REPUBLIQUE DU CONGO - GAVI€¦ · Web viewIn May 2012 the World Health Assembly declared the...

REPUBLIC OF CONGO

MINISTRY OF HEALTH AND POPULATION

DEPARTMENT OF HEALTH

FAMILY HEALTH DIVISION

EXPANDED PROGRAM ON IMMUNISATION

INTRODUCTION PLAN FOR THE INACTIVE POLIO VACCINE (IPV)

IN CONGO

September 2014

Annex A. IPV Introduction Plan in Congo

Summary of the introduction plan

Brief justification for the introduction of IPV and additional considerations that have been taken into account, including comprehensive approaches for disease control.

In May 2012 the World Health Assembly declared the completion of poliovirus eradication to be a programmatic emergency for global public health and called for a comprehensive polio endgame strategy. This plan describes a worldwide approach to complete the eradication, including strategic objective 2, which calls for introducing the IPV in the group of countries that use only the OPV by the end of 2015.

Thus in November 2013, the GAVI board of directors opened a financing window allowing the Alliance's Secretariat to invite eligible countries and those on the way to graduation to submit a support request for the introduction of a dose of inactive polio vaccine (IPV) in their routine immunisation programme by the end of 2015, in accordance with the Strategic Plan 2013-2018 for eradicating polio and the final onslaught against the disease.

The IPV's main goal will be to maintain immunity against type II poliovirus during the worldwide withdrawal of OPV2. Strengthening routine immunisation systems is a key element of this goal, insofar as maintaining a high immunisation coverage is essential for succeeding in eradicating polio and for supporting long-term eradication efforts.

After a respite of several years, in 2010 Congo experienced an epidemic related to an importation of type 1 wild poliovirus. In the course of this epidemic, 441 cases were reported, 194 of which were deaths. Several interventions aiming to strengthen immunity (strengthening routine immunisation, organizing preventive campaigns) and the surveillance system were conducted, allowing the circulation of the poliovirus to be interrupted within a short time.

The epidemiological situation at the regional and subregional level characterized by a resurgence of the circulation of wild poliovirus in Cameroon (5 cases) and in Equitorial Guinea makes the risk of a fresh importation loom for Congo.

With regard to what has preceded and taking into account the intense movements among the peoples of the subregion of Central Africa, Congo has followed the recommendation of the WHO for the introduction of a dose of IPV in the immunisation schedule of routine EPI for children 0 to 11 months. This introduction will be carried out simultaneously in all of the country's health districts starting in July 2015.

Outline of the benefits to the population of introducing IPV and the costs to the programme of its introduction and how the country plans to sustain those costs.

The introduction of a dose of IPV in the immunisation schedule followed by the progressive withdrawal of the OPV type 2 component from routine immunisation will allow the country to:

- avoid the reemergence of cases of cVDPV2;

- make it easier to interrupt virus transmission in case of an outbreak of the type 2 virus by guaranteeing a more rapid and effective immune response;

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- strengthen immunity against types 1 & 3 in children having already been immunised with the OPV, to accelerate the eradication of polio.

Overview of how the vaccine will be introduced (national or phased introduction) and key milestones and activities, such as when the vaccine will be introduced and when preparatory activities should begin.

The Inactivated Polio Virus (IPV) will be introduced on a national scale starting in July 2015. As soon as the application submitted by Congo is accepted by GAVI. Preparatory activities will be launched including:

- The review of all EPI documents (immunisation registers, immunisation schedule, tally sheets, monthly reports, etc.);

- The production of training modules and social mobilization materials;

- Cascaded training of service providers;

- Social mobilization;

- Making IPV available in health facilities before the launch.

Overview of the capacity of the immunisation programme to introduce the IPV, including all aspects of supply chain and logistics, health workforce capacity, etc.

As regards new vaccines, Congo has successfully introduced into routine vaccination the yellow fever vaccine since 2004, in 2007 the hepatitis B vaccine, in 2009 the type B haemophilus influenza (Hib) vaccine in pentavalent form, in 2012 the pneumococcal vaccine and in 2014, the rotavirus vaccine.

An evaluation of effective vaccine management was carried out throughout the external review conducted in 2010. The conclusions arising from this evalution allowed plans for cold chain rehabilitation and EVM improvement to be developed. In accordance with these plans, several actions were conducted:- Acquired cold chain equipment (cold rooms, refrigerators);- Strengthened temperature monitoring (systematize fridge tags);- Trained workers on cold chain equipment maintenance;- Computerized stock management.

At each new vaccine introduction, training sessions are organized at all levels of the health system.

Summary of preparatory activities completed or to be undertaken.

The Ministry of Health and Population in collaboration with the related ministries and development partners held technical meetings to approve the decision to introduce the IPV into the routine EPI and ordered the implementation of preparatory activities (meeting of the technical committee to approve the introduction of the IPV, IPV introduction plan development workshop, finalization

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workshop integrating all input received, meeting to approve documents by the technical committee), with a work timeline. To this end, a multidisciplinary group will be set up as soon as the application has been approved to run through all of the preparatory activities retained in the attached timeline.

Brief description of main risks/challenges associated with the introduction of IPV and outline of the mitigating strategies put into place to address these risks (or meet these challenges).

The main risks brought up for this introduction are:

- The risk related to an increased number of injections. To this end, emphasis will be placed on training workers on injection safety, management of biomedical waste and surveillance of AEFI.

- The likely refusal/reluctance of parents because of the fact that the child is receiving several injections (Penta, Pneumo, IPV) at the same session. Thus a special emphasis will be placed on public relations and social mobilization (community awareness-raising, opinion leaders, religious denominations, media, etc.)

This document covers the following areas:

1. Justification of the introduction of the IPV and national decision-making process

2. General description of the IPV

3. Considerations related to the introduction and use of the vaccine:

4. Situational analysis of the immunisation program

5. Monitoring-Evaluation

6. Advocacy, public relations and social mobilization

1. Justification of the introduction of the IPV and national decision-making process

Demonstrate that the main decision-makers of the organizations concerned (Ministry of Health, Ministry of Finance, etc.) have participated in the discussions about the introduction, taken part in the final decisions regarding the introduction of the IPV and approved it.

Further to the letter from the GAVI Alliance, the Minister of Health and of Population of Congo approved the introduction of the IPV in routine EPI and instructed the EPI team to prepare the GAVI application. The country supports the introduction of the Inactivated Polio Vaccine, as advocated by SAGE. This introduction will not only allow the immunity status of OPV-vaccinated children to be strengthened, but also give a powerful boost to the eradication of this disease by reducing the risk of reemergence of type 2 wild poliovirus which had disappeared since 1999. A multi-disciplinary group made up of executives from the Ministry of Health and Population, related departments supported by the partners (WHO, UNICEF) was set up to draft this plan.

Describe the involvement of other relevant stakeholders, e.g. Civil Society Organizations, community representatives, national regulatory authorities, academic and training institutions and, as applicable, the private sector, in the decision-making process.

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This plan was endorsed by the Inter-Agency Coordination Committee meeting of 11 September 2014. This committee, chaired by the Ministry of Health and Population, saw the participation of executives from the Ministry of Health, the Ministry of the Plan, the Ministry of Finance, civil society, religious denominations, and executives, and learned societies for pediatrics and infectology.

Establish the technical and operational feasibility for the introduction of the IPV, taking into account the experience gained by the country as regards the introduction of other new vaccines.

