NATIONAL COVID-19 DEPLOYMENT AND VACCINATION PLAN

SURINAME 2021

Endorsement

COVID-19 started at the end of 2019 in Wuhan, Hubei Province in China. Due to the rapid spread to several countries with, increasing reports of morbidity and mortality, the World Health Organization (WHO) declared the disease a Public Health Emergency of International Concern on January 30, 2020, and a global pandemic on March 11, 2020.

Suriname detected its first case of the disease on Friday, March 13, 2020. Since December 2020, the country is experiencing the second wave of the disease, and the increasing cases and deaths are of concern to the country. In the absence of definitive therapeutic options for the management and control of this disease, vaccination as a primary prevention measure is a good option for the control of the disease in terms of saving lives through reduction of severe disease and deaths. The COVAX Facility is a mechanism for the equitable access to various vaccine options, and Suriname has signed onto this facility to receive allocation of vaccine doses which have received approval from the WHO and other Stringent Regulatory Authorities. In order to protect the population against the disease, the Government of Suriname has appointed the “Technical Advisory Commission Immunization Policy COVID-19” for the general management and monitoring of the COVID-19 situation in Suriname, and a “Vaccination Committee” to develop a vaccination plan and to guide the implementation of this plan.

Relevant Ministries of the Government of Suriname, and relevant public and private institutions have been involved in the planning of the campaign, and will continue their support to the further implementation of this plan. Specific measures with regard to funding of the campaign, as well as facilitating the approval of the vaccine for use by the Registration Commission, tax exemptions, customs clearance, safe arrival, receipt, and storage of the vaccine and ancillary needs, have been taken.

The vaccination campaign will start soon after the arrival of the first batch of vaccines, that will cover up to 3% of the population, beginning with the first priority group of frontline healthcare workers.

Suriname is open to consider at due time the availability of other vaccines that may be beneficial in terms of cost, dosing schedule, cold chain storage requirements and other factors. The vaccination plan has been developed to consider all possible options.

The Ministry of Health is thankful for the efforts made, and those that will continue to be made by all stakeholders and partners towards a successful fight against this disease.

A. Ramadhin, MD Minister of Health Republic of Suriname

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Table of contents

Contents

Endorsement ...... 1 Table of contents ...... 2 Executive summary ...... 3 1. Introduction ...... 7 2. Regulatory preparedness...... 11 3. Planning and coordination of the vaccine introduction ...... 13 4. Resources and funding...... 15 5. Target populations and vaccination strategies ...... 17 6. Supply chain management and health care waste management ...... 36 7. Human resource management and training ...... 39 8. Vaccine acceptance and uptake ...... 42 9. Vaccine safety monitoring and management of AEFI and injection safety ...... 44 10. Immunization monitoring system ...... 45 11. Disease surveillance ...... 46 12. Evaluation of introduction of COVID-19 vaccines ...... 46 Annex 1: Detailed budget for the COVID-19 Vaccination Campaign ...... 48 Annex 2: ESAVI ...... 53 Annex 3: Terms of Reference for the National Coordination Team ...... 58 Annex 4: Implementation Plan ...... 61

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Executive summary

Since December 2019, there have been more than 101 million cases of COVID-19 worldwide, including more than 1.2 million deaths. In order to control the pandemic, in addition to preventive hygiene measures, effective vaccines are needed to protect against COVID-19, especially in the pursuit of a situation without restrictions on international travel and trade including lockdowns, quarantine and isolation.

A global effort to develop vaccines has been underway since the start of COVID-19. Several vaccine candidates are in various stages of development and to date, some of these have already received Emergency Use Listing by the WHO. Others are expected to receive similar approval for emergency use in the very near future. Suriname has committed itself to the COVAX Facility, the vaccine arm of the Access to COVID-19 Tools Accelerator (ACT) which aims to facilitate equitable access to 2 billion doses of vaccines for countries by the end of 2021.Through this agreement, Suriname already has the guarantee of receiving vaccines to be able to vaccinate 20% of its population.

This plan carefully develops the important processes and procedures required for vaccine regulatory approval, arrival, storage, distribution, administration, registration, logistics, surveillance, reporting, safety monitoring and evaluation. This documentation is necessary in preparation for a responsible and successful course of the national COVID-19 vaccination campaign. The plan follows the “WHO Guidance on Developing a National Deployment and Vaccination plan for COVID-19 vaccines” and contains the following main components, with an estimated budget of USD 16,047,881 for the vaccination of the identified priority groups.

Component 1. Introduction 2. Regulatory preparedness 3. Planning and coordination of the vaccine introduction 4. Resources and funding 5. Target populations and vaccination strategies 6. Supply chain management and health care waste management 7. Human resources management and training 8. Vaccine acceptance and uptake 9. Vaccine safety monitoring and management of AEFI’s and injection safety 10. Immunization monitoring system 11. Disease Surveillance 12. Evaluation of introduction of COVID-19 vaccines

The National COVID-19 Deployment and Vaccination Plan is an important and necessary condition to receive the COVID-19 vaccine. The Technical Advisory Commission Immunization Policy COVID-19 is a multidisciplinary group of national experts responsible for providing independent, evidence-based advice to policy makers and program managers on policy issues related to immunization and vaccines. The committee is able to review the international and regional policy guidelines of the WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) and the PAHO Regional Technical Advisory Group on Immunization (RITAG), taking into account the national context, national priorities and disease epidemiology. The committee will regularly review, revise and update its recommendations to national policymakers, as new evidence becomes available.

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The Government of Suriname is committed to follow international actions and procedures to save lives, and mitigate the effects of the COVID-19 pandemic, by implementing all relevant actions, including vaccination of its population, in order of priority groups that have been identified by the Technical Advisory Commission Immunization Policy COVID-19. Supporting sub-committees and teams have been identified to support the work of this Technical Advisory Commission:

- The National Coordination team to present this Plan and lead the campaign activities, with support of sub groups for: • Personnel: mobilization, training, evaluation. • Finances: Funding, budget management, coordination of payments to service providers and personnel. • Information/Education: Development and dissemination of informational material and messaging to generate demand. • Logistics and Transportation: Vaccine clearance, mobilization of transportation, distribution schedules. • Supply chain management: Forecasting procurement, stock management, materials for the teams and vaccination sites. • Secretarial support: keeping notes of meetings, consolidation of reports by supervisors, consolidation of administrative information, and supervision of the end report. • Partnerships: Coordination of contact with external organizations, mobilization of private sector, donations and sponsoring.

- The Implementation Team, with the rayon (district area) coordinators of the Medical Mission Primary Health Care Suriname (MM), the Regional Health Services (RGD), the Bureau of Public Health (BOG) and the hospitals, for operations management including monitoring and supervision.

• The Central Administrative Team at the BOG.

• The Vaccination Teams at the health facilities managed by the MM, the RGD, and other public and private health facilities.

For the National Immunization Program (NIP) of Suriname, the “Bedrijf Geneesmiddelen Voorziening Suriname (BGVS)” (State Drug Supply Company) is responsible for all actions towards preliminary administrative matters, payment of fees and taxes, customs clearance and transportation of the vaccines received through the PAHO Revolving Fund for Access to Vaccines, following rules of cold chain, from point of arrival to point of storage. Within this authority, the BGVS will do the same for the vaccines and dry store items that will be received for the COVID-19 vaccination campaign.

The received vaccines will be stored in the facilities of the Wanica Streekziekenhuis that complies with cold chain regulations, and has sufficient Ultra Cold Chain (UCC) and regular storage capacities for the expected number of vaccines. The Wanica Streekziekenhuis also has secured space and facilities available for administrative matters of the distribution of vaccines and supply items that need to be kept in stock for the vaccination campaign.

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The distribution of the vaccines will follow the guidelines and procedures as outlined in this plan of action. In summary:

Day of arrival of vaccines Arrival and storage of the vaccines at the Wanica Streekziekenhuis, under responsibility of the National Immunization Program. Two to three days leading The National Coordinating Team will provide an overview of to vaccination the scheduled dates and vaccination sites, and the needed quantities of the vaccines and ancillary items. The vaccination sites will have received prior approval by the National Coordinating Team to receive, store, and further distribute these to the outreach sites under their responsibility. Vaccination sites will be inspected to ensure that the site complies with the protocols for COVID-19 vaccination. Day before Vaccination/ The Supply Chain Manager of the National Coordinating Day of vaccination Team will distribute the requested quantities of vaccines to the vaccination sites, taking into account the rules with regard to cold chain management. After vaccination All unopened vials, reconstituted vials with unused doses, and empty vials from the vaccine sites will be returned to the Supply Chain Manager of the National Coordinating Team, taking into account the rules of vaccine safety, the open vial policy and waste management. This can also be used as a double check for the registration of the administered vaccines.

Suriname has subscribed to the COVAX Facility as a self-financing member for an initial coverage of 20% of the population. The vaccines will be delivered in tranches and proportional to the population.

• The first tranche expected in the second half of 2021 is to cover vaccination of healthcare and social workers which is estimated at 3% of the population. • The second tranche is to cover vaccination of high-risk adults (elderly 60 years and over, and adults with underlying conditions) estimated at 17% of the population. • The third tranche will cover vaccination for other priority groups. To cover more than 20% of the population will depend on the disease context in the country, participants’ vulnerability and the COVID-19 threat. Subsequent doses will become available in the course of this year and 2022. The regimen for the expected vaccine depends on the vaccines to be received, in general 2 doses per person. During the process, the country might decide to access other vaccines to cover a larger proportion of the population, as they become available. If so, then this plan and budget, and the implementation details will be adapted accordingly. The target estimated date for the first administration of the vaccine in the country is 7 (seven) days after arrival, provided that all other needed items, such as appropriate syringes, needles, diluents (if needed), and the logistics are in place.

Table 1 provides an overview of the target groups in order of priority, as identified by the National Coordination Team, and the doses that will be needed to vaccinate these risk groups in two rounds, including a wastage rate of 10%.

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Table 1: Priority groups and vaccine doses needed for 2 doses regimen

Priority Population Persons Doses needed Group 1 Healthcare workers, first line 1,497 2,994 Group 2 Healthcare workers, second line 3,794 7,588 Group 3 Military, police, penitentiary officers, Government Officials 3,500 7,000 Group 4 Populations in elderly homes, including dialysis patients 2,900 5,800 Group 5 Elderly sixty years and over, national level 90,170 180,340 Group 6 Adult population, based on medical grounds/risk factor 30,000 60,000 (Diabetes Mellitus, High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous population. (40 – 59 years) Group 7 Adult population, based on medical grounds/risk factor 11,000 22,000 (Diabetes Mellitus, High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous population, ….) (18 – 39 years) Group 8 Other risk groups 1,100 2,200 Group 9 Healthy population (18 - 59 years) (estimated) 265,779 531,558 Total 409,740 819,480 Wastage rate 10% 81,948 Grand total 901,428

The leading week will also be needed for preliminary activities, before the actual date of commencement of vaccination. The first batch of vaccines to be received will be administered to the health workers, identified as the first priority group. These health workers will preferably receive their vaccination in the institutions where they are employed.

The procurement of the vaccine and the vaccination against Covid-19 will be done within a national strategy, with joint funding from the Government and the private sector. A national fund will be set up, whereby fundraising will be done with the joint effort of the Government, the business community, and other stakeholders. To this end, consultation has already been held with various stakeholders, investors, insurance companies, gold mining companies and the business community. The Government has accepted the willingness of these partners to support local fundraising.

The estimated budget for the campaign is summarized as follows:

Table 2: Estimated budget by category Category Budget Political priority and legal framework (USD) 50,000 Planning and coordination 68,000 Biologicals (vaccines) and supplies 11,433,913 Cold chain 72,600 Training 27,000 Social mobilization 333,150 Operating costs 2,017,530 Supervision and monitoring 145,000 Epidemiological surveillance (including AEFI 195,140 managemeInformation nt)systems 186,650 Research 12,000 Evaluation 48,000 TOTAL 14,588,983 Miscellaneous 10% 1,458,898 Grand total 16,047,881

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1. Introduction

COUNTRY BACKGROUND

The Republic of Suriname, bordered by French Guyana in the east, Brazil in the south, Guyana in the west and the Atlantic Ocean in the north, is located on the northeast coast of South America. The country has a total area of 163,820 km2 and consists of narrow coastal plain with swamps, hills and tropical rainforest. The country is divided into ten administrative districts that are subdivided into 62 regions. The coastal area comprises 2 urban districts and 6 rural districts, and the interior has 2 districts. The 2 urban districts, the capital city and Wanica, cover 0.5 % of the landmass and contain 70% of the total population.

The vital statistics profile by the Algemeen Bureau voor de Statistiek (General Bureau of Statistics) shows a mid-year population in 2018 of 590,100.

The number of registered live births is about 10,000 to give a crude birth rate of 20 per 100,000 and a total fertility rate of 2.5. Mortality has remained relatively stable at around a crude death rate of 6.5 to 7 per 100,000. Life expectancy at birth for males is 69.34 years and for females, 75.01 years.

Demographic Characteristics of the population The Suriname population has many ethnic backgrounds composed of - Hindustanis (27.4%) - Creoles (17.7%) - (14.7%) - Indonesians (14.6%) - Mixed (12.5%) - Amerindians (3.7%) - Chinese (1.8%) - Others (7%)

Sranan Tongo is the ‘’native language”, the main and unofficial language of the population. The official language is Dutch, and English is widely spoken.

Health Care Delivery System The Ministry of Health (MOH) is responsible for the health sector and health system management, specifically the availability, accessibility and affordability of health care. The main responsibilities of the MOH are planning, policy development, inspection, coordination, monitoring and evaluation and setting of standards in the health system. The core- institutions of the Ministry of Health are the MOH Central Office, the Inspectorates (Medical, Nursing and Pharmaceutical) and the Bureau of Public Health (BOG).

