Implementing a Best Practice Measles SIA:

Ethiopia’s Experience

Dr Fiona BrakaWHO Ethiopia

Measles Initiative Meeting, Washington DC, 13-14 September 2011

Ethiopia: BackgroundEthiopia: BackgroundEthiopia: BackgroundEthiopia: BackgroundFederal Ministry of Health

Regional Health Bureau(9 Regions + 2 City Administrations)

Zonal Health Administration(98 Zones)

Woreda Health Offices(819 Woredas)

Kebeles/Health Post (15,000 HP, 1 per 5,000 popln)

• Projected population 2010 (census 2007): 79 million– Growth Rate: 2.6% – Under-1: 3.2%

(2.6m)– Under-5: 14.6%

(11.4m)– Under-15: 45% (35m)

• Rural: 83%

• Infant Mortality Rate: 75/1000 live-births

Measles cases and MCV1 admin coverage Measles cases and MCV1 admin coverage in Ethiopia, 1990 - 2010in Ethiopia, 1990 - 2010

Measles cases and MCV1 admin coverage Measles cases and MCV1 admin coverage in Ethiopia, 1990 - 2010in Ethiopia, 1990 - 2010

Catch Up 2002 -2004

Measles Epidemiology, Ethiopia, 2010Measles Epidemiology, Ethiopia, 2010Measles Epidemiology, Ethiopia, 2010Measles Epidemiology, Ethiopia, 2010Age and vaxn status of confirmed

measles cases. 2010 (n=3527)Spot map of confirmed measles

cases. 2010 (n=3527)

Second opportunity measles vaccination Second opportunity measles vaccination through SIAsthrough SIAs

Second opportunity measles vaccination Second opportunity measles vaccination through SIAsthrough SIAs

Measles SIAs: 2010-2011Measles SIAs: 2010-2011Measles SIAs: 2010-2011Measles SIAs: 2010-2011• Target: 8.5 million (9 – 47

months)

• Phased in 2: – October 2010 (90.8%)– February 2011 (9.2%)

• Integrated interventions:– OPV (0-59 months)– Vitamin A (6-59 months)– De-worming (24-59 months)– Nutritional Screening (6-59 months

and pregnant and lactating women)

2010

2011

SIAs Best PracticesSIAs Best PracticesSIAs Best PracticesSIAs Best Practices

• “Best Practices” – Activities known to lead to predictably good results without

using up too much resources

– Based on local realities and challenges

• Identified in Ethiopia through:– Extensive review of previous reports

– Detailed internal consultations

– Experiences from other AFR countries

Best PracticesBest PracticesBest PracticesBest Practices

• Coordination• Micro planning and training• Logistics• Advocacy and communication• Resource mobilization• Monitoring and evaluation• Strengthening routine EPI

Areas of Focus for Best PracticesAreas of Focus for Best PracticesAreas of Focus for Best PracticesAreas of Focus for Best Practices

Coordination of the Best Coordination of the Best Practices SIA- EthiopiaPractices SIA- Ethiopia

Coordination of the Best Coordination of the Best Practices SIA- EthiopiaPractices SIA- Ethiopia

• National Task Force (NTF) with subcommittees led by FMoH– NTF Chaired by FMoH DG

– Weekly meetings started 5 months prior to SIAs

– ~ 7 – 10 people in every meeting

– Each meeting for >2hrs == >400 person-hours

• Task Forces established at regional, zonal and woreda levels – weekly feedback to NTF

• Emphasis on Kebele level planning with– local knowledge of needs– hard to reach populations

• Work with Statistics Agency for best denominators

• Focus on training quality– Pre/post testing– Participatory and practical– Schedule based on need not time

allotment– Standard agenda

• Evidence-based standard training materials: Field guide and translated pocket guides

Micro planning and TrainingMicro planning and TrainingMicro planning and TrainingMicro planning and Training

• Required distribution of logistics 3-4 weeks before implementation

• PFSA took on distribution role to Woreda level

• Distribution flexibility including transport fleet for emergency distribution

• Bundling of supplies

LogisticsLogisticsLogisticsLogistics

• Advocacy visits to Regional Presidents– 1-2 months prior to SIA– Joint team: FMoH and partners