As regards new vaccines, Congo with support from the partners, has successfully introduced new vaccines into its routine EPI, namely: the yellow fever vaccines in 2004, viral Hepatitis B in tetravalent form (DTP-Hep B) in 2007, and Haemophilus influenza type b in pentavalent form (DTP-HepB-Hib) in 2009, PCV-13 (pneumococcal) in 2012 and rotavirus diarrhea vaccines in 2104. The introduction of these new vaccines had as a prerequisite the rehabilitation of the cold chain at all levels. As regards coordination, there is a new vaccine steering committee directed by the Director General of Health.

As regards logistics, current storage capacities are sufficient at the central level. At the intermediary level in 2015, 6 out of 12 departments and 10 health districts out of 30 have insufficient storage capacity.

Actions will be taken to diminish the existing gap at the level of health districts and departments such as the monthly provision of supplies at the level of departments that are in deficit and 2 times per month at the health district level. This will be helped by the existence of a functional cold chain at Pointe-Noire which will serve the departments in the southern part of the country and the one at Brazzaville for the northern part of the country with the aid of the refrigerated vehicle available at the central EPI. As regards training, national capacities will be developed in order to provide the introduction of the IPV under optimal conditions.

As regards public relations: a public relations plan exists for conducting public relations social mobilization activities for the new vaccine. This plan will be implemented in the framework of the IPV introduction.

The optimal introduction of new vaccines requires:

The commitment of political/administrative authorities;

The involvement of all relevant stakeholders in the introduction process for the new vaccine;

The development of a fact-based public relations plan;

Enhancing staff capabilities;

Creating a detailed timeline of activities at the departmental and health district levels;

Strengthening communication of mass media;

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Strengthening the consistent supply of vaccines and other inputs;

Strengthening the cold chain

Strengthening of formative supervision;

Strengthening the AEFI management system;

Strengthening the waste management system;

Making management tools and data collection materials available;

Collaboration with the different ministries involved in all stages of planning and implementation of the project;

Setting up a rumor management system;

Awareness-raising of opinion leaders, religious leaders, local administrative authorities, and civil society organizations (NGOs, Associations).

2. General description of the IPV2.1 Vaccine preferences

Please specify vaccine preferences in Table B1 below.

Table B1. IPV vaccine preferences and estimated date of introduction

Preferred IPV vaccine

Month and year of first vaccination

Preferred second presentation

Preferred third presentation

Liquid IPV in 10-dose vials

July 2015 Liquid IPV in 5-dose vials

Liquid IPV in single-dose vials

2.2 National Approval Provide information on the status of the NRA in the country, i.e. whether functional and/or

WHO-certified.

From a quality-assurance perspective, NRA medication quality control activities are carried out by the Pharmacy Directorate. However, it is appropriate to note that an institutional development plan was developed in 2010 following an NRA strengthening and operation workshop at the Central African level. The great polio epidemic of 2010 did not allow it to be implemented. However, the implementation of certain plan activities are incorporated in the IPV introduction plan.

Indicate if national approval will prove necessary for the IPV, in addition to pre-qualification from the WHO; if this is the case, describe the procedure and indicate its duration. Indicate whether the country accepts the WHO's accelerated registration procedure for pre-qualified vaccines.

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National approval of the IPV vaccine does not prove to be necessary, because this vaccine will be supplied through the channel of UNICEF. The acceptance of vaccines is based on the lot release certificates provided by the manufacturers, after the quality control carried out by the UNICEF laboratory in Copenhagen.

Describe local customs regulations that are in force, requirements for pre-delivery inspection, special documentation requirements that may potentially cause delays in receiving the vaccine. If delays are expected, indicate the measures that have been taken to remedy them.

Customs clearance and transportation to the central warehouse of the vaccine is taken care of by the government according to the nature of the activity. The customs agents and the other workers working at the airports (Brazzaville, Pointe-Noire) have been trained on the importance of vaccines, especially in regards to their sensitivity and to the harmful effects of inclement weather. Taking into account the importance of vaccines and their sensitivity, an agreement was signed between the General Directorate of Health and the General Directorate of Customs for immediate release of the vaccines.

Therefore, taking into account the above, there is no major constraint that could hinder the proper preservation of the vaccines in the case of possible delayed release of the vaccines, given the nearness of the airport to the EPI central cold chain.

In the context of customs clearance, vaccines and injection materials have preferential rates. However, payment of customs forwarding agent fees and transportation remain the responsibility of the Ministry.

2.3 Target population and vaccine availability Provide an estimate of the target population for a single dose of the IPV to be administered

with the OPV 3, simultaneously with the DTP3/Penta3 vaccines (or DTP2, depending on the DTP immunisation schedule in force, as specified in Section 2.3 of the guidelines relating to the introduction of the IPV), and each year until 2018, starting with the first year of introduction of the IPV. The number of people to be vaccinated with the first dose of IPV must be adjusted depending on the month of the introduction.1

Population estimates for 2015-2018 based on the 2007 RGPH (General Census of Population and Housing).

Year Total population Target population

Vaccine requirements taking into account the instructions from GAVI instructions

2015 4 681 449 187 071 210 7002016 4 821 892 192 683 401 500 2017 4 966 549 198 463 373 200

1GAVI will determine the requirements for vaccines and auto-disable syringes as a function of the size of the target population and immunisation preferences, taking into consideration wastage rates and the regulated inventory of vaccines (25% the first year). If there are differences noted between the coverage estimates provided by the country and those of the WHO and UNICEF, the Secretariat shall base its evaluation on the estimates provided by the latter sources.

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2018 5 115 545 204 417 383 400

NB: the 4% comprise the target population of surviving children

The estimates regarding the target populations, the quantities in terms of vaccines have been obtained from the Epi-log forecasting tools developed by the WHO and UNICEF. This tool incorporates all of the elements of basic data necessary for the quantification of vaccine requirements, storage capacity and related gaps.

Thus, the wastage rate is equal to 50% and the reserve inventory is estimated at 25% for the first 12 months. The objectives for the next five years are: 45% in 2015 because the introduction will be carried out starting in July 2015, 90% in 2016 and 93% for the next three years.

3. Considerations related to the introduction and implementation

3.1 Development of policies

Describe any need to alter the National Immunization Policy to include IPV in the national immunization schedule, including any changes in the current schedule and the likely impact on existing vaccination contacts this may have. Align the dosing schedule of the IPV with the DTP dosing schedule (see section 2.3 of the IPV introduction guidelines).

Before the introduction of the IPV, the EPI will revise the cMYP, the Norms and Standards document and the immunisation schedule. All of the management tools, including the different documents (tally sheets, immunisation registers, vaccine management sheets and monthly immunisation report sheets) will also be updated.

Provide information on immunisation practice decisions, e.g. injection site, order of injections, and which limb for two or more injections.

The IPV will be administered at 4 months by the intramuscular route (IM) simultaneously with OPV3, PCV13-3 and Penta3 at the opposite thigh and/or arm at the base of the deltoid.

The childhood immunisation schedule in force in the Republic of Congo with the introduction of the IPV is shown in the table below.