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Primary Health Care and Prevention The Ministry of Health is responsible for coordinating the national health care system. The Bureau of Public Health coordinates preventive health care, supervises and executes programs that provide information on the distribution of diseases. The Epidemiology Unit operates a surveillance system on communicable diseases in close cooperation with the Regional Health Services and the Medical Mission. This system relies on weekly reports from 31 sentinel stations. At the operational level, the government health care providers include the government subsidized primary health care organizations such as the Regional Health Services, covering the population living in the coastal area, and the Medical Mission, covering the population living in the interior. Primary health care is also provided by the large group of private General Practitioners, especially in the urban districts of Paramaribo and Wanica.

Regional Health Services The Regional Health Services (RGD) has 46 clinics in 8 districts in the coastal area and provides primary health care services and selective prevention activities to mainly the poor and near poor. Approximately 150,000 poor and near poor who are registered with the Ministry of Social Affairs, are covered by a basic package of health services, organized by the State Health Insurance Fund (SZF). The other clients (estimated 250,000) insured by the State Health Insurance Fund (government employees, retired civil servants and their dependents), can also use the services of the RGD, especially in the coastal districts.

Medical Mission Primary Health Care The Medical Mission Primary Health Care Suriname (MM) is responsible for the primary health care and selective prevention activities in the interior. This NGO operates 52 clinics in the interior, with a coordinating center located in Paramaribo, and is subsidized by the Government. They cover about 60,000 people living in the large interior. Their target group is mainly Indigenous and tribal people living in close proximity of the rivers and dispersed in the high lands of south Suriname.

Secondary and Tertiary Health Care The Ministry of Health operates two general and one psychiatric hospital in Paramaribo, and three district hospitals in the western coastal district of Nickerie, in the eastern district of Marowijne, and in the coastal district of Wanica. One of the general hospitals in Paramaribo is also specialized in Maternal and Child Care. There are also 2 private hospitals in Paramaribo, the Diakonessenhuis (DH) and the St. Vincentius Ziekenhuis (SVZ). These eight hospitals have a total of 1500 hospital beds, 3.0 beds/1000 inhabitants. The average bed occupancy rate is approximately 85%. The average length of stay is 7.9 days. There are 40 dedicated ICU beds available in 4 of the hospitals.

The first case of COVID-19 was confirmed in Suriname on 13 March 2020. The cases that followed were quickly traced and isolated, and their contacts were placed in controlled quarantine. Measures were also announced, air traffic was stopped, and Suriname was placed in a 'bubble'. Since the start of the epidemic, the government has applied two important measures to curb the epidemic, namely isolating infected individuals and placing their close contacts in home quarantine. General measures included wearing mouth-nose masks in public places, keeping physical distance, prohibiting public transportation and limiting the number of persons who are allowed to gather in one place.

In the month of December 2020, the 2nd wave of COVID- 19 cases began in Suriname. The reproduction rate (R) quickly climbed to 3.3. Strict measures were promulgated to bring this back down, due to a strict enforcement policy from the government. The reproduction rate went down, but the many cases that were already present in society resulted in many patients. In the second week of January 2021, 91 people with COVID-19 had been admitted to hospital, 10 of whom were in intensive care, and in addition, 299 people with COVID-19

8 were in isolation. The reproduction rate in the second week of January 2021 was still above one (1), which means that the number of COVID-19 cases will continue to increase.

With the second wave that started in the first week of December 2020 there was a fairly sharp increase in the number of hospital admissions from the third week of December 2020 onwards.

Up to 11 January 2021, a total of 138 people has died from COVID-19, with 21 people dying during the second wave that started in December 2020. The picture in these deceased has not changed from the 1st wave of the epidemic in terms of risk factors; the case fatality rate (CFR) till early December was ~2.2%. For the new wave, counting from mid-December, the CFR is ~ 2.0%. The average age of the admitted patients was 69 years and 80% was 60 years and older. The youngest person was 45 years old. More than 80% of these individuals suffered from underlying conditions. More than half had both diabetes and hypertension in their history. Among these individuals, more than half had already suffered complications from these chronic diseases such as stroke and chronic kidney failure. There were 4 patients on dialysis included in this group. A number of people that were admitted due to poor clinical condition, died shortly after admission.

Graph: Cumulative Hospital admissions COVID-19, 27 July 2020 – 9 January 2021

In this second wave of COVID-19, the spread occurred much faster in a shorter time than during the first wave. Partly, this is because people wait too long to seek testing, and therefore stay longer in their infectious and clinical period before seeking care. Isolating infected people is less effective. It is therefore important to start testing as soon as possible, preferably on the day of onset of symptoms. It has not yet been established if the fast spread could be the result of a more infectious virus strain.

The most affected age groups of the confirmed cases remain primarily the productive age groups of 30 – 39 years, followed by 20 - 29 years, 40 - 49 years and 50 - 59 years. These age groups account for 79.7% of all cases. There is a slight rise of infections among the age groups between 20 - 49 years, since the second wave commenced.

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Lessons learned from Influenza A-H1N1 and other relevant activities

The country has had previous experience regarding vaccination in response to a pandemic and will benefit from the lessons learned during that campaign. The Influenza A-H1N1 vaccination campaign in 2010 had targeted 23,000 recipients in specific risk groups. Only 20.2 % of these target groups were vaccinated, as follows: Health workers and other essential workers: 29.8%, Chronic diseases: 14.6%, Pregnant women: 6.4%, Healthy population 5 -19 years: 9.6%.

The low intake may have been the result of a mix of factors related to readiness of the health institutions and the acceptance of the target population, as well as negative campaigning against the vaccination. In planning towards the COVID-19 vaccination campaign, which is also receiving negative publicity, it is therefore important to focus, with regard to the current pandemic, on (mass) communication to all categories of targeted recipients, including health workers, the elderly, community leaders, community workers, social workers, religion leaders, the options available to fight the situation, and advocacy towards vaccination. The communication has started as early as possible, with a targeted risk-based approach.

Towards this end, the Ministry of Health has in production some public service announcements that appear on social media, social networks, radio and television channels. The messages are being communicated in the two main languages, Sranan Tongo and Dutch. Towards the implementation of the campaign, the messages will be expanded to include the ethnic languages widely spoken in the several ethnic groups in the country.

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2. Regulatory preparedness

Most regulatory functions of a National Regulatory System or Authority (NRA) recommended by the WHO are limited or non-existent in Suriname, i.e., market surveillance (MS), pharmacovigilance (PV), Quality Control (QC) and Information (Figure 1). The functioning of the Registration and Pharmaceutical Inspection (PI) is limited due to lack of capacity and resources.

Figure 1

In January 2021, a new Medicine Registration Committee (RC) was installed, based on a Resolution of the . The new committee is in the process of reviewing the current arrangements for registration of health products. The MOH has plans to strengthen the existing PI and to include a Sub-Directorate for Pharmacy which is to carry out most other NRA functions.

In Suriname, vaccines are exclusively being procured by the National Immunization Programme (NIP) of the Ministry of Health (MOH) through PAHO’s Revolving Fund for Access to Vaccines (PAHO-RF), almost since its launch in 1977. The parastatal Medicine Supply Company Suriname (Bedrijf Geneesmiddelen Voorziening Suriname, BGVS) is charged with immediate clearance on arrival and transport of the vaccines to the storage facilities of the NIP. This system has functioned well over the years and challenges are limited to issues with storage capacity, late payments, or errors in forecasting and planning.

Formally, medicines, including vaccines, have to be registered before they are allowed to be imported and used in te country (Medicine Registration Law 1973). For the import of medicine, the Pharmaceutical Inspection (PI) issues a Certificate of Registration to an authorized importer as a ‘no objection for importation’ to the licensing body, the Ministry of Economic Affairs, Entrepreneurship and Technological Innovation, Department of Import, Export and Foreign Exchange Control. The PI further physically checks import samples to ensure that imported medicines are the same as what is stated in the import permits.

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However, vaccines supplied through the PAHO-RF have never been registered. For each procurement, waivers (exemption of registration) are granted by the Pharmaceutical Inspection acting for the Director of the MOH, relying on PAHO-RF’s system for quality assurance for vaccines including pre-qualification by WHO. This procedure may be used as long as vaccines have received approval from WHO and are obtained through the PAHO- RF, which is the expectation for vaccines to be obtained through the COVAX Facility. Alternatively, when other mechanisms are being considered for procurement of COVID-19 vaccines, the country will rely on technical guidance for assessments of these products by qualified organizations, like WHO, PAHO and the Caribbean Registration System (CRS) which rely on the WHO Prequalification Programme’s product approval or approval by Stringent Regulatory Authorities (SRA) acknowledged by the WHO.

Pharmacovigilance and Information 1. The PV and Information functions will be executed as much as possible based on the recommendations of global, regional and subregional bodies (WHO, PAHO and CRS); and, 2. should be done together with the entities undertaking ESAVI & AEFI management. 3. Local pharmacists with expertise on PV and Information functions will be recruited.

In summary: ● COVID-19 vaccines may be imported using the current regulatory arrangements similar to vaccines supplied through PAHO-RF ○ if obtained through the COVAX Facility. ○ if assessments by qualified organizations are available ○ if, in the long-term, registration of vaccines by the RC is realized. ● In-country regulatory arrangements for MS, PV and QC are to be organized based on the existing international technical guidelines, making use of locally available expertise.

The Ministry of Health has received approval of the Ministry of Finance, for tax exemptions regarding this shipment and future shipments of COVID-19 vaccines for this campaign. No such challenges should be expected in the distribution to and storage of the vaccines at local storage points prior to vaccination, since these storage and vaccination sites already are equipped with the proper means to secure the cold chain process. The central storage facility at the Wanica Ziekenhuis is one of the facilities in the country that has UCC storage capacities, and therefore will be in charge of the storage and distribution of the vaccines. They have already taken proper actions towards safe handling during this process. A distribution plan is in the making, and will be implemented as soon as the exact dates of the vaccination campaign have been decided. The transportation of the vaccines to the districts and the hinterland will need specific attention with regard to keeping of the cold chain.

The existing national regulatory processes and procedures for the import of vaccines for the national vaccination program will be in force, in order to expedite vaccine availability in the country. The formal procedures for the import of the COVID-19 vaccines are to be finalized by the Ministry of Health.

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3. Planning and coordination of the vaccine introduction

Following is the organizational chart in place for the coordination mechanism at national and local level.

COVID-19 Organizational structure and partners involved

National National COVID-19 Central Coordination: Director of Health and Technical Advice Registration Direcor BOG Commission Commission Vaccination Policy COVID-19

Working Group Working group Working Group Cold Chain/ Prioritairy Groups Logistcs Supply Chain

Proces Management Management Planning & Monitoring Monitoring cold chain, Training and publc budget vaccinne and supply chain supervision communicati management safety Evaluation logistiek on

RegionaalCoordination Coordination Coordination Coordination East Par'bo, Wanica, West Para • RGD •RGD •RGD •RGD • MMPHC •MMPHC •MMPHC •MMPHC •Ziekenhuis •Hospitals •MMC Marwina

Local Coordination Implementation vaccination sites vaccination

The Technical Advisory Commission Immunization Policy COVID-19 consists of the following authorities: 1. The Deputy Director of Health 2. Infectiologist - clinical expert in infectious diseases. 3. Epidemiologist/researcher of the Public Health discipline of the Faculty of Medical Sciences 4. Registration committee - Expert regulation medicines and vaccine safety 5. Microbiologist 6. Manager of the National Immunization Program 7. Manager of the Epidemiology Unit of the Bureau of Public Health

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The Commission is a multidisciplinary group of national experts responsible for providing independent, evidence-based advice to policy makers and program managers on policy issues related to immunization and vaccines. The Commission is competent and able to review and contextualize the international and regional policy guidelines of the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and the PAHO Regional Technical Advisory Group on Immunization (RITAG), taking into account the national context, national priorities and disease epidemiology. The commission will need to regularly review, revise and update its recommendations to national policy makers as new evidence becomes available.

Responsibilities of the commission, especially in response to the current COVID-19 pandemic, include: • Review of recommendations from SAGE, the RITAG regarding COVID-19 vaccine use in the response. • Periodic review of the national/regional epidemiology and sero-epidemiology of COVID-19, including laboratory confirmed cases, hospitalization and deaths associated with COVID-19, and natural immunity data within selected population groups. • Advise the Ministry of Health on priority groups and vaccination strategies based on scientific information and available international and regional guidelines. • Updating the advice and, in particular, providing vaccine specific recommendations based on new information/updates on: o The characteristics of COVID-19 vaccines under development, including efficacy and effectiveness o The vaccine safety related to different age and risk groups, effect of the vaccine on infection and transmission of infection, available vaccine supply and predictions of vaccine production. o COVID-19 vaccine specific recommendations from SAGE and RITAG. • Advising the Ministry of Health on the best communication approaches regarding the introduction of COVID-19 vaccines, taking into account the characteristics of the vaccine and the dynamics of public acceptance. • Reviewing and advising on cases of serious vaccine adverse events (AEFI’s and Adverse Events of Special Interest (AESI) identified by the passive and active vaccine safety surveillance conducted and examined by the National Immunization Program. • Advising on communication approaches to communities on vaccine safety and vaccine side effects for which no clear answers are yet available. • Reviewing and making recommendations on the development of the National COVID-19 Vaccination Plan.

In preparation for the vaccination campaign, the country has adopted and adapted as needed, the existing national governance mechanism which are in force for the regular immunization program in the country. The Technical Advisory Commission Vaccination Policy COVID-19 is the national coordinating commission, with representation of relevant institutions, as described above.

The NITAG has been dormant for quite a while, needing renewal of its representation and its mandate. There is also no active Inter-agency Coordinating Committee. However, past members of both these committees are involved in the National Coordination Team for the campaign. Technical guidance has also been sought from international organizations e.g. PAHO and UNICEF.

The vaccines to be used for the vaccination campaign will be selected upon criteria adopted by the Ministry of Health and upon approval from the Registration Committee.

