Foa_Content_of_CDC-RFA-GH-24-0058 (2).pdf

Signature Date

Centers for Disease Control and Prevention

Center for Global Health

Strengthening immunization program implementation in sub-national consequential geographies

CDC-RFA-GH-24-0058

03/04/2024

Table of Contents A. Funding Opportunity Description

B. Award Information

C. Eligibility Information

D. Application and Submission Information

E. Review and Selection Process

F. Award Administration Information

G. Agency Contacts

H. Other Information

I. Glossary

Part I. Overview Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA- GH-24-0058. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) B. Notice of Funding Opportunity (NOFO) Title:

Strengthening immunization program implementation in sub-national consequential geographies C. Announcement Type: New - Type 1:

This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For purposes of this NOFO, research is defined as set forth in 45 CFR 75.2 and, for further clarity, as set forth in 42 CFR 52.2 (see eCFR :: 45 CFR 75.2 -- Definitions and https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR- 2007-title42-vol1-sec52-2.pdf. In addition, for purposes of research involving human subjects and available exceptions for public health activities, please see 45 CFR 46.102(l) (https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section- 46.102#p-46.102(l)).

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-GH-24-0058

E. Assistance Listings Number:

93.318 F. Dates:

1. Due Date for Letter of Intent (LOI):

01/26/2024 https://www.grants.gov/ https://www.grants.gov/ https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section-46.102#p-46.102(l) https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-A/part-46/subpart-A/section-46.102#p-46.102(l)

Recommended but not Required A Letter of Intent (LOI) is requested but not required. The purpose of an LOI is to allow CDC program staff to estimate the number of and plan for the review of submitted applications. If known, the LOI should include the country component(s) to which the applicant will apply.

LOI must be sent via email to:

Karen Clackum

CDC, CGH

Email address: KClackum@cdc.gov

2. Due Date for Applications:

03/04/2024 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call CDC will host two informational calls for interested applicants. The content of both calls will be identical. Questions and answers from each session will be compiled and amended in the NOFO.

The two times are offered as a way to help accommodate the schedules of interested applicants and their locations in varying time zones. Due to limited space, applicants should only register for Webinar 1 or 2, but not both.

▪ When: Jan 17, 2024 8:00 AM Eastern Time (US and Canada)

▪ Topic: Informational Call #1 - NOFO CDC-RFA-GH-24-0058

▪ Register in advance for this webinar:

https://cdc.zoomgov.com/webinar/register/WN_1eM6P8ROScyZKO80ehGzLA

▪ When: Jan 17, 2024 8:00 PM Eastern Time (US and Canada)

▪ Topic: Informational Call #2 - NOFO CDC-RFA-GH-24-0058

▪ Register in advance for this webinar:

https://cdc.zoomgov.com/webinar/register/WN_MeU7BbDGTEKGiP91d6hJMw

F. Executive Summary:

Summary Paragraph The purpose of this NOFO is to increase immunization program capacity in high priority countries and targeted sub-national areas to identify underserved populations and implement tailored interventions to vaccinate underserved populations; implement comprehensive vaccine preventable disease (VPD) surveillance systems; improve preparedness and response to outbreaks of VPDs; and strengthen quality and sustainability of immunization delivery systems.

This cooperative agreement will address targeted sub-national areas in the Democratic Republic of the Congo, Ethiopia, Nigeria, Brazil, Indonesia, and the Philippines. Applicants may apply to work in one or more countries, and must clearly indicate the country or countries in their application. Work conducted under this NOFO will be critical to achieve VPD control, mailto:mmulholland@cdc.gov https://www.grants.gov/ https://cdc.zoomgov.com/webinar/register/WN_MeU7BbDGTEKGiP91d6hJMw elimination, and eradication targets (i.e., polio eradication, measles and rubella elimination, hepatitis B elimination, maternal and neonatal tetanus elimination) and more broadly reduce VPD-related morbidity and mortality.

a. Eligible Applicants:

Open Competition

b. NOFO Type:

CA (Cooperative Agreement)

c. Approximate Number of Awards Up to 12 applicants may be awarded with a maximum of two awards per country component.

d. Total Period of Performance Funding:

$225,000,000

e. Average One Year Award Amount:

$7,500,000 The average annual award amount varies, depending on the country. Estimated annual funding per country:

1. DRC: $10,000,000

2. Ethiopia: $10,000,000

3. Nigeria: $10,000,000

4. Brazil: $5,000,000

5. Indonesia: $5,000,000

6. The Philippines: $5,000,000

f. Total Period of Performance Length:

5 year(s)

g. Estimated Award Date:

May 01, 2024

h. Cost Sharing and / or Matching Requirements:

No Part II. Full Text A. Funding Opportunity Description

1. Background

a. Overview **Definitions for terminology are listed in the Glossary, section I.