Age Vaccine Means of administration

Administration sites

Births OPV Zero Oral

BCG Intradermal Outside of the right arm

HepB Intramuscular Outside of the left arm (base of the deltoid muscle)

2 months DTP-HepB-Hib1 (Penta1) Intramuscular Antero-external side of the right thigh

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OPV1 Oral PCV-13 Intramuscular Antero-external side of

the left thighRota 1 Oral


OPV2 Oral PCV-13 Intramuscular Antero-external side of

the left thighRota2 Oral


Pneumo3 Intramuscular Antero-external side of the left thigh

Rota 3 OralIPV Intramuscular Outside of the left arm

9 months VAR1 Subcutaneous Outside of the left armYFV Subcutaneous Outside of the right arm

15 months MCV2: Subcutaneous Outside of the left arm

Describe any integrated delivery of other health interventions that are planned.

During Mother and Child Health Weeks (SSME), supplementary immunisation activities (SIA), systematic deworming and vitamin A supplementation for children are commonly organized in the context of catch-up campaigns for children. IPV administration will be included in these interventions with a view to increasing immunisation coverage in children 0 to 11 months old.

3.2 National coordination mechanism to facilitate the introduction of the vaccine

Summarize the IPV introduction schedule, as shown in Annex C. The main activities to be implemented in the framework of the introduction of the IPV are the following:

Development of the IPV introduction plan in September 2014;

Endorsement of the plan by the ICC in September 2014;

Submission to GAVI of the endorsed plan in September 2014;

Strengthening the cold chain 2015-2016

Revising the communication plan for IPV in August 2014;

Developing of the crisis communication plan in February-March 2014;

Microplans at the health district and health area level in December 2014;

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Developing mobilizer and town crier guides for the IPV in March 2015;

Receipt and customs clearance for vaccines in April 2015;

Revision and production of training modules for providers, mobilizers and town criers in May 2015;

Revising and producing communication materials (posters, pamphlets, banners, t-shirts, etc.) and immunisation materials (immunisation registers, tally sheets, monthly reports, immunisation schedule, vaccine management sheets, etc.) in March-April 2015;

Drafting vaccine distribution plans in May 2015;

Supplying vaccines and injection materials to health departments/districts in May-June 2015;

Implementing of communication activities May-June 2015;

Organizing quality formative supervisions of the central level towards the departmental level from January to December 2015;

Implementing cascaded trainings for service providers at all levels in May-June 2015;

Official launch of the IPV introduction July 2015;

Post-introduction assessment for IPV and sharing with partners in August 2016;

Describe the national level management process to oversee IPV introduction, including any steering committee and/or subcommittee tasked with supervising various activities for the introduction.

The management processes for the introduction of IPV at the national level are the following:

A national steering committee headed by the Director General of Health and sub-committees that will be created for preparations and implementation for the introduction of the IPV. These sub-committees will be comprised of: the Director of Family Health (DSF); the Director of Epidemiology and the Fight Against Disease (DELM); the Director of Hygiene and Health Promotion (DHPS); the Director of Pharmacies; and the Head doctor for the Expanded Programme on Immunisation (EPI).

The sub-committees will be tasked with:

The technical sub-committee will be tasked with preparing technical planning documents, implementation of the introduction, and monitoring and evaluation of the IPV introduction;

The logistics sub-committee will be responsible for estimating requirements for vaccines, consumables, cold chain and transportation logistics equipment, the supply and distribution of vaccines and inputs, as well as waste management;

The communication sub-committee is tasked with developing the implementation and monitoring communication strategies and activities;

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The resources mobilization sub-committee is responsible for advocating to mobilize financial resources;

The AEFI surveillance and management sub-committee is tasked with the development, implementation and monitoring of pharmacovigilance.

3.3 Affordability and financial sustainability of the vaccine Summarize the budget and financing of IPV introduction, as presented in Annex D.

The total amount of requirements for the introduction programme for this additional dose of IPV for the Republic of Congo is estimated at 598932 US Dollars, not including the purchase of vaccines and other inputs.

The main headings for this budget are set out below:

- Planning and preparatory activities: 42 467 US Dollars, or 7.1% of the budget;

- Improving human resources capabilities: 63 541.7 US Dollars, or 10.6% of the budget;

- Logistics (purchase of cold chain equipment): 284 423.7 US Dollars, or 47.5% of the budget;

- Monitoring/Supervision: 58 333.3 US Dollars, or 9.7% of the budget;

- Communication: 146792 US Dollars, or 24.5% of the budget;

- Programme management: 3 375 US Dollars, or 0.6% of the budget.

The financing for the Congo IPV introduction plan will come through two sources:

- GAVI support in the amount of 136 479.2 US Dollars, or 22.8% of the budget;

- Financial resources valued at 462452.9 US Dollars to be mobilized by the national party and its partners, or 77% of the budget.

Provide the method used to estimate these costs.

For the method used to estimate the costs, see Annex D.

Include the identification of the non-vaccine operational costs for introduction and whether funds are secured. N/A

Discuss the overall trend of country immunization financing, of both government funding and donor funding (if applicable), and plans to absorb the additional costs of related to the introduction of the IPV.

Additional costs related to the introduction of the IPV will be covered by:

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The Government, up to 271 932 US Dollars;

UNICEF, up to 110 417 US Dollars;

The WHO, up to 80 104 US Dollars.

If co-financing, please indicate how the co-financing amounts will be paid (and who is responsible for this).

For the first year of IPV introduction, there will be no co-financing as regards the purchase of the vaccine and injection materials. All related costs are supported by GAVI.

3.4 Overview of cold chain capacity at district, regional and central levels Describe adequacy of storage capacity for IPV at each level of the cold chain, based on the

vaccine supply and distribution system planned for the introduction.

The Congo currently has available, at all levels of the health pyramid, cold chain equipment that meets the standards required for better vaccine preservation. Storage capacity can be adapted with the additional volume related to the introduction of this new vaccine. However, to absord the existing deficit at the operational and health district levels, the rate of supply will be readjusted.

The main source of energy utilized to power the cold chain equipment differs from one department to another, with oil being predominant. Following the introduction of the rotavirus vaccine in 2014 and the IPV in 2015, the configuration of the cold chain stock, vehicles and current vaccine transportation has changed appreciably. An analysis highlights the following points:

At the central level: the existing capacity is 26 191 liters in positive and 3 030 liters in negative and is fueled by the electricity provided by the national company supplemented by a generator. This volume is sufficient for storing traditional vaccines and can be adapted with the introduction of the rotavirus vaccine and the IPV until 2017.

At the departmental level: the capacity is 7445 in positive (fridges) and 10763 in negative (freezers). This capacity is sufficient for stocking traditional vaccines and the new vaccines at the departmental warehouse level.

However, in the health districts, there is a deficit of 5824 liters in positive (two brands of solar energy new generation refrigerators whose capacity varies between 156 and 216 liters, four brands of electric refrigerators whose capacity varies between 95 and 135 liters) whereas in negative (freezers) there is no deficit. The rehabilitation of the health districts and health centers as regards the cold chain will be done progressively according to the rate at which this equipment is acquired.