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4. Resources and funding

Financing COVID-19 vaccination

The procurement of the vaccine and funding of the vaccination program for Covid-19 will be done within the framework of a national strategy using Government financing and partnerships with the private sector. A national fund is being established, involving fundraising with the joint effort of the Government, the business community and other stakeholders. This decision regarding the fund resulted from a meeting between the President, the Minister of Health, and the Minister of Foreign Affairs, International Business and International Cooperation. Consultations were held with various stakeholders, investors, insurance companies, gold mining companies and the business community. They will collaborate in local fundraising, which is accepted by the government. The fundraising will take place through a national fundraising campaign and the fund will be jointly managed by the business community and the government, resulting in transparency.

Other resources have been made available through the regular budget of the Ministry of Health, the Ministry of Finance, and other related Ministries, related to this matter.

Budgeting and funding COVID-19 vaccination campaign preparations and implementation

Table 3 summarizes the category of activities and the costs estimated for the implementation of the Plan. The budget is estimated on best practices and experiences. The detailed budget for phase 1 is provided in annex 1. The budgets for the other groups in remaining 3 phases follow the same template, however, these budgets were adapted to the specific circumstances for these remaining groups, and taking into account that certain items were already covered in the first phase. It is noted that this budget will be adapted accordingly, based on the cost of the vaccine to be used in the first phase and the subsequent phases.

Table 3: Summary of campaign budget (USD)

Summary all 4 phases Phase 1 Phase 2 Phase 3 Phase 4 Total Political priority and legal framework 20,000 10,000 10,000 10,000 50,000 Planning and coordination 17,000 17,000 17,000 17,000 68,000 Biologicals and supplies 326,315 2,516,216 1,174,832 7,416,550 11,433,913 Cold chain 72,600 - - - 72,600 Training 27,000 - - - 27,000 Social mobilization 89,300 67,950 87,950 87,950 333,150 Operating costs 315,226 616,726 315,226 770,352 2,017,530 Supervision and monitoring 25,000 40,000 25,000 55,000 145,000 Epidemiological surveillance and laboratory 56,250 38,790 28,100 72,000 195,140 Information systems 98,850 29,100 29,350 29,350 186,650 Research 3,000 3,000 3,000 3,000 12,000 Evaluation 12,000 12,000 12,000 12,000 48,000 Total 1,062,541 3,350,782 1,702,458 8,473,202 14,588,983 Miscellaneous 10% 106,254 335,078 170,246 847,320 1,458,898 Grand Total 1,168,795 3,685,860 1,872,704 9,320,522 16,047,881

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Table 3a: Summary by phase

Group Description Phases Target Budget Group 1 Healthcare workers, first line Phase 1 11,691 1,168,795 Group 2 Healthcare workers, second line Group 3 Military, police, penitentiary officers, Government Officials Group 4 Populations in elderly homes, including dialysis patents Group 5 Population sixty years and over, national level Phase 2 90,170 3,685,860 Group 6 Population, based on medical grounds/risk Phase 3 42,497 1,872,704 factors (40 – 59 years) Group 7 Population, based on medical grounds/risk factors, (18 – 39 years) Group 8 Other risk groups Group 9 Healthy population (18 -59 years) (estimated) Phase 4 265,779 9,320,522 Grand Total 409,740 16,047,881

Partners and Financing • Ministry of Health through its institutions: BOG, MM, RGD and others. • Ministry of Regional Development: Meetings with District Commissioners, District Council, Resort Council, local transportation (hinterland). • Ministry of Education: Schools, additional vaccination sites, … • Medical Faculty of the ADEK University of Suriname (MWI): Support staff, vaccinators. • Public and Private Hospitals, Nursing schools: Support staff, vaccinators. • Ministry of Public Works: Logistics. • Ministry of Defense: Logistics, Security. • Ministry of Justice and Police: Security. • Private sector, Service Clubs: Sponsoring of human and financial resources, logistics, public announcements, food, refreshments, advertisements, document duplication, data input, computer hardware, internet facilities. • International Agencies.

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5. Target populations and vaccination strategies

The following groups have been identified by the National Coordination Team, to be included in the vaccination campaign. Vaccination will be free of charge and will be accepted on a voluntary basis (out of free will). Table 4 summarizes the target groups in order of priority.

Table 4. Summary total persons by priority group, to be vaccinated in one round

Priority Population Persons Group 1 Healthcare workers, first line 1,497 Group 2 Healthcare workers, second line 3,794 Group 3 Military, police, penitentiary officers, Government Officials 3,500 Group 4 Populations in elderly homes, including dialysis patents 2, 900 Group 5 Population sixty years and over, national level 90,170 Group 6 Population, based on medical grounds/risk factor (Diabetes Mellitus, 30,000 High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous, ….) (40 – 59 years) Group 7 Population, based on medical grounds/risk factor (Diabetes Mellitus, 11,000 High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous, ….) (18 – 39 years) Group 8 Other risk groups 1,100 Group 9 Healthy population (18 -59 years.) (estimated) 265,779 Total 409,740

The following tables details on where the priority groups will be vaccinated, the estimated teams to be deployed and the basic inventory needed by a team.

For the calculation of number of teams, the following assumptions/criteria are used:

- It will take 5 minutes to register, including questioning on contraindications, of one person in an outside facility. - In one hour, 1 vaccinator can vaccinate 15 persons, personal break time included. - One vaccination session will start at 8.00 am and end at 4:00 pm, in total 8 hours, minus 1 hour break time, a day. Facilities will be open until the last person has been vaccinated. So, overtime and consumption for the team have been included in the budget. - Accordingly, one team can vaccinate 3 x 15 x 7 = 315 persons in a one-day session. - Some clinics with small populations can be joined together, taking into account the geographic possibilities. - Since there is no system of postcodes or other criteria to daily organize the flow to the facility, it might happen that all those needing the vaccination, will show up on one day, if not well informed or organized properly. In order to address this issue, it would be practical and cost saving to do a district in 1 day, by the available teams in that district area, assisted by additional teams from other districts, or the RGD, or volunteers, provided that there is sufficient transportation organized. - For the city and other communities, it can be decided to do a vaccination day with so many teams simultaneously, as practically organizable. Given this reasoning, it is advisable thus that the vaccination is organized by district. - It must be noted that smooth flow of vaccine recipients through the phases of registration, vaccination and observation post-vaccination, will need adaptation to the situation during the activities. A practical issue would be that, if for example 15

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persons receive the vaccination in one hour, these 15 persons will have to spend the required 15 – 30 minutes in the observation area. A continuous flow of the recipients in the observation area will pose practical issues with regard to accommodation of all, at once and to ensure adherence to the COVID-19 public health measures. - The same process will be repeated for the second dose to be given 3 - 4weeks later, depending on the vaccine being used.

The following table gives a breakdown of what would be the basic inventory for 1 vaccination team. More than 1 team may be deployed to one site, in order to facility smooth operation.

Table 5: Breakdown of the basic inventory needed for a team Item Unit price Needed Total Vaccine carrier 40 1 40 Thermos box (where needed) 0 Ice packs, at least 4 per carrier 10 1 10 Laser thermometer 75 1 75 Cotton rolls 5 1 5 Disinfectants 2 10 20 Hand sanitizers 2 10 20 Paper towels, toilet paper 5 2 10 Band aids (box of 100) 1 5 5 Vaccination cards, at least 500 per session 0.1 500 50 Stamp and stamp pad 25 1 25 PPE Equipment (masks only) 1 100 100 Disposable gloves 2 15 30 Safety boxes 10 5 50 Waste bags 5 10 50 Manuals, intake forms, ESAVI surveillance, 10 1 10 writing materials, Total 500

The following tables give an overview of vaccination sites where the priority groups will be vaccinated. More than 1 team may be deployed to one site, in order to facility smooth operation.

Table 5a. Group 1: Health Care workers, first line

Basic Hospitals/Health Centers To Vaccinate Teams Days Inventory Militair Hospitaal Academisch Ziekenhuis Paramaribo 422 2 1 1,000 Diaconessenhuis 200 1 1 500 Lands Hospitaal 115 1 1 500 St. Vincentius Ziekenhuis (RKZ) 188 1 1 500 Wanica Ziekenhuis 138 1 1 500 Mungra Medisch Centrum Nickerie 44 1 1 500 RGD 65 1 1 500 Medische Zending 100 1 1 500 PCS 25 1 1 500 Others (MOH team, Swab teams, and others) 200 1 1 500 Total 1,497 11 10 5,500

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Table 5b. Group 2: Health care workers, second line.

Hospitals/Health Centers To Vaccinate Teams Days Cost Militair Hospitaal 1,200 4 2,000 Academisch Ziekenhuis Paramaribo 630 2 1,000 Diaconessenhuis 340 1 500 Lands Hospitaal 276 1 500 St. Vincentius Ziekenhuis (RKZ) 375 1 500 Wanica Ziekenhuis 120 1 500 Mungra Medisch Centrum Nickerie 200 1 500 RGD 590 1 500 Medische Zending 63 1 500 PCS Total 3,794 13 1 6,500

Table 5c. Group 3: Military, police, penitentiary officers, Government Officials

Hospitals/Health Centers To Vaccinate Teams Days Cost Militair Hospitaal 2,000 5 1 2,500 Academisch Ziekenhuis Paramaribo 1 Diaconessenhuis Lands Hospitaal St. Vincentius Ziekenhuis (RKZ) Wanica Ziekenhuis 1,000 3 1 1,500 Mungra Medisch Centrum Nickerie 500 2 1 1,000 Other vaccination sites, public and private

Total 3,500 10 4 5,000

Table 5d. Group 4: Populations in elderly homes, including dialysis patents Target: 2,050 and 850 persons respectively.

Hospitals/Health Centers To Vaccinate Teams Days Cost Militair Hospitaal for the Dialysis patients 850 4 1 2,000 Academisch Ziekenhuis Paramaribo Diaconessenhuis Lands Hospitaal St. Vincentius Ziekenhuis (RKZ) Wanica Ziekenhuis Mungra Medisch Centrum Nickerie Other vaccination sites, public and private 2,050 10 1 5,000 Total 2,900 14 1 7,000

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Table 5e. Target group 5: Population 60 years and older, national level

District Resorts Communities Target 6 7 1,171 Commewijne 6 37 5,163 Coronie 3 4 574 Marowijne 6 29 2,843 Nickerie 5 22 6,060 Para 5 45 3,458 Paramaribo 12 114 45,148 Saramacca 6 36 2,784 Sipaliwini 6 41 4,811 Wanica 7 135 18,158 Total 62 470 90,170

Vaccine and related costs for the population 60 years and older

This list is based on two sources: 1. The Central Bureau for Public Affairs (Centraal Bureau voor Burgerzaken) (CBB) with an overview of all persons over 60 years, as registered in the respective districts, resorts (district areas), and communities. 2. The Medical Mission Primary Health Care, with all their clients registered in the respective districts and resorts.

For further elaboration of this risk group, both sources have been used. For the population of the Medical Mission, their sources have been used, while for the remaining RGD resorts, the CBB data have been used. The total number of persons over 60 years as provided by the CBB, have not been altered for the general analysis.

Teams and sessions for the implementation of the campaign, of the population over 60years old

According to CBB data, the total population in this age group is 90,170 living in 10 districts, in 62 resorts, and 470 communities. Most of these communities have health facilities operated by the Regional Health Services (RGD) in the coastal area, and the Medical Mission in the hinterland. (The hospitals and private facilities are excluded here).

The facilities in the coastal area are in general geographically easily accessible, while only a part of those in the hinterland can be reached by road. Most of the communities/villages in the hinterland can only be reached over water or by air. In planning the logistics of the campaign, transportation over water and air constitute a significant part of the costs. Transportation over road from village to village was taken into account, when planning the number of teams needed per district.

The basis of the planning for human resources, is that a fixed/mobile/outreach team will consist of: 3 vaccinators, 1 administrative support, 1 driver and 1 “gatekeeper”. The administrative support and the “gatekeeper” can be recruited from the local facilities, or other support services available there. The teams operating in Paramaribo and parts of some districts can move easily from facility to facility, by road transportation.

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Table 5e-1: Number of vaccination sessions needed per district, resort and population in the service area of the Medical Mission.

Note: The information in this table for the MM is derived, based on the information from the table by CBB. The CBB table is left in its original format, minus the sessions in the MM area, to indicate the (total) population size in all districts.

