ENHANCED OUTREACH STRATEGY (EOS) - WHO · children 6-59 months of age in the 11 regions of the country (Ethiopian Health and Nutrition Research Institute, 1996). The situation is

Guideline for the

ENHANCED OUTREACH STRATEGY (EOS)

for Child Survival Interventions

June 2004

Federal Ministry of Health - UNICEF Addis Ababa - MOST / Enhanced Outreach Strategy / June 2004

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TABLE OF CONTENTS

1. INTRODUCTION TO THE EOS 4

1.1 BACKGROUND 4 1.2 RATIONALE FOR EOS 5 1.3 TARGETED POPULATION AND COVERAGE 5 1.4 OBJECTIVES 5 1.5 STRATEGIES AND ACTIVITIES 6

2. VITAMIN A SUPPLEMENTATION (VAS) 7

2.1 WHAT IS VITAMIN A? 7 2.2 WHY IS VITAMIN A SO IMPORTANT TO HEALTH? 7 2.3 WHAT CAN REDUCE THE LEVEL OF VITAMIN A STATUS? 7 2.4 WHAT ARE THE EFFECTS OF A LOW VITAMIN A STATUS? 8 2.5 WHO NEEDS VITAMIN A AND WHY? 8 2.6 HOW TO INCREASE THE CHANCES OF SURVIVAL FOR YOUNG CHILDREN? 8 2.7 LOGISTICS AND SUPPLIES 8 2.8 WHAT ARE THE DOSES AND SCHEDULES FOR VITAMIN A SUPPLEMENTS? 10 2.9 HOW TO ADMINISTER VITAMIN A SUPPLEMENTS SAFELY USING CAPSULE? 10 2.10 HOW TO MONITOR AND SUPERVISE THE DISTRIBUTION OF VITAMIN A SUPPLEMENTS? 11 2.11 HOW SAFE IS IT TO DISTRIBUTE VITAMIN A SUPPLEMENTS? 11 2.12 EMERGENCY ACTIONS IN CASE OF ADVERSE EVENTS 12 2.13 CHECKLIST FOR SUPERVISORS AND COORDINATORS 13

3. DE-WORMING 15

3.1 INTRODUCTION 15 3.2 WHY DE-WORM CHILDREN? 15 3.3 PRACTICAL ISSUES 16

4. SCREENING ACUTE MALNUTRITION 17

4.1 CAUSES OF MALNUTRITION 17 4.2 DIFFERENT TYPES OF ACUTE MALNUTRITION 17 4.3 CLASSIFICATION OF ACUTE MALNUTRITION 18 4.4 SCREENING METHODOLOGY 18 4.4.1 SELECT THE CHILDREN WITH HEIGHT LESS THAN 110 CM 18 4.4.2 CHECK FOR BILATERAL OEDEMA 19 4.4.3 TAKE THE MUAC 19 4.4.4 TAKE THE WEIGHT AND HEIGHT 20 4.4.5 CALCULATE THE WEIGHT/HEIGHT % 23 4.4.6 REGISTRAR ALL THE SCREENED CHILDREN IN THE SCREENING BOOK 24 4.4.7 TASKS AND ORGANISATION DURING THE SCREENING 25

5. MEASLES VACCINATION 28

5.1 INTRODUCTION 28 5.2 THE EPIDEMIOLOGY OF MEASLES 29 5.2.1 THE NATURE AND MAGNITUDE OF THE PROBLEM 29 5.2.2 THE ORGANISM 29


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5.2.3 THE DISEASE (PATHOGENESIS AND CLINICAL PROBLEMS) 29 5.2.4 TRANSMISSION AND IMMUNITY 30 5.3 MEASLES PREVENTION AND CONTROL 30 5.3.1 MEASLES CONTROL PHASE 30 5.3.2 OUTBREAK PREVENTION PHASE 31 5.3.3 MEASLES ELIMINATION PHASE 31 5.4 STRATEGIES 31 5.4.1 ROUTINE IMMUNISATION 31 5.4.2 SECOND OPPORTUNITY FOR MEASLES IMMUNISATION 32 5.4.3 ENHANCING MEASLES SURVEILLANCE AND LABORATORY DIAGNOSIS 32 5.4.4 IMPROVEMENT OF CASE MANAGEMENT 32 5.5 SAFETY OF VACCINES AND INJECTIONS 33 5.5.1 THE MEASLES VACCINE 33 5.5.2 VACCINE SAFETY 33 5.5.3 SAFETY OF INJECTIONS AND DISPOSING 35

6. SOCIAL MOBILIZATION 36

6.1 WHAT ARE THE SERVICES? 37 6.2 WHEN WILL BE CONDUCTED? 37 6.3 WHO SHOULD RECEIVE THE SERVICES? 37 6.4 WHO WILL GIVE THE INJECTION? 37 6.5 WHERE SHOULD BE GIVEN? 37 6.6 ENSURING SAFE INJECTIONS IN MEASLES IMMUNISATION 37 6.7 THE EOS KEY MESSAGES 38

7. OUTREACH POST ORGANISATION 39

7.1 ELEMENTS OF AN EOS POST 39 7.2 FURNITURE AND EQUIPMENT 39 7.3 CLIENT FLOW AT EOS POST 40 7.4 HOW TO KEEP THE POST ORGANISED 41 7.5 WAYS TO AVOID OVERCROWDING OR INSUFFICIENT FLOW 41 7.6 ROLES OF THE CROWD CONTROLLER 41 7.7 ROLES OF THE SUPERVISOR (HEALTH WORKER) 41 7.8 IF THERE IS SHORTAGE OF SUPPLIES 42 7.9 IF THERE IS SHORTAGE OF TALLY SHEETS 42

8. MICRO-PLANNING AND REPORTING 43

8.1 HOW TO PREPARE THE EOS INTERVENTION? – TRAINING AND MICRO-PLANNING 43 8.1.1 TRAINING PROCESS 43 8.1.2 MICRO PLANNING 43 8.2 HOW TO RECORD YOUR INTERVENTIONS – TALLY SHEETS? 45 8.3 HOW TO REPORT AND CALCULATE COVERAGE? 46

ANNEXES 47


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1. INTRODUCTION TO THE EOS 1.1 Background Ethiopia is the third most populous country in Africa with estimated population of 70 million and land area of 1.1 million square km. The country is characterised by great geographical diversity and climate ranging from temperate to sub-tropical and tropical, all within relatively short distances. Because of the size, physical diversity and under-developed infrastructure, Ethiopia faces serious challenges in terms of service delivery, logistics, transport and communication.

The infant mortality rate is estimated at 97/1,000 live births and the under-five mortality rate at 174/1,000, which are the sixth highest rates in the world. These high mortality rates are due to the combined effects of a high incidence of infectious diseases and inadequate infant and young child nutrition. The chronic malnutrition rate (stunting) is reported to be 51% in Ethiopia (DHS, 2000). The major immediate causes of childhood mortality include diarrhoea, acute respiratory infections, chronic and acute malnutrition and measles. The prevalence of tuberculosis and malaria are also increasing, as is HIV/AIDS.

Measles is one of the five major causes of childhood illnesses, which together contribute to 70% of under-five morbidity and mortality. The case fatality rate is 4%, which is one of the highest in the world. According to the WHO measles burden estimator, the annual cases are estimated at 1.45 million and the deaths at 69,000. According to this estimate Ethiopia contributes to 46% of the cases and 51% of the deaths from measles among eight eastern African countries.

Ethiopia has been experiencing drought and chronic food insecurity for the last four decades. The situation in the last three years has been serious. Due to the scanty and erratic rains many parts of the country have experienced shortages of water and food. Although almost all regions were affected by the 2002/2003 droughts, the early warning system identified 325 woredas in ten different regions as most affected in 2003. These drought affected areas faced particularly high acute malnutrition rates ranging from 10 to 34% GAM1 and 1 to 8% SAM2. Some 460,000 children under five (15%) were estimated to be suffering from acute malnutrition and 60,000 (2%) from severe acute malnutrition.

Vitamin A deficiency (VAD) is a severe public health problem in Ethiopia affecting 30-95% of children 6-59 months of age in the 11 regions of the country (Ethiopian Health and Nutrition Research Institute, 1996). The situation is probably worse in emergency affected areas. Vitamin A deficiency has also been observed in school age children up to 14 years of age (World Vision, 1997).

Ethiopia has 1,311 health posts, 2,452 health stations, 412 health centres and 115 hospitals. Nevertheless, overall access to health care is estimated at 51.5%. At only 5% of GDP, funding for the health sector is sub-optimal. Consequently, health infrastructure is plagued with shortage of trained human resources, high attrition and shortage of medicines and medical equipment. In line with the national commitment towards disease eradication and control from the country, Ethiopia has been consistently conducting immunisation campaigns since 1996 at different levels through support of partner organisations, particularly WHO, CDC, UNICEF, CIDA, USAID, JICA, the Government of Japan and Rotary International.

During 1998-1999 vitamin A supplementation coverage in children aged 6-59 months used to be greater than 70% twice a year during NIDs3, house-to-house campaigns. However, coverage dropped to 30% and less in 2000-2001 because of deaths reported to be associated with vitamin A administration. Since 2002, with more training and advocacy efforts, the coverage achieved has increased during NIDs and measles/vitamin A campaigns, reaching 64% coverage of one dose between 2002. Although progress has been made, the challenge is to distribute vitamin A to at least 90% children 6-59 months every 6 months and at least 70% of postpartum mothers within 40 days of delivery. Distribution to postpartum mothers is particularly low because most deliveries take place in homes. 1 GAM: global acute malnutrition (moderate and severe wasting and Kwashiorkor) 2 SAM: severe acute malnutrition (wasting and Kwashiorkor) 3 NID: national immunisation day


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1.2 Rationale for EOS Immunisation and vitamin A supplementation – along with other child survival interventions – can be carried out even under difficult circumstances. Immunisation currently saves the lives of 2.5 million children each year and has the potential to prevent the deaths of another 3 million children through full EPI coverage. It is estimated that vitamin A supplementation of deficient populations can prevent the deaths of as many as 2 million children per year (in Ethiopia, 17% of child deaths or 83,300 child deaths, Profiles) due to childhood illnesses such as measles and diarrhoeal disease.