• Evidence-based messages

• Sensitization and engagement of political leaders, Women’s Groups, Pediatric Society, Clinicians

• Diverse channels of communication • Mass media: radio/ TV/ billboards,

mobile vans• Town criers• Schools (notified via Ministry of

Education)• Door to door visits by community

volunteers (some places responsible for participation)

Advocacy and CommunicationAdvocacy and CommunicationAdvocacy and CommunicationAdvocacy and Communication

• Government contributions

• High level cooperation between EPI partners

• Engagement of partners at all levels:

o Human resources, transport, social mobilization, logistics

Item

Total Budget (USD)

FMOH Measles Initiative Nutrition Partners

(EOS)

Global Polio

InitiativeTo WHO To UNICEF

Vaccine & injection materials 5,371,901 3,345,097 2,026,804

Operational costs 6,464,204 746,219 2,101,540 1,364,240 1,502,205 750,000

Grand Total 11,836,105 746,219 2,101,540 4,658,097 1,502,205 2,776,804

Target population (< 5) 12,859,245 Cost per child $0.92

Resource Mobilization Resource Mobilization Resource Mobilization Resource Mobilization

• High level launch at national level by HE The President and at regional levels by Presidents/ dignified authorities

• Approximately 178,320 vaccination teams including 66,870 health workers and more than 72,870 volunteers

• Daily monitoring of performance through review meetings and SMS text messaging in phase 2

ImplementationImplementationImplementationImplementation

• Pre campaign assessments (3-4 weeks and 1 week prior to SIA) and feedback given to address gaps

• Different methods utilized to monitor performance:– Methods: Daily review meetings

(with administration), supervision

– Data Sources: Administrative, rapid convenience monitoring, independent monitoring

• Improving data flow through use of SMS text messaging

Multiple Data Sources (Tigray)

MonitoringMonitoringMonitoringMonitoring

Administrative follow-up measles SIAs Administrative follow-up measles SIAs coverage. Ethiopia.coverage. Ethiopia.

Administrative follow-up measles SIAs Administrative follow-up measles SIAs coverage. Ethiopia.coverage. Ethiopia.

Admin coverage, 2007- 2009

>=95%

90-94%

80-89%

<80%

Admin coverage, 2010 - 2011

•93% measles

Independent Monitoring Assessment of Independent Monitoring Assessment of Woreda PerformanceWoreda Performance

Independent Monitoring Assessment of Independent Monitoring Assessment of Woreda PerformanceWoreda Performance

Proportion of Children missed in Evaluated

Woreda

Woredas Reaching Targets for

Measles Vaccination

Woredas Reaching Targets for

Polio Vaccination

>10% 106 (27%) 107 (27%)

5-10% 67(17%) 79 (20%)

<5% 222 (56%) 209 (53%)

Source of data: Post SIA Independent monitoring, 395 Woredas sampledNote: Poor quality finger markers compromised the independent monitoring process in many areas

1. Post SIA coverage surveyo To assess coverage estimates for all interventionso 80 woredas in the 2 phases of the SIA; 4,420 children

2. Best practices evaluationo To determine best practices implemented and their

effect on coverageo 20 woredas

3. Strengthening of routine EPI through the SIAo 4 regions: 8 zones; urban and rural representation

4. Impact assessment

Evaluation of the SIAEvaluation of the SIAEvaluation of the SIAEvaluation of the SIA

Post SIA Coverage Survey, 2010-Post SIA Coverage Survey, 2010-20112011

Post SIA Coverage Survey, 2010-Post SIA Coverage Survey, 2010-20112011

Limitations: assessment of finger marking compromised by quality of markers and timing of phase 1 survey; non availability of screening card in some areas

Phase 1: 87.8%Phase 2: 93.1%

Best practice activities

P-value

Measles Coverage

Polio Coverage Vitamin A coverage

De-worming coverage

Presence of enough vaccine carriers

0.044 0.005 - -

Appropriate cold chain

0.018 - - -

Use of multiple locally available channels

- - 0.048 0.041

Task force meeting at all levels

0.023 0.02 - -

Best Practices EvaluationBest Practices EvaluationBest Practices EvaluationBest Practices Evaluation

