key: cord-0838139-pdd4yxdy
authors: Al-Shaikh, Ala'a; Muthu, Nazeema; Aidyralieva, Chinara; Cristina Profili, Maria; Bellizzi, Saverio
title: COVID-19 vaccine roll-out in middle-income countries: lessons learned from the Jordan experience
date: 2021-06-29
journal: Vaccine
DOI: 10.1016/j.vaccine.2021.06.078
sha: e2042995f34ccc0fd000ac2a15880c43e152d08e
doc_id: 838139
cord_uid: pdd4yxdy

nan

Jordan is an upper-middle income country which was dramatically affected by two waves of COVID-19, the first wave in November 2020 and the second peaking mid-to-late March 2021.

The country has developed its first National preparedness and response plan even before the first case of COVID-19 had been reported and has been being updating periodically. Similarly, Jordan has developed an effective plan for COVID-19 vaccine roll-out, thereby starting the registration to vaccination during late 2020. The aim of the vaccination program was changed from vaccinating 20% of the population to vaccinate over 5 million residents, corresponding to over 80% of the total population over the age of 18 years. Securing bilateral agreements and the ability to ensure additional vaccine supplies enabled the country to increase its vaccination target. Similar to equitable COVID-19 response in Jordan, COVID-19 vaccination plan includes all population, including refugees and migrants.

The National Immunization Program (NIP) of Jordan is one of the most effective and successful public health programs which is highly trusted by the public. Country has reported immunization coverage rates over 90% for all vaccines during pre-COVID-19 period. A recent survey conducted by the World Bank reported that a country's ability to roll out mass adult vaccination programs doesn't depend on the existence of a well-functioning childhood immunization system [1] . This is evident through the recently established electronic registration, reporting, and monitoring system for COVID-19 vaccination. While childhood immunization is still relying on a paper-based vaccination electronic system, the COVID-19 vaccination data system is built on a solid electronic registration system, with minimal data entry.

The national collaborative efforts and coordination mechanism was started early amid the planning phase by establishing a multi-sectorial COVID-19 vaccination National Coordinating 

The prioritization of target population was built on WHO Strategic Advisory Group of Experts on Immunization (SAGE) recommended values framework of human well-being, equal respect, national equity, reciprocity, and legitimacy. Endorsed by the National Immunization Technical Advisory Group (NITAG), the NDVP had 11 tiers prioritizing frontline healthcare workers, elderly healthcare workers, elderly population, chronic illnesses patients and essential workers

Prior and throughout implementation, the Government of Jordan (GoJ) conducted various surveys and studies to better appreciate vaccine acceptance and help counter rumors and generate vaccination demand. one of the surveys which reported barriers in accessing the electronic registration system by elderly population and those with limited education, has enabled the initiation of a hotline to combat restricted access to the registration platform. Results of few other studies have increased the rescheduling of missed appointments and the tailoring of communication messages to motivate younger generation to register their elderly at-risk family members. Moreover, the weekly monitoring report enabled decision-makers to determine equitable distribution of vaccines to all gender, class and at-risk population. For example, following the early weeks of vaccine roll-out, the registration and vaccination among noncommunicable diseases (NCD) patients was unsatisfactory. As they are the most vulnerable and prioritized population for vaccination, a specialized well-trained team contacted NCDs patients' and one-to-one counselling was provided to increase their vaccine acceptance and help combat misinformation which led to increased vaccine confidence and accordingly registrations.

National equity was among the most important factors distinguishing the NDVP and vaccine roll-out. From day one, all people residing in Jordan were part of the COVID-19 response, regardless of their nationality and citizenship status. This translated into refugees, regular and irregular migrants being specifically mentioned in the NDVP. Moreover, the GoJ assured that no irregular migrant will be excluded from vaccination, due to registering on the electronic COVID-19 vaccination platform. This led to similar vaccinated proportion among refugees, migrants and expats compared to Jordanians. Over 124 nationalities in the electronic registration platform, and subsequently were vaccinated. International service providers are fully supportive to GoJ in reaching out to irregular migrants to increase their registration and vaccination. However, a nationwide strategy to reach these irregular migrants is required, as they often live in overcrowded living conditions and low socioeconomic status.

GoJ also activated several mobile teams to enable the vaccination of the population with restricted access at the comfort of their houses in addition to elderly care-homes. Moreover, the NDVP carefully considered geographical distances and population density in the distribution of vaccination centers which led to establishment of over 85 vaccination centers across the urban and rural areas of the country. Jordan also allocated a specific vaccination day for people with disability.

Jordan started their COVID-19 vaccination program on January 13 th , 2021 with the registration starting on December 24 th 2020. During the first month of registration over 300 thousand registered through the electronic platform. This was followed by a decrease in daily registration in February with an average of only 2,000-3,000 daily registration. With the increase in reported cases and hospitalization in March, the registration process regained its momentum reaching a daily registration of over 25,000 by mid-March, reaching to 1.4 million overall registrations in April. Seeing the increase in acceptance and hence the registration, Jordan increased the number of first dose vaccinations by extending the interval between vaccine doses to 12 weeks for AstraZeneca and 6 weeks for Pfizer BioNTech vaccine. This came in accordance with SAGE interim guidance that the interval may be extended to a certain limit to maximize population receiving one dose [3, 4] , the availability of vaccines and planned procurement.

Building on the value of reciprocity and in order to enable resilience in the healthcare systemallowing it to respond to the pandemic growing needs but also to routine health services, healthcare workers were targeted through open vaccination days that enabled all private and public sector healthcare providers to walk-in and get vaccinated.

COVID-19 has created an opportunity to health sector in all countries across the world to address the gaps in service delivery and demand side. Jordan's successful experience in COVID-19 vaccine roll-out could provide a number of lessons for other lower-and middle-income countries in Eastern Mediterranean region and at the global level. "A country heavily affected by refugee crisis for decades and surrounded by countries enduring conflict, Jordan was at high threat of transmission from neighboring countries which have the highest mortality rates in the region. However, effective decision making and coordination with multi-sectoral partners, including private sectors has remarkably achieved equality in vaccine distribution.

Further, the country has used this opportunity to improve the cold chain inventory, including temperature monitoring. Electronic documentation and recording system which was developed for COVID-19 vaccination could be applied for routine immunization to build a harmonized data system for national immunization programme. Nonetheless, this significant outcome needs to be holistically approached in order to enable sustainability in terms of service provision and multisectoral collaboration which would positively strengthen the healthcare system and its resilience.

The World Bank. ASSESSING COUNTRY READINESS FOR COVID-19 VACCINES: FIRST INSIGHTS FROM THE ASSESSMENT ROLLOUT

Readiness-for-COVID-19-Vaccines-First-Insights-from-the-Assessment-Rollout.pdf 2. World Health Organization. WHO SAGE values framework for the allocation and prioritization of COVID-19 vaccination

World Health Organization. Interim recommendations for use of the AZD1222 (ChAdOx1-S (recombinant)) vaccine against COVID-19 developed by Oxford University and AstraZeneca

World Health Organization. Interim recommendations for use of the Pfizer-BioNTech COVID-19 vaccine, BNT162b2, under Emergency Use Listing. 2021. Declaration of interests

Dr Aidyralieva, Dr Profili, and Dr Bellizzi are all technical officers working for the Jordan WHO Country Office, which actively supported the Jordan Ministry of Health in the planning of the National COVID-19 Deployment and Vaccination Plan

All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work