Universal vitamin A supplementation should always be provided to child populations with high child mortality and/or high prevalence of vitamin A deficiency. Other interventions may be identified nationally or locally, for instance, essential nutrition actions such as the promotion of appropriate breastfeeding and complementary feeding practices.

In order to significantly reduce severity of common childhood infections and child mortality rates, vitamin A supplementation is an essential and urgent action to be taken. Taking into consideration the limitations of the health system, the proposed strategy for 2004-2006 is to organise an accelerated enhanced outreach strategy with priority given to emergency areas. This activity will be coordinated by UNICEF with the Federal Ministry of Health (FMOH), the regional health bureaux (RHB), the USAID micronutrient project (MOST) and other key partners. In 2004 the Ethiopian government is starting implementation of a health extension package (HEP), a new initiative included in the HSDP III. This innovative community-based health care delivery system will include vitamin A supplementation, thereby allowing the scaling up of the twice a year Vitamin A supplementation in 2005 and 2006.

This project will also contribute to the broader Government Food Security Coalition Initiative led by the Prime Minister’s Office. The Food Security Initiative is seen as an important initiative for child survival because health and nutrition interventions have been included in the food security objectives.

1.3 Targeted population and coverage The target population is 6,779,867 children from 6 to 59 months of age living the 325 most food insecure and worst drought affected woredas in the country in 57 zones and 10 regions of the country.

1.4 Objectives The overall objective is to enhance child survival by reducing mortality and morbidity in children less than 5 years of age.

The specific objectives are as follows:

• At least 90% of children 6-59 months given vitamin A every 6 months in the targeted woredas.

• Ensure access by children 6-59 months to the following key child survival interventions in the targeted woredas:

De-worming

Screening for acute malnutrition and referral to the nearest feeding centre when appropriate

Social mobilisation for routine immunisation and immunisation against measles for children under two year old

Information, education and communication (IEC) on infant and young child feeding; promotion of hand washing and HIV/AIDS prevention


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1.5 Strategies and activities Health facilities and local NGO programs in priority zones will be strengthened to work with communities and provide the child health package in an accelerated manner. This will involve accelerated activities for static and outreach stations every 6 months. Outreach activities in hard-to-reach areas will be organised and delivered by mobile teams at temporary community posts where necessary, building on the WHO SOS4 model and other enhanced strategies such as measles SIA5 model used by UNICEF. Training will be conducted for health workers and health extension workers to improve their knowledge and skills in vitamin A supplementation and other child health interventions. Students from nursing schools and health extension workers will also be included in the mobile teams where possible as part of their pre-service training.

For sustainability, links will be established with the planned health extension package planned by the FMOH. The training of the first group of health extension workers has already been started since October 2003. The enhanced outreach strategy could provide a useful field learning experience for health extension trainees and similarly these workers will be useful resource for community and social mobilisation in the enhanced outreach strategy.

The intervention strategies will be introduced in a phased manner beginning with vitamin A and de-worming to avoid overloading the delivery system in the early stages of implementation, and it will be phased in geographically. The priority is to establish a sustainable system for distributing vitamin A every 6 months, adding on other child health and nutrition interventions as the program develops. During the micro-planning sessions, each region will develop a schedule for distribution based on human resources available on the ground.

Community capacity development approaches will be emphasised during implementation to ensure that communities are not passive beneficiaries. Their participation will contribute to the sustainability of the program and ensure the package is relevant to their situation. Using appropriate communication methods, the capacities of caregivers and communities will be strengthened to improve child care practices. These include exclusive breastfeeding, child feeding practices, early recognition of danger signs and seeking of appropriate health care, personal hygiene, sanitation, and other community IMCI family and child care practices.

4 SOS: sustainable outreach strategy 5 SIA: supplementary immunisation activities


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2. VITAMIN A SUPPLEMENTATION (VAS)6 Vitamin A deficiency (VAD) is a severe public health problem in Ethiopia affecting 30-95% of children 6-59 months of age in the 11 regions of the country (Ethiopian Health and Nutrition Research Institute, 1996). The situation is probably worse in emergency affected areas. Vitamin A deficiency has also been observed in school age children up to 14 years of age (World Vision, 1997). Clinical vitamin A deficiency, untreated, leads to childhood blindness and it is likely that vitamin A deficiency is one of the major contributing factors to the high under-five mortality rate of Ethiopia (174 per 1000, UNICEF). And approximately 30% of Ethiopia’s children growing up with lowered immunity, leading to frequent ill health and poor growth.

2.1 What is vitamin A? Vitamin A is an essential nutrient called micronutrient because it’s needed in small amounts for the body to function properly. It is a fat-soluble vitamin and the body cannot make it but can store it for up to 6 months.

Vitamin A in the body comes from two sources:

• Preformed vitamin A in animal foods such as breast milk, liver, whole milk products and butter, fish, meat and eggs.

• Pro vitamin A carotenoids in plant foods, which are precursors that change into vitamin A in the body, are present in orange and yellow fruits, orange and yellow vegetables and dark green leafy vegetables (like gommen for example).

2.2 Why is vitamin A so important to health? Vitamin A helps to protect our health and vision in many ways:

• Helps to decrease the severity of many infections such as diarrhoea and measles by enhancing the immune system

• Increases chances of survival for your young children

• Is necessary for growth and development

• Is vital for the proper functioning of the eyes

• Contributes to the foetal development

Vitamin A is essential for the body and increases the chances of survival for young children

2.3 What can reduce the level of vitamin A status? Vitamin A deficiency results:

• When body stores are depleted because too little vitamin A present in the foods, or where there is too little absorption of vitamin A from foods.

• From rapid utilisation of vitamin A during illnesses (particularly measles, diarrhoea and fevers), pregnancy and lactation, and during phases of rapid growth in young children.

6 Prepared by MOST, the USAID micronutrient project


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2.4 What are the effects of a low vitamin A status? If the vitamin A status in the body is very low:

• The immune systems become weak and illness is more common and more severe, increasing under-five death rates.

• The eye could be damaged with appearance of lesions, and when severe, can cause blindness

• There is an increase a woman’s risk of dying during pregnancy and the first three months after delivery

2.5 Who needs vitamin A and why? To increase their chances of survival, children 6 to 59 months need vitamin A.

Children need vitamin A to:

- To reduce severity of diarrhoea and measles.

- To grow up, vitamin A is essential for the growth of the children;

- To ensure the proper functioning of the eye. If a child has a low level of vitamin A in his/her body, he may have difficulty to see at dusk that can lead to blindness if not treated.

Pregnant and lactating women have increased requirements for vitamin A, and often develop night blindness or Bitot’s spot.

Vitamin A decreases the severity of many infections and helps children to grow.

2.6 How to increase the chances of survival for young children?

Supplementation is a low cost and highly effective means of improving vitamin A status, the quickest intervention to implement on a national scale.

• Vitamin A capsules twice yearly at six months intervals to children 6 to 59 months is protective, and appropriate for a child’s requirement.

• Vitamin A capsules to post partum mothers within 45 days after delivery increases the amount of the vitamin A in the breast milk and therefore the infant’s intake of vitamin A.

Dietary approaches:

• Fortification is the process of adding vitamin A to foods commonly consumed by vulnerable population. It is an effective and sustainable strategy to combat vitamin A deficiency.

• Breastfeeding and home gardens are essential components of vitamin A deficiency reduction program.

In order to increase the chance of survival for young children, intensive support for supplementation and fortification is needed from authorities.

2.7 Logistics and supplies - What are the different types of capsules?

o Capsules of 100,000 IU

o Capsules of 200,000 IU


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In Ethiopia, capsules of 100,000 IU are more frequent.

- What are the supplies needed for a vitamin A supplements distribution?

o Vitamin A capsules

o Scissors to open the capsules

o Wipes or towels to clean oil off hands

o Tally sheets/reporting sheets

o Protocol of supplementation

o Mobilisation materials (Posters, Banners, Leaflet, etc.)

- How to estimate the vitamin A supplements requirements?

If you do not have a census or register with the total number of children in your catchment area, use:

- 1.8% of the total population as an estimate for the number of children 6 to 11 months

- 13.9% of the total population as an estimate for the number of children 12 to 59 months

• An additional 10% is always added for wastage,

• Order enough supplies for follow up doses every 4 to 6 months through routine services, and

• Order vitamin A supplies several months before your stocks end.

- Where to procure the supplies for vitamin A supplements distribution?

o UNICEF ships off vitamin A supplies to the Ethiopian government.

o Vitamin A capsules are stocked at the national warehouse, thereafter

o Vitamin A capsules are sent to each regional warehouse

o Regional warehouse provides vitamin A capsules to woredas, then woredas to all health facilities.

- How to distribute the vitamin A supplements?

o The distribution of vitamin A supplies should be combined with other supplies such as vaccines and essential drugs and transported together to local sites.

o Program managers will need to make sure that there are enough scissors, IEC materials and recording forms at each distribution site.

- How to store vitamin A supplements?

Vitamin A supplements are more stable than vaccines. However, air and sunlight will damage the vitamin. Vitamin A capsules should:

o Be kept out of direct sunlight.

o Be kept cool

o Not be frozen

Vitamin A supplements, if unopened, will keep their potency under good conditions of storage for at least two years. However, once a bottle containing vitamin A capsules is opened, the capsules should be used within one year.

Write the date on the label when you open a new bottle containing capsules, so that you will know when to stop using it.

Always check the expiration date printed on the label of the bottles of vitamin A.

If the capsules have come directly from a cold place, they may need to be warmed to room temperature by leaving the container open for a short time before the distribution session – the gelatine coat of capsules can become quite hard when cold.


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2.8 What are the doses and schedules for vitamin A supplements?

