of people immunized by district and province

- Immunization cost- Projected budget, total and per immunized person- Real cost of the campaign, total and per immunized person (percentage of execution)- Proportion of real costs by backer (GAVI, Ministry, other)

- Logistics and management of waste- Vaccine wastage rate, total and by province- AD syringe wastage rate- Total number of filled safety boxes generated during the campaign- Proportion of boxes destroyed one month after the campaign- Quantity of vaccines remaining in stock at the end of the campaign

- AEFI- Number of minor and major AEFI reported- Proportion of major AEFI investigated- Number of major AEFI attributable to immunization

Some indicators for the CTC: Number of vaccine vials with VVM turned Wastage in closed and open vials Average wastage in HZ with CTC compared to HZ with

traditional CC Number of temperature threshold indicators that have

changed color Number of people immunized per day by teams working in

CTC compared to those working otherwise % of HZ having organized a campaign with CTC % of personnel trained in CTC

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6. Strengthening of surveillance

For surveillance strengthening, two aspects will be considered:

In the three provinces selected for the campaign, support for meningitis surveillance strengthening will be organized as a part of integrated disease surveillance and response. For this, General Hospitals of Reference will be strengthened in the following areas: personnel training, sampling kits, transport mediums, rapid diagnostic tests, collection tools and means of supervision. The three Provincial Laboratories will also be strengthened in their culture and data management capacities.

At the national level, following financing, the bacterial meningitis sentinel surveillance sites will be extended to the cities of Kananga (Kasai Occidental province) and Kisangani provinces (Orientale province).

5. TIMELINE OF ACTIVITIESImplementation of activities will follow the established timeline and the level of preparation of the campaign will be regularly presented to the ICC. The details of the timeline can be found in annex 2.

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Annex 1: OVERALL SIA BUDGET

NIVEAU CENTRAL SUD KIVU NORD KIVU P. ORIENTALE TOTAL

RUBRIQUESPop cible 17,915,493 4,562,277 5,484,301 7,868,916 17,915,493

Coût Total Vaccins et matériel injection $12,682,837 $12,682,837 $12,682,837Coûts Vaccins MenA $10,948,361 $10,948,361 $0 $10,948,361

Coûts Matériel Injection MenA $1,734,477 $1,734,477 $0 $1,734,477

Ressources Humaines $3,041,100 $14,000 $747,830 $895,170 $1,384,100 $3,041,100Collation personnel $2,962,850 $732,930 $880,770 $1,349,150 $2,962,850Personnel permanent PEV $11,000 $5,000 $1,200 $1,200 $3,600 $11,000Coordination $24,500 $9,000 $3,700 $3,700 $8,100 $24,500CPC, CDC ET CLC $42,750 $10,000 $9,500 $23,250 $42,750Outils de gestion $320,000 $0 $80,000 $90,000 $150,000 $320,000Outils de gestion $320,000 $80,000 $90,000 $150,000 $320,000Microplanification et formation $697,735 $52,720 $158,478 $122,076 $364,461 $697,735Microplanification, briefing et défenses $536,560 $52,720 $122,520 $59,880 $301,440 $536,560Formation $161,175 $35,958 $62,196 $63,021 $161,175Supervision, suivi et évaluation $991,600 $640,000 $131,200 $991,600Supervision suivi et évaluation $573,600 340,000 52,600 49,800 131,200 $573,600Appui technique superviseurs internationaux et nationaux $118,000 $118,000Enquête post campagne $300,000 $300,000 $300,000Transport et logistique $3,357,671 $1,093,382 $988,272 $2,772,426Carburant $772,183 $173,893 $91,575 $506,715 $772,183Distribution Intrants $1,458,668 $1,093,382 $82,180 $96,749 $186,357 $1,458,668Renforcement de la logistique et Labo Surveillance $702,420 $27,250 $35,425 $54,500 $117,175Location Transport $424,400 $93,800 $89,900 $240,700 $424,400Mobilisation sociale $722,688 $75,000 $341,877 $797,688Mobilisation sociale $722,688 $75,000 $173,066 $207,745 $341,877 $797,688Gestion des déchets $1,192,000 $272,000 $256,000 $664,000 $1,192,000Sous total $23,191,442 $14,591,691 $1,280,958 $1,387,784 $4,096,340 $22,672,012

Coûts opérationnels $10,322,794 $1,875,102 $1,258,308 $1,363,246 $4,023,910 $9,812,549

frais de transferts/bancaires locaux (1.8%) $185,810 $33,752 $22,650 $24,538 $72,430 $176,626

Frais administratifs (7%)

Evaluation du projet $20,000 $20,000 $20,000

Coûts opérationnels + frais de transfert $10,528,604 $1,928,854 $1,280,958 $1,387,784 $4,096,340 $10,009,175