Type of equipment and storage volume at the central EPI, Republic of Congo, August 2014

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EPI -central

Type of existing Volume Num- Existing Total net Volume Defi

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equipment per equipment

m3

ber net volume

volume per level

Required per level

cit

Zendre Positive cold room

30 000 1 7 14326 190 7 554 0


40 000 2 19 047

Zendre Negative cold room

10 000 1 3 333 3 333 3200

Pointe Noire sub baseType of existing equipment

Gross volume per equipment

in m3

Num-ber

Existing net

volume

Total net volume per

level

VolumeRequire

d per level

Deficit


30000 1 952410 884 3 564 0

Vestfrost MK304 Refrigerator

108 10 1080

Vestfrost MK204 Refrigerator

75 3 225

Sibir 170K/E Refrigerator

55 1 55

Zendre Negative cold room

10000 1 3333 5878 206 0

VestfrostMF314 Freezer

264 6 1585

VestfrostMF214 Freezer

192 5 960

Department of Brazzaville

Type of existing equipment


in m3

Num-ber

Existing net

volume

Total net

volume per level

VolumeRequired per level

Deficit

VestfrostMK304 chest refrigerator

0 0 0 0 3404 0

VestfrostMF314 chest freezer

281 1 271 271 125 0

Vaccines for the department of Brazzaville are stored at the central EPI level. There is no deficit for Brazzaville.

Department of Pool

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in m3

Num-ber

Existing net

volume

Total net

volume per level


Deficit


296 2 200 400 587 187


281 1 271 271 180 0

Department of Plateaux



in m3

Num-ber

Existing net

volume

Total net

volume per level


Deficit


296 2 200 400 434 34


264 1 264 264 140 0

Department of Bouenza



in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit

Vestfrost MK 304 chest refrigerator

296 3 200 600 766 166


192 1 192 192 150 0

Department of Likouala


Gross volume

per equipment

in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit

Vestfrost MK304 chest refrigerator

296 1 200 395 382 0

Sibir E/K 170 upright refrigerator

55 2 110

Dulas solar refrigerator

85 1 85


281 1 271 271 148 0

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Department of Niari


Gross volume

per equipment

in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit


296 3 200 624 573 51

Electrolux Hemocold Refrigerator

24 1 24


192 1 192526 264 262


281 1 271


45 1 63

Department of Pointe Noire


Gross volume

per equipment

in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit


296 3 200 600 1802 0


192 1 192 192 160 0

The vaccines for the department of Pointe Noire are stored in the sub-base of the central EPI. There is no deficit at Pointe Noire.

Department of Lékoumou



in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit

16


63 3 189619 240 0


296 2 400

Transane refrigerator

30 1 30


192 1 192 463 110 0

Chest freezer 281 1 271

Department of Cuvette



in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit


296 2 400 455 387 68


55 1 55


281 2 542 542 160 0

Department of Cuvette Ouest


Gross volume per

equipment in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit


296 2 400540 182

0

Sibir 170KE upright refrigerator

55 1 55

Dulas chest refrigerator

85 1 85


192 1 192 463 150 0


281 1 271

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Department of Sangha


Gross volume per

equipment in m3

Num-ber

Existing net

volume

Total net volume

per level


Deficit


296 1 200395 213 0

Sibir V170K/E refrigerator

55 1 110

Dulas solar refrigerator

85 1 85


281 1 271 271 132 0

Department of Kouilou



in m3

Num-ber

Existing net

volume

Total net volume per

level


Deficit


296 2 200 400 188 0


192 1 192 192 123 0

The vaccine and input distribution system is done by air and ground transport starting from the Brazzaville central warehouse. The following routes have been defined:

- Route 1: Brazzaville-Pointe-Noire serving the interdepartmental warehouse (Niari, Bouenza, Kouilou and Lékoumou);

- Route 2: Brazzaville-Pool serving the warehouse for the department of Pool;

- Route 3: Brazzaville to the warehouses of the country's northern departments (Plateaux, Cuvette-Ouest and Cuvette);

- Route 4: Brazzaville-Sangha serving the warehouse for the department of Sangha;

- Route 5: Brazzaville-Likouala serving the warehouse for the department of Likouala.

The current frequency of supply is quarterly for the departments and monthly for the health districts and health areas. Vaccine delivery operations are supported by funding from the State. A reserve inventory equivalent to 3 months' consumption is prescribed for each routine vaccine at the central level.

The introduction of the IPV will not change the delivery schedule and will not involve any additional costs.

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The post-introduction evaluations for the pentavalent and the PCV-13 indicate that the introduction of these vaccines has contributed overall to the improvement of the different components of the programme, such as vaccine supply, quality and logistics, especially vaccine storage capacity.

Where capacity is deficient, provide an estimate of needs and budget to strengthen transport and the cold chain at the central level (cold rooms, refrigerators, cold boxes and icepacks, vaccine carriers) at the national level to accommodate the introduction of the IPV.

Current storage capacity for vaccines at the central level are sufficient for the introduction of the IPV in the EPI in 2015. However, at the departmental and operational level a deficit was noted for the cold chain equipment, which will be made up by the increase in supply frequency as described above.

The cold chain rehabilitation process in progress is oriented towards an option of gradually replacing oil-fueled equipment with electrical and solar equipment in stages. This policy is justified by the progressive electrification of most of the country's administrative districts with the new Imboulou hydroelectric dam coming on line.

However, the efforts made aimed at making up the deficits in the districts will continue with the support of the partners until 2017. The 2015 State investment budget provides for the purchase of cold chain equipment. In addition to this, the EPI, in its cold chain rehabilitation plan, will turn to the window for cold chain strengthening opened by GAVI and the HSS application to GAVI. An estimate of eventual requirements is numbered at 63 refrigerators, with the budget for them amounting to 183 882 USD, with a purchase of 40 fridges the first two years.

Provide evidence of availability of sufficient funding at local levels for the ongoing power supply and maintenance of any new cold chain equipment.

Electricity costs for healthcare facilities at all levels are always covered by the State.

As regards the maintenance of cold chain equipment, all of the health districts have been in the process of contracting for equipment maintenance since 2012.

3.5 Waste management and injection safety Describe existing injection safety and vaccine waste management activities and detail

whether any changes are needed to accommodate IPV in line with national policies and how and when this will be ensured, if applicable.

The Congo has a national injection safety and biomedical waste management plan. The implementation of this plan involves:

- The systematic use of auto-disable syringes for each injection;

- The collection of used syringes and needles in safety boxes;

- Destroying full safety boxes by incineration or by burying the burned materials in a pit in those health facilities that do not have an incinerator. It is worth noting that operational

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incinerators only are found in the Brazzaville and Pointe-Noire hospitals. Mechanisms for collecting safety boxes around the operational incinerators are being studied.

If the country decides to purchase vaccine administration devices on its own, indicate whether these are devices pre-qualified by the WHO and if not, describe the approval process used in the country.

Congo purchases vaccines and injection materials through UNICEF.

3.6 Health worker training and supervision Describe the current adequacy of trained human resources to introduce IPV across all sectors

of the immunisation programme, e.g. for vaccine storage and management, in-country distribution, training of healthcare workers at peripheral levels, supervision, delivery, etc.

The central EPI team and the department executive teams received MLM training (vaccine and cold chain management, supervision, planning, etc.) Since 2009 In order to strengthen capacities of recently recruited EPI management personnel, an MLM training course is planned for the 2nd quarter of 2014.

The introduction of the yellow fever vaccine in 2004, the PCV-13 (pneumococcal) vaccine in 2012, and the rotavirus diarrhea vaccine in 2014 allowed providers' skills to be strengthened as well.Thus, in addition to the skills already acquired by the service providers at the time of the previous new vaccine introductions, cascaded trainings for the introduction of the IPV will be organized at all levels.

Describe how any additional need will be addressed.

There will be no additional training needs.

