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 Federal 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 in Ethiopia, 1990 - 2010 Catch Up 2002 -2004 3

Measles Epidemiology, Ethiopia, 2010 Age and vaxn status of confirmed measles cases. 2010 (n=3527) Spot map of confirmed measles cases. 2010 (n=3527) 4

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 6

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 7

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 9

Micro planning and Training 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 KAP Survey Findings Health Workers (KAP) 86% support the idea of SIAs 55% know the importance of 2nd measles dose 9% know how to estimate vaccine supplies Community Members (FGD) 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: Human resources, transport, social mobilization, logistics Item Total Budget (USD) FMOH Measles Initiative Nutrition Partners (EOS) Global Polio Initiative To 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 4,658,097 2,776,804 Target population (< 5) 12,859,245 Cost per child $0.92

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

Multiple Data Sources (Tigray) 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. 97% polio >95% coverage: - 81/95 (85%) Zones - 740/ 814 (91%) Woredas 93% measles Admin coverage, 2010 - 2011 Admin coverage, 2007- 2009 >=95% 90-94% 80-89% <80% 16

Independent Monitoring Assessment of Woreda Performance Proportion of Children missed in Evaluated Woreda Woredas Reaching Targets for Measles Vaccination 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 17

Evaluation of the SIA 1. Post SIA coverage survey To assess coverage estimates for all interventions 80 woredas in the 2 phases of the SIA; 4,420 children 2. Best practices evaluation To determine best practices implemented and their effect on coverage 20 woredas 3. Strengthening of routine EPI through the SIA 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 19

Best Practices Evaluation 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

Enhancing Routine Immunization through SIAs 7 key areas identified in the planning phase and efforts made to maximize on RI strengthening: Micro planning Training Logistics Management Advocacy and Social Mobilization AEFI monitoring and management Surveillance Monitoring and Evaluation Ongoing effort to strengthen RI; Description of efforts in each aspect to strengthen RI

Survey Sites: 4 Regions; 2 zones/ region; urban & rural 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 SNNPR Somali Pre-SIA Post SIA Post-SIA Monitoring chart up to date 50% 63% 35% 99% 100% 60% 64% Health facilities with adequate functional cold chain 83% 26% 22% 32% 14% 80% Health facilities with adequate safety boxes 92% 96% 93% Health workers who know the use of additional doses of measles immunization 75% 46% 74% 76% 27% 87% Health workers who know the correct site of measles vaccine injection 94%

Outcomes of the SIA Confirmed measles cases, Ethiopia, 2007-2011 Measles incidence, Ethiopia, 2006-2011 Age shift (~70% above 5 years)

Major Lessons Learned Early identification of best practices at the country level Strong federal government leadership and ownership Micro planning should be bottom up Include both technical and administrative officials 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 Use of SIA Coordination structures for future SIAs and routine EPI activities such as new vaccine introduction Pre-SIA registration of target children and identification of hard to reach populations useful for subsequent SIA and RI Capacity building of PFSA in logistics management Local partnerships for RI and SIAs

Acknowledgement 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

Acknowledgement Ethiopia Federal Ministry of Health Integrated Family Health Partnership JSI Research & Training Institute, Inc.