RESSORT CLINIC SESSIONS TOTAL BROKOPONDO 1 2 NW. KOFFIEKAMP 1 1 2 Nw. LOMBE (boat) 1 Brownsweg MARCHALLKREEK 1 1 PHEDRA 1 1 POWAKKA 1 2 REDI DOTI 1 BROKOPONDO 1 1 ASIGRON 1 1 Brokopondo BALINGSOELA 1 1 LEBIDOTI 1 1 Bovenlandse Bovenlandse SIPALIWINI (air) 1 2 Indianen en Indianen ALALAPAROE (air) 1 West PALUMEU (air) 1 Suriname 2 PELELE TEPOE (air) 1 PULEOWIME (air) 1 2 (air) 1 (air) 1 (air) 1 3 AMOTOPO (Air) 1

1 1 WEST SURINAME WITAGRON Boven DEBIKE DEBIKE 1 Suriname HEKOENOENOE 1 3 KAMBALOA 1 PIKIEN SLEE 1 1 DJOEMOE DJOEMOE (air) 1 2 KAJANA (air) 1 SEMOISIE (boat) 1 1 1 2 LADOANI DOEWATRA 1 GOEJABA (boat) 1 2 LADOANI (boat) 1 SOEKOENALE (boat) 1 1 JAW-JAW 1 1 1 1

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PIKIN SARON 1 1 MIDDEN MIDDEN 1 1 SURINAME SURINAME (by air) 1 1 NJ JACOB KONDRE (by air) 1 1 DRIETABIKI (air) 1 1 DRIETABBETJE GODORO (air) 1 1 KARMEL (air) 1 1 AGAIGONI (boat) 1 1 APOEMA (boat) 1 1 OOST (boat) 1 1 SURINAME GAKABA (boat) 1 1 GONINI (boat) 1 1 (boat) 1 1 LAWATABIKI (boat) 1 1 NASON (boat) 1 1 STOELMANSEILAND (air) 1 1 Total sessions 52 52

Table 5e-2. Number of vaccination sessions needed per district, resort and population, using CBB data

DISTRIKT RESSORT POPULATION Sessions needed, based Total on target population size sessions and geographic needed accessibility Brokopondo Brownsweg 340 Centrum 282 Included in Klaaskreek 227 the previous Kwakoegron & Klaaskreek table of the 125 & MM 197 Commewijne Alkmaar 915 2 Bakie & Margaretha 189 1 1835 5 12 Nieuw 1167 2 1057 2 Coronie & Totness & 574 2 2 Welgelegen Marowijne Albina 1038 2 Galibi 143 1 1246 3 8 Moengo Tapoe 137 1 & Wanhati 279 1 Nickerie 419 1 2391 6 13 1006 2

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Wageningen 592 1 1652 3 Para Bigi Poika 75 Carolina 77 Included in the previous Noord 1118 table of the Oost 1195 MM Zuid 993 Paramaribo 2911 6 7113 13 Centrum 5342 13 Flora 3713 9 Latour 3807 9 Livorno 1299 3 104 Munder 3045 9 2573 6 Rainville 5340 13 2750 6 3043 7 Welgelegen 4212 10 Saramacca Calcutta 242 1 Groningen 520 2 822 2 8 407 1 534 1 259 1 Sipaliwini 78

Boven Saramacca 109 Included in 2279 the previous Coeroenie 185 table of the 297 MM 1863 Wanica 4080 10 Domburg 1234 4 2300 5 3046 7 47 2349 6 3456 10 Saramacca Polder 1693 5 TOTAL 90170 194 194

Thus, the total number of sessions for the 60+ group on national level is (52 + 194) x 2 = 492 sessions for both vaccination rounds.

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Transportation costs will be added depending on the geographical area of the site.

Table 5e-3: Roundtrip transportation cost Medical Mission

TRANSPORTATION COSTS MEDICAL MISSION – 1 round (USD) Poesoegroenoe and Nw Jacob kondre (air) 1,353 Kwakoegron/ Witagron / Pikin Saron (road) 440 Bigi Poika and Pikin Saron (road) 220 Sipaliwini/ Alalaparoe (air) 2,428 Pelele Tepoe/ Palumeu (air) 2,150 Puleowime/ Kawemhakan (air) 1,620 Coeroeni/ Amotopo/ Kwamalasamutu (air) 2,324 Kajana/ Djoemoe (air) 1,526 Djoemoe/ Semoisie (boat) 100 Debike/Hekoenoenoe/ Kambaloa/ Pikin Slee (boat) 250 Ladoani/ Goejaba (boat) 178 Pokigron/ Duatra (road) 430 Brownsweg/ nw. Koffiekamp (road) 240 Klaaskreek/ nw. Lombe (road/boat) 176 Marchallkreek/ Phedra (road) 155 Powakka/ Redi Doti (road) 154 Brokopondo/ Balingsoela (road) 200 Brokopondo/ Asigron (road) 30 Brokopondo/ Lebi Doti (road/boat) 300 Stoelmanseiland/ Gonini/ Agaigoni (air/boat) 1,783 Drietabbetje (flight)/Stoelmanseiland (drop vaccines)/ Cottica /Lawatabiki 2,156 TOTAL USD 18,213

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Based on these criteria, the following overview is presented in table 5e-4.

Table 5e-4: Costs for reaching out to vaccination sites (USD) for the 60+ target group

Overtime/ District Population Sessions Inventory Transport Consumption Brokopondo 12 6,000 1,800 1,171 Bovenlandse Indianen 9 4,500 1,350 West Suriname 1 500 150 18,213 Boven Suriname 12 6,000 1,800

Midden Suriname 6 3,000 900

Oost Suriname 12 6,000 1,800 Commewijne 5,163 12 6,000 300 1,800 Coronie 574 2 1,000 500 300 Marowijne 2,843 8 4,000 500 1,200 Nickerie 6,060 13 6,500 700 1,950 Included in specification Para 3,458 by MM Paramaribo 45,148 104 52,000 200 15,600 Saramacca 2,784 8 4,000 200 1,200 Included in specification Sipaliwini 4,811 by MM Wanica 18,158 47 23,500 500 7,050 Total 90,170 123,000 29,583 36,900

Vaccine and related costs for the 60+ population

The components in the following table have been included in the detailed budget and this will be programmed separately. Fine tuning will be needed, once the prices for the ancillary items have been determined.

Table 5e-5: Vaccine doses needed (including 10% wastage rate) per district for the population of 60 years and older

Population Vaccine Syringes/ If reconstitution needed District doses needles Diluent vials Syringes 5ml Needles Brokopondo 1,171 incl.20%2,576 2,576 10515 ml reconstitution515 reconstitution515 Commewijne 5,163 11,359waste 11,359 2,272 2,272 2,272 Coronie 574 1,263 1,263 253 253 253 Marowijne 2,843 6,255 6,255 1,251 1,251 1,251 Nickerie 6,060 13,332 13,332 2,666 2,666 2,666 Para 3,458 7,608 7,608 1,522 1,522 1,522 Paramaribo 45,148 99,326 99,326 19,865 19,865 19,865 Saramacca 2,784 6,125 6,125 1,225 1,225 1,225 Sipaliwini 4,811 10,584 10,584 2,117 2,117 2,117 Wanica 18,158 39,948 39,948 7,990 7,990 7,990 Total 90,170 198,374 198,374 39,675 39,675 39,675

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Table 5e-6: Vaccine and syringes/needles cost for a vaccine that costs 10.50 USD per dose (example)

District Population Vaccine Syringes/ Vaccines Syringes/ Total USD Brokopondo 1,171 doses 2,576 needles2,576 32,460 Needles185 32,646 Commewijne 5,163 incl.20%11,359 11,359 143,118 818 143,936 Coronie 574 waste 1,263 1,263 15,911 91 16,002 Marowijne 2,843 6,255 6,255 78,808 450 79,258 Nickerie 6,060 13,332 13,332 167,983 960 168,943 Para 3,458 7,608 7,608 95,856 548 96,404 Paramaribo 45,148 99,326 99,326 1,251,503 7,151 1,258,654 Saramacca 2,784 6,125 6,125 77,172 441 77,613 Sipaliwini 4,811 10,584 10,584 133,361 762 134,123 Wanica 18,158 39,948 39,948 503,340 2,876 506,216 Total 90,170 198,374 198,374 2,499,512 14,283 2,513,795

Table 5f. Group 6: Population, based on medical grounds/risk factor (Diabetes Mellitus, High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous) (40 – 59 years)

Target: 30,000 persons

The details with regard to where these persons are located, where they will be vaccinated, and what will be the cost for this group, will be confirmed when full information about this group becomes be available.

Hospitals/Health Centers To Vaccinate Teams Days Cost A designated location or tent on the grounds of the hospital or near the hospital, where the patient can go after visiting the specialist 10,000 10 10 5000 Outreach (mobile) clinics for surrounding villages/polders. 5,000 5 10 2500 Designated outpatient clinics (separate location in the clinic, or a tent on site). 5,000 5 10 2500 Temporary clinics or mobile outreach teams 5,000 5 10 2500 Other vaccination sites, public and private 5,000 5 10 2500 Total 30,000 30 15,000

Table 5g. Group 7: Population, based on medical grounds/risk factor (Diabetes Mellitus, High Blood Pressure, Sickle Cell Anemia, Cardio vascular Diseases, COPD, Oncologic Diseases, Indigenous) (18 – 39 years)

Target: 11,000 persons

The details with regard to where these persons are located, where they will be vaccinated, and what will be the cost for this group, will be determined when full information about this group will be available.

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Hospitals/Health Centers To Vaccinate Teams Days Cost A designated location or tent on the grounds of the hospital or near the hospital, where the patient can go after visiting the specialist 4,000 2 8 1,000 Outreach (mobile) clinics for surrounding villages/polders. 2,000 2 4 1,000 Designated outpatient clinics (separate location in the clinic, or a tent on site). 2,000 2 4 1,000 Temporary clinics or mobile outreach teams 2,000 2 4 1,000 Other vaccination sites, public and private 1,000 2 4 1,000 Total 11,000 10 5,000

Table 5h. Group 8: Other risk groups

Hospitals/Health Centers To Vaccinate Teams Days Cost Through the existing facilities of the Medical Mission, RGD, and private/public health facilities 1,100 4 1 2,000 Total 1,100 4 1 2,000

Table 5i. Group 9: Healthy population, 18 – 59 years

For the vaccination of this group, estimated at 265,779 persons, a national vaccination campaign will be needed, utilizing all existent facilities and strategies, as detailed for the group of 60 years and older. Given the size of the target population, and the order of priority, this group of healthy populations between 18 and 59 years, it is expected that the vaccination of this group will be done in the course of 2022 or 2023. It is assumed here that the needed vaccines will be available when this group will be vaccinated. It is also kept in mind that not everybody in this group will accept the vaccination. Hypothetically, one can argue that this will be 20% in the first round/year, 25% in the second round/year, and 30% in the third round/year.

Hospitals/Health Centers To Vaccinate Teams Days Cost Militair Hospitaal To be determined Academisch Ziekenhuis Paramaribo Diaconessenhuis Lands Hospitaal St. Vincentius Ziekenhuis (RKZ) Wanica Ziekenhuis Mungra Medisch Centrum Nickerie RGD Medische Zending PCS Other Total (estimated extrapolation of the 8 priority 265,779 108,764 Vaccinesgroups 7,367,394 Syringes/Needles 42,099 Inventory 362,546 Transport 72,852 Overtime 108,764 Total 8,062,419

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Table 6: Summary of vaccination costs for all risk groups (actual prices vaccines to be used. For this table 10.50 USD per dose was used as an example).

Summary of all To Vaccines Syringes Inventory Transport Overtime Total risk groups Vaccinate Group 1 1,497 3,293 3,293 5,000 1,000 1,500 7,500 Group 2 3,794 8,347 8,347 6,500 1,300 1,950 9,750 Group 3 3,500 7,700 7,700 4,500 900 1,350 6,750 Group 4 2,900 6,380 6,380 7,000 1,400 2,100 10,500 Group 5 90,170 198,374 198,374 123,000 29,853 36,900 189,753 Group 6 30,000 66,000 66,000 15,000 1,400 2,100 18,500 Group 7 11,000 24,200 24,200 5,000 1,000 1,500 7,500 Group 8 1,497 3,293 3,293 2,000 1,000 1,500 4,500 Group 9 265,779 584,714 584,714 362,546 87,993 108,764 559,303 Total 410,137 902,301 902,301 530,546 125,846 157,664 814,056 Vaccine cost 9,474,165 9,474,165 Syringes/Needles 45,115 45,115 cost Grand Total 10,333,336

Table 7. Proposed vaccination sites for the first priority group

Institution Strategy Target group Elderly homes and Vaccination on site by health staff and/or Health professionals nursing homes Outreach teams. Residents elderly (national level) homes

Private dialysis centers Vaccination on site by health personnel Health professionals (national) and/or Outreach teams. . Dialysis patients

Hospitals (- AZP, LH, Through the structures of the institution Health workers first and DH, SVZ) (Paramaribo) (e.g. infection nurses). second line Individuals working directly with COVID-19 infected patients should be prioritized. Special groups of patients are vaccinated Dialysis patients in the hospital MH (Paramaribo and Through the structures of the institution. Health professionals outposts) Outreach teams. Essential groups in the army SZW (Wanica, Para) Through the structures of the institution Health workers second (e.g. infection nurses). line Individuals working directly with COVID-19 infected patients should be prioritized - MMC (Nickerie, Through the structures of the institution Health workers second Coronie) (e.g. infection nurses). line - SZM (Marowijne, Individuals working directly with COVID-19 Saramacca) infected patients should be prioritized Special group patients will be vaccinated Dialysis patients in the hospital. - RGD (Paramaribo, Through the structures of the institution. Health workers first line Wanica, Para, Coronie, Individuals who work directly with Nickerie, Saramacca, (suspect) COVID-19 infected patients Marowijne should be prioritized.

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- MMPHCS (Brokopondo, Para, Sipaliwini) BOG (Paramaribo) Medical Center or separate location on Essential Groups site Outreach teams that are going to vaccinate on location.

Table 8. Proposed vaccination places for the second and third priority group

Institution Strategy Target group - AZP, LH, DH, SVZ A designated location or tent on the Risk groups 1 and 2 (Paramaribo) grounds of the hospital or near the (outpatients) hospital, where the patient can go after the visit to the specialist. - MMC (Nickerie, A designated location or tent on the Risk groups 1 and 2 Coronie) grounds of the hospital or near the (outpatients) - SZM (Marowijne, hospital, where the patient can go after Saramacca) visiting the specialist. Outreach (mobile) clinics for surrounding Risk groups 1 and 2 villages/polders. Elderly over 60 - RGD (Paramaribo, Designated outpatient clinics (separate Risk groups 1 and 2 Wanica, Para, Coronie, location in the clinic, or a tent on site). Elderly over 60 Nickerie, Saramacca, Marowijne Temporary clinics or mobile outreach Risk groups 1 and 2 - MMPHCS teams. Elderly over 60 (Brokopondo, Para, Sipaliwini) BOG BOG Medical Center or separate location Risk groups 1 and 2 on site. Elderly over 60 Temporary clinics or mobile outreach Risk groups 1 and 2 teams. Elderly over 60

The second and third priority groups are less easily accessible within an institution. In order to vaccinate as many people as possible, within a short period of time, an outreach campaign will be organized to support the in-facility activities. Various locations within the community will be used for this purpose, such as schools and other public locations. In certain locations large tents will be set up which can be disassembled for transport to another vaccination locations.