Vitamin A for prevention:

VITAMIN A SUPPLEMENTATION PREVENTIVE SUPPLEMENTATION PROTOCOL FOR CHILDREN

Age Dose Frequency

Children 6-11 months 100,000 IU (1 capsule of 100,000 IU) Once

Children 12-59 months 200,000 IU (2 capsules of 100,000 IU) Once every 4 to 6 months

* Do not give vitamin A capsule if children already received a dose within last one month

* Do NOT give vitamin A capsule to any woman of reproductive age during EOS (large dose vitamin A supplements can damage the foetus if the woman is pregnant)

2.9 How to administer vitamin A supplements safely using capsule?

• Check the age of the child,

• Ask the caretaker if the child has received vitamin A capsule in the last one month. If the answer is yes, confirm and do not administer,

• If the answer is no, ask the caretaker to hold the child firmly, make sure the child is calm,

• Give the appropriate dose of vitamin A to the child:

o 100,000 IU to child 6-11 months

o 200,000 IU to child 12-59 months

• Cut the nipple of the capsule with scissors and immediately squeeze the drops of liquid into the child’s mouth,

• Check if the child is comfortable after swallowing the drops,

• Put all capsules that have been used into a plastic bags and

• Wipe your hands to clean off oil

• Record the dose on the tally sheet.

Do not put the capsule into the child’s mouth or allow the child to swallow the capsule There are no contraindications to giving vitamin A supplements to children


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2.10 How to monitor and supervise the distribution of vitamin A supplements?

• Doses and date of vitamin A supplementation should be recorded:

o On the immunisation or health cards for each child, write the date and the quantity of vitamin A supplements the child has received.

o On the tally to calculate the coverage of under five children who received vitamin A in your area, these tally sheets should be available at each outreach post.

• Each supervisor should:

o Have a supervisory checklist to make sure that supplies needed are available, and that supplementation activities are properly undertaken.

o Review tally sheet with the health worker to ensure proper recording.

o Review stock levels available for future activities and future ordering.

o Submit a report of the summary sheets to the program coordinator.

2.11 How safe is it to distribute vitamin A supplements? When the correct dosage is given, vitamin A is safe and very effective.

• Side effects: occasionally, some children may experience side effects such as headache, loss of appetite, vomiting or a bulging fontanel (in infants). These symptoms have been investigated by researchers and confirmed to be minor, harmless and transitory, and require no special treatment. Advice parents that this is normal, that symptoms will pass and that no treatment is necessary (be sympathetic and reassuring).

• Toxicity from vitamin A supplementation through EOS type of activities is extremely rare. Under normal situations toxicity from vitamin A is not likely to occur if:

o Protocol is followed and proper dose is given

o An interval of at least one month is maintained between high doses

o Proper training is given

o Proper recording is done

o There is adequate supervision

• High dose vitamin A capsules should NOT be given to any woman of reproductive age or any pregnant woman because of the risks to the foetus (teratogenic effects).

• Children should NOT be given the capsule to swallow, and health workers should keep hands free from oil to minimise the risk of accidental choking.

• Health workers should be fully informed that properly dosed and administered vitamin A supplements are harmless. Beyond transitory side effects in some children, there are no adverse effects let alone any risk for child’s health and life.


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2.12 Emergency actions in case of adverse events In case of choking:

For infants:

o Lay the infant on your arm or thigh in a head down position,

o Give 5 blows to the infant's back with heel of hand,

o If obstruction persists, turn the infant over and give 5 chest thrusts with 2 fingers, one fingerbreadth below nipple level in midline.

For Children:

o Give 5 blows to the child's back with heel of hand with child sitting, kneeling or lying.

o If the obstruction persists, go behind the child and pass your arms around the child's body; form a fist with one hand immediately below the child's sternum; place the other hand over the fist and pull upwards into the abdomen; repeat this Heimlich manoeuvre 5 times.

o If the obstruction persists, check the child's mouth for any obstruction, which can be removed.

o If necessary, repeat this sequence with backslaps again.


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Symptoms Preventable? Action required

Side effect Headache, loss of appetite, vomiting or a bulging fontanel (in infants)

Not harmful

NO, happens with approx. 5% of children

Advise the parent that this is normal, symptoms will pass and no medical treatment is necessary

Overdose Vomiting and lethargy/listlessness

Only occurs if child takes multiple doses together

YES, if follow protocol Refer for medical treatment

Report

Choking Accidental blocking of trachea

YES, if follow proper administration

Resuscitation

Report

2.13 Checklist for Supervisors and Coordinators * Checklist for planning a distribution/outreach:

When will capsules arrive?

Have enough been ordered?

Is there a list of the dates and locations for the distribution?

Have the vaccinators been trained?

Supplies:

• Vitamin A capsules

• Scissors to open the capsules

• Wipes or towels to clean oil off hands

• Bag or box to put used capsules

• Tally sheets

• Reporting forms

• Protocol for supplementation

• Mobilisation materials (banners, posters etc.)

Check the bottles of vitamin A capsules – check expiry dates and type of capsules7

Do teams know what to do with left over capsules?

What is the plan for collecting tally sheets and reporting results?

What is the plan for reporting if any (adverse effects) problems occur?

* Supervisor checklist during a distribution/outreach:

Are there enough stocks of vitamin A capsules?

At the distribution are there:

• Scissors to open the capsules

7 If the capsules are not the blue 100,000 IU capsules, check with your supervisor. Make sure to adjust as needed and explain any changes with the protocol to the vaccinators


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• Wipes or towels to clean oil off hands

• A plastic bag or box to throw away used capsules

• Tally sheets/ reporting sheets

• A protocol for supplementation

• Are capsules stored away from direct sunlight?

• Is site organised for children to get vitamin A before measles shots?

Practice:

• Does the health worker give correct dose for age?

• Does the health worker open, administer and dispose the capsule correctly?

• Are hands clean and free of oil?

• Does the health worker make sure the child is calm before giving?

• Does the health worker check to see that the child swallows the drops and is alright?

• Does the health worker record the dose on the tally sheet?

• Does the health worker give parent messages about receiving vitamin A?

• Does the health worker tell the parent when to bring the child again for the next dose of vitamin A?

• Does the health worker report any problem during the distribution? If yes, explain:________________________________________________________________________________________________________________________________________________________________________________________________________________________


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3. DE-WORMING 3.1 Introduction Intestinal worm infections are caused by soil-transmitted helminthes (STH):

• Ascaris lumbricoides (roundworm)

• Ancylostoma duodenal and Necator americanus (hookworms)

• Trichuris Trichuria (whipworm)

Intestinal worm infections represent a serious public health problem wherever environmental conditions coupled with inadequate sanitation and unhygienic conditions prevail.

3.2 Why de-worm children?

• Worm free children have a better nutritional status, grow faster and learn better - STH infections are associated with significant loss or malabsorption of micronutrients

• Worm free children have a better vitamin A status - Vitamin A deficiency is a major contributor to childhood mortality and illness

- Lower absorption - competing with the host – Malabsorption due to chronic infection

- Link b/n A. lumbricoides and lower Vitamin A levels

• Worm free children have a better immune response - The constant and lifelong immune activation due to helminth infections is associated with an

impaired immune response

- Immune cells from highly immune activated individuals are defective which is gradually restored after de-worming

- De-worming also enhance proliferation and response of T-cells

• De-worming can increase the EOS coverage - De-worming is an extremely popular intervention with communities and parents. This is partly

because there is an immediate and visible effect as the worms (esp. A.lumbricoides, the most prevalent species in pre-school aged children) are expelled in the faeces.

- Strengthens community’s trust in their health personnel.


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3.3 Practical Issues Target children: Children between one and five years of age.

Recommended drugs for de-worming pre-school children (1 -5 years)

Any of the following drugs can be used for de-worming

Dose for each age group Drugs

0 - 1 year 1 - 2 years 2 - 5 years Comments

Albendazole

400 mg tablet

No treatment ½ tablet 1 tablet

Mebendazole

500 mg tablet

No treatment ½ tablet 1 tablet

These two are particularly attractive because they are single dose and there is no need to weigh the children

Levamisole

40 mg tablet

No treatment 2.5 mg/kg 2.5mg/kg Scale is necessary

Pyrantel

palmoate

No treatment 10mg/kg 10mg/kg

All these drugs have excellent egg reduction rates.

De-worming drugs are extremely safe

- De-worming drugs are poorly absorbed from GIT – No significant side effects

- Minor side effects like nausea and abdominal discomfort are rare (1-5%) and transient and well tolerated by the children.

- Less than one year old children are not treated as they are not exposed to infection

- Accidental repeated treatment with several doses of de-worming is not dangerous

No special training is needed for distributors - Non- health workers with minimal training can easily and safely give them

- In few hours one can train someone on how to administer the drugs and the benefits of de-worming


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4. SCREENING ACUTE MALNUTRITION LEARNING OBJECTIVES

After studying this chapter, the participant should be able to: - Know the causes of malnutrition

- Recognise the different types of malnutrition - Know how to take anthropometric measurements and calculate the Weight/Height percentage

- Know when to refer a child to a nutrition unit

___________________________________________________________

Malnutrition is a disease caused by not getting enough of the right food to eat or enough quantity of food.

4.1 Causes of malnutrition Malnutrition can be caused by different factors:

1/ biological factors (plant, animal, people and insect) can be a block to food path:

- the wrong crops were planted.

- the crops were planted in the wrong way so that soil erosion takes place.

- the crops were destroyed by animals.

- people are too sick to work hard.

- too many people and not enough land.

- too many people have left their farms and gone to town.

- the pests have destroyed stored food crops.

2/ physical factors (water, landscape, house, climate, air):

- too little rain.

- the rain is late.

- there is not enough land.

- the land is not fertile.

- the land is rented.

3/ social factors:

- family: age of the mother, number of children, family size, pregnant mother, no family planning.

- socio-economical: instruction of the mother, poverty, war, religion, culture, politic.

- health: diarrhoea, infections, no vaccination, health centre far away, another child with malnutrition in the family.

- nutritional: under weight at birth, short breast-feeding, food used for weaning, age of the child for the weaning, bottle-feeding, malnutrition of the mother.

- hygiene and sanitation: access to safe water source.