The U.S. Centers for Disease Control and Prevention (CDC) has a long-standing commitment to support and implement global immunization priorities and lifesaving, cost-effective public health interventions to reduce the risk of disease, disability, and death from vaccine preventable diseases (VPDs). While the U.S. has reduced the domestic VPD burden, the nation remains at risk from importation of VPDs abroad. CDC’s Global Immunization Division (GID) prioritizes activities in countries at the highest risk for VPDs to prevent outbreaks, limit disease transmission and importation and ultimately protect the lives of the American people.

The 2022 WHO/UNICEF estimates of routine immunization coverage (WUENIC) show a significant decline from levels achieved in 2019 (Vaccination and Immunization Statistics - UNICEF DATA), leaving large numbers of children susceptible to VPDs. Large outbreaks of VPDs have increased during 2021-2023, underscoring the global health security threat for the U.S. The largest number of unprotected children (i.e., children who have not received any doses of routine childhood vaccines) live in just ten countries, including Nigeria (2.3 million), Ethiopia (1.1 million), Democratic Republic of the Congo (DRC) (753,000), the Philippines (637,000), Indonesia (571,000), and Brazil (431,000), and concerted efforts to reach and immunize these children are critical to reverse the global declines in immunization coverage and reduce the risk of large and disruptive outbreaks.

Sub-national areas with weak immunization program infrastructures play a large role in continued VPD outbreaks and exportation of VPD pathogens to other geographic areas.

Outbreaks in these sub-national areas, or “consequential geographies” (CGs), are more likely to affect neighboring geographies, giving them significant – or “consequential” – impacts beyond their geographic size or population. A CG has multiple overlapping risks, often rooted in social, economic, ecological, and health system factors that result in combinations of low vaccination coverage, high pathogen exposure, and worse health outcomes from VPDs. Activities must be tailored to individual country contexts and challenges that may include, but not be limited to:

• mobile populations

• internally displaced persons (IDPs)

• hard-to-reach areas (e.g., insecurity/conflict, geography)

• difficulty in retaining high-performing health staff

• geographic areas with large inflows/outflows of people to other countries resulting in exportation of VPD cases/outbreaks

• vaccine hesitancy and/or inequitable or low access to care resulting in chronic areas of un- and under-immunized populations

To address these issues, this NOFO will enable CDC and partners to strengthen immunization systems, comprehensive VPD surveillance, and VPD outbreak response in sub-national areas of the following countries:

• Democratic Republic of the Congo (DRC)

• Ethiopia

• Nigeria

• Brazil

• Indonesia

• The Philippines

Sub-national geographies will be determined in consultation with Ministries of Health and CDC after the award is made, and geographic prioritization within countries may change over the course of the period of performance.

In FY 2023, CDC/GID provided funds to Nigeria, Ethiopia, and DRC to implement consequential geography activities in sub-national areas. The activities under this NOFO will leverage FY 2023 investments and activities.

https://data.unicef.org/topic/child-health/immunization/ https://data.unicef.org/topic/child-health/immunization/

b. Statutory Authorities Section 307 of the Public Health Service Act, as amended [42 USC 242l]; Section 301 (a) [42 USC 241 (a)] of the Public Health Service Act, as amended; Section 317(k)(1) [42 USC 247b(k)(1)] of the Public Health Service Act, as amended.

c. Healthy People 2030 This program addresses the “Healthy People 2030” focus areas of Global Health (Global Health - Healthy People 2030 | health.gov), Infectious Disease and Vaccinations (Infectious Disease — Evidence-Based Resources - Healthy People 2030 | health.gov), Global Polio Eradication Initiative (GPEI) (https://polioeradication.org), Immunization Agenda 2030 (IA 2030) (https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind) and CDC’s Health Equity Strategy (https://www.cdc.gov/globalhealth/equity/).

d. Other National Public Health Priorities and Strategies This NOFO will support the US Government-endorsed Global Polio Eradication Initiative (GPEI) GPEI Strategy 2022-2026 – GPEI (polioeradication.org) and the Immunization Agenda 2030 (IA2030). In addition, this NOFO will support CDC’s Global Health Strategy, which focuses on: 1) improving the health and well-being of people around the world; 2) improving capabilities to prepare for and respond to infectious diseases, other emerging health threats and public health emergencies; and, 3) maximizing the potential of CDC’s global programs to achieve public health impact.

e. Relevant Work This announcement supports the CDC Global Immunization Strategic Framework (GISF) 2021– 2030 and expands on previous work to strengthen sub-national capacities. Through Fiscal Year (FY) 2023 funds, GID is implementing CG activities to strengthen sub-national capacity. Funds were provided in sub-national geographies in Nigeria, DRC, and Ethiopia. Activities will include but are not limited to the following: 1) microplanning including with satellite and geographic information systems (GIS) mapping, 2) intensified routine immunization, 3) urban-tailored interventions; and 4) communications to improve immunization confidence and uptake.

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

CDC-RFA-GH24-0058 Logic Model: Strengthening immunization program implementation in sub-national consequential geographies. This logic model applies to each country included in the NOFO: DRC, Nigeria, Ethiopia, Brazil, Indonesia, and the Philippines.