Provide information on the development and provision of training materials for IPV, e.g, handbook for health workers, FAQs, fact sheets, training video, posters, pre- and post-knowledge tests, etc.

The training modules covering all aspects of the IPV, technical as well as social mobilization, will be developed for supervisors/trainers, service providers and mobilizers.All management materials (vaccine order form, vaccine inventory management sheet, immunisation register, tally sheet, immunisation card, monthly activity report, immunisation schedule, etc.) will be revised during a workshop.

Outline the training plan, the method used and the refresher sessions on immunisation practices (injection safety, communication on AEFI, etc.).

Cascaded training workshops will be organized at all levels:

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- Training a pool of trainers at the central level, training an CSS executive team;- Training of service providers and persons in charge of communication (journalists,

community relays).

Describe the plans intended to strengthen supervision activities before, during and after the introduction of the IPV.

A multidisciplinary pool of supervisors at the central level will be set up and trained on supervision techniques. This team will be called upon to supervise activities in the following areas:

- Vaccine services;- Management of AEFI; - Ordering and receiving vaccines; - Cold chain management; - Waste management;- Disease surveillance;

Formative supervisions will be carried out at all levels of the health system after the introduction of the vaccine. The supervisions will allow problems to be identified and corrective action to be taken with the participation of actors on the ground. According to the level, the frequency of these supervisions will be quarterly from the central level to the operational level and monthly from the operational level to the health centers.

3.7 Risks and challenges Identify main risks and challenges to the new vaccine introduction, e.g. financial,�

mobilization of communities, programmatic, etc., - and outline the plans to address them.

Risks and challenges

Comments Measures

Financial Financing the operational cost of the IPV introduction requires a major contribution from the government.

Advocate to the government for financing operational costs

Programmatic -The immunisation schedule will include a dose of IPV at 4 months. -There are gaps to be filled in for storage capacity at the intermediary and operational levels.

-Service providers and beneficiaries will be made aware of the new immunisation schedule. -Increase the frequency of supply.-Mobilization of financial resources

Community acceptance Mothers can be reluctant, due to the fact that their child receives three (3) injections at the same time (Penta 3, Pneumo3 and IPV) at 4

-Involve pediatricians, midwives, social workers and other persons responsible for children in the IPV introduction process.

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months. -Strengthen communication with service providers and beneficiaries on the benefits of this procedure.

4. Situational analysis of the immunisation program

4.1. General country context Summarize the country context, health system, health priorities, and organizational structure

of National Immunisation Programme.

a) Country contextThe Republic of Congo covers an area of 342,000 km2 bordered by the Atlantic Ocean with 170 km of coastline, and it is located on the western coast of central Africa, straddling the Equator. It extends along the right bank of the Congo river and its tributary, the Oubangui. It is bordered to the north by the Central African Republic and Cameroon, to the east and south by the Democratic Republic of Congo and the Republic of Angola (Cabinda enclave) and to the west by the Gabonese Republic and the Atlantic Ocean.

In 2011, the population of Congo was estimated to be 4 111 159 inhabitants, with an average population density of about 10.4 inhabitants per square kilometer. This population is primarily young (the proportion of young people under 20 years of age is 55%) and concentrated in the major cities (58%). The female population makes up 51.7% of the total population. The indicators below show the country's demographic situation.

- Crude birth rate: 41.7% (RGPH 2007);- Crude mortality rate: 13% (RGPH 2007);- Infant Mortality Rate: 39% (EDS 2011-2012);- Under-five mortality rate: 68% (EDS 2011-2012); - The maternal mortality rate per 100 000 live births: 426 (EDS 2011-2012);- Life expectancy: around: 51.6 years (RGPH 2007);- Schooling rate for young girls in Congo: 9.4% (EDS 2011-2012); - The rate of natural population increase is 3.4 (RGPH 2007).

Congo's economy is mainly based on subsistence agriculture and the craft industry, as well as on an industrial sector that is largely reliant on hydrocarbons. Oil, which has been refined in Pointe-Noire since 1976, has replaced forestry as the main economic activity. It supplies 90% of the State's revenue and constitutes the same percentage of the country's exports.

After the socio-political conflicts of the 90s, which brought about a massive destruction of socio-economic infrastructures, the Congo entered a reconstruction phase. Per capita income increased from USD$843 in 2000 to USD $3082.9 in 2010. In 2010, the growth rate reached 11%, compared to 6.8% in 2009.Inflation rose in the short term with the increasing growth and it has been maintainted at 4.7% above the CEMAC convergence criteria, which is 3%.

b) Health System

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Congo has a National Health Development Plan (PNDS 2007-2011) in the implementation of its health policy. This policy is based on the development of primary care, which is built around 6 priority areas:

- Increasing national health coverage;- Improving quality of care and services;- Integrating the operational components of targeted health programs;- Reducing exclusion and inequalities in access to quality care and services;- Stimulating community participation in their own health care management and in the

functioning of the health care system (Bamako Initiative);- Strengthening partnerships through bi- and multilateral cooperation and intersectoral

collaboration.The healthcare system in Congo is pyramidal, with three hierarchical levels for administration and the care system.The health system is administered by the Ministry of Health and Population, which is divided into three hierarchical levels: central, intermediary, and peripheral.The care system centers on three operational levels: general hospitals; basic hospitals, and integrated health centers. Care is provided by the public sector and by the private sector.

c) EPI structure

The Expanded Programme on Immunisation (EPI), an important wing of the Directorate for Disease Campaigns, was established in 1981 following Congo adoption in 1979 of a health policy assigning priority to preventive medicine and primary health care. The objective was to provide the universal immunisation of children and to reduce the incidence of vaccine-preventable diseases.

From 1986, the national immunisation campaign allowed the objective of "universal immunisation of children" to be obtained with 80% DTP3. These gains were able to be maintained from 1988 until 1996, the year in which the partners decreased their contributions, with no significant financial compensation from the government. The reduced financing from the partners coincided with the socio-political unrest of the 90s, which had caused the destruction of health infrastructures and resulted in lowering the immunisation coverage. Since the implementation of the comprehensive multi-year plan 2004-2008, the EPI has made tremendous progress. The implementation in districts of the Reach Every District (RED) approach has been the strategy that has sustained this growth. The strengthening of the RED strategy has always held a place of choice in the multi-year plans developed by the programme, including this one (cMYP 2012-2015).Operations and EPI supportive components are the two primary categories of intervention implemented in Congo.

- Support componentsThe supportive components relate to programme management, funding and capacity building.Programme management and coordinationThe EPI Programme reports to the Directorate of Family Health (DSF) within the Directorate General of Health (DGS) of the Ministry of Health and Population. The EPI is a department among many in this central directorate (DSF). Since 1999, strategic coordination for the EPI has been provided by the Interagency Coordination Committee (ICC) chaired by the Minister of Health and Population.

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At the central level, the EPI is a department placed under the coordination of a head doctor and includes several sections: logistics, epidemiological surveillance, social mobilization, monitoring/evaluation and training, finances and administration. At the department level, the department directors and EPI supervisors carry out implementation, monitoring of immunisation activities and epidemiological surveillance of targeted diseases.At the CSS level, immunisation is coordinated by EPI focal points reporting to CSS head doctors. EPI financing can be summed up by three sources: the State budget, support from partners (WHO, UNICEF, GAVI) and by the community at the peripheral level (payment of costs). The State's contibution is constantly increasing, and it allows the purchase of 100% of the traditional vaccines, 60 to 70% of operational costs for the programme and payment of the share in GAVI co-financing.