Vaccination strategies and vaccine distribution

The following points of attention are being taken into account when planning the vaccination strategy: • If a COVID-19 vaccine requires diluent to be purchased separately, this will be handled and distributed in the same way as the vaccine. • THE COVID-19 vaccination will not take place within the regular national immunization programme (childhood vaccinations, etc.), so that the progress of this program will not be burdened. • The campaign will take place in phases, according to the prioritization of target groups and locations, and the availability of the vaccines. • A limited number of vaccination locations will be set up to facilitate quality delivery, security of the vaccines and for the ease of the logistics organization. • During 2021, vaccinations will not be carried out through the general practitioners.

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Planning of vaccination strategies is being done together with stakeholders. Depending on the local conditions and the target group (size and accessibility) other strategies will be considered.

Campaign dates

Exact dates for the implementation of the campaign are to be decided by the National Coordination Team. This will depend on the expected date of arrival of the vaccines. After the vaccines have arrived, the activities will be implemented according to: - Preliminary activities: week 1 - Start of vaccination (1st dose): week 2 - End of vaccination (1st dose): week 3 (depending on strategies used) - Data analysis and evaluation: week 4 – week 5 - Second round of vaccination: 3-4 weeks after weeks 2 and 3.

The vaccination sites for the first priority group (first line health workers) will preferably be set up within the existing facilities of the selected hospitals, health centers and policlinics. Necessary adjustment will be needed in order to prevent physical contact between clinic staff, visitors, vaccination unit staff and those coming for the vaccination, as well as other persons in and outside the facility. Strict demarcations will be set, to allow for a walk-through procedure, with separate entrance and exit ways.

The team will consist of: • 1 team leader/coordinator, also responsible for paper and electronic registration of the recipient and vaccination. • 3 vaccinators (more or less, depending on target number to be vaccinated) to include responsibilities for cold chain, waste disposal, observation post vaccination. • 1 “gatekeeper” to ensure that recipients are using protective masks and maintaining the required physical distance etc., and to check the temperature, and disinfect the hands, keep the order, etc. A physician with knowledge and experience on adverse reactions and anaphylaxis must be available and within reach during the vaccination session and up to 30 minutes after the last dose is given. The vaccination site will be organized such that there is one way traffic for recipients, minimal physical contact, open air flow, and other precautionary measures.

The group of first line health workers is the first priority group to be vaccinated, with the first batch of vaccines to be received. These health workers are the easiest to be identified and vaccinated, since they work in a specific setting, where the vaccination activities can be implemented. These are 5 hospitals in the city, and the regional hospitals in Nickerie, Marowijne and Wanica. Other government and private facilities are available, and will be included as needed. The other priority groups, as presented before will follow, depending on the arrival of the subsequent batches of vaccines in the course of 2021 and beyond.

A one-way traffic setting will be observed, from entrance, to exit from the observation area post vaccination. The basic setting, organization, and inventory of a vaccination site will include:

- Waiting area outside the facility, in tents or using other weather protective means, taking into account safe distancing and other preventive measures.

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- Numbering system to observe “first come, first serve” principle. Exceptions will be agreed upon in the team. - Office equipment (desk, chairs, laptops) for registration of the individuals (attendance and vaccination card), in a dedicated area in the waiting area. - Hand sanitization facilities, and temperature control by the “gatekeeper”. - The vaccination area which will be accessible for persons with special needs and will have sufficient furniture to place vaccination materials (e.g., vaccine carriers and emergency trays) as needed. - One table for preparation of the injection and for writing purposes. - Emergency tray, Ambu bag, and other needed items - Three or more chairs, separated by screens. - Other materials or equipment as needed e.g., safety boxes, waste bins/bags for other waste material, computer equipment, … - The observation area post vaccination will have ample number of chairs or other seating means, and beds (where available) taking into account the rules with regard to safe distancing and other preventive measures. - Area for the team for their personal belongings, breaks, refreshments …

A pre-vaccination screening list with check boxes (Yes/No/Don’t Know) will be used at the registration table. This form will help to determine if there is any reason that the person should not get the COVID-19 vaccine today. This screening list will include at least: • Name of the recipient • Date of birth/age • Feeling sick today • Ever received a COVID-19 vaccine. If yes, then the name of vaccine received and the date. • Ever had an allergic reaction to a component of the COVID-19 vaccine (list to elaborate) • An allergic reaction to another vaccine or medication • An allergic reaction for COVID-19 or told that had COVID-19 • Allergic reaction to something other than a component of COVID-19 vaccines such as food, pets, environment, medication. • Received a vaccine in the past 14 days • Ever tested positive forCOVID-19 • Ever received treatment for COVID-19 • Have weakened immune system (elaborate) • Have bleeding disorder • Pregnant • Breastfeeding

This list will be reviewed to determine whether or not the person is eligible to receive the COVID-19 vaccine today.

When found eligible to receive the COVID-19 vaccine, then the person will be registered in the vaccination database, either electronic or on paper, depending on the situation of the site. The registration will record at least:

• Last name • First name • Date of birth • Gender • Ethnicity

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• Address disaggregated by district and resort • Contact phone number • Occupation (to identify health care workers) • Underlying conditions (all to be listed) • Date of first vaccination • Name of Manufacturer • Batch or Lot number • Site of vaccination (e.g., right or left arm) • Name of vaccinator • Date of second vaccination • Name of Manufacturer • Batch or Lot number • Site of vaccination (e.g., right or left arm) • Name of vaccinator • Any other information the country wants to collect e.g., if pregnant and trimester (for women) and history of confirmed COVID-19 diseases in the previous 3-6 months

The Ministry of Health has considered options for a database to document vaccine recipients, doses administered and adverse events for collation and analysis. The existing database to record the current vaccination activities in the country is capable of including the COVID-19 registration, provided that eventually needed upgrade of hardware, software, and staff training is taken care of. The current vaccination registration by RGD, MM, and other private or public practitioners is being reported through the respective district coordinator to the central registration site of the BOG where this data is entered in the database, and analysis and reporting is being done.

The tool being used, is configured to capture all the information on the standard reporting forms for adverse events monitoring, inclusive of the signs and symptoms, time and date of development of these, the outcomes e.g., hospitalization or death and the final classification of the AEFI/ESAVI e.g., coincidental, vaccine related, operational etc. An example of an adverse event investigation form is given in annex 2.

The data will be recorded in a simple Excel spreadsheet or an Access data base directly linked to the main registration computer at the headquarters. Both a manual (paper based) registration and electronic registration will be done, because electronic systems may fail at any time. This may also be more practical for places without electricity or back-up electricity generators.

At the vaccination site, a basic setting is needed, as described above. A basic list of inventories was mentioned in table 5. Not all figures in the table of basic inventory will be doubled (for example, for carriers, ice boxes, etc.) when used for the second round of vaccination, or when the team is being deployed to another vaccination site, Specific number of vaccines, AD syringes and needles, reconstitution syringes and needles, will be added, depending on the target population. Additional costs will be considered on-site, such as the costs for setting up the facility, like rental of tents, chairs, etc.

It is estimated that one person can vaccinate 15 persons in an hour. A team of 3 vaccinators, working 8 hours (minus 1 hour break) will thus be able to vaccinate 315 persons. Based on this assumption, the following table gives an overview of the vaccination facilities and the persons to be vaccinated. Since COVID-19 vaccination will not take place through the routine vaccination structure of the National Immunization Programme, designated vaccination sites and needed personnel

32 will be identified and trained. The location of vaccination site is determined by the density (size) of the target group in that specific area.

Vaccination will take place in phases, according to the prioritization of the different target groups and the number of vaccines available. It should be taken into account that the second dose should be administered according to instructions of the vaccine used, generally 4 weeks after the first dose. Following is a selection of some vaccines in the pipeline, for the short term. The detailed budget in annex 1 uses a random vaccine for budget estimation purposes, for a price of USD 10,50 per dose. The calculation will be adapted according to the vaccine to be used.

Table 9: COVID19 Vaccine Pipeline – short term

Vaccine Number of doses Route of Vaccine developer/manufacturer platform and timing administration 1 dose Non-replicating 2 doses (0, 28 days) AstraZeneca/Oxford University viral vector 2 doses (0, 28 days) Intramuscular Janssen Pharmaceutical Companies 1 dose Intramuscular Sinovac Inactivated 2 doses (0, 14 days) Intramuscular Moderna/NIAID 2 doses (0, 28 days) Intramuscular BioNTech/Fosun Pharma/Pfizer RNA 2 doses (0, 28 days) Intramuscular Novavax Protein subunit 2 doses (0, 21 days) Intramuscular

Given the specific characteristics of the COVID19 vaccination campaign, the vaccination campaign will focus on the vaccine that has been decided on, and approved by the relevant authorities for use in Suriname.

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Table 10: Vaccine Characteristics and Authorization for Use

Characteristics Pfizer-BioNTech COVID-19 Moderna mRNA-1273 Oxford-AstraZeneca Novavax NVX-CoV2373 Vaccine vaccine against COVID-19 COVID-19 vaccine Type mRNA mRNA Viral vector Protein subunit (Part of virus genetic code) (adenovirus modified to carry the spike protein) Recipients 16 years and older 18 years and older 18 years and older Doses 2 doses 0.3 ml, 2 doses, 0.5ml, 28 days apart. 2 doses, 4 weeks apart 2 doses 21 days apart May be extended to 42 days apart How given Intramuscular injection in the Intramuscular injection in the Intramuscular injection in Intramuscular injection in upper arm upper arm the upper arm the upper arm Effectiveness 95% 94.5% 70 % 89 % (preliminary data) Storage -70 °C + 2 – 8° C for 30 days or + 2 - 8° C for at least 6 + 2 - 8° C - 20 for up to six months months Presentation 5 dose vials 10 dose vials Needs Yes. With 0.9% Sodium No Reconstitution Chloride Injection, USP (not provided) Interchangeability Not interchangeable with other Not interchangeable with other Not interchangeable with Not interchangeable with COVID19 vaccines COVID19 vaccines other COVID19 vaccines other COVID19 vaccines Side effects Local, fever, chills, fatigue, Local, fever, chills, fatigue, Local, fever, chills, fatigue, More information will be headache, muscle pain, headache, muscle pain, joint headache, Transverse available after the late- anaphylaxis, Bell's Palsy, stiffness, anaphylaxis, Bell’s myelitis stage trial results are chills, joint pain, nausea, palsy, cases of multisystem published. Other side malaise, and inflammatory syndrome effects were mild or absent. lymphadenopathy Emergency Canada, UK, EMA, USA, EMA UK, India, EMA authority use Switzerland, USA, WHO granted

Characteristics Sinovac Bharat Biotech Covaxin Johnson & Johnson Sinopharm Type Inactivated Inactivated Viral Vector Inactivated Recipients 18 year and older 18 year and older 18 year and older 18 year and older Doses 2 2 1 2 How given Intramuscular injection in the Intramuscular injection in the Intramuscular injection in Intramuscular injection in upper arm upper arm the upper arm the upper arm Effectiveness 50% - 78% (preliminary data) No data 66% (preliminary data) 79% Storage +2-8˚C +2-8˚C +2-8˚C +2-8˚C Presentation Needs Reconstitution Interchangeability Not interchangeable with other Not interchangeable with other Not interchangeable with Not interchangeable with COVID19 vaccines COVID19 vaccines other COVID19 vaccines other COVID19 vaccines Side effects local; fever, chills, fatigue, local; fever, chills, fatigue, local; fever, fatigue, local; fever, chills, fatigue, headache headache, muscle pain, headache, muscle pains headache nausea, vomiting Emergency China, Brazil, Turkey India authority use granted

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6. Supply chain management and health care waste management

Preparation for storage of COVID-19 vaccine

The COVID-19 vaccine is expected to cover about 20% of the Surinamese population, that is about 120,000 people. The recommended dose for complete vaccination depends on the vaccine being used and the interval as required between doses. This indicates that for a population of 20%, approximately 240,000 doses of vaccine will be required without including a wastage factor. The arrival of the vaccine will be in stages, probably ranging from 5,000 - 50,000 doses per stage. The required storage capacity will depend on how much vaccine will enter the country per phase. Based on the time interval in which the next phase is expected, the overlapping of vaccine arrival will have to be taken into account.

The storage capacity per dose will also depend on the vial presentation; single dose (1 dose) or multi-dose (5 - 20 doses) vials. Multi-dose vials will require less storage capacity than the single-dose vials.

Current storage capacity

The current vaccine stock capacity for -20° C and +2° C - + 8° C at the NIP is considered sufficient to additionally stock the COVID-19 vaccine and related ancillary items. The Wanica Ziekenhuis also has sufficient capacity for the same. Special attention will be given if, depending on the vaccine being used, additional storage space is required.

If needed, the country is open to receiving - 80°C/- 20°C vaccine(s) with a short shelf life. There is enough storage capacity available in the Wanica Ziekenhuis. Other facilities with this specific storage capabilities are located at the AZP and the Central Laboratory of the BOG. The Wanica Ziekenhuis has been appointed as the central storage facility for these vaccines.

The COVID-19 tool has been applied to the available capacity at the NIP. The total storage capacity (cold chain + dry store) for the NIP at national level is currently 108,715.26 liters.

• The total freezer capacity for storage of vaccines at -20 ° C amounts to a total of 1,847.2 liters. • The total refrigerator capacity for vaccine storage at + 2 ° C - + 8 ° C is a total of 4,754.4 liters. • The total dry store storage capacity, mainly for storage of syringes and needles, is 35,453.33 liters.

The storage capacity is continuously utilized by the regular immunization program, and is currently running at approximately 75% of its total storage capacity.

The RGD, MM and other vaccination partners in the country have a sufficient set of cold chain equipment and vaccine carriers at their disposal for their routine vaccination activities. For the COVID-19 vaccination campaign, however, additional equipment and tools will be needed, such as freezers, refrigerators, thermometers, vaccine carriers, ice packs, etc. while some of these need replacements given their age and current condition. These needs have been included in the detailed budget. The table below provides an overview of the storage capacity by type of temperature storage.