STRATEGY SHORT-TERM

OUTCOMES (CDC

GISF Priority #)

INTERMEDIATE-TERM

(CDC GISF Priority #)

LONG-

TERM

https://polioeradication.org https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind) https://www.who.int/publications/m/item/immunization-agenda-2030-a-global-strategy-to-leave-no-one-behind) https://www.cdc.gov/globalhealth/equity/).

https://polioeradication.org/gpei-strategy-2022-2026/ https://www.cdc.gov/globalhealth/immunization/framework/index.html https://www.cdc.gov/globalhealth/immunization/framework/index.html

1. Strengthen immunization services in targeted sub-national areas

Improved capacity to:

• characterize underserved populations with immunity gaps* and implement tailored delivery strategies to reach them across the life-course (1.1, 1.3)

• enhance implementation of strategies that address barriers, facilitators, and solutions to improve demand and uptake of immunization (1.2)

• introduce vaccines and monitor and evaluate post-introduction (1.4)

• strengthen immunization data accuracy, timeliness, and use (1.5)

• Increased identification of un-/ under-immunized populations (1.1),

• Improved tailored delivery strategies implemented to reach un- /under-immunized populations (1.1)

• Increased demand for routine and campaign immunization services (1.2)

• Improved access to, and utilization of, immunization across the life-course (1.3)

• Increased number of new or under-utilized vaccines introduced (1.4)

• Improved recording, reporting, and use of immunization program data (1.5)

2. Support and continuously improve comprehensive

VPD

surveillance systems in targeted sub-national areas

• Improved comprehensive VPD surveillance system capacity (across surveillance system functions) (2.1)

• Increased capacity to generate, interpret, and use VPD

• Improved comprehensive VPD surveillance system performance (2.1)

• Increased use of VPD surveillance data to improve immunization program performance (2.1, 2.3)

Improvements towards sustainable, high, and equitable vaccination coverage***

Progress towards and achievement of VPD control, elimination, and eradication targets***

Reduced mortality and morbidity from VPDs*** surveillance data (2.3)

3. Prepare for and respond to VPD outbreaks in targeted sub-national areas

• Improved capacity, quality, and timeliness for VPD outbreak preparedness and response (3.2-3.3)

• Reduced number of large or disruptive VPD outbreaks (3.2- 3.3)

4. Foster immunization program sustainability in targeted sub-national areas

• Improved evidence-based, translation, and use of immunization economic and financing information, including on vaccine pricing and procurement (4.1)

• Improved functionality and effectiveness of technical advisory groups to support evidence-based decision making for immunization policy and programs (4.2)

• Increased capacity for and implementation of vaccine safety surveillance and response (4.3)

• Improved immunization workforce** development strategies

• Improved effectiveness of immunization safety monitoring and risk communication (4.3)

• Improved capacity, performance, and accountability of immunization workforce (4.4)

** according to the WHO Standard Competencies Framework for the Immunization Workforce, including workforce for advocacy and communications; disease surveillance, investigation, and response; human resources and performance management; monitoring, evaluation, information system management and data use; policy, planning, and finance; safety of vaccines and immunization; vaccines, supplies, and logistics; vaccination service delivery; and leadership and management.

i. Purpose Available NOFO funding will support critical immunization efforts to achieve global VPD goals in specified consequential geographies. The goals are to 1) identify and vaccinate un- and under-immunized children, 2) support polio eradication, measles and rubella elimination, and hepatitis B and maternal and neonatal tetanus elimination, 3) strengthen comprehensive VPD surveillance,

4) support outbreak preparedness and response, including planning and implementation of supplemental immunization campaigns, and 5) strengthen immunization delivery systems and capacities in high priority countries.

ii. Outcomes Short-Term Outcomes

Strategy 1. Strengthen Immunization Services in targeted sub-national areas

Improved capacity to:

• characterize underserved populations with immunity gaps and implement tailored delivery strategies to reach them across the life-course (1.1). For example:

o target populations accurately mapped through walk-through microplanning supplemented with geo-spatial analysis o targeted polio, measles, or other VPD high-quality campaigns using innovative strategies in conflict or fragile settings o enhanced implementation of intensification of routine immunization (IRI) in an integrated primary health care system o un- and under-immunized populations in hard to reach, conflict, fragile, displaced, urban settings, or other complex settings identified and reached though tailored delivery strategies across the life-course implemented and evaluated (4.4)

5. Collaborate with government and implementation partners

• Improved government and implementation partner coordination and communication

(GISF

Partnership-based principle)

• Sustained coordination and collaboration between government and immunization partners (GISF Partnership-based principle) o behavioral, social, and access-related drivers are identified in general and key populations o key insights on any prevalent mis/disinformation related to routine or new vaccines are available in a timely manner to inform infodemic management strategies