4.2 Geographical, economic, policy, cultural, gender and social barriers to immunisation Please complete Table B2 below to report immunisation coverage data for the two most recent

years. As a part of the priority for gender parity and equity, please report sex-disaggregated coverage data, if available.

Table B2. National immunisation coverage trends

Vaccine Type of vaccine used

Target population Coverage recorded

(Joint report)

2013 Year 2013 Year 2012BCG BCG 190629 89 91OPV 3 OPV 3 176332 90 83DTP 1 / Penta 1 Pentavalent1 176332 91 91DTP 3 / Penta 3 Pentavalent1 176332 84 84Measles 1 Rouvax 176332 78 78PCV 1 PCV-13 176332 91 42PCV 3 PCV-13 176332 86 40

Please describe any specific geographical, economic, policy, cultural, gender and social barriers to immunisation. Given the priority of GAVI to ensure gender parity and reduce inequity in access to immunisation services, please describe any gender and/or equity analyses that have been conducted including actions taken to mitigate barriers.

Types of barriers

Description Corrective actions

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Geographical Difficult to access areas (small islands, mountains listed in the departments (Likouala, Sangha, Cuvette, Bouenza, Pool and Lékoumou). The population affected varies between 5 and 10%, according to the department.

-Intensification of advanced and mobile strategies;-National Immunisation Days;

-Economic - Insufficient state contribution to the health budget and to the EPI;

- Difficulties disbursing funds (difficult mechanisms);

- Congo is a GAVI graduated country. It will no longer benefit from GAVI financial support in a short time.

- Advocate for increasing the budget line allowance and for setting up simple disbursement mechanisms;

- Developing a GAVI transition plan.

Sociocultural - Existence of religious groups that resist immunisation (beliefs, rumors);

- Existence of native populations that are difficult for the health department to reach.

- Strengthening communication strategies;

- Implementing strategies adapted for reaching vulnerable populations.

According to the data from EDS 2011-2012, there is no difference between boys and girls as regards immunisation. Immunisation coverage in boys is estimated at 72.1% for DTP3 and in girls/women is on the order of 71.4%.

4.3 Findings from recent programme reviews

Highlight key competencies/strengths of the immunisation programme that make it feasible to carry out IPV introduction including recent changes to address any weaknesses previously identified.

Following the recommendations from the post-introduction evaluation for PCV-13 carried out in October 2013 enabled improvements in the preparations for introducing other new vaccines as to:

- The existence of effective coordination teams at all levels.

- The existence of a quite effective logistics system that enabled the optimal introduction of the PCV-13 and the rotavirus vaccine;

- The existence of national capabilities to conduct trainings at all levels;

- The existence of an effective data reporting system;

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- The existence of a strategic EPI communication plan with a new vaccine introduction component;

- The existence of a monitoring and evaluation plan for EPI activities.

During the external review of the Congo EPI organized in October 2010, the review of the administrative data at the central level showed that there was good use of immunisation services which translated into a drop-out rate for DTP1-DTP3 below 10% with disparities at the departmental level.

At the departmental level, 90% of EPI managers for social and health constituencies were well-versed in the EPI targeted diseases, the immunisation schedule and immunisation strategies.

Summarize findings from recent programme reviews, indicating whether the recommendations are part of a subsequent national Plan of Action, and describe the status of implementation of recommendations and how these will impact on the proposed new vaccine introduction.

The country received the external review for the EPI in 2010, for the Evaluation of Effective Vaccine Management in 2010 and a review of surveillance in 2012. The strengths of these evaluations related to having good coverage for the integrated provision of services in health facilities. Areas needing improvement included logistics, effective vaccine management and community-based surveillance.

The recommendations deriving from these evaluations enabled the development of cold chain rehabilitatin plans, EVM improvements, and strengthening surveillance of vaccine-preventable diseases.

The implementation of the plan to improve discrepancies in EVM, carried out in 2010, enabled improvements in vaccine supply chain management. However, there remain gaps to be filled in terms of vaccine storage at the district level. In order to resolve this, the supply frequency will be 2 times per month at the district level.

The level of implementation of the improvement plan recommendations is estimated at 80%. Training related to logistics management has not been carried out to date. It will be accounted for during the MLM course.

An external review of the EPI, an audit of data quality, an evaluation of effective vaccine management and an immunisation coverage survey will be conducted during the month of October 2014. The conclusions of these different evaluations will be used for a successful introduction of the IPV.

Highlight whether there are resource constraints in implementing recommendations from recent reviews and how these will be overcome.

The implementation of the recommendations drawn from recent assessments has been compared with constraints in terms of financial resources:

- the 2013 EPI activities report notes a poor mobilization of State resources for routine immunisation;

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- a lack of financing for immunisation activities in particular for C4D and active surveillance components.

To remedy this situation, funds for reprogramming the health system strengthening were harnessed to finance certain aspects of the programme such as logistics (purchase of fridges, motorcycles, freezers, vaccines and inputs), provision of services (formative supervision, surveillance) and communication in favor of the EPI (holding community-based meetings).

Describe any previous experience with introducing a new vaccine and how lessons learnt will be used to ensure a smooth introduction of the new vaccine under consideration.

In Congo, the previous experience of new vaccine introduction (Yellow fever 2004, Pentavalent in 2009, Pneumo in 2012 and Rota in 2014) leads us to place particular emphasis on the following points:

- Creating a detailed timeline of introduction activities at the departmental and health district levels;

- Organizing training sessions/recycle providers on management of the cold chain and vaccines in all of the health districts;

- Organizing formative supervisions in order to continue reinforcing the management skills of the personnel;

- Organizing multi media campaigns as well as advocacy at all levels;

- Creating favorable conditions for a simultaneous introduction of the new vaccine in all of the health districts;

- Strengthening the implementation of advanced strategy immunisation in the health areas;

- Strengthening the AEFI management system;

- Strengthening the waste management system.

Otherwise, the recent experience of IPV introduction in several developing countries highlights the importance of emphasizing:

- collaboration with the different ministries involved in all stages of planning and implementation of the project;

- setting up a rumor management system;

- Awareness-raising of community leaders, religious leaders, local administrative authorities, and civil society organizations (NGOs, Associations).

4.4 Stock management

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Provide a brief overview of the stock management system in use in the country, i.e. whether computerized, manual or other, highlighting foreseeable issues in stock management with IPV introduction and how these will be addressed.

Stock management is done at the central level on the basis of computerized stock management tools and district Vaccine Data Management Tool (DVDMT) developed by the WHO as well as in manual registers. The departmental level uses the computerized tool known as the "District Vaccine Data Management Tool" (DVDMT). Practical measures will be taken to extend this tool to the department and district level.

The monitoring of vaccine usage, implemented at all levels, enabled wastage rates per antigen to be calculated. The IPV will be integrated and managed in the same context. We do not anticipate any problem that could result from this introduction.

Provide a description of the transport system available for delivery of vaccines to the periphery; whether the frequency of deliveries needs to be increased, and if so, whether there are sufficient funds, e.g. for vehicles, drivers, fuel, and per diem, among others things, for distribution of the new vaccine at all levels.