4.2 Different types of acute malnutrition Different types of acute malnutrition occur when there is not enough energy-giving, growth-promoting and protective foods in the diet. The mortality risk of a malnourished child is high. Therefore, it is very important to identify children with malnutrition and to refer them to a nutritional unit as quickly as possible.

There are 3 different clinical types of acute malnutrition that you have to know and recognise:


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1/ Marasmus: Children with marasmus have lost weight and have a gross loss of muscle mass. They are very thin particularly the shoulders and the buttocks. They are sometimes called ‘skin and bone children’. The face is also wrinkled and the bones stand out. Looking like a ‘little old man ‘, marasmic children are usually hungry and worried. Marasmus is common in babies. Some difficulty with breast-feeding usually causes it. A child’s mother may have had too little breast-milk, or she may have died. Older children can also get marasmus if they do not eat enough food.

2/ Kwashiorkor: The body is swollen (called oedema) especially the feet, legs and hands because there is too much fluid under his skin. If you press an oedema swelling, it feels like a ripe pawpaw and your finger makes a hole. Sometimes he has a round face like a full moon (moon face). His muscles waste and make his upper arm thin. A child with kwashiorkor is unhappy. He sits still, he does not move and is not interested in anything (apathy). Even through he is malnourished, he does not want to eat. A child with kwashiorkor has hair which is easy to pull out. Sometimes it is thin and pale, or slightly red. He is anaemic. He has a large liver. Often, he has chronic diarrhoea, or sores at the corners of his mouth. Sometimes there is too little sugar in his blood, so that he has drowsiness, coma or fits (hypoglycaemia).

3/ Marasmic - kwashiorkor: Some children are very thin like the child with marasmus, and have oedema and the rash of kwashiorkor. Children like this have a mixture of both diseases called marasmic-kwashiorkor.

4.3 Classification of acute malnutrition The Weight/Height percentage (W/H) together with the presence of bilateral oedema are used to identify and classify acute malnutrition8.

MODERATE ACUTE MALNUTRITION SEVERE ACUTE MALNUTRITION

MARASMUS W/H between 70 and 79% W/H less than 70%

KWASHIORKOR NO YES*

* Kwashiorkor is always a severe form of acute malnutrition.

4.4 Screening methodology The population screened for acute malnutrition is

children under 5 years old,

pregnant women and lactating mothers of children less than 6 months old

4.4.1 Select the children with Height less than 110 cm Usually, age is not easy and inaccurate data to collect. During mass screening exercise, the height is used to select children under 5 years old. Children above 5 years old might be selected if they are stunted (growth retardation), but they will benefit from the supplementary program if they are found to be acutely malnourished. A simple wooden stick cut at 110 cm is used to rapidly select the children less than 5 years.

Select all the children with height less than 110cm using the wooden stick

8 Weight/Height is used to identify wasting and Kwashiorkor (= acute malnutrition) ; Height/Age is used to identify stunting (= chronic malnutrition) and Weight/Age is used to identify underweight (= wasting and stunting).


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4.4.2 Check for bilateral oedema Bilateral oedema is the sign of Kwashiorkor. Kwashiorkor is always a severe form of malnutrition. You do not need to take anthropometric measurement of children with bilateral oedema as they are directly identified to be acutely malnourished. Those children are at high risk of mortality and need to be referred to the nearest nutrition unit.

In order to determine the presence of oedema, normal thumb pressure is applied to the both feet for three seconds. If a shallow print persists on the both feet, then the child presents oedema. Only children with bilateral oedema are recorded as having nutritional oedema.

Record the children with bilateral oedema in the screening book (column “oedema”) and refer them to the nearest hospital and/or nutrition unit as well as to the supplementary feeding

programme

4.4.3 Take the MUAC MUAC stands for mid-upper arm circumference. This means of measurement is used to see if the child is malnourished or not. The MUAC can be used only for children more than 1 year. For the children less than 1 year, the MUAC has no significant values. In mass screening exercise, the MUAC is taken only in children that are able to walk (= around 1 year old).

Send the children that do not walk directly to the weight and height post without taking the MUAC

For the children that are able to walk, the MUAC is used as a first step for selection.

How to measure the MUAC? Put the strip around the left child’s upper arm (half way between the elbow and the shoulder) and read the number where the strip meets the marker line.

When the MUAC is more than 12.5cm, it is not needed to take the weight and height. It is assumed that the W/H% is more than 80%.

If MUAC is more than 12.5cm, record it in the screening book (column W/H>80%) and send the child to the exit

If MUAC is less than 12.5cm, send the child to the weight and height post

The MUAC should be taken at the left arm, while the arm is hanging down the side of the body and is relaxed. It should be measured at the mid-point between the shoulder and the tip of the elbow. The measurement is read between the 2 arrows.


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MUAC will be also taken for obviously pregnant women and mothers lactating a child less than 6 months old.

Refer pregnant women and lactating mother with MUAC less than 21cm to supplementary feeding programme

4.4.4 Take the weight and height The weight and height will be taken for:

Children that are not walking

Children that walks with MUAC less than 12.5 cm

How to take the weight? Children are weighed by using a 25 kg hanging sprint scale graduated by 0.100 kg. Do not forget to re-adjust the scale to zero with the empty weighing pants hanging before each weighing

Place the child undressed in the pants. When the child is steady record, record the measurement to the nearest 100 grams, the frame of the scale being at eyes level. When impossible to undress the child, the weight of the clothes has to be deducted from the measurement. Each day, the scales must be checked by using a known weight in order to guarantee their good functioning.


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How to take the height? For children less than 85 cm, the measuring board is placed on the ground. The child is placed, lying along the middle of the board. The assistant holds the sides of the child’s head and positions the head until it firmly touches the fixed headboard with the hair compressed. The measurer places his hands on the child’s legs, gently stretches the child and then keeps one hand on the thighs to prevent flexion. While positioning the child’s legs, the sliding foot’ plate is pushed firmly against the bottom of the child’s feet. To read the measure, the foot’ plate must be perpendicular to the axis of the board. The height is read to the nearest 0.1 centimetre.


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For children more than 85 cm, the measuring board is fixed upright where the ground is level. The child stands, upright in the middle, against the measuring board. The child’s head, shoulders, buttocks, knees, heels are held against the board by the assistant, while the measurer positions the head and the cursor. The height is read to the nearest 0.1 centimetre.


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4.4.5 Calculate the Weight/Height % Example: For a child of 80.5 cm and weighing 8.7 kg, reference tables give a median weight for a child of this height of 10.9 kg: ⎢ Weight-for-height = (8.7/10.9) x 100 = 80%

How to use the weight/height ratio tables? Example: a child is 63 cm tall and weighs 6.5 kg

Take the table, look in the 1st column and look for the figure 63 (=height).

Take a ruler or a piece of card place it under the figure 63 and the other figures on the same line.

On this line find the figure corresponding to the weight of the child, in this case 6.5.

Look to see what column this figure is in. In this case it is in the WEIGHT NORMAL column. In this example the child’s weight is normal in relation to his height. He is therefore growing normally.

Example: a child is 78 cm tall and weighs 8.3 kg

This child is in the 80% column. He is too thin in relation to his height. He is malnourished.

NOTE: It may be that the weight or the height is not a whole number.

Example: height 80.4 cm and weight 7.9 kg. These 2 figures are not in the table. For the height: The height measurement has to be rounded to the nearest 0.5cm, as it is in the following example.

Height in cm

80.0 80.1 80.2

80.3 80.4

80.5 80.6 80.7 80.8 80.9 81.0 81.1 81.2

For the weight: Looking at the table, for a height of 80.5 cm the weight is 7.9 kg. This is between 7.6 and 8.1 kg. Conclusion, to express the fact that the child is between these 2 weights, write down that this child’s percentage is between 70 and 75%.

80.0cm is used for 80.1 and 80.2cm

80.5cm is used for 80.3 and 80.4cm.

80.5cm is used for 80.6 and 80.7cm

81.0cm is used for 80.8, 80.9cm as well as 81.1 and

81.2 cm


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4.4.6 Registrar all the screened children in the screening book After screening the child, a tick, which matches the right indicator, is put in the matched box of the screening book.

Month :………. W/H>=80% W/H70 to 79.9% W/H<70% Oedema MUAC>=21cm MUAC<21cm

Week 1from …./…./….To …./…./….

Week 2from …./…./….To …./…./….

Week 3from …./…./….To …./…./….

Week 4from …./…./….To …./…./….

Total

SCREENING FOR MALNUTRITION

Children from 6 months Pregnant women and lactating mothers


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4.4.7 Tasks and organisation during the screening WHERE WHO WHAT

Before the screening post

1 person with a wooden stick 110cm

- select all the children with height < 110cm and refer them to the screening post - select the obviously pregnant women and mothers lactating a child less than 6 months old

1 first selector with MUAC tape

- check the presence of bilateral oedema; - If presence of bilateral oedema, quote “oedema” on the child paper; send the child directly to the

registrar. Do not take anthropometric measurement on oedematous child; - If no oedema, look if the child is able to walk; - If the child does not walk, send him to the measurers; Do not take MUAC of child who is not walking; - If the child walks, take the MUAC; - If the MUAC is more than 12.5cm, quote the MUAC on the child paper, send him to the registrar; Do

not take weight and height of child with MUAC>12.5cm; - If the MUAC is less than 12.5cm, quote the MUAC on the child paper, send him to the measurers.

2 measurers - take the weight and height of the child sent by the first selector (ie only a child with no oedema and does not walk or child who walks with MUAC<12.5cm); Do not take weight and height of child with MUAC>12.5cm; - write the weight and the height on the child paper; - send him to the registrar.