• enhance implementation of strategies that address barriers, facilitators, and solutions to improve demand and uptake of immunization (1.2). For example:

o community insight on demand and uptake through engagement with religious and community leaders o implementation of evidence-based, tailored strategies that address gender-related barriers to immunization to improve caregiver health-seeking behavior and vaccine demand o implementation of evidence-based, tailored strategies to improve quality of immunization service delivery and responsiveness to community needs o improved capacity of community actors for defaulter tracing and effectively linking those data with health facilities o improved capacity to identify and respond to Adverse Events Following Immunization (AEFI)/safety concerns o implementation of targeted strategies based on systematic assessments of the immunization program o address system barriers to catch up vaccinations (e.g., policies, information systems, health worker training, demand) o infodemic management strategies implemented to reduce mis/disinformation

• introduce vaccines and monitor and evaluate post-introduction (1.4). For example:

o novel oral poliovirus vaccine 2 (nOPV2) introduced in geographies with circulating vaccine-derived poliovirus type 2 o high catch-up campaign coverage achieved for rubella vaccine introductions o a reduced number of breakthrough infections post human papillomavirus vaccine

(HPV) and malaria vaccine introduction

• strengthen immunization data accuracy, timeliness, and use (1.5). For example:

o improved knowledge and skills on use of immunization data to prevent, detect and respond to VPDs o improved knowledge and skills of facility, district, regional, and national immunization staff on how to triangulate immunization-related data from multiple data sources (e.g., administrative data, surveillance data, logistics data, survey data, etc.) and analyze, visualize, and interpret these data to inform immunization programs o strengthened interoperability and integration of EPI health information system to support data use and data quality improvement strategies o expanded evidence base on implementation of EPI information systems to inform development of operational tools, guidelines, and technical standards documents.

o development of standardized templates for data management and analytics to use in routine EPI programs, VPD surveillance, and campaigns

Strategy 2. Support and continuously improve VPD surveillance systems in targeted sub-national areas

• Improved comprehensive VPD surveillance system capacity (across surveillance system functions) (2.1). For example:

o trained staff in comprehensive VPD surveillance to perform supportive supervision of facility-based staff responsible for case detection and reporting o support for representative and complete detection of VPDs among the intended populations and geographic areas o strengthen and support integration of polio surveillance with other VPD surveillance systems

• Increased capacity to generate, interpret, and use VPD surveillance data (2.3). For example:

o trained national and sub-national health staff in triangulation of multiple data sources o development of a workforce appropriately trained in surveillance core competencies, including data analysis and interpretation o support for the development of interoperability between VPD Surveillance, laboratory, and immunization information systems to support collection, analysis, sharing and programmatic use of data

Strategy 3. Prepare for and respond to VPD outbreaks in targeted sub-national areas

• Improved capacity, quality, and timeliness for VPD outbreak preparedness and response (3.2-3.3). For example:

o periodic, standardized training delivered to front-line staff on outbreak detection, case investigation, and timely response o high quality immunization campaigns implemented immediately following outbreak declaration according to standard operating procedures o implementation of enhanced surveillance during outbreak response o work plans developed to prevent future outbreaks that address issues identified by root cause analysis o systems developed that ensure every child is reached with polio, measles and other VPD antigen campaigns

Strategy 4. Foster immunization program sustainability in targeted sub-national areas

• Increased capacity for and implementation of vaccine safety surveillance and response (4.3). For example:

o staff trained in reporting and interpretation of passive surveillance data o active surveillance for AEFI has been established along with standard operating procedures for investigation and response o countries development of vaccine related event (VRE) plans to support local response to immunization safety concerns in a timely manner

• Improved immunization workforce development strategies implemented and evaluated (4.4). For example:

o improved immunization program capacity to assess (e.g., improved capacity to conduct and interpret root cause analysis, rapid performance assessments) and improve workforce performance (e.g., supportive supervision, upskilling, reskilling, training, skills assessment, competency and position/career path alignment, etc.)

o performance improvement strategies for immunization workforce identified, assessed, and scaled up o improved workforce capacity to generate and use immunization economic and financing information to inform immunization program planning, budgeting, and resource mobilization o improved understanding of immunization staff perceptions of safety

Strategy 5. Collaborate with Government and Implementation Partners

• Improved government and implementation partner coordination and communication (GISF Partnership-based principle). For example:

o EPI managers at sub-national levels understand their immunization and PHC priorities and collaborate on interventions to address them

Intermediate-Term Outcomes

Strategy 1. Strengthen Immunization Services in targeted sub-national areas

• Increased identification of un-/ under-immunized populations (1.1)

• Improved tailored delivery strategies implemented to reach un- /under-immunized populations (1.1). For example:

o using digitized maps to regularly update location of un- and under-immunized populations o proportion of un- /under-immunized populations reached, and uptake of immunization

• Increased demand for routine and campaign immunization services (1.2). For example:

o increased vaccine confidence and demand in health authorities and communities o support periodic intensification of routine immunization to build immunity levels for polio and other antigens

• Improved access to, and utilization of, immunization across the life-course (1.3). For example:

o catch-up and keep-up vaccination policies and strategies adopted and implemented o additional platforms across the life course established, strengthened and integrated into routine programming (e.g., second year of life, health care worker, school-based platforms and others)