Enhancing Routine Immunization through Enhancing Routine Immunization through SIAsSIAs

Enhancing Routine Immunization through Enhancing Routine Immunization through SIAsSIAs

• 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening:

1. Micro planning2. Training3. Logistics Management4. Advocacy and Social Mobilization5. AEFI monitoring and management6. Surveillance7. Monitoring and Evaluation

Impact of Measles SIAs on the Routine Immunisation Impact of Measles SIAs on the Routine Immunisation System, Ethiopia. System, Ethiopia.

KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)

Impact of Measles SIAs on the Routine Immunisation Impact of Measles SIAs on the Routine Immunisation System, Ethiopia. System, Ethiopia.

KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)

Survey Sites: 4 Regions; 2 zones/ region; urban & ruralAddis AbabaAddis Ababa OromiyaOromiya SNNPRSNNPR SomaliSomali

Pre-SIAPre-SIA Post SIAPost SIA Pre-SIAPre-SIA Post-SIAPost-SIA Pre-SIAPre-SIA Post SIAPost SIA Pre-SIAPre-SIA Post-SIAPost-SIAMonitoring chart up to date

50% 63% 35% 99% 100% 100% 60% 64%

Health facilities with adequate functional cold chain

83% 100% 26% 22% 32% 14% 80% 80%

Health facilities with adequate safety boxes

83% 92% 96% 99% 96% 100% 93% 100%

Health workers who know the use of additional doses of measles immunization

75% 92% 46% 74% 76% 100% 27% 87%

Health workers who know the correct site of measles vaccine injection

100% 100% 99% 94% 64% 96% 87% 87%

Confirmed measles cases, Ethiopia, 2007-2011

Outcomes of the SIAOutcomes of the SIAOutcomes of the SIAOutcomes of the SIAMeasles incidence, Ethiopia, 2006-2011

Age shift (~70% above 5 years)

• Early identification of best practices at the country level• Strong federal government leadership and ownership• Micro planning should be bottom up

o Include both technical and administrative officials o Adjustments after submission should be shared back down

• Evidence-based social mobilization and training materials• Interpersonal communication (door-to-door where feasible) is

effective• Daily intra campaign monitoring is essential for real-time results to

ensure all children are reached.• Routine Immunization strengthening should be included in all aspects

of planning, implementation and review, especially maintaining coordination structures

Major Lessons LearnedMajor Lessons LearnedMajor Lessons LearnedMajor Lessons Learned

• Consideration of wider age group for the next SIA in view of ongoing transmission

• Local resource mobilisation for measles control efforts based on SIA experience

• Partnerships forged and strengthened• Routine system strengthening

o Use of SIA Coordination structures for future SIAs and routine EPI activities such as new vaccine introduction

o Pre-SIA registration of target children and identification of hard to reach populations useful for subsequent SIA and RI

o Capacity building of PFSA in logistics managemento Local partnerships for RI and SIAs

Future Perspectives for Measles Future Perspectives for Measles Elimination in EthiopiaElimination in Ethiopia

Future Perspectives for Measles Future Perspectives for Measles Elimination in EthiopiaElimination in Ethiopia

AcknowledgementAcknowledgementAcknowledgementAcknowledgement

• FMOH (Neghist Tesfaye)

• Balcha Masresha

• Meseret Eshetu

• Pascal Mkanda

• Gavin Grant

• Sisay Gashu

• Luwei Pearson

• Tirsit Assefa

• Habtamu Belete

• Yodit Hailemariam

• Halima Dao

• David Brown

• Kathleen Wannemuehler

• Theresa Diaz

• Edward Hoekstra

• Mitike Molla

• National SIA Task Force

• MEDCO

AcknowledgementAcknowledgementAcknowledgementAcknowledgement

Ethiopia Federal Ministry of Health

Integrated Family Health Partnership

JSI Research & Training Institute, Inc.