Effective Integration of COVID-19 Vaccination with Routine Immunization: A Case Study from Kinshasa, DRC

"Targeted demand generation by community health workers drove immunization success."

In the Democratic Republic of the Congo (DRC), characterised by high numbers of zero-dose children, the COVID-19 pandemic posed a severe risk of eroding the progress made in vaccine coverage, thereby increasing the vulnerability to vaccine-preventable diseases amidst the ongoing health crisis. In response, VillageReach, in collaboration with the Ministry of Public Health Prevention and Hygiene in Kinshasa, DRC, integrated COVID-19 vaccination with routine immunisation (RI) services at two primary healthcare facilities (HFs). Through a rapid appraisal involving key informant interviews and analysis of pre- and post-integration service delivery data, this case study explores the operational dynamics and outcomes of VillageReach's multimodal approach to immunisation in the DRC.

In June 2022, VillageReach initiated the integration of COVID-19 vaccination into government HFs already offering routine vaccines. This initiative leveraged the infrastructure and trust established to achieve two primary objectives: enhance overall vaccine coverage and specifically target zero-dose and under-vaccinated children by utilising COVID-19 vaccination resources. The approach centred around three additional standalone fixed sites in densely populated areas (allowing for the simultaneous promotion of RI and COVID-19 vaccines), a network of outreach vaccination sessions in high-traffic community areas, and door-to-door vaccine promotion conducted by community health workers (CHWs) to engage communities directly in their homes, raising vaccine awareness and identifying individuals eligible for vaccination, with a particular emphasis on reaching zero-dose and under-immunised children. These CHWs played a crucial role in community mobilisation and sensitisation, distributing tokens to track referrals. These CHW referrals remained a cornerstone for vaccine delivery, showcasing the trust and reliance placed in community networks.

To explore the role of this integrated approach within the health system and the process of transferring this approach to a government facility, quantitative data collection was complemented by key informant interviews with staff and management from both the multimodal initiative and the integrated HFs.

Overall, the vaccination sites, outreach, and integrated HFs administered 229,983 (33%) of COVID-19 vaccines in Kinshasa, of which 53% were referred by CHWs. Results demonstrated that the integrated approach not only maintained COVID-19 vaccine coverage but also significantly enhanced RI uptake, particularly among under-immunised and zero-dose children: 998 under-immunised children received RI, of whom 126 were zero-dose children.

Key success factors included sustained CHW engagement, localised strategies, accessible vaccination points, and robust data management. For instance, leveraging their established trust and connections within communities, CHWs' ability to engage with communities, including those with a strong mistrust of vaccines - highlighted in specific instances like church communities resistant to vaccination - was instrumental. CHWs' neighbourhood-specific strategies and their agility in allocating outreach sessions to areas with identified under-immunised or zero-dose children facilitated increased vaccine access, underscoring the importance of community-based health workers in vaccination campaigns. Adequate training, support, and remuneration is critical in sustaining CHW motivation and effectiveness in community engagement and sensitisation efforts.

In conclusion: "The findings suggest that such integrative strategies can effectively bolster immunization coverage in urban poor communities, offering valuable insights for similar initiatives in the DRC and beyond."