• Increased number of new or under-utilized vaccines introduced (1.4). For example:

o recommended new vaccines are introduced into the routine immunization schedule o new vaccine coverage data regularly monitored and used to target immunization activities

• Improved recording, reporting, and use of immunization program data (1.5). For example:

o improved immunization campaign data quality and use

Strategy 2. Support and continuously improve VPD surveillance systems in targeted sub-national areas

• Improved comprehensive VPD surveillance system performance (2.1). For example:

o increased sensitivity and timeliness of VPD case detection through active, comprehensive surveillance o faster detection of and response to VPD outbreaks through use of VPD surveillance data

• Increased use of VPD surveillance data to improve immunization program performance (2.1, 2.3).

Strategy 3. Prepare for and respond to VPD outbreaks in targeted sub-national areas

• Reduced number of large or disruptive VPD outbreaks (3.2-3.3). For example:

o faster outbreak detection and response o reduced duration and magnitude of outbreaks

Strategy 4. Foster immunization program sustainability in targeted sub-national areas

• Improved effectiveness of immunization safety monitoring and risk communication (4.3).

For example:

o strengthened capacity among health care workers for prevention, identification, reporting and responding to serious AEFI o improved surveillance sensitivity for AEFI o improved capacity to respond to immunization safety concerns

• Improved capacity, performance, and accountability of immunization workforce (4.4).

For example:

o strengthened workforce performance o improved workforce capacity to estimate budgets, secure adequate and timely resources for immunization service delivery, and track budget execution

Strategy 5. Collaborate with Government and Implementation Partners

• Sustained coordination and collaboration between government and immunization partners (GISF Partnership-based principle). For example:

o regular national-level meetings of the Interagency Coordinating Committee

iii. Strategies and Activities For FY 2024-28, the specific sub-national geographies and immunization activities for implementation within the six countries (i.e., DRC, Nigeria, Ethiopia, the Philippines, Indonesia, and Brazil) will be identified in agreement between the CDC and host governments. Once impact is demonstrated (by defined annual monitoring and evaluation indicators, including but not limited to increased immunization coverage), additional funding and technical assistance may be made available in future budget periods to expand the geographic footprint to other high-priority areas in these countries, in agreement between the CDC and host governments.

In the application, applicants are encouraged to use the examples of activities described below if they are appropriate to the applicant's proposed approach and their assessment of the needs in the relevant geographic area(s). Additionally, applicants may propose activities not listed below which are appropriate to the geographic area(s) and their suggested approach. All proposed activities must align with the logic model in the NOFO.

While all recipients are expected to carry out a mix of national and regionally focused activities, it is expected that recipients working in DRC, Nigeria, and Ethiopia will implement a greater proportion of locally focused activities than broader, national-level activities, and that recipients working in Indonesia, Brazil, and the Philippines will implement a greater proportion of national-level activities than locally focused activities.

Activities may include but are not limited to:

Strategy 1. Strengthen immunization services in targeted sub-national areas

• Characterize underserved populations with immunity gaps and implement tailored delivery strategies to reach them across the life-course (1.1) o Conduct regular microplanning (with digitization, when available) to accurately characterize underserved populations, plan for future immunization campaigns, and plan for mobile and outreach immunization services where possible.

o Use tailored interventions to deliver polio, measles, and other recommended vaccines in settings with underserved, hard to reach or population in security compromised areas known for sustained VPD transmission o Implement tailored interventions to improve quality of immunization service delivery and responsiveness of services to community needs

• Enhance implementation of strategies that address barriers, facilitators, and solutions to improve demand and uptake of immunization (1.2) o Identify local barriers to equitable and high vaccine coverage through measuring the behavioral, social, and operational drivers of vaccination access, demand & uptake and utilizing this information to develop evidence-based strategies to improve vaccine uptake.

o Measure behavioral and social determinants of vaccine uptake using context-appropriate tools such as surveys, rapid community assessments, and/or qualitative methods o Measure prevalence and trends in mis/disinformation through activities such as social listening and related insights generation o Evaluate the status of implementation of catch-up immunization guidelines/policies and make recommendations for strengthening o Tailor targeted vaccination interventions to improve uptake of and demand for immunizations based on identified barriers and community context o Develop and evaluate community-based strategies to improve demand for immunization and the quality and reach of vaccination services.

o Develop and evaluate systems-based strategies such as building healthcare worker capacity for interpersonal communication/ motivational interviewing for improving quality of caregiver/beneficiary interaction and improving vaccine demand and uptake among healthcare workers o Develop and evaluate strategies that incorporate addressing gender barriers to immunization at the caregiver level and health system level

• Introduce vaccines and monitor and evaluate post-introduction (1.4) o Provide technical assistance to National Immunization Technical Advisory

Groups (NITAGs) for decision making on making recommendations for new vaccines.

o Provide personnel support and technical assistance to targeted sub-national areas to introduce the recommended new and under-utilized vaccines.

o Conduct post-introduction evaluations (PIEs) to generate evidence-based recommendations.

o Conduct assessments of behavioral and social drivers to understand high and low performing areas.

o Implement training for new vaccines introduction into routine immunization.