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Table 11. Inventory of cold chain equipment and storage capacity at national level, December 2020

Item for storage Type Net Capacity Gross volume Manufacturer (liter) (liter) Cold room AC +2°C - +8°C 22,428 25.578 Amerikooler, INC. Cold room BC +2°C - +8°C 21,953 25.578 Haier Total Cold room (44,381) Delivery room Dry store 22,279.33 167.095 - Dry Store 2 Dry store 21,798.93 158.992 - Dry Store 3 Dry store 13,654.40 102.408 - Total Dry store (57,732.66) Icepack Freezer -20°C 70 227.7 Electrolux Freezer BV -20°C 592.4 1.074 General Electric Freezer CV -20°C 592.4 1.074 General Electric Freezer DV -20°C 592.4 1.074 Electrolux Total Freezer (1,847.2) Refrigerator 1 +2°C - +8°C 334.5 435.5 Whirlpool Refrigerator 2 +2°C - +8°C 351.5 435.5 Whirlpool Refrigerator 3 +2°C - +8°C 378.4 435.5 General Electric Refrigerator 4 +2°C - +8°C 410.5 435.5 Frigidaire Refrigerator 5 +2°C - +8°C 410.5 435.5 Whirlpool Refrigerator 6 +2°C - +8°C 410.5 435.5 Frigidaire Refrigerator 8 +2°C - +8°C 410.5 435.5 White Consolida Refrigerator 9 +2°C - +8°C 410.5 435.5 Whirlpool Refrigerator 10 +2°C - +8°C 410.5 435.5 Frigidaire Refrigerator 11 +2°C - +8°C 410.5 435.5 Whirlpool Refrigerator 12 +2°C - +8°C 410.5 435.5 Whirlpool Refrigerator 13 +2°C - +8°C 410.5 435.5 Whirlpool Total (4,754.4) Refrigerators TOTAL 108,715.26

Vaccine distribution at the regional and local level

Distribution of the COVID-19 vaccine to regional and local level will take place separate from the distribution system of the regular vaccination program so that there is no pressure on this system. As we are dealing with the introduction of a new vaccine and the implementation of a vaccination campaign, the vaccine distribution will to be adjusted so that the release and tracing of the vaccine can be accurately tracked. The VSSM system for documenting receipt, distribution and recall of vaccines are in place centrally and will be used to accommodate the central storage for the COVID-19 vaccines at national and subnational storage and distribution site in the system

In order to receive the COVID-19 vaccine, the cold chain and the dry-store storage capacity may need expansion at the national and sub-national levels. When calculating the extra storage capacity, account has been taken of maintaining a buffer storage for any unforeseen emergencies within the NIP. The table below provides an overview of the additional capacity to be purchased, including eventual need for ultra cold chain capacity.

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Table 12. Extra capacity needed for receiving COVID-19 vaccines national level

Net Number of Estimated Item type Type Capacity units price (USD) (litres) 56.3 KVA Back-up Generator 2 30,000 DITRA int. Airconditioning units 3 3,000 Freezers (-20˚C) 2 2,000 Refrigerators 4 +2°C - +8°C 4,000 Vaccine Carriers 100 +2°C - +8°C 4,000 Thermometers 250 5,000 Freeze tags 100 1,000 TOTAL estimated cost 49,000

Management and monitoring of the vaccine supply and cold chain at the national level are part of the NIP responsibility. In preparation for receiving the COVID-19 vaccine, an evaluation of these components, including the cold chain storage capacity, was carried out. The vaccine and supplies stock management for COVID-19 vaccines to the coastal facilities will be done by NIP. For the distribution to the level of vaccine administration additional transportation means by road, river and air have been included in the budget. The transportation of vaccines and related needs to and from the hinterland will be carried out in collaboration with the MM.

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7. Human resource management and training

For vaccination practices, the need for supporting human resources will be discussed with the Medical Faculty of the University and the training schools for nurses and affiliated professions (COVAB), as has been done for previous campaigns. The facility supervisors at the clinic level will remain responsible for coordinating the vaccination teams, and will perform random supervisory visits, or visits upon request, and provide technical assistance in cases where needed. They will also supervise the daily activities and ensure that daily reports are collected and handed over to the National Coordination Team.

A vaccination team will be responsible for the day-to-day vaccination sessions at the site. A registered nurse will lead this team, with the support of: - 2 registered nurse or medical and/or nursing students who are authorized to administer injections - 1 administrative support - 1 driver - 1 “gatekeeper” - Other support as needed

Support services will be provided under coordination of the National Coordination Team such as public information and mobilization, additional transportation needs, distribution of supplies and resources, and collection of materials after the campaign.

Local hospital pharmacists are available to assist with QC of the storage and distribution and assist with the preparation of the vaccine doses and administration to patients, for example, by developing protocols to ensure temperature monitoring during storage and proper handling.

This team and others directly related to the campaign, as well as the clinic responsible, will be trained one week before start of the campaign by the Coordination Team in virtual group sessions. The training material will be based on the training modules developed by PAHO/WHO, adapted to the country and environmental situation.

The training will be done by qualified and experienced trainers to be recruited from the Medical Faculty of the University of Suriname, the Central Training Institute for Nurses and related professions (COVAB), the RGD, Medical Mission, BOG, NIP, and other resources.

Implementation

A National Coordination Team is in charge for the overall planning, monitoring and reporting of the activities. This team has support commissions and teams: An Implementing Team, a Central Administrative Team and a Team of Vaccinators. The Coordination Team will work with its main focal point, the BOG/National immunization Program. (Details of the teams and their tasks are in annex)

In preparation for the campaign, BOG will lead planning meetings with all the partners, to agree on detail programming and logistics, core staff of facilitators, vaccinators, roles, responsibilities, provision of needed materials, media communication, public information, reports, and plans for training and evaluation moments. A final implementation plan for the

39 operational aspects of the campaign will be discussed and agreed. BOG will coordinate with the National Coordination Team the training of the core group of facilitators and vaccinators. Preparation weeks

The National Coordination Team will: - Finalize a written implementation plan with budget - Identify and secure personnel needed for the implementation of the campaign - Identify and secure the availability of vaccines and related supplies - Identify and secure finances - Produce information and educational material: o Video documentary of 5 - 10 minutes on vaccinations and COVID19 vaccination to be aired on select TV stations according to a defined broadcast plan o Radio information messages in the 4 main languages (others as needed) o Posters, pamphlets, folders o Banners for strategic points in the city and the districts and at the health facilities. o T-shirts and ID-cards for the campaign teams and others involved - Distribute posters, pamphlets, folders and install banners at identified localities - Produce standard letters for communication with national, regional and local authorities, businesses, service clubs, etc. - Distribute letters and other materials - Finalize a plan for safe waste disposal - Produce the following for the administration of the vaccinations: o Vaccination cards o Vaccination registers (paper based and electronic) o Communication letters with schools, businesses, organizations, for their support, input, etc… o Vaccination registers o Stock management forms o Forms for reporting ESAVIs o Letters to physicians in case of contra-indications for vaccination and monitoring of AEFI’s - Protocols for supervisors and team leaders - Protocols for vaccinators - Rubber stamps designed for the campaign and stamp pads - Maps of the country, Paramaribo, other cities, the districts and district resorts - Purchase of paper material: envelopes, files, folders, writing pads, ballpoint pens (two colors), printing paper, white boards, flip chart papers and boards, felt pens, - Secure needs for the vaccination o COVID19 vaccines o If needed: NaCl diluent (as needed for the vaccine being used) o AD Syringes/Needles and syringes/needles for reconstitution o Thermos boxes (as needed) o Vaccine carriers o Ice packs o Cotton rolls o Alcohol o Band-aids o An emergency tray with Adrenaline, Hydrocortisone, Ambu bags, IV giving sets, normal saline, branulas, needles, syringes. o Waste disposal boxes and bags

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o Hand sanitizers/hand towels, hand soap o Hand towels, paper towels, toilet paper - Secure PPE availability and distribution - Organize technical-planning meetings with BOG units involved, RGD Rayon Coordinators, MM Region Coordinators, Districts Commissioners office and other national, district and resort authorities, local/ tribal/village authorities, media and other Ministries involved (Public Works, Regional Development, Education, Justice and Police, Defense, Private Businesses, Organizations, Red Cross, Service Clubs, .,..). - Organize trainings for coordinators/supervisors/field vaccinators/ administrative support team. - Start media campaign

Implementation Weeks

- Continue media campaign - Official launch of the campaign. Venue and date to be decided - Field orientations by National Coordination Team - Daily debriefings of National Coordination team - Respond to eventualities as reported, solve issues reported - Continued communication between teams - Collect data forms from teams - Start input of data in electronic format (if not done at vaccination site) - Data collection and analysis (coverage, AEFI’s

Evaluation Weeks

- Rounds of evaluation meetings as needed, with National Coordination Team, Implementation Team, Administrative Team and others - Consolidation of all forms, reports - Payment of providers - Finalization of data input, analysis and reporting

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8. Vaccine acceptance and uptake

Keeping a record of vaccinations is important for determining vaccination coverage. In addition, in the event of any side effects, it can be traced back what happened and it must also be kept for the client if he has had a full series of vaccinations.

For an accurate registration, both a manual and an electronic registration will be done by trained personnel at all vaccination sites and from the "outreach" teams. The electronic registration will be an online system (where available), with real-time registration of the vaccinations, so that it can be found from every vaccination location when and with which vaccine a client was previously vaccinated. In addition to the registration by the vaccination site in the registry, the client must also receive proof of vaccination. There are several options for this: a) Special Covid-19 vaccination card

b) Existing International Vaccination Record, in case the person has one. c) Other, to be developed

Communications (Vaccine acceptance and demand generation)

Introducing a new vaccine - especially to new target groups, through possibly new administration strategies - is a challenge. Ensuring that COVID-19 vaccination is accepted and implemented nationally, poses a unique set of problems, but is key to successfully reducing the transmission and control of the pandemic.

To ensure acceptance of COVID-19 vaccination, an integrated approach will be used, that: • starts with listening to and understanding audiences, generating behavioral and social data about the drivers of uptake, and designing targeted strategies and messages to respond to them; • builds a supportive and transparent information environment, and tackles misinformation through social listening and assessments in support of digital engagement initiatives;

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• builds confidence and acceptance of the vaccines through community involvement by civil society organizations, especially for vulnerable target groups; • provides health professionals with the required knowledge of COVID-19 vaccines as first adopters, trusted influencers and vaccinators, giving them the skills to communicate effectively and convincingly with target groups and communities; and • prepares the country to respond to any reports of AEFI’s and develop plans to mitigate any resulting confidence crises. The pursuit of equality in access to vaccines is a guiding principle for Suriname to adequately protect groups more heavily burdened by COVID-19 disease.

A survey to determine knowledge about COVID-19 and attitudes and concerns relating to the vaccine has been conducted and the recommendations have been used to inform the communications campaign and messages. This will facilitate a structured approach to awareness-raising and promotion of the COVID-19 vaccine targeting the priority groups for vaccination and the public in general, with facts to address concerns and debunk prevailing myths. Confidence in the health sector will be demonstrated. Prominent public figures will be publicly vaccinated with media coverage; the President, Ministers of the Cabinet, Parliamentarians, health specialists, etc.

The communications aimed at informing persons of the vaccination locations, dates and times will be done one week preceding the campaign and during the period of implementation, on national level for all districts, making use of government communication systems, radio, TV, newspapers, and other techniques such as use of text messages etc. Press releases and periodic reporting of coverage will be done to keep the public informed.

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9. Vaccine safety monitoring and management of AEFI and injection safety

Safe injection guidelines in all three aspects (those vaccinated, health personnel and the environment) in the context of the pandemic are in place at the National Immunization Program. These will also be used in the training of the health workers for the campaign.

The surveillance of the vaccine safety of COVID-19 vaccines requires specific attention, as the development of COVID-19 vaccines uses new technologies that have not previously been employed for vaccines. With the introduction of the COVID-19 vaccine, real-time monitoring, communication and knowledge exchange will be done at the national, regional and global levels for an adequate surveillance system for vaccine safety. The existing surveillance system at the BOG, along with those applied by the Medical Mission and the RGD are available, and will be involved in the surveillance of vaccine safety during and after this campaign. These are also competent in surveillance of AEFIs (Adverse Events Following Immunization) and AESIs (Adverse Events of Special Interest). The hospitals and General Practitioners will also be co-opted for the monitoring and reporting of AEFIs as well.

A quality surveillance system for AEFI and AESI will promote stakeholder and general public confidence in the immunization program. Currently there is no specific focal point for surveillance and receipt of reports of vaccination side effects. There is a general pharmaco-vigilance system from the Ministry of Health and side effects that occur with vaccinations are reported directly to the Coordinator of the National Immunization Program (NIP). For reporting side effects of the COVID-19 vaccine, the existing system in the COVID response, such as the 178 hotline, will be used. Training of 178 hotline physicians and call agents will be done.

A registration system for AEFI will be incorporated into the vaccination registration database. This makes it easier to generate data for identifying, investigating, evaluating and validating data on the safety of the vaccine. An analysis and classification of the side effects can also be made from this process. There is an existing ESAVI form in use that will be adapted for the COVID-19 vaccination.

Since emergency plans are only a success if they are a resemblance of the natural course of events, the several levels and routes of communication are identified and standardized. From the bottom up - where the ESAVI is recognized by the health worker, general practitioner or medical specialist - the necessary information will be routed through the appropriate levels in case of an institution as the Medical Mission (MZ) or the Regional Health Services (RGD) directly to the EPI manger.

During the course of the campaign, all AEFIs observed will be followed up within 24 hours, by completing the COVID-19 reporting forms, and sending these to the central coordinating team for further review and classification. A Review Committee will determine the need of and the extent of the Response Team. The Review Committee and the Response Team will be officially appointed by the Ministry of Health, with clear responsibilities and routes of action and communication. Parallel to this assessment the responsible health authorities (Minister of Health, Director of Health and the PAHO/WHO Representative) will be notified of the ESAVI, before any media action is taken.

