Best Practices and Lessons Learned from Implementing a Massive Ebola Vaccination Program: Summarizing UMURINZI Team Experience

"A rigorously designed community awareness and sensitization program that gets community members and leadership involved as well as respects their values and cultures could be effective during the implementation of similar programs in any resource-limited setting."

In December 2019, the Rwandan Ministry of Health officially launched an Ebola vaccination programme - UMURINZI - Unprecedented Movement to drive a Unified Rwandan Initiative for National EBOLA Immunization - in an effort to protect the population against Ebola Virus Disease (EVD) through the Ad26.ZEBOV (first dose) and MVA-BN®-Filo (second dose) vaccines. This article examines the community engagement component of UMURINZI as it was carried out in the Rubavu and Rusizi districts of Rwanda. It documents best practices and lessons learned to inform policymakers and those implementing similar programmes in Rwanda and globally.

The first day of the December 2019 campaign was launched with an introductory workshop. Among the 50 people who were invited for vaccination on that first vaccination day were well-known, influential individuals such as leaders of associations, local government authorities, and local health authorities. In total, 216,321 people had accepted invitations to receive the second dose by the end of the programme in September 2021.

To suport this vaccination campaign, UMURINZI's community engagement approach aimed to create a supportive environment and positive behaviour change amongst the communities at risk of an Ebola infection outbreak. Specifically, the community engagement strategy was designed to: mobilise the priority population to receive vaccination; manage the recruitment process to ensure that the flow of potential vaccine recipients did not exceed daily per-site capacity; and foster a conducive environment for voluntary participation in the vaccination campaign by addressing rumours, building community trust, and providing accurate information about risk and prevention strategies. The strategy involved maximising opportunities for dialog, consultation, and formation of authentic partnerships and aimed to be mindful and respectful of the social, cultural, and political realities of the individual communities alongside the border with the Democratic Republic of Congo (DRC).

Before the implementation of the UMIRINZI programme, a community engagement guide that covered programme sensitisation, community mobilisation, volunteer recruitment and follow-up, and retention strategies was developed. Using this tool, 2 approaches were used to recruit volunteers (2 years of age and above) deemed to be at risk for EVD: people who frequently cross Rwanda and the Democratic Republic of Congo borders, potential first responders who have not previously been vaccinated against EVD, and people who reside in high-risk border-proximate areas of the Rubavu and Rusizi districts. Recruitment at the sites was conducted in close collaboration with each health area's community health workers (CHWs). Volunteers were informed that the programme involved being fully vaccinated (2 doses of Ebola vaccines) within 2 months apart in the allocated vaccination sites.

Mobilisers identified association members who met the programme's behavioural inclusion criteria (routine border crossing and/or working at border sites) and thus were included in the programme. Association-level meetings were held to mobilise these groups for vaccination and to schedule appointments/issue invitations. Leaders of the association collaborated in the scheduling of members of the association to ensure a smooth and fair process. From these associations, and through active community engagement and outreach activities, community members became aware of the programme and then voluntarily communicated when they were available to visit the vaccination sites. The programme started with few vaccination sites but, as it scaled up, additional vaccination sites were opened.

Lessons learned throughout this experience can be categorised into 4 pillars:

1. Infrastructure: UMURINZI used brick-and-mortar buildings or tents to accommodate operations, staff, and volunteers. At times, locations had a high daily attendance beyond expectations, causing people to wait for long hours and return to their homes without being vaccinated that day. It is necessary to anticipate such issues and work to address them.
2. Leadership: Key leaders' involvement and visibility created and maintained a supportive environment for citizens who were volunteering to receive the vaccine, as they are trusted and believed to lend their support only to what is good for the citizens.
3. Myths: Myths arose within the community, since the Ebola vaccination was a novel preventive option. For example, some said that, following the Ebola vaccination, volunteers would become infected with the Ebola virus. Social mobilisation efforts by programme managers, CHWs, and community advisory groups actively helped to mitigate some of the myths. The fact that Rwandans normally have a high rate of vaccine acceptance, demand, and uptake, as well as the trust they have for their leaders, might have influenced the dismissal of these myths.
4. Partnership with respect: Stakeholder involvement throughout the implementation of the UMURINZI programme was essential. For example, the partnership created between Projet San Francisco and Rinda Ubuzima supported the programme's awareness and sensitisation efforts. One of the suggested and used strategies was recruiting programme staff from within the programme communities.

Best practices include:

• Collaboration with CHWs: CHWs in Rwanda are a trusted channel by community members within their respective communities. They leveraged a variety of outreach strategies, including village-level mobilisation meetings, meetings of associations/clubs in target areas, and home visits.
• Involvement of national and local leaders: For example, with the aid of local leaders (from the district level to the village level), meetings were organised to facilitate the flow of communication between the programme and the community, hence increasing the population's understanding of the UMURINZI programme.
• Use of a comprehensive engagement plan: For example, in addition to mass media communications, group-based mobilisation meetings were held with sub-groups of the intended population (e.g., faith-based organisations and parents' groups).
• Training: For example, training equipped partner organisations with all the information, education, communication (IEC) materials and processes required for successful community engagement. Overall, training was essential to the empowerment of UMURINZI staff and volunteers to promote trust and confidence in the vaccination campaign.
• Resource mobilisation: For example, flyers were produced for education, street banners were pinned on strategic sites such as marketplaces and bus stations, flip charts and brochures were given to health centres with information about the UMURINZI programme, megaphones and billboards were used to spread the word, and radio and television spots were broadcast. These resources created awareness of the programme and helped ensure adherence to vaccination.

"Although the lessons learned and best practices were specific to the context of the Ebola prevention strategy in Rwanda, some of the principles behind it may be transferable to similar mass community engagement programs."