At the screening post

1 registrar - take the child paper and quote the result in the screening book; - if the child has oedema, quote in “oedema” column; refer him the nearest hospital and/or Nutrition unit as well as to the supplementary feeding programme* - if the child walks and MUAC>12.5cm, quote in “W/H>80%” column; - when weight and height are taken, look for the W/H percentage and quote in the screening book in the appropriate column (W/H<70% or W/H 70-79.9% or W/H>80%) - refer the child to the nearest supplementary site when appropriate* (W/H< 80%)

* Referring a child means filling the supplementary card and giving it to the child

* Children with W/H< 80% and/or oedema will be referred to the supplementary feeding programme (SFP)

* Children with bilateral oedema and/or W/H<70% will be referred to the nearest Hospital and/or Nutrition unit as well as to the SFP

SPECIAL CASES – PREGNANT WOMEN AND MOTHERS LACTATING A BABY LESS THAN 6 MONTHS - Take the MUAC to every obviously pregnant women AND mothers lactating a baby less than 6 months

- If MUAC < 21 cm, refer the woman to supplementary feeding programme


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A- Calculate the weight/height percentage by using the weight for height table of the percentage of the median. Write your answer in the space provided in column of the table below. 1- A boy of 85cm height with a weight of 9.2kg 2- A girl of a height of 88cm and a weight of 7.9kg has on her belly a persistent skin-fold

and her fontanel is depressed 3- A girl has a height of 100cm with a weight of 14kg 4- A boy of 102cm height with a weight of 16.5kg has bilateral oedema on his feet 5- A girl has a height of 106cm and a weight of 11.2kg. 6- A boy has a length of 79cm with a weight of 8.9kg Child Height/length (cm) Weight (kg) Percent median Nutritional status 1 85 9.2 2 88 7.9 3 100 14 4 102 16.5 5 106 11.2 6 79 8.9 B- Based of the previous information, first specify the nutritional status of the child: normal nutritional status: N – moderate acute malnutrition: MM – severe acute malnutrition: SM, in column 2 C- Choose the right answer (a-b-c) to the different cases (1-2-3-4-5). 1- Mother lactating since 3 months has a MUAC of 20cm, 2- Pregnant woman of 6 months has a MUAC of 22cm, 3- A 6 months old child has a W/H of 74% ; 4- A child of a height of 109cm has a W/H of 75%; 5- A child of a length of 75cm has a W/H of 65%. a- Should be referred to the nearest Nutrition unit b- Should be referred to the nearest Supplementary site c- Should not be referred.

Evaluate Yourself!


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D- Based on the anthropometry, classify the nutritional status of 12 children and 5 mothers in the underneath table and fill the above report Cases W/H % Oedema MUAC Child 1 62.7 N Child 2 102 N Child 3 80.3 N Child 4 86.7 Y Child 5 100.5 N Child 6 97.6 N Child 7 92.2 N Child 8 88.6 N Child 9 101.8 N Child 10 80.6 N Child 11 96.4 N Child 12 75 N Mother 1 21 Mother 2 22 Mother 3 21.5 Mother 4 20 Indicators #persons screened and referred W/H >= 80% 70%=<W/H<80% WH<70% Bilateral Oedema PW/LM: MUAC<21cm PW/LM:MUAC>= 21cm Total screened *Pregnant Women=PW; Lactating Mothers=LM


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5. MEASLES VACCINATION 5.1 Introduction Measles is the single leading cause of childhood morbidity and mortality worldwide. It is estimated that over 30 million cases and 875 000 deaths still occur every year from measles. These deaths represent 50–60% of the estimated 1.6 million deaths caused annually by vaccine preventable diseases of childhood. Globally, therefore, measles remains the leading cause of vaccine preventable child mortality. The majority of this mortality is taking place in the poorest countries, particularly sub-Saharan Africa, where a combination of factors such as crowding, exposure at younger age and malnutrition contribute substantially to the higher case fatality rates. The World Summit for Children goals for measles call for a reduction by 95% of measles deaths and a reduction by 90% of measles cases by the year 2000. In addition, raising of measles immunisation coverage at least to 90% in infants of one year of age at district and community level and reducing case fatality rate to less than 1%, were additional targets to be achieved by the year 2000. A joint UNICEF and WHO Measles Mortality Reduction and Regional elimination plan 2001 – 2005 is drawn and is being implemented. It updates the previous WHO document on measles control in the 1990s.

The Strategic Plan seeks to reduce measles mortality worldwide. A new target for the reduction of global measles mortality is presented, together with strategies for achieving it. The following goals are included:

• to reduce the number of measles deaths by half by 2005;

• to achieve and maintain interruption of indigenous measles transmission in large geographical areas with established elimination goals;

• to review the progress and assess the feasibility of global measles eradication at a global consultation in 2005, in collaboration with other major partners.

The strategies recommended for reducing measles mortality include:

(1) providing the first dose of measles vaccine to successive cohorts of infants;

(2) ensuring that all children have a second opportunity for measles vaccination;

(3) enhancing measles surveillance with integration of epidemiological and

laboratory information;

(4) improving the management of every measles case.

In Ethiopia measles is the commonest cause of mortality and morbidity in children. Though routine measles coverage has increased from 29 % in 1994 to 42% in 2002, is still very low. Because of the low coverage and prevailing poor living conditions, measles outbreaks frequently occur in different parts of the country, mainly in urban slum areas.

Considering the burden of the disease, measles immunisation is included in the package of the Enhanced Outreach Strategy for Child Survival interventions targeting infants 6 – 23 months of age. During the EOS intervention days, a single dose of measles vaccine will be given to all children aged 6 – 23 months, irrespective of their immunisation and disease history status. Children who received measles vaccine in the last 1 month will not be given the vaccine again. The purpose of including measles immunisation in the EOS interventions is to improve routine measles vaccination coverage and keep up the high coverage achieved during measles campaigns.


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5.2 The epidemiology of measles 5.2.1 The nature and magnitude of the problem Measles ranks as one of the leading causes of childhood mortality in the world. Before measles vaccine became available, virtually all individuals contracted measles with an estimated 130 million cases each year. Humans are the only natural host. Measles is a highly communicable infection. Despite the remarkable progress made in measles control with the introduction of measles vaccination, it is estimated that in 2002 nearly 777,000 deaths from measles still occurred, the majority of them in Africa. Outbreaks of measles continue to occur even in highly vaccinated populations.

5.2.2 The organism Measles virus is a paramyxovirus of a single serological type.

5.2.3 The disease (pathogenesis and clinical problems) The incubation period usually lasts 10 days (with a range from 7 to 18 days) from exposure to the onset of fever. The disease is characterised by prodromal fever, conjunctivitis, coryza, cough and the presence of Koplik spots (reddish spots with a white centre) on the buccal mucosa. A characteristic red rash appears on the third to seventh day beginning on the face, becoming generalised and lasting 4-7 days.

Clinical case definition: Any person in whom a clinician suspects measles infection

OR Any person with fever, and maculopapular rash (i.e. non-vesicular), and cough, coryza

(i.e. runny nose) or conjunctivitis (i.e. red eyes)

Laboratory criteria for diagnosis* At least a four-fold increase in antibody titre, or isolation of measles virus, or presence of measles-specific IgM antibodies.

* only recommended for countries in the measles elimination phase

Complications occur in around 10-15% of cases and include diarrhoea, otitis media, pneumonia, croup and, typically, encephalitis.

Low vitamin A status has been associated with a higher rate of complications and a higher death rate, as it has similar pathological effects on epithelia and the immune system. Most measles deaths (98%) occur in developing countries, where vitamin A deficiency is common. The case fatality rates in developing countries are normally estimated to be 3-5%, but may reach 10-30% in some situations. This compares with 0.1% in many industrialised countries. Through synergy with measles infection, vitamin A deficiency contributes to the estimated 1 million childhood deaths from measles every year. Half of the childhood corneal blindness in developing countries is attributable to vitamin A deficiency, and half to measles infection.


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5.2.4 Transmission and immunity Transmission is airborne, by droplet spread or by direct contact with the nasal and throat secretions of infected persons. Measles is one of the most highly communicable diseases in man, with a basic reproductive rate of 17-20 (i.e., the introduction of one case of measles in a completely susceptible community generates 17-20 new cases). The disease is communicable from slightly before the prodromal period to four days after the appearance of the rash. Natural infection produces a lifelong immunity. Measles vaccine induces long-term and probably lifelong immunity in most individuals; the vaccine virus has not been shown communicable.

5.3 Measles prevention and Control The introduction of measles vaccine into routine immunisation programs results in a marked reduction in incidence of the disease and its associated morbidity and mortality.

There are three sequential phases for measles immunisation programs (Fig.1).

• Measles control phase

• Measles outbreak prevention phase

• Measles elimination phase

5.3.1 Measles control phase Measles control is defined as a significant reduction in measles incidence and mortality. When high levels of vaccine coverage are attained (i.e. vaccine coverage >80%), measles incidence decreases and the intervals between outbreaks are lengthened (e.g., 4-8 years) when compared to those observed during the pre-vaccine era (e.g., 2-4 years). As high levels of vaccine coverage are maintained, an increasing proportion of cases will occur among individuals in older age groups. As vaccine coverage improves, the proportion of cases with a vaccination history increases.


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5.3.2 Outbreak prevention phase Once measles have been drastically and persistently reduced through a sustained increase in immunisation coverage, countries may wish to implement strategies aiming at the prevention of periodic measles outbreaks. These strategies include improved surveillance in order to understand the changing epidemiology of the disease (e.g., changes in the age distribution of cases, settings for measles transmission, etc.) and in order to identify populations at higher risk. It is possible to predict outbreaks and to prevent them by timely immunisation of susceptible individuals in populations at higher risk and by improving overall levels of vaccine coverage in the population. If an outbreak is anticipated, supplementary immunisation activities may be considered.

5.3.3 Measles elimination phase Both developing and industrialised nations have begun to implement innovative measles immunisation and surveillance strategies in an effort to eliminate indigenous transmission of measles virus. The development of these strategies has been prompted by the persistence in these countries of low-level transmission and intermittent outbreaks, despite high coverage with either one-dose or two-dose immunisation schedules.

A common principle to all measles strategies currently implemented is the need to maintain the number of susceptible individuals in the population below the critical number that is required to sustain transmission of the measles virus.