Vaccines and injection supplies are transported to the regions by ground and by air. Considering the fact that all cargo leaves from Brazzaville, the routes were established as follows:

Route 5: Brazzaville-Pointe-Noire serving the interdepartmental warehouse (Niari, Bouenza, Kouilou and Lékoumou);

Route 2: Brazzaville-Pool serving the warehouse for the department of Pool;

Route 3: Brazzaville to the warehouses of the country's northern departments (Plateaux, Cuvette-Ouest and Cuvette);

Route 4: Brazzaville-Sangha serving the warehouse for the department of Sangha;

Route 5: Brazzaville-Likouala serving the warehouse for the department of Likouala.

The current rate of supply is quarterly for the departments and monthly for the health districts and health areas. Vaccine delivery operations are supported by funding from the State. A reserve inventory equivalent to 3 months' consumption is prescribed for each routine vaccine at the central level.

The supply frequency for health facilities whose storage capacity is insufficient will go to two per month if the cold chain equipment is not obtained with the delivery of the IPV.

5. Monitoring-Evaluation

5.1 Updating of the monitoring instruments Describe measures to update, print and distribute EPI monitoring and supervision tools

(recording and reporting formats, including tally sheets, registers, immunisation cards, wall

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charts, computerized database, etc.) to include IPV and other new vaccines envisioned in the current cMYP, prior to the launch of IPV.

Before the introduction of the IPV, all of the management tools (tally sheets, immunisation registers, immunisation cards, monthly activity report, stock sheets, immunisation schedule, stock register as well as the EPI norms and standards document) will be revised before integrating all of the aspects related to the IPV. The training modules will also be revised for training/recycling of providers and communicators, then disseminated at all levels prior to the introduction of the vaccine.

The monitoring indicators, namely immunisation coverage, the specific drop-out rate, wastage rate, stock-outs for vaccines and inputs, unimmunised and missed children will be adapted, used and monitored at all levels.

The data analysis will be done through coordination meetings and self-assessments that are organized once a month at all levels. Monthly meetings to standardize the data, quarterly monitoring meetings with the departments to assess performances, retro-information and data quality will also be organized. A post-introduction assessment will be conducted in August 2016 after the introduction date and the report will be sent to the partners.

In line with GAVI's policy advocating for gender equality as a means to improve immunisation�� coverage and access to services, please be sure all immunisation tracking forms can collect and report vaccine delivery by sex, if current forms do not already do so.

In its preambule, the Congo constitution proclaims that a human being, regardless of race, religion, sex, or beliefs, has sacred and inalienable rights. In this legal clause, services do not differentiate between men and women with regard to health. Vaccination services are available to all children, regardless of gender.

However, during the revision of data collection tools, gender-based data will be incorporated.

5.2 Adverse Event Following Immunisation (AEFI) surveillance

Provide information on the national AEFI policy, e.g. describe the national capacity to implement a national system of pharmaco-vigilance, AEFI investigation and response to AEFIs, to effectively address relevant rumours and potential allegations.

The EPI norms and standards document has guidelines available for management of AEFI at all levels of the health system, starting with the community up to the health facilities as regards immunisation. In this way, all cases of AEFI must be recorded in the monthly EPI activities report. Major AEFIs must be investigated and managed at the health center, or if necessary, referred to the nearest hospital. Training courses in pharmacovigilance have been organized for the attention of health personnel.

Even though in the monthly EPI report there is a management item in case of the MAPI, we note that this item is insufficiently documented. However, we note a better management of cases during

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supplementary To fight AEFIs, rumors and other possible allegations, a committee will be set up to draft a specific crisis plan for their surveillance and their management for routine immunisation.

In the framework of the IPV introduction, a device for monitoring EAFI will be set up in the country in accordance with pharmaco-vigilance procedures.

Provide information on a national AEFI Expert Review Committee (if available) and methods of establishing causality assessments of AEFIs. N/A

The AEFI Experts committee is integrated as regards pharmacovigilance under the supervision of the pharmacies. This committee does not exist in Congo, but in the framework of the implementation of the institutional development plan this activity will be a priority.

Describe process and procedures for monitoring adverse events following IPV introduction at local, district, region/provincial, and national levels.

In the framework of monitoring adverse events following IPV introduction, the tools and definitions of AEFI cases will be developed. These tools will be integrated in the pharmacovigilance guide and disseminated to all of the health facilities. The AEFI surveillance system in use in the country will be used for the IPV. The country will benefit from this introduction to strengthen health workers' skills on data collection, on the surveillance of AEFI cases, and the management and monitoring of AEFI cases.

6. Advocacy, public relations and social mobilization

Describe the measures intended to raise awareness of political leaders and opinion leaders on the national/regional level and at the district level on IPV introduction, its benefits for the population and its contribution to the strategy for eradicating polio and the final onslaught against the disease.

The introduction of the inactivated polio virus (IPV) in the children's immunisation schedule in Congo is an opportunity to promote routine immunisation in general. For, despite the substantial progress made, the EPI for Congo faces a series of challenges, in particular:

• Stagnating immunisation coverages with the persistence of low-performing districts;• The increase in the number of inadequately immunised children. Only 45.5% of children from

12 to 24 months are completely immunised according to the EDSC 2011 and 4% have never received vaccines;

• The reemergence of epidemic outbreaks of vaccine-preventable diseases.

Indeed, even if the CAP study carried out in 2013 highlighted a favorable attitude of the Congolese population towards immunisation (78%), several weaknesses related to knowledge and perceptions with regard to immunisation remain. This involves: - The poor knowledge of the immunisation schedule (only 29% of people surveyed knew the ages

for immunisation);- The low execution rates of educational sessions and demonstrations of family practices in the

health centers;

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- The absence of a budget line for communication activities in favor of mother and child survival; - The shortage of human resources in quality and quantity in the area of C4D; - The limiting of communication activities in favor of immunisation in the cities and during

supplementary immunisation activities; - Outside of the EPI, there is no public relations department in the programmes and in the

decentralized level of the health system;- The existence of rumors that weaken parents' support for immunisation; - The lack of involvement of the other partners in public relations activities.

Thus, in order that the children may benefit from the IPV with all of these advantages, it is vital that the children's parents support immunisation by standing up and being counted at the different routine immunisation sessions in the health centers, according to the immunisation schedule. In terms of public relations, the strategy for the introduction of the IPV will be positioned in an overall strategy of promoting routine immunisation with the dissemination of key messages on the advantages of the introduction of IPV. It is in this framework that the introduction of the IPV was planned in June 2015 during the immunisation week during which immunisation is promoted in general, with intensified fixed, advanced and mobile strategy immunisation activities as well as the strengthening of activities for advocacy, social mobilization and communication in favor of immunisation.

To this end, the EPI has an integrated communication plan that represents a body of proposals intended to allow a greater involvement of all of the players from the sectoral area of Healthcare in general, and immunisation in particular, of policy personnel, deciders, partners, technical personnel, civil society, opinion leaders and beneficiary populations.

In this plan, it is intended that the intensification of communication actions in favor of routine immunisation, of epidemiological surveillance and IPV introduction be handled with respect to the strategic lines below:

Advocacy:

In the framework of the IPV introduction in Congo, a specific communication plan was drafted taking into account the strategic communication plan of the Ministry of Health. This plan contributes to improving support of the populations for the different immunisation actions by making them permanent by means of the programmes to strengthen skills for EPI managers, for immunisation players, community and media professionals involvement in all stages of planning, implementation, monitoring and evaluation. Several activities will be conducted, namely:- advocacy towards political leaders, opinion leaders and journalists;- Focus with the clinicians (pediatric doctors and other healthcare personnel) on the introduction of

the IPV.

