The Intra-Action Review (IAR) was an important exercise that have reviewed the South Sudan Coronavirus disease-2019 (COVID-19) national preparedness and response best practices and challenges, and developed recommendations to maintain and institutionalized best practices and address challenges.The IAR reviewed the COVID-19 vaccination deployment and roll-out process, epidemiology and surveillance, and laboratory testing capacity at the national and sub-national levels. The review was conducted in two days (05-06 August 2021) using the World Health Organization (WHO) working group IAR methodology. The participants of this COVID-19 IAR were drawn from partners and government agencies at all levels who are currently involved in COVID-19 vaccination, epidemiology and surveillance and laboratory testing in South Sudan. The review involved an interactive, structured methodology using user-friendly materials and interactive facilitation techniques both onsite and online. Three virtual breakout rooms (vaccination, surveillance, and laboratory) and one common platform were created to facilitate the interaction between onsite and online participants.
During the review exercise, several best practices and challenges were identified leading to the development of appropriate actions that would be implemented immediately, and in the mid to long-term periods. The best practices include: availability of surveillance system – Early Warning, Alert and Response System (EWARS) for Acute Respiratory Tract Infection (ARI) alert reporting and verification; regular daily and weekly briefings among COVID-19 response team; activation and reformation of Rapid Response Teams (RRTs) at national and sub-national levels; contact tracing formation and activation; availability of teams to conduct contact listing and follow-up (for the epidemiology and surveillance pillar); availability of sample management SOPs; trained laboratory staff at all levels with well structured modules and professional experts; monitoring of quality of testing in the private laboratories by the National Public Health Laboratory (NPHL); decentralization of COVID-19 testing to the states through repurposing of GeneXpert machines to test for COVID-19; efficient stock management system that prevented stock out of reagents and other consumables (for the laboratory pillar); effective vaccaination planning from the Ministry of Health (MoH) in coordination with partners culminating in the development of the National Deployment and Vaccination Plan (NDVP); development of vaccine distribution plan based on approved microplan and prioritized health facilities (mapping) endorsed by the MOH; leveraging of existing supply chain infrastructure (Partnership approach with United Nations Humanitarian Air Services (UNHAS)) to deliver the vaccine with Standard Operating Procedures (SoPs); and, joint supportive supervision visits conducted by MOH, and partners especially for pilot hosptials and health facilities in Juba (for the vaccination pillar).
The challenges identified includes: not all community calls successfully connected to the call center; denial of results by patients thus resulting in provision of wrong numbers/physical addresses; community screening and testing are hindered due to shortage of funding to support the sentinel surveillance sites; limited number of cases detected through the existing health system, health care facilities and community surveillance system (for the epidemiology and surveillance pillar); lack of quality assurance system at GeneXpert sites for COVID-19 testing; trained laboratory staff deserted the National Public Health Laboratory (NPHL) in search of better paying jobs especially following the opening of private COVID-19 testing laboratory in Juba; lack of in-country COVID-19 genomic-sequencing surveillance capacity; donation of laboratory commodities with short expiry duration, including Antigen Rapid Diagnostic Testing (Ag-RDT) kits (for the laboratory pillar); non-completion of Adverse Event Following Immunization (AEFI) reporting forms for serious and non-serious AEFIs; inadequate supervision to monitor data quality; non allocation of funds for supportive supervision; lack of training handouts for vaccinator trainees; and, non inclusion in the COVID-19 Technical Team of members from the Drug and Food Control Authority (DFCA) from whom regulatory support was not available regularly (see table below). The respective technical working groups with MoH leadership developed recommendations and a way forward for the implementation of the recommendations. The recommendations include: enhance risk communication and community engagement to increase alert notification, investigation and contact tracing; increase the number of hotline service providers by engaging new telecommunication companies such as Digitel to accommodate increased calls; procure additional phones with long-lasting battery; strengthen daily and weekly response briefings at national and sub-national levels; institutionalize the concept of RRTs to respond to all hazards; establish COVID-19 information management and data flow through the District Health Information System (DHIS2) platform; train RRT and contact tracing team on data management tools including Case Investigation Form (CIF); enhance coordination within and between pillars; enhance community testing to determine the level of transmission at sentinel surveillance and GeneXpert sites (for the epidemiology and surveillance pillar); roll out Antigen Rapid Diagnostic Test (Ag-RDT); mobilize funds to support the COVID-19 laboratory human resources; enroll GeneXpert sites into the DHIS2 or E-governance platform; establish quality assurance system for the Polymerases Chain Reaction (PCR), GeneXpert and Ag RDT platforms; establish genomic surveillance capacity in South Sudan (for the laboratory pillar); conduct surveys and research to explore community and health workers’ perception on COVID-19 vaccination; establish national and state AEFI committees; engage with the Drug and Food Control Authority (DFCA) on their roles in vaccine pharmacovigilance including reporting AEFI; scale up vaccination in 80 Counties; and, integrate COVID-19 vaccination in Routine Immunization (RI) services (for the vaccination pillar (see the table below).
The COVID-19 Vaccination, Surveillance, and Laboratory Technical Working Groups (TWGs) lead and co-leads will continue working with the National Steering Committee (NSC) secretariat to institutionalize the best practices; address challenges and implement prioritized recommendations in the immediate and medium to long term to improve preparedness and response. Moreover, the state ministry of health and partners were part of the IAR process; hence, the final IAR report will be shared with them to oversee and monitor the implementation of the recommendations. The IAR report incorporated a timeline and indicators to monitor the progress of implementation and provide timely feedback.