5.4 Strategies The achievement of measles mortality reduction requires improvement in both the coverage and quality of immunisation services. Sustainable reduction is possible by implementing the following four strategies:

1. high routine immunisation: providing the first dose to successive cohorts of all infants;

2. provision of a second opportunity for measles vaccination for all children;

3. measles surveillance;

4. improve management of complicated cases.

5.4.1 Routine immunisation This is the foundation of effective measles control. Increasing and sustaining high measles routine coverage (i.e. over 90%) is essential for achieving a sustainable reduction in measles mortality. Routine immunisation is defined as the regular provision of immunisation services to successive cohorts by means of a combination of strategies. The reasons for low coverage should be determined and remedied.

Activities to improve routine immunisation coverage should include:

• training to improve management of immunisation services at all levels;

• enhancement of supervision;


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• reduction of missed opportunities and drop-out rates;

• provision of more efficient fixed vaccination sites;

• design and implementation of information, education and communication activities and materials;

• special tactics for reaching the unreached;

• improvement of the quality of services.

5.4.2 Second opportunity for measles immunisation With a one-dose policy, even where immunisation coverage is high, a substantial proportion of children will remain susceptible to measles. The average seroconversion rate of 85% following a single dose at nine months of age, the recommended strategy for routine immunisation in developing countries, leaves a proportion of children susceptible. Furthermore, the routine delivery system in many countries has failed to reach many children at the age of nine months. A second opportunity for measles vaccination is required in order to protect these children. This second opportunity can be delivered, as appropriate, through regular routine or supplemental immunisation activities.

5.4.3 Enhancing measles surveillance and laboratory diagnosis The routine reporting of communicable diseases (e.g. the disease notification system) is the backbone of measles surveillance. Effective surveillance for measles and the monitoring of vaccination coverage is critical for determining the impact of vaccination activities and adapting policies and strategies. Further strengthening of measles surveillance systems is required in all countries. Measles surveillance should include only the information that is most useful for documenting disease burden and guiding program activities. The minimum data requirements for measles mortality reduction include:

• measles case counts by month and geographical area;

• age distribution and vaccination status of cases and deaths in both urban and rural areas;

• timeliness and completeness of reporting;

• reports from outbreak investigations and record reviews. Outbreak investigations are very useful for monitoring changes in measles epidemiology and identifying and remedying weaknesses that have led to outbreaks.

5.4.4 Improvement of case management Many children experience uncomplicated measles and require only supportive measures, including vitamin A treatment, nutritional support and education for mothers about complications. However, in an important proportion of measles cases in developing countries at least one complication can be expected and some may involve multiple complications.


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5.5 Safety of vaccines and injections 5.5.1 The measles vaccine

The attenuated live measles vaccine if potent and correctly administered at the right age, the efficacy is usually 85 -95 %. Protection is life long.

Vaccine schedule During the implementation of the EOS, a single dose of measles should be given, irrespective of immunisation and disease history, to all children aged 6 – 23 months. Those children who received measles immunisation in the last 1 month will not be immunised.

Dosage and administration Measles vaccine is given sub-cutaneously (45- degree angle) at the outer part of the child’s upper arm in a single dose of 0.5 ml.

Reaction and complication A mild fever and rash may develop in a small percentage of children. Encephalitis as a complication is very rare (one case per million doses administered).

Contraindication Virtually none

Vaccine storage and Transport Freeze-dried measles vaccine should be kept below +8o c. At central stores and when the vaccine is not to be distributed or administered immediately, it is recommended to keep the vaccine (and not the solvent) at a temperature of – 200 c. Protect from light. Reconstituted measles vaccines quickly loose their potency at exposure to room temperatures. It is therefore extremely important to keep reconstituted measles vaccine cool and protected from sunlight. The reconstituted vaccine should be used only for one vaccination session

5.5.2 Vaccine safety Although modern vaccines are safe, no vaccine is entirely without risk. Most vaccine-induced reactions are mild and temporary. In rare instances, reactions following immunisations can result in serious illnesses. Reactions can result from the following factors:

Program error

• in handling

• in reconstituting

• in administering the vaccine

Examples of this include using contaminated syringes, or needles, reconstituting vaccine with something other than the diluent, using wrong doses, administering poorly mixed vaccines or injecting vaccine in the wrong site.


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Nature of the vaccine or individual responses In rare circumstances some individuals might respond to the vaccine showing some symptoms like fever or febrile convulsions following measles. Although the rates of serious events are difficult to estimate precisely, they are far less frequent than the complications of the disease itself.

Coincidence Medical incidents, which occur after immunisation, can be purely coincidental. There is no association between the immunisation and the medical incident following immunisation. Sometimes illness appears to be more frequent following immunisation, due to parental concern or more intense observation for illness following immunisation.

Unknown cause Adverse Events following immunisation (AEFI) is a medical incident occurring after an immunisation, which is believed to be caused by the immunisation. Most AEFI are mild and transient and the most frequent being fever and rash following measles immunisation. Severe AEFI are extremely rare and are defined as events, which require treatment with prescription drug, which, result in death or hospitalisation.

AEFI can undermine an immunisation program by causing parents and the community to loose confidence in the benefit of immunisation. Therefore, it is important that supervisors monitor AEFI and that appropriate actions are taken to correct.

Health workers and parents should all participate in surveillance for the following events:

▪ Injection site abscess

▪ Death that are thought by health worker, the public or both to be related with immunisation

▪ Cases requiring hospitalisation that is thought by health workers, the public or both to be related to the measles administration.

▪ Other severe or unusual medical incidents that are thought by health workers, the public or both to be related to measles.

Prompt case investigation(s) and the following immediate action should follow the monitoring.

1. Treatment of the patient

2. Communication with parents and the community to explain the cause of the AEFI and action taken, or to explain lack of association and thereby dispel rumours and fears.

3. Improvements or correction of service delivery if the AEFI was caused by programmatic error.

4. Identification and removal of the vaccine (measles) if the association is confirmed

5. Further investigation on AEFI with an unknown cause.


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Opened vials on measles must be discarded at the end of each immunisation sessions.

5.5.3 Safety of injections and disposing 1) Measles vaccine shall be administered with ONLY auto-destruct syringes (AD

syringes).

2) The AD-syringes must be disposed properly. Safety boxes are available for disposing the syringes. Each safety box is to dispose 100 AD-Syringes with the needles.

3) Needles must not be recapped after use. Needles should remain uncapped and placed immediately into a safety box and disposed by burning, as soon as possible after use.

4) Woredas should assign at least one health worker who shall administer measles vaccine. The administration of the measles injection should be the last thing after a child has received Vitamin A supplementation and other services.

5) The woredas should select a health facility with incinerator or a site for burning the safety boxes. Either the solo shots or the safety boxes should not be thrown away, even into garbage collection sites.

6) Vehicles and or locally available means should be employed to collect the safety boxes with the used solo shots to transport to the burning sites or incinerators. The materials should be burnt on the day it has arrived at the site.

7) Woreda should also make sure the availability of adequate 5ml disposable syringes for reconstituting the measles vaccine. It should be noted here that AD- syringes will not be used for reconstituting the measles vaccine.


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6. SOCIAL MOBILIZATION Communication is a major component of the EOS that contributes to the achievement and maintenance of high health service coverage. Communication is the process/mean whereby individuals within a group or organization can insure that they:

• agree that there is a problem

• agree on the major causes of the problem

• agree to pull their resources together to address the problem’s causes

• agree on major lessons learned to solve the problem

From the above statements communication works require full participation and involvement from every stakeholder.

Communication challenges: In Ethiopia, there are communication and education efforts made although they are inadequate. Opportunities to develop community capacity to educate and inform their own community about health services are substantially missed. Health education and information messages are not transmitted on regular basis, and are not consistent. Up until the recent initiative taken in Health Extension Package, information and communication were deficient and irregular, especially at lower levels, such as at woreda and community levels. In general community and partners/allies involvement in the health service is weak. Communication is a strong mean of raising the community demand for health services and improving the service coverage.

Strengthening the communication organ: To effectuate these activities, right from the planning stage all the way through to the end, including in the supportive supervision and evaluation stages of the EOS the communication component should be considered. In order to put this in action the FMOH and RHB ICC can play a significant role by reviewing plans, monitoring, evaluating and doing supportive supervision in the EOS sites. To this effect like to any other EOS components, the communication committee and/or organ have to be strengthened at all levels, down from the kebele up to the regions. Re-establishing communication committee where there was before and establishing communication committees in places where there were no before is crucial. More importantly, assigning communication focal persons at all levels in charge of EOS communication planning, implementing, monitoring and evaluation activities is necessary for communication to serve its purposes. To this effect communication committees and communication focal persons at various levels have to be well acquainted with the EOS packages before they start playing their role in the EOS.

Involvement of local traditional religious leaders, women groups, youth groups, teachers associations, NGOs in mobilising the population for the EOS Child Survival Interventions is critical. Any rumour should be anticipated and controlled. In this respect, right from the beginning key people and groups should participate in specific promotional activities.

The creation of Community Health Committee should be encouraged to organise the social mobilisation.


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6.1 What are the services? During the EOS intervention days a team of health workers and support staff from the community will provide the following services to children between 6 and 59 months old in health facilities (static post) and outreach post.

• Vitamin A supplementation to every children 6-59 months old every 6 months

• De-worming of children 1-5 years

• Measles immunisation to children 6–23 months

• Screening for acute malnutrition and referral to the nearest supplementary feeding centre when appropriate (under 5 children, pregnant and lactating women).

• Social mobilisation for routine immunisation

• Information, education and communication (IEC) on infant and young child feeding, personal hygiene and HIV/AIDS prevention.

6.2 When will be conducted? The Child Survival interventions will be carried every 6 months. The communication intervention is entertained 1-2 months before and during the intervention.

6.3 Who should receive the services?

▪ All children with age group between 6 to 59 months.

▪ Children between 6 months and 23 months will be given measles vaccine

▪ Pregnant and lactating women will be screened for malnutrition and referred accordingly

6.4 Who will give the injection? Health workers must give the injection.

6.5 Where should be given? The service will be provided at all static and outreach posts.

6.6 Ensuring safe injections in measles immunisation There is increased public awareness that unsterile injections may cause hepatitis B infection and HIV infection. In addition subcutaneous abscess is a common complication of unsterile injection. Each injection is administered safely with a single sterile syringe and needle.

