Preparing for COVID-19 vaccine roll-out through simulation exercises.

As the COVID-19 pandemic reached over 97 million cases and exceeded 2 million deaths globally only 1 year after its emergence, several candidate vaccines have shown promising efficacy and safety profiles, with some already approved for emergency use and rolled out globally.

At this juncture, it is critical that the national deployment and vaccination plans are carefully crafted as recommended in the WHO guidance on developing a national deployment and vaccination plans for COVID-19 vaccines. Countries need to be ready to carry out unprecedented mass vaccination, including having procedures in place for national regulatory agencies to approve vaccines for emergency use; coordination systems between national regulatory agencies and import control entities; communication strategies to address rumours and misinformation to combat vaccine hesitancy; systems for the monitoring and management of adverse events following immunisation; and logistics and delivery systems for maintaining cold chains.

To ensure countries have the best chance of a successful COVID-19 vaccine deployment, WHO with COVAX partners including UNICEF have developed two COVID-19 vaccine-specific tabletop exercise simulation packages to test planning assumptions before national vaccine roll-out. The first exercise focuses on regulatory and safety issues so that countries can test their regulatory frameworks and systems for granting the emergency approval of vaccines or exploring how they might rely on WHO's prequalification and emergency use listing, as well as procedures and oversight for monitoring vaccine safety after it is deployed. The participants could be from national regulatory agencies, medical standards and regulations agencies, and departments for monitoring the safety of new vaccines post-introduction. The second tabletop exercise focuses on strategy, supply chain, and communications to help countries identify the target populations and test vaccination strategies, manage supply chains, and prepare communication plans to promote vaccine acceptance and uptake. The participants could be decision-makers, logisticians, warehouse managers, freight services personnel, communication specialists, vaccinators, health promotion and behaviour change specialists, and community leaders. For both exercises, the participants will represent their actual roles and respond as if in a real situation.

The two vaccine tabletop exercises developed should be customised to mimic the country context as realistically as possible. To begin, the facilitators will first introduce the exercise and the specific purpose, scope, and objectives. As the simulated scenario evolves over the course of the exercise, open-ended questions and problem statements will be used to provoke constructive discussion of what actions participants might take in line with the national deployment and vaccination plans. At the end of the exercise, a debrief will be done to identify strengths and bottlenecks and propose recommendations, which should be developed into an action plan to enhance the existing vaccine deployment plan.

To complement these national vaccine-specific tabletop exercises, the exercises should also be done at the global and regional levels. These global and regional simulations will have a different purpose, scope, and objectives and could involve other stakeholders. However, they are important to ensure that vaccines are delivered correctly and are disseminated as planned. These targeted exercises will help support the coordination of global vaccine procurement and distribution managed by the wider international community.

In addition to testing the system before vaccination launch, for new vaccines, WHO also recommends a post-introduction evaluation to be done 6–12 months after their introduction. Given COVID-19 vaccines have been developed and approved in an expedited manner with mass vaccination planned or already underway, continual review of vaccine deployment is vital as various vaccines are rolled out. Therefore, WHO has collaborated with the group responsible for the post-introduction evaluation of new vaccines within the COVAX working group to develop the vaccination component for the country COVID-19 intra-action review.8, 9 Frequent review of this component can allow the close monitoring of vaccine roll-out and prompt actions to address obstacles encountered. The findings from these intra-action reviews can then feed into the post-introduction evaluation.

As the pandemic evolves, it is key that countries take a comprehensive approach to test and fine-tune their national deployment and vaccination plans before vaccine deployment using tabletop exercise at all levels, conduct regular intra-action reviews during vaccine roll-out, especially with variants emerging that might reduce vaccine efficacy, before the post-introduction evaluation. This recommendation is in line with the sixth meeting of the Emergency Committee under the International Health Regulations of Jan 14, 2021, which recommended state parties to “Prepare for COVID-19 vaccine introduction and post-introduction evaluation using the guidance, tools, and trainings for national/subnational focal points and health workers developed by the Access to COVID-19 Tools (ACT) Accelerator's Country Readiness and Delivery workstream”.

Both vaccine-specific tabletop exercises and intra-action review adopt a whole-of-society approach that involves different sectors of the government, private and public sectors, community organisations, and academia to conduct studies to understand vaccine hesitancy and how to promote positive behaviour change. Hence, being one of the biggest vaccination endeavours in history, everyone needs to be on board. By working together, being prepared, and staying one step ahead, we can prevail in the fight against COVID-19.