With the introduction of the COVID-19 vaccine, it is more than timely to have the Review Committee formally appointed and mandated for the proper management after an ESAVI has been reported. The mandate of the Technical Advisory Commission Immunization Policy COVID-19 and its representation supports the role of the Technical Advisory Commission to

44 fulfill the role of the Review Committee. The formal appointment of the NITAG is an administrative act that remains, now that the terms of reference and its representation has been submitted to the Ministry of Health.

The Review Committee will determine the need of and the extent of the Response Team. The EPI Technical Committee that functioned as the NITAG, has fulfilled its responsibility in the past, as members of the Response Team. Each member will have a substitute and a second substitute, since in general, persons suitable for these positions are often engaged with other important issues and are not be able to respond timely or respond at all on that particular moment. To ensure the authority of this important group the team must be chaired preferably by the director of the Bureau of Public Health.

Parallel to this assessment, the responsible health authorities (Minister of Health, Director of Health and the PAHO/WHO Representative) will be notified of the ESAVI, before any media action is taken.

Especially, timely and adequate management of the media and communication of the investigations, measures and implications for the safety of the vaccination program are deemed necessary. One person will be in charge for communication with the media and the general public. This will prevent conflicting information from reaching the public, which could potentially damage confidence in the program.

The crisis plan will be finalized for the worst-case scenario and depending on the severity of the situation, the EPI manager or his substitute will mobilize the necessary investigations and measures. Since Suriname is a small country, the crisis plan is concise, practical, makes use of existing systems as much as possible, and the communication lines are short. On the other hand, direct access to scarce funds and political responsible powers must be swift and effective. Therefore, official ratification of the crisis plan and installation of the response team by the Minister of Health is necessary.

A full-fledged ESAVI monitoring or surveillance system will be in place to ensure the execution of an adequate high quality EPI program. However, first the protocols, standards, flow-charts and functionality of the response must be in place to ensure prompt, adequate action and proper management of ESAVI’s. Subsequently, gradually more cases that are reported can be investigated and thus the monitoring and surveillance system will gain structure.

The reference hospital for the management of serious adverse events will be the Academic Hospital Paramaribo (AZP) since all medical disciplines needed are represented there, as well as the revalidation department and social workers.

10. Immunization monitoring system

Currently, all monitoring within the National Immunization Program of the country is being done using vaccination registration at the local level. There is a monthly reporting form that is being submitted to the main office, where this information is being input in electronic registry databases.

At the local level, the clinic submits a monthly report to the next higher level, with information that is taken from the vaccination registry. This report includes the number of persons

45 vaccinated, by vaccine, with their personalia, along with the dropouts and their present vaccination status. Furthermore, an overview is reported of the vaccines and related items received, used, and in stock. The rayon coordinator reviews and collates these reports for their rayon and submits it to the next higher level, the main office, who then officially submits its report to the NIP. The NIP enters the data in the central database for further analysis, and for reporting of use of the services, the coverage, dropout, and other routine information.

At the central level of the NIP, there are standard procedures to monitor vaccine arrival, registration in VSSM, storage, cold chain management, and distribution of needed vaccines and ancillary items to the regional level.

For the COVID-19 campaign these procedures will be adapted with the additional actions that come with the introduction of the new vaccine.

11. Disease surveillance

The current disease surveillance system existing at the Bureau of Public Health is minimally equipped to continue the regular active and passive disease surveillance in the country and perform the weekly reporting responsibilities. Currently this unit is fully engaged with the day- to-day monitoring of the COVID-19 epidemiology in the country. In their routine activities, the Epidemiology Unit works in close collaboration with the hospitals, the RGD, the MM and other public and private health providers. This collaboration will be continued and expanded as needed, to include the COVID-19 surveillance.

There are teams in charge that perform field surveillance activities according to existing procedures. Including surveillance in relation to COVID-19 these teams need update training. These teams will therefore also be part of the training preceding the campaign.

Reports of AEFI’s and AESI’s are followed up immediately and within 24 hours, by site visits and the formalities as mentioned in the ESAVI surveillance forms, and reported to the Director of Health. Adding surveillance in relation to COVID-19 campaign needs upgrade of equipment and staff.

12. Evaluation of introduction of COVID-19 vaccines

Periodic reports are already being used in the regular immunization program of the country. These are completed at the facility level, and submitted monthly to the central level. The reporting includes basic data about the persons vaccinated, vaccination doses administered to the target groups, vaccine stock balances, vaccines usage, and vaccine wastage.

Periodic evaluations to assess vaccine coverage is being done upon reporting as mentioned above. Daily reporting will be done during the campaign for immediate follow up of developments as they are reported. The vaccination team at the clinics will submit their reports on a daily basis to the Central Coordination Team, where the date will be entered (preferably) same day in the central database.

Aspects of program evaluation will be done during the course of the campaign. The focus will be more specific on the functioning of the data collection, analysis and reporting at local,

46 regional and central level. The evaluation will continue the evaluation process already in place for the regular immunization program in the country such as for the supply/cold chain system, wastage, and monitoring of the key risk populations. With the present logistics and equipment at the local, sub national and national level, it is necessary to focus on equipment, strengthening and training of these units for monitoring and evaluation.

After the campaign, consolidated reports will be submitted through the official channels to the National Coordination Team. This team, with its supporting teams, will submit the final report on the campaign. A post campaign assessment will be done to determine efficiency and lessons learned with respect to operational aspects and AEFI surveillance for example.

There are no facilities in the current evaluation practices to evaluate vaccine effectiveness or to perform impact evaluations. The Epidemiology Unit of the BOG and those responsible at the Medical Mission and the Regional Health Services will need additional staff and training to perform such evaluations, if this is really to be followed up. External collaboration through partnering with the University of Suriname and foreign Universities is one option to conduct such studies like vaccine effectiveness.

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Annex 1: Detailed budget for the COVID-19 Vaccination Campaign

The proposed budget deals with the planning, implementation, monitoring and evaluation of the COVID-19 vaccine campaign in the course of 2021 and following years, according to the availability of vaccines, and other criteria. The vaccination of the priority groups will be done according to the availability of the vaccines. The presented budget deals with the initial activities for starting up of the campaign in year 1. Follow up budgets focus on the recurrent items such as vaccines, needles, syringes, etc.

Estimated Budget COVID-19 Vaccination Phase 1 Phase 2 Phase 3 Phase 4 Total DescriptionCampaign Cost/unit Units Total Sub Units Total cost Sub Units Total cost Sub total Units Total Sub Phase 1 - cost total total cost total 4

Political priority and legal framework Planning, monitoring and evaluation meetings 500 20 10,000 20,000 10 5,000 10,000 10 5,000 10,000 10 5,000 25,000 with local leaders by administrative districts 10,000 Meetings with local and traditional leaders 500 20 10,000 10 5,000 10 5,000 10 5,000 25,000 Planning and coordination - Operational costs of the Technical Advisory 5,000 1 5,000 17,000 1 5,000 17,000 1 5,000 17,000 1 5,000 20,000 ImplementationCommission COVID19 costs Immunizationof the COVID 19 10,000 1 10,000 1 10,000 1 10,000 1 10,000 17,000 40,000 Immunization mplementing team Administrative Support Team 2,000 1 2,000 1 2,000 1 2,000 1 2,000 8,000 Biologicals and supplies - Vaccines by phase 12.60 25,72 324,075 326,315 198,374 2,499,512 2,516,2 92,620 1,167,012 1,174,832 584,7 7,367, 11,357,993 AD Syringes and needles 0.07 25,720 1,852 198,374 14,283 16 92,620 6,669 584,714 42,099394 7,416, 64,903 Safety boxes for used syringes and needles 1.20 2570 309 1,984 2,380 926 1,111 5,84714 7,017 550 10,817 Paper materials (forms, reports, etc.) (pages) 0.04 2,000 80 1,000 40 1,000 40 1,000 40 200 Cold chain - UCC Freezers for central storage 400 - 500 L - - - 72,600 ------Vaccine UCC carriers ------Vaccine freezers -20C for central storage NIP 1,000 2 2,000 ------2,000 Refrigerators for central storage NIP 1,000 10 10,000 - - - 10,000 Vaccine refrigerators for local storage RGD and 1,000 50 50,000 - - - 50,000 MM Thermos boxes for field activities 30 250 7,500 - - - 7,500 Additional Ice packs 1 200 100 - - - 100 Digital laser thermometers for temperature 30 100 3,000 - - - 3,000 checks in cold chain equipment Training - Data recording, collection and reporting 1,000 2 2,000 27,000 - - - - - 2,000

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Training of health workers 1,000 10 10,000 - - - 10,000

Training materials 1,000 10 10,000 - - - 10,000 - Trainers 500 10 5,000 - - - 5,000 Social mobilization - Production of educational, prevention and 10,000 1 10,000 89,300 1 10,000 67,950 1 10,000 87,950 1 10,000 40,000 Productionincentive materials Video's to promote institutional 2,000 10 20,000 10 20,000 10 20,000 10 20,000 87,950 80,000 Pvaccinationroduction Radioand the infomercials coverage 200 10 2,000 10 2,000 10 2,000 10 2,000 8,000 Air time radio and TV information for 1 month - 1 900 900 ------900 Days x times x broadcast TV material Air time and distribution of information material 1 450 450 ------450 Posters- Days x (2times languages) x broadcast Radio material 20 1,000 20,000 - 1,000 20,000 1,000 20,000 60,000 Pamphlets (2 languages) 2 10,00 20,000 10,000 20,000 10,000 20,000 10,00 20,000 80,000 Flyers (5 languages) 2 1,0000 2,000 1,000 2,000 1,000 2,000 1,0000 2,000 8,000 Banners (5 languages) 150 50 7,500 50 7,500 50 7,500 50 7,500 30,000 T-shirts for field teams 15 250 3,750 250 3,750 250 3,750 250 3,750 15,000 Fees sound trucks for 1 month in all resorts 30 90 2,700 90 2,700 90 2,700 90 2,700 10,800 Operating costs - Vehicle rental during implementation period 1,000 10 10,000 315,226 10 10,000 616,726 10 10,000 315,226 30 30,000 60,000 Fuel(accumulated liters 30 days) 1 1,000 1,000 5,000 5,000 1,000 1,000 3,000 3,000 770,35 10,000 Transportation of goods and persons to the 400 20 8,000 100 40,000 20 8,000 60 24,000 2 80,000 Overtimeclinics (accumulated supervisors 30 days) (average, national 100 50 5,000 100 10,000 50 5,000 150 15,000 35,000 Overtimelevel) vaccination team 3,000 30 90,000 100 300,000 30 90,000 90 270,00 750,000 Overtime Administrative team 100 30 3,000 100 10,000 30 3,000 90 9,0000 25,000 Overtime drivers 100 30 3,000 100 10,000 30 3,000 90 9,000 25,000 Transportation of personnel and supplies 400 20 8,000 80 32,000 20 8,000 60 24,000 72,000 Transportation costs Medical Mission 18,213 2 36,426 2 36,426 2 36,426 4 72,852 182,130 Transportation costs, except Medical Mission 31,800 2 63,600 2 63,600 2 63,600 4 127,20 318,000 Consumption for sessions 37,050 2 74,100 2 74,100 2 74,100 4 148,200 370,500 Disinfectants etc. 10 250 2,500 500 5,000 250 2,500 750 7,5000 17,500 Phone cards, internet 30 250 7,500 500 15,000 250 7,500 750 22,500 52,500 Internet 12 months broadband for Coordination 50 12 600 12 600 12 600 12 600 2,400 team Writing materials 10 250 2,500 500 5,000 250 2,500 750 7,500 17,500 Supervision and monitoring - Supervisory visits of coordinating teams and 500 30 15,000 25,000 60 30,000 40,000 30 15,000 25,000 90 45,000 105,000 supervisors (10 districts, average) 55,000 Rapid Coverage Monitoring (select sites) 100 100 10,000 100 10,000 100 10,000 100 10,000 40,000 Epidemiological surveillance and laboratory -

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Waste disposal boxes for used vials etc. 2 500 1,000 56,250 430 860 38,790 200 400 28,100 1,500 3,000 5,260 Waste disposal bags 1 500 500 430 430 200 200 1,500 1,500 72,000 2,630 PPE and related equipment (Gloves, masks, 250 5012,500 250 12,500 250 12,500 250 12,500 50,000 Disposablehandsanitizers,etc) gloves 1 5,000 5,000 10,000 10,000 5,000 5,000 15,00 15,000 35,000 0 Disposable face masks 1 1,000 1,000 10,000 10,000 5,000 5,000 15,00 15,000 31,000 Digital body temperature thermometers for field 25 250 6,250 - - 0 - 6,250 EunitsSAVI surveillance as needed 500 10 5,000 10 5,000 10 5,000 10 5,000 20,000 Emergency trays etc. 100 250 25,000 - - - - 200 20,000 45,000 Information systems - Development of data recording and reporting 2,000 1 2,000 98,850 1 2,000 29,100 1 2,000 29,350 1 2,000 8,000 Reportforms writing 200 10 2,000 10 2,000 10 2,000 10 2,000 29,350 8,000 Maps and manuals 100 3 300 - - 3 300 3 300 900 Desktop computer + printer incl. for 12 Rayons 1,000 20 20,000 - - - 20,000 FormsRGD and reports (pages) 0.10 500 50 1,000 100 500 50 500 50 250 Office supplies 100 250 25,000 250 25,000 250 25,000 250 25,000 100,000 Stationary, vaccination cards 0.10 450,0 45,000 - - - 45,000 00 Computers and accessories 1,500 3 4,500 - - - 4,500 ResearchNationalCoordination Team - Rapid tests as needed 20 100 2,000 3,000 100 2,000 3,000 100 2,000 3,000 100 2,000 8,000 3,000 Other related activities 1,000 1 1,000 1 1,000 1 1,000 1 1,000 4,000 Evaluation - Meetings with local and traditional leaders, all 500 20 10,000 12,000 20 10,000 12,000 20 10,000 12,000 20 10,000 40,000 districts 12,000 Other planning and evaluation meetings 100 20 2,000 20 2,000 20 2,000 20 2,000 8,000 Total 1,062,5 1,062,5 3,350,782 3,350,7 1,702,458 1,702,458 8,473, 14,588,983 41 41 82 202 8,473, Miscellaneous 10% 106,254 106,254 335,078 335,078 170,246 170,246 847,32 1,458,898 Grand Total 1,168,7 1,168,7 3,685,860 3,685,8 1,872,704 1,872,704 9,320,0 847,202 32 16,047,881 95 95 60 522 9,320,0 522