▪ Auto-destruct syringes with fixed needle and safety boxes will be used during the EOS interventions. The auto-destruct syringe presents the lowest risk of person to person transmission of blood borne pathogens because it cannot be reused.

▪ Supervisors during the EOS days will inspect injection safety practices.


38

▪ Care should be taken how to dispose the ashes and other pieces.

▪ Adverse events following measles immunisation (AEFI) and vitamin A administration will be monitored. Public awareness about the safety of the injection should be increased

All social mobilisation activities at all levels should use uniform messages about the child survival interventions.

6.7 The EOS key messages Communication/ social mobilisation activities at all levels should use uniform messages about the child survival interventions. The way they are presented can differ according to the purposes they serve (for advocacy, social mobilization and program communication activities). Selection of communication messages should not be left to health specialists alone, neither to the communication focal person/specialist alone. Communication is an integral component of EOS and the involvement and contributions of all stakeholders is highly appreciated.

Below are the health professionals suggested core/key messages of EOS for communication stakeholders to focus on in developing communication materials and do other communication activities.

▪ Children between 6 months and 59 months should go to a nearby EOS post to receive the child survival services.

▪ Measles is a very contagious disease that frequently kills children. Every year more than 50 to 60,000 children less than five years old die because of measles and its complication.

▪ Children can have life long immunity with only one injection of measles vaccine.

▪ Vitamin A prevents blindness.

▪ Vitamin A prevents death from Measles, Diarrhoea, and Pneumonia etc.

Social mobilisation activities should be continuous and intensified two to three weeks before the intervention days. The activities should include:

▪ Making house to house visits

▪ Announcing the child survival package during community meetings

▪ Mobilising leaders to convince the community to respond

▪ Hanging posters and banners in the community

▪ Distributing brochures


39

7. OUTREACH POST ORGANISATION An outreach post will be organised in a village beyond the reach of the nearby health facility. 1 health worker (team leader and vaccinator), 3 Health Extension Workers and 3 volunteers will staff the post. The team moves from one post to another established in each village. The post will be open for one day in a village depending on the size of the target population. Strong social mobilisation will be done to mobilise all eligible children and mothers to come to the post in one day.

The post will be organised in such a way that the children, mothers or caretakers go through the following steps to get the services.

1. Kebele officials and team leader welcomes the people and explain the purpose and benefit of the interventions

2. The people will be divided into groups to discusses on important health issues: infant and child feeding, immunisation, hygiene promotion and HIV/AIDS prevention

3. ‘The Line’- 1) Vitamin A administration, 2) De-worming, 3) nutrition screening and 4) Measles vaccination.

Always give the Vitamin A before doing the screening and/or the vaccination, when the child is quite9

7.1 Elements of an EOS post

▪ Should have some shade

▪ Should have at least 7 people, one of whom should be a health worker,

▪ Should have a banner/ poster in order to clearly stand out.

▪ Should be situated in an area that is easily accessible to the community with adequate space for crowds of people. Schools, churches, kebele offices etc. could be used as posts depending on past experience.

▪ This should preferably be in a building or a veranda or under a good shade. The site should be located in a clean environment and accessible to conveniences.

▪ The local community leaders should participate in selecting suitable location of posts. Encourage at least two community leaders to be present at the posts throughout the intervention days by shift.

7.2 Furniture and equipment

▪ 3 tables

▪ 5 chairs

▪ Other suitable materials e.g. benches, mats, etc. to be used by the parents/guardians/children

9 If vitamin A is administered to a crying child, there is a risk the child will choke.


40

▪ Vaccine carriers with 4 or 5 well frozen ice packs, vaccine packed in polythene bags tally sheets and pens

▪ A container with water (for hand washing)

▪ A basin and soap

▪ Towel/tissue (or toilet paper) to clean the hands from the vitamin A oil

▪ Scissors to cup the vitamin A capsules

▪ A banner/ poster to mark the site

▪ A plastic bag for used vials, vitamin capsules

▪ Adequate number of 5 ml syringes, auto-destruct syringes, safety boxes

▪ At least 1 ampoule of adrenaline with a syringe and a file ready in case of anaphylactic shock.

7.3 Client flow at EOS post


41

7.4 How to keep the post organised Design the EOS post for efficient flow and avoid "bottle-necks" like excess crowding, waiting too long or confusion. The post should be opened early especially on market days since parents might bring their children early and may like to leave early enough to go to the market. Depending on the local conditions the post should be opened early and be closed not too late to give adequate time for parents to be home before dark.

7.5 Ways to avoid overcrowding or insufficient flow

▪ Enough space at the EOS posts

▪ Adequate number of organised volunteers with defined tasks and responsibilities

▪ Good crowd control.

▪ Service provided on first -come. "First served" basis

▪ A designated entry and exit at the post and one way flow through the post. This will prevent backtracking through the crowd after getting the service.

7.6 Roles of the crowd controller ▪ Welcomes the parent/guardian and the child

▪ Verifies that the child is within the target group (6 -59 months)

▪ Have not taken measles vaccine within the last one-month for children under 2

▪ Children do not come twice to receive the same service (remember that receiving 2 doses of vitamin A in a short period can be dangerous)

Note: Sometimes the parent/guardian does not know the age or birth date of the child. In this case, use other ways to determine whether the child falls within the target group. For example there may be important local or historical, events, which the parent can remember in relation to the child's birth date on the local calendar, which could be used. Stick 110 cm long could be used to screen children below the age of 5 years i.e. children whose height is below 110 cm are considered to be younger than 5 years.

7.7 Roles of the supervisor (health worker)

▪ Welcomes the parent/guardian and the child

▪ Leads the team and supervises the overall post activity.

▪ Ensures that the vaccine is kept in the vaccine carrier with frozen ice packs.

▪ Prepares and administer the measles vaccine.

▪ Supervising the volunteers

▪ Ensuring efficient flow through the post

▪ Designating specific responsibilities and tasks to the volunteers e.g. collecting of the safety boxes etc.

▪ Answering questions of the people who are waiting


42

▪ Mobilising parents and children to seek out other eligible children

▪ Making sure that the tally sheets are complete

▪ Ensuring that all the equipment/logistics, tally sheets and the balance of vaccines are returned to the distribution centre.

7.8 If there is shortage of supplies

▪ Do not wait until supply is finished. If you foresee a shortage, try to find more vaccines, Vitamin A, Albendazole etc.

▪ Send "somebody" by the quickest means to obtain more supplies. You can use local transport such as horses or mules.

▪ Explain to the parent /guardian that more supply is coming.

▪ Try to seek assistance from your supervisor or other volunteers.

7.9 If there is shortage of tally sheets

▪ Do not loose information

▪ Use the back of the tally sheets or another kind of paper.

▪ Try to obtain more tally sheets from your supervisor.


43

8. MICRO-PLANNING AND REPORTING 8.1 How to prepare the EOS intervention? – Training and

micro-planning 8.1.1 Training process Two months before the implementation of EOS, training of trainers (ToT) will be given to woreda health managers (= supervisors) by regional facilitators. At same time woreda level micro planning will be prepared (see micro planning format in annex). One month later, health workers will be trained for 2 days by the woreda trainers. Two weeks before the implementation supportive staffs will be trained, mainly on acute malnutrition screening techniques for 2 days by the trained health workers. The training is based on the EOS guideline and includes all the component of the guideline: overview of the EOS project, components and implementation of EOS, social mobilisation, organisation of the EOS service delivery post, theoretical and practical session on screening, micro planning and reporting. Training process:

When What Who Content 2 months before EOS

Training of trainers + micro planning exercise

Woreda health professionals (= supervisors)

- 1 day on vitamin A supp., de-worming, measles vaccination and EOS organisation - 1 day on screening acute malnutrition (½ day theory and ½ day practice) - 1 day for micro planning

1 month before EOS

Training on EOS implementation

Health workers - 1 day on vitamin A supp., de-worming, measles vaccination and EOS organisation - 1 day on screening acute malnutrition (½ day theory and ½ day practice)

2 weeks before EOS

Training on EOS implementation

Supportive staff

- 1 day on vitamin A supp., de-worming, measles vaccination and EOS organisation - 1 day on screening acute malnutrition (½ day theory and ½ day practice)

8.1.2 Micro planning Two formats are proposed in annex for an easy calculation of the needs, both in term of operational costs and supplies. All the formulas are explained on the formats. The formats are prepared for woreda level where each kebeles are listed (row 1 to 20). When regional summary have to be prepared, the same format can be used replacing the kebele by the woredas.


44

Population breakdown: In the micro planning format, we give the national population breakdown. For the regional micro planning, use the regional data10:

6-59 months

(% of the total pop.)

12-59 months

(% of the total

pop.)

6-11 months

(% of the total

pop.)

6-23 months

(% of the total pop.)

12-23 months

(% of the total

pop.)

PW/LM[1] (% of the

total pop.)

Tigray 15.9 14.1 1.8 5.4 3.6 Afar 13.4 11.9 1.5 4.5 3 Amhara 15.65 13.9 1.75 5.25 3.5 Oromia 16.45 14.6 1.85 5.55 3.7 Somali 14.15 12.5 1.65 4.95 3.3 B. Gumuz 15.25 13.4 1.85 5.55 3.7

SNNP 16.7 14.8 1.9 5.7 3.8 Gambella 13.9 12.3 1.6 4.8 3.2 Harare 13.9 12.3 1.6 4.8 3.2 Addis Ababa 9.05 7.9 1.15 3.45 2.3

Dire Dawa 14.8 13.1 1.7 5.1 3.4

National 15.7 13.9 1.8 5.4 3.6 1.9 Target population calculation:

• Vitamin A supplementation and screening (6-59 months) = total population x 15.7%

• De-worming (12-59 months) = total population x 13.9% • Measles vaccination (6-23 months) = total population x 5.4%

Personnel requirement:

• The EOS team is composed of 7 people: one health worker, and 6 supportive staffs

• Number of EOS post11: the post has to deliver the services in 1 day and should cover at least 300 children in the day = number of targeted children/ 300

• Number of team: the all operation should last for 10 days maximum = number of EOS posts/ 10

• One supervisor and one driver for 10 EOS posts • The training cost includes the two times 2 days training for the health workers

and supportive staff. 10 Source: Health and health related indicators, FMOH, 1995 (E.C) 11 This calculation is proposed as an indication only. In practice, the number of EOS posts has to be adapted to the field constraints. It is recommended that the service delivery in 1 post last only for 1 day to avoid children receiving vitamin A twice or more.