The documents and tools for this advocacy will be prepared in the IEC section of the EPI, the IEC department of the directorate of hygiene and health promotion with the support of UNICEF.

e) Strengthening of capacities

Strengthening providers' capacities is crucial, for it enables them to own this high-impact initiative for the health of the population with a view to attaining the millenium development goals (MDG 4).

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It will involve training health agents, agents responsible for IEC in the health centers, CAS (social action) workers, community relays and mobilizers on interpersonal and group communication during immunisation sessions and other communication opportunities identified to this effect. They will thus be equipped with skills allowing them to disseminate good messages on the advantages of the IPV and of the other vaccines, the importance of following the updated EPI immunisation schedule, the management of rumors and of cases of refusal, the analysis of data at the health center level to periodically identify low performing areas and catch-up on drop-outs, etc. with a view to gaining the trust of parents and guardians of children, dispelling their fears and give rise to support from the whole community for immunisation.

Training will be carried out by the members of the IEC department of the EPI, the IEC department of the directorate of hygiene and health promotion with the support of the C4D team from UNICEF.

Social mobilization;

The mobilization will aim for identification and involvement of political/administrative and traditional leaders at the local level, the leaders of the different associations/NGOs/community-based organizations, leaders of religious denominations, leaders of the media and other opinion leaders who make up a communication network at the community level in the implementation of participatory approaches such as direct dialogue between the members of these partners who will work in a coordinated manner.

It is a matter of organizing community information and awareness-raising meetings to ensure the support and backing of all of these leaders with a view to effectively reaching the whole population and especially managing potential cases of refusal caused by rumors. All in all, this strategy will allow for:

- Making the communities of each health district become aware of the risks of polio, of low immunisation coverages and acknowledgements relative to their knowledge, attitudes and practices with regard to these themes. Make them capable of analyzing them, improving them and mobilizing resources, make decisions to conduct activities in order to change the situation in a positive way;

- Gather together at the departmental level, but especially at the local and community level, partners and allies with the objective of rallying them to the EPI objective in general, guaranteeing high immunisation coverages, and encourage community support for the introduction of the IPV.

The documents and tools for this advocacy will be prepared in the IEC section of the EPI, the IEC department of the directorate of hygiene and health promotion, mainly on the basis of the data, with the support of UNICEF.

3. Communication for behaviour change

The CBC acts mainly on the individual by strengthening his/her capacities in the framework of an interactive and participatory process. It will contribute to reinforcing knowledge, attitudes and positive practices of populations relative to immunisation and the acceptance of the IPV. To do this, the population must be informed, educated and made aware of the benefits of this new vaccine for

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the population's health in general and that of children in particular on the eradication of polio. The main players of this strategy are health workers, workers in charge of IEC, community leaders, NGOs/local associations, and community media.

According to the results of the CAP 2013 study which will be attached to this document, it emerges that:

- the health workers represent one of the main sources of information for parents, mothers, and children's guardians in the context of immunisation. Once trained, they must perform interpersonal communication during the immunisation sessions in order to reassure children's parents that the multiple doses and vaccines, the management of side effects, the course of action in case of AEFI, the importance of respecting the immunisation schedule and the benefit to the child of receiving all of the different doses of all of the planned vaccines.

- workers in charge of IEC, community relays and mobilizers with the support of the neighborhood/village leaders will have the task in this component of carrying out educational informal talks in the health centers and at the community level, as well as home visits to provide all of the information necessary regarding immunisation in general, allowing drop-outs to continue with the immunisation schedule, the ignorant as well as the reluctant to accept immunisation thanks to the right information being shared;

- At the religious denomination level, the departmental denominational committee briefed on the introduction of IPV and the importance of immunisation will raise awareness of the parish leaders, the places of worship and mosques that will disseminate the messages during worship and any other meeting opportunity with the faithful believers where educational informal talks can be organized with the support of workers responsible for IEC.

The introduction of the IPV being planned during the African immunisation week, as regards the media, the strategie will consist in broadcasting the information in the media outlets, namely commercials, programmes, and press conferences with a view to promoting immunisation in general with specific messages on the reasons and benefits of the IPV introduction in order to drive the parents to have the children immunised in the health center and the different immunisation spots chosen for this so that the children may benefit from all of the vaccines.

Strengthening coordination and supervision of communication activitiesHealth professionals responsible for communication at the central and departmental level do not supervise the communication activities enough in the health centers. Supervision visits will be carried out in order to regularly monitor the activities conducted on the ground and take corrective action by targeting problem areas.

Strengthening of monitoring-evaluation and operational research Outside of the independent monitoring usually carried out during immunisation campaigns against polio, the routine EPI communication activities require the same monitoring mechanism to improve activities. This assessment mechanism will consist of two points:

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- Organize a post-introduction survey in order to obtain the perceptions of the parents with regard to multiple injections and the acceptance of the IVP, the implementation of communication activities in the health centers;

- Organize an annual review of communication activities in the framework of the annual review of the programme.

Describe the development of a communication strategy for IPV introduction at the community level with identification of key messages, communication channels, and methods for greatest impact. Describe, if necessary, the extent to which the results of the assessment of the skills, attitudes, practices and beliefs of the service providers and/or studies of the obstacles to immunisation have been utilized to clarify the public relations strategy for the introduction of the IPV.

The integrated communication plan cited above that describes the different lines of strategy is the fruit of the analysis of the results of:

- "The CAP study on immunisation, the AMPE, mobile phone service, the knowledge of danger signs and seeking care when faced with a child suffering from malaria, diarrhea and pneumonia in Congo" carried out in 2013;

- "The post-introduction survey for the pneumo vaccine" carried out in 2013;

- "The pre-introduction survey for the rotavirus vaccine on the perceptions and knowledge of parents of children on diarrheal diseases" carried out in 2013.

Describe the process of preparing information, education and communication (IEC) materials, media campaigns, discussion groups and demographic evaluations of the primary target groups, if applicable.

Information, education and communication materials will be developed by the communication sub-committee made up of members of the IEC department of the Directorate of Hygiene and Health Promotion (DHPS), the Expanded Programme on Immunisation (EPI) and of partners (UNICEF, WHO). These various materials will be endorsed during a workshop.

More precisely, first of all, the revision and dissemination of image boxes and the immunisation schedule with the IPV component incorporated in all of the health centers was planned. Posters, notices and banners will also be produced to strengthen the promotion of immunisation during the African immunisation week during which the IPV will be introduced. Key messages, communiqués, reports, press conferences, and programmes will be produced and broadcast in the media.

The results of CAP studies and independent assessments of supplementary immunisation activities will be used in order to improve the quality of the messages to be disseminated.

Describe the measures that have been taken to organize a kickoff ceremony on a national scale, if necessary, and ceremonies at the sub-national level, if necessary, including the

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potential promotion of immunisation programmes and the integrated strategies to combat disease.

Before the introduction of the IPV, advocacy by the Ministry of Health and Population and the partners will be done to obtain the official launch by the highest authorities at the national level. Whereas at the departmental level this launch will be presided over by the prefects.The plan is to introduce the IPV during the African immunisation week (SAV) in July 2015 where the promotion and immunisation activities will be carried out.

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