• Strengthen immunization data accuracy, timeliness, and use for decision-making (1.5) o Evaluate the accuracy, completeness, and timeliness of immunization data o Implement strategies – including tools to facilitate data entry, analysis, interpretation, and visualization - to improve the accuracy, completeness, and timeliness of immunization data o Strengthen use of immunization data to target program activities to prevent, detect, and respond to VPDs, including analysis with triangulation of multiple data sources where appropriate o Where appropriate, integrate immunization information systems with other health information systems and support data quality improvement strategies

Strategy 2. Support and continuously improve comprehensive VPD surveillance systems in targeted sub-national areas:

• Improve comprehensive VPD surveillance system capacity (across surveillance system functions) (2.1) o Support enhanced case detection through trained community informants and health-care workers, including training on VPD case reporting procedures and VPD case definitions o Strengthen timely specimen collection, transport to qualified laboratory national lab, testing, and result sharing o Support the implementation of innovative technologies (e.g., multi-bead assays, rapid diagnostic tests) for rapid detection of VPDs from specimens and the environment through operational research and technical assistance o Strengthen and sustain workforce capacity to test and report laboratory diagnostics from submitted specimens

• Increase capacity to generate, interpret, and use VPD surveillance data (2.3) o Support and strengthen sustained workforce capacity for improved VPD surveillance data quality, management, analysis and visualization (including triangulation of multiple data sources), dissemination, and use, including for outbreak detection o Improve data linkages between VPD laboratories and surveillance units to facilitate analysis and visualization of surveillance data o Improve routine reporting of VPD surveillance data even in the absence of cases, i.e., zero case reporting

Strategy 3. Prepare for and respond to VPD outbreaks

• Improve capacity, quality, and timeliness in targeted sub-national areas for VPD outbreak preparedness and response (3.2-3.3) o Strengthen local workforce capacity for case detection and investigation, and response readiness, planning, implementation, and evaluation o Conduct risk assessments to identify populations and/or communities at high risk of VPD outbreaks and develop evidence-based recommendations to mitigate outbreak risk o Promote the use of data collected during supplemental immunization activities (SIAs) and geospatial data, where possible, to update microplans o Increase community awareness and participation in detecting and reporting potential VPD outbreaks o Support outbreak response immunization, evaluation, and development of quality improvement plans o Contribute to routine immunization and surveillance strengthening in the outbreak response settings, including identification and implementation of interventions to address root causes of outbreaks

Strategy 4. Foster immunization program sustainability in targeted sub-national areas:

• Increase capacity for and implementation of vaccine safety surveillance and response (4.3) o With local government, strengthen vaccine safety surveillance systems o Collect and analyze routine immunization safety monitoring data to improve immunization safety surveillance and response quality o Improve risk communication by developing and implementing vaccine-related event response plans o Implement innovative methodologies (including active surveillance for AEFIs) to collect, visualize, and analyze immunization surveillance data o Identify vaccine safety risks for special populations or settings as needed o Reduce barriers for reporting of AEFIs among frontline health care workers

• Improve immunization workforce development strategies to be implemented and evaluated (4.4) o Use evidence-based program-wide practices and approaches to strengthen workforce capacity. Focus areas include but are not limited to the following:

supportive supervision, worker performance improvement, workforce preparedness during public health emergencies, health worker interactions with caregivers, gender equity, safety and motivation, and health worker vaccination.

o Identify, implement, and evaluate best practices; leverage opportunities (e.g., collaborations); and address gaps in workforce development strategies o Identify and address factors (e.g., incentives and consequences) and strengthen tools and resources affecting workforce performance o Improve the quality, use, and standardization of immunization workforce resources (e.g., assessments; management tools; standard operating procedures;

trainings; job aids) o Support immunization health workers and volunteers to effectively collaborate and coordinate with local communities o Build capacity for the generation and use of economic and financial information, including economic evaluation of vaccination and immunization system interventions

Strategy 5. Collaborate with government and immunization partners

• Improve government and partner coordination and communication (GISF Partnership-based principle) o Strengthen the Interagency Coordinating Committee (ICC) by ensuring cross-partnership consensus on:

▪ ICC mission, financial support, and standard operating procedures

▪ Member representation, selection, and terms of reference o Support the government to convene the ICC, at least monthly, and regularly share meeting summaries and the status of follow-ups across immunization partners o Facilitate information sharing between and within MOH, partners, and non-governmental organizations (NGOs) to increase collaboration on VPD control/elimination/eradication, VPD surveillance, routine immunization and related data system activities o Participate in monitoring and evaluation of programs and activities in collaboration with MoH and partners

1. Collaborations

a. With other CDC programs and CDC-funded organizations:

Recipient is expected to collaborate with other immunization partners including CDC programs and CDC-funded organizations. Organizations may include but not be limited to:

• WHO regional and country teams

• UNICEF regional and country teams

• International Federation of Red Cross and Red Crescent Societies (IFRC)

• African Field Epidemiology Network (AFENET)

• Training Programs in Epidemiology and Public Health Interventions Network

(TEPHINET)

• Eastern Mediterranean Public Health Network (EMPHNET)

• Stop Transmission of Polio Program (STOP)

• National Stop Transmission of Polio Program (NSTOP)

• Field Epidemiology Training Program (FETP)

• Integral Global Health and Integral Global Consulting (IGH/IGC)

• Global Health Development (GHD)

• CDC subject matter experts in other Centers and Offices (required when applicable)

• CDC staff in specific countries (required when applicable)

• CDC Incident Command leadership and staff (required when applicable)

b. With organizations not funded by CDC:

Recipient may collaborate with other organizations external to CDC as deemed necessary to achieve project outcomes. Example organizations may include but not be limited to:

• Bill & Melinda Gates Foundation

• Medecins Sans Frontieres (MSF)

• National Red Cross/Crescent Societies

• USAID

• Gavi, the Vaccine Alliance

• Rotary International

• Ministries of Health

• Other non-state actors/non-governmental organizations

Effective implementation will require close coordination with the government immediately following the award decision.

2. Population(s) of Focus The CDC Global Health Equity Strategy builds upon CDC’s global public health mission and agency-wide principles and goals. Health equity (HE) for CDC is realized when everyone can achieve their highest attainable level of health and no one is disadvantaged from achieving this potential because of social position or any other socially, economically, demographically, or geographically defined circumstances or physical condition.

This NOFO, including funding and eligibility, is not limited based on, and does not discriminate on the basis of race, color, national origin, disability, age, sex (including gender identity, sexual orientation, and pregnancy) or other constitutionally protected statuses.

a. Health Disparities The goal of health equity is for everyone to have a fair and just opportunity to attain their highest level of health. Achieving this requires focused and ongoing societal efforts to address historical and contemporary injustices; overcome economic, social, and other obstacles to health and healthcare; and eliminate preventable health disparities.

Broadly defined, social determinants of health are non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces (e.g., racism, climate) and systems include economic policies and systems, development agendas, social norms, social policies, and political systems. See content below and in other sections (e.g., Approach, Collaborations, Populations of Focus) for information on how this specific NOFO affects social determinants of health.

A health disparity is a preventable difference in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by populations that have been socially, economically, geographically, and environmentally disadvantaged. Health disparities are inextricably linked to a complex blend of social determinants that influence which populations are most disproportionately affected by these diseases and conditions.

This NOFO supports GID’s efforts to improve the health of populations disproportionately affected by VPDs by maximizing the health impact of immunization services, reducing disease prevalence, and promoting health equity by reducing or eliminating systematic disparities in health and healthcare systems and services. Health equity is a desirable goal that entails special efforts to improve the health of those who have experienced social or economic disadvantage.

In an effort to ensure that activities funded through this NOFO (1) affirm and advance, as appropriate, the role of health equity and an equitable, diverse, and inclusive workforce as core principles, and (2) advance the reduction of stigma and discrimination through the promotion, consistent with applicable laws, of civil and human rights to improve the health outcomes in support of the elimination or reduction of vaccine preventable diseases, the awards resulting from this NOFO may address the following activities, where and when appropriate:

• Engage with local area organizations including establishing community boards. Support community level involvement in the design, implementation, monitoring of immunization and services targeting underserved and hard-to-reach populations.

• Engage with members of the community and use human centered design principles with sensitivity to local language, customs and culture to support activity success.

• Conduct training for implementing partners involved in the design, implementation, and/or monitoring of activities on stigma, discrimination, gender equitable norms, human rights, and community engagement to minimize the likelihood for activities that unintentionally increase stigma and discrimination of marginalized communities.

• Design, implement, monitor, and evaluate programs to address evidenced health disparities and social barriers.

• Use data to monitor disparities and implement strategies to improve access, service use, and outcomes.

For more information, visit: CDC Global Health Equity Strategy

iv. Funding Strategy The geographic distribution of VPDs is widespread. This NOFO focuses on improving public health outcomes in six specific countries and, within those countries, targeted sub-national areas (also known as “consequential geographies”) because those areas have experienced sustained transmission of specific VPDs, not achieved vaccine coverage targets, and/or have important unaddressed barriers to disease control or elimination goals. The sub-national areas and specific activities will be determined at the time of award by the current needs in-country in order to improve the morbidity and mortality from vaccine preventable diseases and target those who are most vulnerable (un- and under-vaccinated).