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Details PERSONNEL Technical Advisory Commission COVID 19 Vaccination Campaign p.m. Coordinators/subgroups - Human Resources - Data Management - Finances - Supplies - Transportation - Health Education - Secretariat - External Partners Representatives p.m. - Ministry of Education - Ministry of Health - Ministry of Public Works - Ministry of Regional Development - Medical Mission - RGD Overtime for p.m. - supervisors RGD and MM - Vaccination Team RGD, MM, Adm. support, drivers, - Supporting team members and coordinators - Central Administrative Team Coordinator, Adm. Support, Health TRAVELEducation, AN DataD OVERNIGHT Management, Drivers Ad hoc per diems for p.m. - National coordination team p.m. - Drivers p.m. - Field workers p.m. - Others p.m. Car Rental - X vehicles for y days Included - Gas aboveIncluded Planning meetings and trainings above - Refreshments for participant per meeting Included - Transportation cost for trainers and participants aboveIncluded Evaluation Meetings above - Refreshments for participants per meeting Included - Transportation cost for trainers and participants aboveIncluded Forms and other paper works above - Provisional vaccination cards Included - Vaccination registry forms above - Training protocols - Information letters - Attendance lists - Stock keeping forms - ESAVI reporting forms - Contra-indication reporting forms - Envelopes size x - Envelopes size y - Folders - Binders - Writing pads size x - Writing pads size y

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- Stamps and pads - Ballpoints - Copy paper Automatization - Two desktop computers + Office software - 1 Printer, laser, color - Printer toners Maps and manuals - Maps of Paramaribo - Maps of all districts - Maps of all ressorts - Flip-over paper - Flip-over board - White Board - Felt markers Cold chain equipment - Vaccine carriers - Thermos boxes - Thermometers - Ice Packs Miscellaneous - Waste disposal boxes - Waste disposal bags - Cotton rolls - Disinfectants - Hand sanitizers - Paper towels - Hand soap - Toilet paper - Telephone calls - Internet/Wi-Fi

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Annex 2: ESAVI

Crisis Plan Suriname with focus on EPI

Events Supposedly Alleged to Vaccines and immunizations (ESAVI) are not routinely reported in Suriname. At the moment, approximately two or three mild cases are reported annually to the EPI manager. However, with a functioning system in place that everyone is familiar with, this frequency is likely to increase.

In the past, when an ESAVI was reported to the NIP Manager, the Manager formed an investigation team with the then well-functioning EPI Technical Committee. In this Committee, led by the NIP Manager, the representatives came from the Epidemiology Unit of the BOG, the Medical Mission, the RGD and supported by the PAHO/WHO Immunization Program Manager, and a Pediatrician. An investigation form existed to guide the investigation. The investigation report was then sent and discussed with the Director of Health, who then informed the PAHO/WHO and other partners involved. It was the Director of Health who also was the spokesperson to the media.

With the formal appointment of the ESAVI/EAFI/EASI Committee, the final steps towards a structure and its responsibilities towards management of a reported case will be secured, as well as the needed standard operating procedures, including the needed investigation, review and reporting formats.

Case Investigation ESAVI Form

The existing case investigation form will be adapted and formalized. Following are the items in the investigation form.

GENERAL INFORMATION Notification done by Date Vaccinating facility Name of supervisor Vaccinating person/nurse Supervising Nurse Family doctor

PERSONAL DATA Patient last name Patient first name Sex Date of birth Age Weight Address: Street, Number, District

RELEVANT MEDICAL BACKGROUND PRIOR TO VACCINATION Health History Previous diseases and treatment (include cancers) Known Allergies

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Diseases of the liver Disease of the kidney Diseases of the heart or cardiovascular system Epilepsy Immunosuppressive diseases Treatment with corticosteroids Autoimmune diseases Family history of diseases Nutritional status General Health Status Specialist reference Living conditions

VACCINATION DATA Vaccine given Manufacturer Where injected Lot/batch nr. Expiry date Name and location of facility where vaccinated Vaccination site (on body) Date and time of vaccination Syringe/needle brand name Expiry date syringe/needle Dates of previously received doses Other vaccinations received at the same time? Y/N If yes, names, batch numbers, and expiry dates

MEDICATION PRIOR TO VACCINATION

DESCRIPTION OF THE ESAVI Date and time of onset Date of vaccination Date of report of ESAVI Describe further progress of the ESAVI Admitted in hospital? Y/N If yes, diagnosis Death? Y/N If yes, date of death Location of death

REACTIONS OBSERVED DATE OFONSET DURATION OF REACTION Fever Diarrhea Vomiting

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Fatigue/malaise/lethargy Add here known side effects ofCOVID-19

Irritability Coughing Exanthema Swelling Redness Pain Headache Muscle pain Convulsions Add here known side effects ofCOVID-19 Fainting or unconsciousness Anaphylactic reaction Angioedema Urticaria Paralysis Nausea Joint paints Other

Actions taken/medication/therapy when symptoms seen When made contact with clinic/hospital

PROGRESS OF THE ESAVI Doctor who treated What treatment given Medication Resuscitation Patient recovered Patient hospitalized Patient died

TESTS POST ESAVI Lab tests PA/Postmortem Result

INSPECTION VACCINATION SITE Date Responsible doctor Responsible nurse for vaccination program

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Health worker who provided the vaccination Interview with the responsible nurse Description of vaccination locality/site Information provided to recipient on vaccination receiving Information provided to recipient about other possible adverse reactions What information is given when adverse reactions happen Location where vaccine was given Route of administration of vaccine. Dose Is vaccine drawn before the person is seen

Syringes/Needles How are syringes/needles stocked Syringes/needles used other than those provided by the immunization program Open packaging syringes/needles are used in next sessions Brand/expiry date syringes/needles Visual check of storage facility of syringes/needles Cooling (AC available) Sterile practices used when handling vials, syringes, needles, area of injection

COLD CHAIN How is vaccine stocking done Vaccine transported in correct manner to clinic Inspection of the refrigerator Is the area prone to power outages Check fridge temperature charts Location of where the fridge is placed Check power line and plug Fridge placed level

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Fridge placed in direct sunlight or near heat source Door rubbers functioning Ice forming in Freezer If ice forming, thickness How many ice packs in freezer Status of ice packs Temperature in the fridge How are Diluents and vaccines kept in the fridge Quantity of vaccines in stock, by vaccine, expiry date Other items being kept in fridge Inspection of vaccine carrier Where and how is vaccine carrier stored Carrier being wiped dry after use Tear signs in/on carrier

HOUSE VISIT Date Interview with family Family status Family background Recent clinical history of family Information on other recipients of same vaccine batch including those vaccinated at the same facility on the same day

CONCLUSION Place of vaccination Process of vaccination

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Annex 3: Terms of Reference for the National Coordination Team

The group that will be responsible for the planning, distribution, implementation, security, evaluation and reporting will consist of four teams.

1. The National Coordination Team with representatives from: - BOG - RGD - Medical Mission - Ministry of Regional Development - Ministry of Public Works - Ministry of Education - Ministry of Justice and Police - Ministry of Health Tasks: - Develop a work plan and financial budgets (national and regional) - Organize planning meetings with key persons and organizations - Mobilize political-administrative contribution - Mobilize human resources - Public information and education - Train the teams - Write the handbook for the field work - Coordinate the distribution of all needed inventory: vaccines, syringes, needles, vaccination cards, reporting forms, etc. - Monitor the progress of the campaign - Manage inter-sectoral coordination - Manage the finances - Manage centralized collection, consolidation and analysis of data - Organize evaluation meetings - Write the end-report

There will be sub-commissions within the National Coordination Team for: - Personnel: mobilization, training, evaluation - Finances: budgeting, budget management, coordination of payments to service providers and personnel - Information/Education: development and dissemination of information material - Transportation: mobilization of transportation, transport schedules - Supplies: Purchasing, stock management, materials for the teams and locations - Meetings and reports: keeping notes of meetings, consolidation of reports by supervisors, consolidation of administrative information, and supervision of end report. - Coordination of contact with external organizations, mobilization of private sector, donations, sponsoring

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2. The Implementation Team with the rayon coordinators in the clinics of the MM, RGD, BOG and the hospitals.

Tasks: - Coordinate the day-to-day activities in their clinics and communicate with the National Coordination Team and the field - Secure supplies and logistics for their clinics - Manage needed supplies (vaccines, education material, forms, etc.) - Collect vaccination forms from the field Implementation Team and submit to the National Coordination Team - Develop a workplan for the clinic - Develop a work schedule for the field workers - Supervise and support the teams of field workers - Keep an attendance list - Identify and communicate with local authorities and external partners - Collect and manage waste material - Identify and solve problems to secure continuation of the campaign - Organize day to day evaluation sessions with field team - Take notes and produce reports of meetings - Pay field workers, service providers - Draft the end report for the resort

3. Central Administrative Team at the BOG

Formed by - The Coordinator of the National Coordination Team - The Secretary of the National Coordination Team - The stock/supply manager of the National immunization Program - The National Immunization Program Manager - The Health Education Unit of the BOG - The Coordinator Data Management at BOG - The Financial Administrator of BOG - Two administrative supports - Two drivers

Tasks - Distribute supplies to the Implementation Teams at MM and RGD - Collect vaccination forms from the Implementation Teams - Input of vaccination data in electronic format - Keep communication with providers and with the media on production and publication of messages and information - Produce financial overviews of activities and prepare payment documents to service providers, field workers - Pay service providers, in collaboration with the supervisors - Coordinate waste management - Monitor cold chain with the Implementation Team

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4. The Vaccination Teams at the health facilities

Each health facility has a Vaccination Team led by the Nursing Coordinator of the facility, with the support of three vaccinators, 1 administrative support, and a driver (depending on the size of the facility). Medical-technical backup will be available at the facility when needed.

Tasks: - Prepare the facility for the vaccination - Monitor the supplies needed and the cold chain - Register the visitors coming for vaccination, registration of vaccinations given and issuing a vaccination card - Vaccinate the people - Report any issues experienced to the Rayon Coordinator - Provide information flyers, pamphlets, etc. - Monitor safe collection and disposal of waste material

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Annex 4: Implementation Plan

Implementation plan COVID-19 Vaccination Campaign 2021 2022 2023 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Fe Ma Apr May Jun Jul Aug Sep Oct Nov Dec Preliminary activities (see next pages) b r Vaccine Arrival Phase 1: Groups Vaccination first round 1 - 4 Vaccination Second

DataRound Analysis and

Phase 2: Group 5 VaccinationEvaluation first round Depending on Vaccination Second

vaccine DataRound Analysis and availability Phaseavailability 3: Groups 6 VaccinationEvaluation first round -8 Depending on Vaccination Second vaccine DataRound Analysis and Phaseavailabilty 4: Group 9 VaccinationEvaluation first round Depending on Vaccination Second vaccine DataRound Analysis and availability Evaluation Data analysis and report writing onDependingvaccine To be programmed depending on vaccine availability

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Preliminary activities prior to vaccination campaign

• Formalize the status of the National Coordination Team, the Implementation Team, the Central Administrative Team and the Vaccination team. • Activate NITAG • Formalize ESAVI Response Team and Review Team • National Fund operational. Fundraising activities ongoing • Finalize protocols and forms o ESAVI reporting, surveillance, response o Registration form for vaccine receiving person o Pre-vaccination screening o Field surveillance o Monitoring o Evaluation o Vaccine receiving o Vaccine returning o Vaccination cards o Protocols for supervisors, team leaders and vaccinators o Other • Secure needs for the vaccination sessions: vaccines, syringes, needles, cold chain equipment, etc. • Organize technical-planning meetings with all collaborating partners, national, district and resort authorities, local/ tribal/village authorities, media and other Ministries involved. • Organize transportation for vaccine distribution and for personnel • Identify and secure the availability of vaccines and related supplies • Identify and secure finances • Identify the vaccination centers: fixed, mobile, outreach • Identify the vaccination teams • Organize trainings for coordinators/supervisors/field vaccinators/ administrative support team trainings • Officially communicate with the vaccination centers, elderly homes, etc. about the campaign and their input …etc. • Plan for campaign dates, places, teams, transport, distribution, • Decide and procure table 5 inventory per team • Secure Inventory for vaccination site • Pre vaccination checklist • Public service announcements • Public communication re COVID-19 and vaccination campaign • Produce and distribute communication, information and education materials • Finalize a plan for safe waste disposal • Instructions to health facilities regarding adverse events and reporting • Rubber stamps designed for the campaign + pads • Purchase of paper material: envelopes, files, folders, writing pads, writing materials, printing paper, white boards, flip-over papers and boards, felt pens, • Secure/purchase of two desktop computers + one laser printer (color) + toners • Start media campaign

Implementation Week • Distribute vaccines and related items • Continue media campaign • Official start of the campaign, to be implemented simultaneously all over the country?

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• Field surveillance, orientations • Daily debriefings of National Coordination team • Respond to eventualities as reported, AEFI/AESI/ESAVI and solve issues reported • Continued communication between teams • Collect data forms from teams • Input of data in electronic format • Return unopened, unused, etc. vials • Safe waste management practices • Day before campaign: Distribution of vaccines • After vaccination: return unused/open vials

Evaluation Weeks • Evaluation meetings with National Coordination Team, Implementation Team, Administrative Team and others • Consolidation of all forms, reports • Payment of providers • Finalization of data input, analysis and reporting • Mop-up campaign. If necessary, other strategies will be applied, such as outreach activities.

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