STOP 34

Mission Report-Ethiopia

Field Report

From June 1st – August 31, 2010

By

Ugo EnebeliSarah Hubka

Dean Seneca

Abednego Yeboah

Outline

Mission- STOP 34

Background

AFP, Measles, and NNT Surveillance

Expanded Program on Immunizations

Challenges

Recommendations

Conclusions

STOP 34 Mission

•The main mission was to conduct epidemiological surveillance surrounding Polio (AFP), Measles and NNT.

•Review the Expanded Program on Immunizations to assist the administration of vaccinations in accordance with WHO intentions.

•Provide sensitization regarding surveillance and vaccination of the above mentioned diseases.

Background Ethiopia is a landlocked country located in the north eastern

part of Africa.

An estimated population of 79 million according to the most recent national census

86% of the population lives in rural areas.

There are approximately 195 government run hospitals, 1,362 health centers, and 12,488 health posts.

During our assignment we supported:◦ Total of 12 Zones Supported

◦ Total of 103 Woredas Supported

◦ Total of 196 Health Facilities Visited

Places Visited

ZoneWoreda Health

Offices Visited

Health Facilities,

Hospitals, Health

Posts Visited

Clinics

(private)

Holy Water Sites,

Traditional

Healers Visited

Individuals

Sensitized

Eastern (Tigray) 7 17 0 0 38

Guji 14 18 1 0 186

Jima 17 27 3 0 184

Mekele 1 7 0 0 18

Metekel 7 17 0 0 89

North Shoa 10 14 0 0 207

North Wello 10 21 0 0 52

South Gonder 13 21 0 0 289

Southern

(Tigray)2 5 0 0 12

Wag Hamira 6 13 0 0 38

West Gojjam 7 12 0 0 201

West Shewa 9 11 0 1 175

TOTALS 103 196 4 1 1489

Zones Supported

AFP, Measles and NNT Surveillance“Strengths”

Most health workers are knowledgeable of AFP, measles, NNT case definitions and specimen collection procedures.

Case definitions posters are visibly displayed in vantage points for health workers.

WHO officers performed regular ACS visits and provide continuing support to woredas and health facilities

Most woredas have a recently trained designated surveillance focal people

0

5

10

15

20

25

30

35

Ethiopia: Expected vs. Reported cases of AFP

in Zones visited by STOP 34 Weeks 23 and 33

Expected AFP

Reported

Week 23

Reported

Week 33

0

1

2

3

4

5

6

Ethiopia NP AFP Rates of Zones Visited by

STOP 34: Week 23 vs Week 33

NP AFP

Wk 23

NP AFP

Wk 33

0

20

40

60

80

100

120

Ethiopia AFP Stool Adequacy Rates in Zones

Visited by STOP 34 Week 23 vs Week 33

Stool

Adeq.

Wk 23

Stool

Adeq.

Wk 33

0

100

200

300

400

500

600

700

800

Ethiopia: Expected vs. Reported Measles

Cases in Weeks 16 and 33 in Zones Visited

by STOP 34

Expected

Measles

Reported

Week 16

Reported

Week 33

0

5

10

15

20

25

Ethiopia: Measles Detection Rates in Zones

visited by STOP 34 Weeks 16 vs 33

Det Rate

Week 16

Det Rate

Week 33

0

20

40

60

80

100

120

Ethiopia: Adequacy Rates Measles in Zones

Visited by STOP 34 Week 16 vs 33

Adeq Rate

Week 16

Adeq Rate

Week 33

2 missed suspected cases of AFP; 133 missed suspected cases of measles; 7 missed suspected cases of NNT

Lack of logistics to support surveillance, forms, specimen supplies, designated vaccine carriers, etc…

Insufficient knowledge amongst many health workers of the reporting requirements for AFP, measles and NNT.

Limited feedback on submitted specimen samples. Case files are not available at many health facilities nor

woreda offices; not existent for the previous three years Few zonal or woreda IDSR FPs had a plan for visiting

sites and ACS was not evident in the registers

AFP, Measles and NNT Surveillance“Challenges”

Expanded Program on Immunizations“Strengths”

Adequate supply of basic EPI logistics, AD syringes, safety boxes, mixing syringes, etc…

Most health facilities have a refrigerator

Most sites observed good injection safety practices

Most health centers maintain refrigerator temperatures between 2 and 8 degrees Celsius, when monitored

• The cold chain was not consistently maintained in many facilities due to kerosene shortages, power outages, and staff transitions or staff absence during training

• Insufficient vaccine management, inadequate recording of vaccine usage, expired VVM, expired vaccines, no wastage monitoring

• There was poor data management, analysis and interpretation; many of the Vaccine Monitoring Charts were outdated

• Vaccines are administered in unsanitary conditions.

• Improper waste disposal

Expanded Program on Immunizations“Challenges”

RecommendationsGeneral Improve the conditions of the health

facilities by making them clean and orderly.

Woredas and health facilities would benefit from cross-training multiple staff to perform different key roles within their organization.

Increased supportive supervision

Increase training in EPI, AFP, measles and NNT surveillance and refresher training should be available on a quarterly basis.

RecommendationsSurveillance Institute Active Case Search at all levels

Ensure that all supplies and materials are available for investigation and reporting

Ensure individual case investigation files for AFP, measles and NNT are completed and inventoried for the last three years

Decrease the time to allow results from National Lab to reach all zones, woredas and health facilities in a timely manner

RecommendationsEPI Vaccine monitoring charts should be completed and updated

monthly

Health facilities should work toward a strong defaulter tracing mechanism to ensure dropout rates are <10%

Increase frequency and number of staff trained who work on the cold chain maintenance

Woredas and all health facilities should take a weekly inventory of vaccine supply and record type of vaccine, number of vials, VVM stage, and expiration date

Vaccine wastage rate should be calculated and recorded monthly

Repair and/or replace non-functional refrigerators, provide spare parts, and needed supplies as necessary

All health facilities should have an effective, safe, and appropriate waste management system such as a functional incinerator or shallow pit that is burned when full

Conclusion

STOP Team 34 identified gaps in surveillance during the two field missions. Active case search (ACS) was most lacking in many zones. Also identified weaknesses in EPI, particularly cold chain and vaccine management. The team was able to educate many facility staff about the importance of ACS and the need to frequently monitor vaccine stock.

Acknowledgements World Health Organization, Ethiopia Federal Ministry of Health, and

U.S. Centers for Disease Control and Prevention (CDC).

All of the Staff at the WHO EPI Office (including Dr. Pascal Mkanda, Dr. Fiona Braka, Dr. Kasahun Mitiku, Dr. Sisay Gashu, Dr. Gavin Grant, Dr. Teklay Kidane, Dr. Ayisheshem Ademe, Mr. Tesfaye Bedada, and Mr. Dawit Getachew, Ms. Welansa Belayneh, Ms. Meseret Fikru, Ms. Selamawit Bogale, Mr. Hanok Kebede and Mr. Behailu Demissie), the medical surveillance officers in the zones we visited, and the others who supported us during our time in Ethiopia

We would like to thank the regional, zonal and woreda EPI/IDSR focal persons for their support during our field missions.

We would also like to thank our WHO drivers, Mesele,YohannesKimfe, Fisseha, Tadesse,andYeseph for their safe driving, sound judgment and translation.

Lastly, we would especially like to thank the health workers in each woreda, kebele, and community we visited. Their efforts are truly appreciated and are vital in the fight against polio, measles, and neonatal tetanus.