This 5-year NOFO is divided into six components. Each component is specific to the indicated country, including sub-national area(s) to be defined as follows:

1. DRC: Estimated annual funding is $10,000,000.

2. Ethiopia: Estimated annual funding is $10,000,000.

3. Nigeria: Estimated annual funding is $10,000,000.

4. Brazil: Estimated annual funding is $5,000,000.

https://www.cdc.gov/globalhealth/equity/index.html

5. Indonesia: Estimated annual funding is $5,000,000.

6. The Philippines: Estimated annual funding is $5,000,000.

This NOFO will provide funds for immunization activities at both the national level and in targeted sub-national areas. The proportion of funding awarded for activities conducted at the national level (versus the sub-national level) may be higher in Brazil, Indonesia, and the Philippines than in DRC, Ethiopia, and Nigeria. Overall funding amounts per country also reflect the need for larger amounts of funding in DRC, Ethiopia, and Nigeria, due to these countries having weaker immunization systems. For all countries, the bulk of funds will be awarded for sub-national activities.

Applicants are required to apply for work under at least one country component under the NOFO and may apply for multiple country components. For each country component proposal, the applicant must submit a separate and clearly marked project narrative including work plan, and a separate and clearly marked budget narrative. The work plan should be included with the project narrative for each country component, as described in section D. Required Registrations, 11.

Work Plan. The budget narrative should be submitted as a separate attachment following the naming convention and guidance listed in section D. Required Registrations, 12. Budget Narrative. Applicants are encouraged to submit a country-specific budget(s) at or near the Year 1 estimated funding level as detailed above. Proposed Year 1 budgets should not exceed the Year 1 estimated funding level. Years 2-5 will be awarded on an annual basis after submission of a non-competing continuation application.

b. Evaluation and Performance Measurement

i. CDC Evaluation and Performance Strategy

The purpose of evaluation and performance measurement is to: (1) Monitor the extent to which activities were successfully completed; (2) Demonstrate progress toward achieving program outcomes (e.g., Were outcomes of interest described in the logic model achieved in targeted sub-national areas?); and (3) Inform decisions about future programming that drive continuous program improvement for more efficient and effective program performance (e.g., What and how could performance be improved?). Evaluation and performance measurement can also determine if the intended populations are reached. CDC’s evaluation strategy is grounded in the CDC Evaluation Framework for Public Health, MMWR, September 18, 1999, Vol. 48 / No. RR- 11.

CDC requires ongoing evaluation and performance measurement under this NOFO. CDC expects recipients to maintain sufficient staffing and analytic capacity to meet these requirements. With support from CDC, recipients will be required to submit a more detailed Evaluation and Performance Measurement Plan (EPMP) within the first 6 months of receiving the award, as described in the Reporting Section of this NOFO. CDC will review and approve the recipient’s monitoring and evaluation plan to ensure that it is appropriate for the activities to be undertaken as part of the agreement and for compliance with the monitoring and evaluation guidance established by CDC or other guidance otherwise applicable to this cooperative agreement. As a living document, the EPMP should be reviewed and can be updated on an annual basis to reflect changes resulting from program activities, feedback and lessons learned throughout the NOFO award period, and/or changing realities on the ground.

The primary objective of the EPMP implementation is to determine the progress of activities under this NOFO and indicate how they relate to the desired outcomes. A secondary objective of the EPMP is to track and report on expenditures of funds. The results will be used for program improvement, accountability and reporting. The data CDC collects for performance measurement and evaluation are directly related to the implementation of the strategies and/or the desired outcomes indicated in the logic model and may be used for sharing with partners and other stakeholders.

Performance Measures Monitoring:

The data reported to CDC should be related to the implementation of the strategies and/or the desired outcomes indicated in the NOFO logic model. Recipient should consider adaptations of the following proposed performance measures in Table 1 for monitoring the activities and outcomes described in the logic model. The following measures included in Table 1 are proposed and can be modified by the recipient in their proposal. Not all process measures included in the below table may be relevant for the recipient.

Table 1: Proposed Performance Measures for Activities

Outcome Number

(NOFO

strategy)

Process indicators

(Proposed process measures for the strategies and activities in the NOFO)

All process indicators ate intended to measure activities supported with use of CDC funds.

* *Implementation status to include a qualitative description of the progress the partner has made in implementing agreed upon activities, including barriers and facilitators to implementation.

Outcome indicators

(Proposed outcome measures for the period of performance outcomes in the logic model)

1.1 & 1.3

(Strategy 1)

1) Number and implementation status* of relevant activities.

2) Reports on microplan validation of accuracy and completeness.

3) Description of identified characteristics of underserved populations in targeted sub-national areas.

4) Number and description of targeted interventions employed to reach populations with each of the identified characteristics.

1) Number of zero-dose children in targeted sub-national geographies reached.

2) Percent of SIAs in targeted sub-national areas that reach greater than 90% coverage overall and greater than 50% coverage in un- or under-immunized children, as measured by independent coverage surveys

3) Breadth of protection in targeted sub-national areas: mean coverage for the following antigens recommended by WHO: Diphtheria, Tetanus, Pertussis, Hepatitis B, Hib, Measles, Measles

5) Number of children reached with vaccination through targeted interventions, by antigen.

second dose, Pneumo, OPV, IPV, Rubella, Rotavirus, HPV.

4) Number of un- and under-immunized children identified…