AGFIN (10%) $1,052,860 $1,000,918Coûts opérationnels + frais administratif $11,581,465Grand Total 23,692,930Coût par personne vaccinée $0.65avec AGFIN

RDC_SYNTHESE DU BUDGET CAMPAGNE MenAfriVac dans les Provinces de Nord Kivu, Sud Kivu, et P ORIENTALE, 1 an à 29 ans

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Annex 2: TIMELINE OF ACTIVITIES

Principales activités

Sem1 Sem2 Sem3 Sm4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4 Sem1 Sem2 Sem3 Sem4

Commande des vaccins et des intrants X Log/PEV

Reception des vaccin X Log/PEV

Reception des intrants X X Log/PEV

Mise a jour de la situation de la chaine du froid et moyen transportconformement au CTC

X X X X Log/PEV

Elaboration du plan de deploiement des vaccins et autres intrants X Log/PEV

Deploiement interne de la chaine du froid selon besoin X X Log/PEV

Distribution des vaccins et intrants vers les provinces, antennes PEVet ZS

X X X X X Log/PEV

Elaboration et m ise en oeuvre d'un plan de gestion des dechets X X X X X X X Log/PEV

Recyclage des accumulateurs X X X X X Log/PEV

Expédition des canevas de microplanification dans les ZS X X Div Tech/PEV

Briefing des facilitateurs du niveau central sur la micro planification X X Div Tech/PEV

Briefing du MIP, MCP, MCZ, IS, B4, MCDP, MCA, Lop, Log (noyaux provinciaux) et lesAPA sur la micro planification

X Div Tech/PEV

Micro planification dans les AS et dénombrement X X Div Tech/PEV

Consolidation de micro-plans des AS au BCZ X X Div Tech/PEV

Défense dans les pools et validation de micro-plans X Div Tech/PEV

Validation des données au niveau central et feed back aux provinces X X Div Tech/PEV

Déploiement des superviseurs du niveau central X Div Tech/PEV

Briefing des superviseurs provinciaux X Div Tech/PEV

Formation des superviseurs des axes et prestataires (superviseurs des équipes,vaccinateurs, pers sites de stockages, mobilisateurs)

X Div Tech/PEV

Identifier et prospecter les sites de stockage X X X Div Tech/PEV

Elaborer et disséminer les directives sur la communication aux niveaux provincial et local X Div Appui/PEV

Elaborer le document de plaidoyer en faveur de la campagne de lutte contre la meningite X X Div Appui/PEV

Appuyer l’organisation de réunions de plaidoyer auprès des décideurs et leaders de 3provinces et des réunions dans chaque ZS pour leur implication et l’appui de lacommunauté

X X X Div Appui/PEV

Assurer le suivi de mise en oeuvre des plans de communication des ZS en fonction desproblèmes communautaires de chacune des ZS

X X X X X X X Div Appui/PEV

Reproduire les affiches, les banderoles et dossards X X Div Appui/PEV

Produire et diffuser les emissions radio/tele X X X X Div Appui/PEVOrganiser la campagne de communication en faveur des AVS contre la meningite à tous lesniveaux

X X X Div Appui/PEV

Organiser le lancement officiel de la campagne au niveau provincial et dans le site choisi àcet effet

X CNC/CPC/CDC/CLC

Conduire les enquêtes rapides de convenance X X Div Tech/PEV

Vacciner toutes les cibles au MeniAfriVac X X Div Tech/PEV

Conduire les enquêtes post campagne en raison de 30 grappes par Zones de Sante X X X X Div Tech/PEV

Mise en place du Poste de coordination de la campagne au niveau national et provincial X X CNCMise en place du noyau technique de suivi et d’évaluation des activités de vaccinationintégrées

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X CNC

Assurer un partage régulier d’information entre le niveau central et provincial, avant,pendant et après la mise en œuvre de la campagne

X X X X X X X X X X X X X X X X X X X X X X X X X X CNC/com Tech

Tenir au moins 1 réunion toutes les deux semaines, 2 mois avant la mise en œuvre de lacampagne, et 1 fois par semaine, 1 mois avant et chaque jour une semaine avant et lors dela mise en œuvre au niveau des différents comités (CLC), (CDC), (CPC) et (CNC)

X X X X X X X X X X X X X X X X X X XCNC, CPC, CDC et

CLC

Elaborer et rendre disponible le rapport de la campagne X X X X Div tech, MIP, MCP et MCA

Collecter et analyser tous les rapports technique et financier et les transmettre au niveaucentral au plus tard 1 semaine après la fin de la campagne.

X X X MIP

2015

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