Implementing a Best Practice
Measles SIA:
Ethiopia’s Experience
Dr Fiona Braka
WHO Ethiopia
Measles Initiative Meeting, Washington DC,
13-14 September 2011
Ethiopia: Background
• Projected population 2010
(census 2007):
79 million
–
–
–
–
Growth Rate:
Under-1:
Under-5:
Under-15:
2.6%
3.2% (2.6m)
14.6% (11.4m)
45% (35m)
Federal Ministry of Health
Regional Health Bureau
(9 Regions + 2 City Administrations)
Zonal Health Administration
(98 Zones)
• Rural: 83%
• Infant Mortality Rate: 75/1000
live-births
Woreda Health Offices
(819 Woredas)
Kebeles/Health Post
(15,000 HP, 1 per 5,000 popln)
Measles cases and MCV1 admin coverage
in Ethiopia, 1990 - 2010
Catch Up
2002 -2004
Follow Up 2005 - 2009
90
7000
80
6000
70
60
5000
50
4000
40
3000
30
2000
20
1000
10
0
0
Cases
Measles Coverage
Administrative Coverage (%)
Number of Measles Cases
8000
Measles Epidemiology, Ethiopia, 2010
Age and vaxn status of confirmed
measles cases. 2010 (n=3527)
Spot map of confirmed measles
cases. 2010 (n=3527)
Second opportunity measles vaccination
through SIAs
Measles 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
Best
Practices
SIAs
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
Areas of Focus for Best Practices
•
•
•
•
•
•
•
Coordination
Micro planning and training
Logistics
Advocacy and communication
Resource mobilization
Monitoring and evaluation
Strengthening routine EPI
Coordination of the Best
Practices 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
Micro planning and Training
• 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
Health Workers
(KAP)
– local knowledge of needs
– hard to reach populations
KAP Survey Findings
• 86% support the idea of
SIAs
• 55% know the importance
of 2nd measles dose
• 9% know how to estimate
vaccine supplies
Community
Members
(FGD)
• Emphasis on Kebele level
planning with
• Few knew about SIAs
• Most willing to vaccinate
children
• Major source of health
information are HEW and
kebele leaders
Logistics
• 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
Advocacy and Communication
•
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)
Resource Mobilization
• 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
Nutrition Global
Partners
Polio
To UNICEF
(EOS)
Initiative
Measles Initiative
To WHO
Vaccine & injection
materials
5,371,901
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
3,345,097
Cost per child $0.92
2,026,804
Implementation
• 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
Monitoring
• 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)
Administrative follow-up measles SIAs
coverage. Ethiopia.
Admin
coverage,
2010 - 2011
• 106% measles
• 97% polio
• >95% coverage:
•93% measles
- 81/95 (85%) Zones
- 740/ 814 (91%) Woredas
>=95%
90-94%
80-89%
<80%
Admin coverage,
2007- 2009
Independent Monitoring Assessment of
Woreda 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 sampled
Note: Poor quality finger markers compromised the independent monitoring process in many areas
Evaluation of the SIA
1. Post SIA coverage survey
o To assess coverage estimates for all interventions
o 80 woredas in the 2 phases of the SIA; 4,420 children
2. Best practices evaluation
o To determine best practices implemented and their effect
on coverage
o 20 woredas
3. Strengthening of routine EPI through the SIA
o 4 regions: 8 zones; urban and rural representation
4. Impact assessment
Post SIA Coverage Survey, 2010-2011
Phase 1: 87.8%
Phase 2: 93.1%
Limitations: assessment of finger marking compromised by quality of markers and timing of phase 1
survey; non availability of screening card in some areas
Best Practices Evaluation
Best practice
activities
Presence of
enough vaccine
carriers
Appropriate cold
chain
Use of multiple
locally available
channels
Task force
meeting at all
levels
P-value
Measles
Coverage
0.044
Polio Coverage
0.005
Vitamin A
coverage
-
De-worming
coverage
-
0.018
-
-
-
-
-
0.048
0.041
0.023
0.02
-
-
Enhancing Routine Immunization through
SIAs
• 7 key areas identified in the planning phase and efforts
made to maximize on RI strengthening:
1.
2.
3.
4.
5.
6.
7.
Micro planning
Training
Logistics Management
Advocacy and Social Mobilization
AEFI monitoring and management
Surveillance
Monitoring and Evaluation
Impact of Measles SIAs on the Routine Immunisation
System, Ethiopia.
KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)
Survey Sites: 4 Regions; 2 zones/ region; urban & rural
Addis Ababa
Oromiya
Pre-SIA Post SIA Pre-SIA Post-SIA
SNNPR
Pre-SIA
Post SIA
Somali
Pre-SIA Post-SIA
Monitoring chart up to
date
Health facilities with
adequate functional
cold chain
50%
63%
35%
99%
100%
100%
60%
64%
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
Health workers who
know the correct site
of measles vaccine
injection
75%
92%
46%
74%
76%
100%
27%
87%
100% 100%
99%
94%
64%
96%
87%
87%
Outcomes of the SIA
Measles incidence, Ethiopia,
2006-2011
9
Number of Woredas with >5 Measles Cases/year
250
Woredas with >=5
Measles Cases/year
200
8
7.8
7
Measles Incidence
6
150
5
4.7
4
100
50
3.5
3.4
2.0
3
2
2.0
1
0
0
2006
Age shift (~70% above 5 years)
2007
2008
2009
2010
2011
Measles Incidence (per 100,000 population)
Confirmed measles cases,
Ethiopia, 2007-2011
Major Lessons Learned
• 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
Future Perspectives for Measles
Elimination in Ethiopia
• 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 management
o Local partnerships for RI and SIAs
Acknowledgement
• FMOH (Neghist Tesfaye)
• Yodit Hailemariam
• Balcha Masresha
• Halima Dao
• Meseret Eshetu
• David Brown
• Pascal Mkanda
• Kathleen Wannemuehler
• Gavin Grant
• Theresa Diaz
• Sisay Gashu
• Edward Hoekstra
• Luwei Pearson
• Mitike Molla
• Tirsit Assefa
• National SIA Task Force
• Habtamu Belete
• MEDCO
Acknowledgement
Ethiopia Federal Ministry of Health
Integrated Family Health Partnership
JSI Research & Training Institute, Inc.