45

Supplies requirement: • Vitamin A capsule (100,000 UI) = [number of target children 6-11 months +

(number of target children 12-59 months x 2)] + 10%12 • Scissor = two per EOS team • Albendazole tablets (400 mg) = [(number of target children 6-23 months x 0.5) +

number of target children 24-59 months] + 10% • Screening kit = 1 Salter scale + 1 pack of 5 weighing pants + 1 measuring board

+ 10 MUAC tapes + 2 screening guideline (laminated) + 2 weight/height table (laminated) + 1 screening book = one per team

• Measles vaccine vials (10 doses) = (number of 6-23 months target children/ 10) + 10%

• AD syringe = number of 6-23 months target children + 10% • Mixing syringe = number of vials of Measles vaccine • Safety box = (Number of AD syringes + Number of mixing syringes)/ 100 • Vaccine carrier = one per team • Cold box = one for 5 teams • Stationary = 4 note books + 8 pens + 7 EOS guidelines for each team • Mother and child health card = number 6-59 months target children • Tally sheets = 15 per EOS post • Reporting format at woreda level

8.2 How to record your interventions – Tally sheets?

THE TALLY SHEETS ARE PROPOSED IN ANNEXE. THE TALLY SHEET HAS TO BE COMPLETED TOGETHER WITH THE SERVICE DELIVERY ITSELF:

1 tally sheet with the person in charge of the vitamin A and the de-worming, he should tally after each supplementation

1 tally sheet with the vaccinator, he has to tally after each vaccination 1 screening registration book with the screening team, they should tally after

each child’s measurements Daily: At the end of the day, all the tally sheets and the screening registration book will be compiled by the team leader, using the same tally sheet format. Every 2 days: The supervisor is in charge of collecting all the tally sheets of all the EOS posts and to compile them at kebele level. At the end of the operation and within 1 week: The woreda coordinator is in charge of collecting all the kebele compilations and to compile them at woreda level. After receiving the woreda reports and within 1 week: The regional coordinator is in charge of collecting all the woreda compilations and to compile them at regional level.

12 10% is added for wastage


46

8.3 How to report and calculate coverage? The reporting format will be used only at regional level (see format in annexe). Vitamin A supplementation coverage = number of children supplemented with vitamin A x 100 number of target children 6-59 months De-worming coverage = number of children de-wormed x 100 number of target children 1-5 years Measles vaccination coverage = number of children vaccinated against measles x 100 number of target children 6-23 months Screening coverage for children 6-59 months = number of children screened x 100 number of target children 6-59 months % of children screened with moderate acute malnutrition = number of children screened with W/H 70-79% x 100 number of children screened % of children screened with severe acute malnutrition =

nb of children with W/H<70% + nb of children with bilateral oedema x 100 number of children screened

Screening coverage for pregnant women and lactating mothers (PW/LM) = number of PW/LM screened x 100 number of target women % of PW/LM with MUAC < 21 cm = number of PW/LM with MUAC < 21 cm x 100 number of PW/LM screened


47

ANNEXES

Federal Ministry of Health– UNICEF-MOST / Enhanced Outreach Strategy for Child Survival / June 2004

48

EOS (Enhanced Outreach Strategy for Child Survival Interventions) - Micro planning - Operational costs - Woreda level*

REGION ZONE WOREDA

YEAR MONTH DAY

A B C D E F G H I J K L M N

Name of the kebele

Tota

l pop

.

Pop.

6-5

9 m

onth

s (1

5.7%

)

Nb

of E

OS

post

Nb

of te

am

Hea

lth

wor

ker

cost

Supp

ort

staf

f cos

t

Supe

rvis

or

cost

Driv

er c

ost

Fuel

cos

t

Soci

al

mob

. + s

oft

pape

r Cos

t

Trai

ning

co

st

Tota

l cos

t

Cos

t/ ta

rget

ed

child

=B x 15.7% = C/ 300 = D/ 10 = D x 58 = D x 35 = D/ 10 x 70 = D/10 x 58 = 765 = 800 = E x 1,400 =F+G+H+I+J+K+L = M/ C

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

TOTAL

A List all the kebeles in the woreda H Calculate the supervisor (Sup) cost: nb of EOS post/10 x 1 Sup per 10 post x 70 BirrB Write the total population figure for each kebele I Calculate the driver (Dr) cost: nb of EOS post/10 x 1 Dr per 10 post x 58 BirrC Calculate the target population children 6-59 months = 15.13% of the total population J Calculate the fuel cost: 100 km x 10 days x 0.17 litres x 4.5 BirrD Write the number of EOS post you need to implement in each kebele, approx. target children/ 300 children K Write the social mobilisation + soft paper cost per kebele = 800 BirrE Write the number of team you need, approx. 1 team per 10 EOS post L Calculate the training cost = nb of team x 1,400 BirrF Calculate the health worker (HW) cost: nb of EOS post x 1 HW per post x 58 Birr M Calculate the total cost per kebeleG Calculate the supportive staff (SS) cost: nb of EOS post x 6 SS per post x 35 Birr N Calculate the cost per targeted children

* For summary at region level, list the woredas' name in column A and write the total cost per woreda in each column


49

EOS (Enhanced Outreach Strategy for Child Survival Interventions) - Micro planning - Supply needs - Woreda level*REGION ZONE WOREDA

YEAR MONTH DAY

A B C D E F G H I J K L M N O P Q R S T U V W X Y

Name of the kebele

Tota

l pop

.

Nb

of E

OS

post

Nb

of te

am

Pop.

6-5

9 m

onth

s (1

5.7%

)

Vit.

A

caps

ules

(1

00,0

00 U

I)

Scis

sors

Pop.

1-5

yea

rs

(13.

9%)

Alb

enda

zole

40

0mg

tabl

ets

Salte

r sca

le25

kg

Wei

ghin

g pa

nts

(pac

-5)

Mea

surin

g bo

ard

MU

AC

tape

Scre

enin

g gu

idel

ine

(lam

inat

ed)

Wei

ght/h

eigh

t ta

ble

(lam

inat

ed)

Scre

enin

g bo

ok

Pop.

6-2

3 m

onth

s (5

.4%

)

Mea

sles

va

ccin

e vi

als

(10

dose

s)

AD

syr

inge

Mix

ing

syrin

ge

Safe

ty b

ox

Not

e bo

ok

Pen

EOS

guid

elin

e

Mot

her a

nd

child

hea

lth

card

=B x 15.7% * = D x 2 =B x 13.9% ** = D = D = D = D x 10 = D x 2 = D x 2 = D = B x 5.4% = (Q/ 10) +10% = Q = R = (S + T)/100 = D x 4 = D x 8 = D x 7 = E

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

TOTAL

* For summary at region level, list the woredas' name in column A and write the total supply needs per woreda in each column

* F = [ (C x 0.018) + (C x 0.139 x 2) ] + 10%** I = [ (C x 0.054 x 0.5) + (C x 0.103) ] + 10%

DO NOT FORGET THE COLD BOXES (1 for 5 teams) AND THE VACCINES CARRIER (1 per team)DO NOT FORGET SUFFICIENT TALLY SHEETS AND REPORTING FORMATS

StationaryGeneral information Vit. A supplementation De-worming Screening kit Measles vaccination


50

EOS - Enhanced Outreach Strategy for Child Survival Interventions - Daily tally sheet

Region: _______________ ; Zone: _______________ ; Woreda: _________________ ; Kebele: _______________ ; EOS post name: _____________

Name of team leader: ________________ ; Round: _________ Date: ______/______/______

Vitamin A supplementation 6-59 months De-worming

12-59 months Measles vaccination 6-23 months*

6-11 months (1 capsule) 12-59 months

(2 capsules) 12-23 months (1/2 tablet) 24-59 months

(1 tablet) 1st dose 2nd dose

*Please separate children who receive the Measles vaccine for the 1st time and those who receive it for the 2nd time Total number of children supplemented with vitamin A Total number of children de-wormed Total number of children vaccinated 6-11 months 12-59 months Total 6-59 months 12-23 months 24-59 months Total 12-59 months 1st dose 2nd dose Total

Total nb of

children screened Nb of children W/H >= 80%

Nb of children W/H 70-79%

Nb of children W/H < 70%

Nb of children with bilateral oedema

Total nb of women screened

Nb of women MUAC < 21cm

Nb of women MUAC > 21cm

Supply received used Returned unused Remark

Vit. A capsules Measles vaccine vials Albendazole tabletss


51

EOS (Enhanced Outreach Strategy) for Child Survival Interventions - Reporting form

Results of the round number _____ in _______ woredas of __________________ region - Date: ______/______/______

# Woreda Zone No. of kebeles Total population

Target pop.(6-59 months)

Nb of children suppl. with

Vit.A

Vit. A supp. coverage %

Target pop.(1-5 years)

Nb of children de-wormed

De-worming coverage %


Nb of children vaccinated

Measles vaccination coverage %

A B C D E F G H I J K L M= D x 15.7% = F/ E = D x 13.9% = I/ H = D x 5.4% =L/ K

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

De-worming Measles vaccinationVit.A supplementation


52

EOS (Enhanced Outreach Strategy) for Child Survival Interventions - Reporting form

Results of the round number _____ in _______ woredas of __________________ region - Date: ______/______/______

# Woreda Zone No. of kebeles Total population


Nb of children screened

Screening coverage %

Nb of children W/H>=80%**

Nb of children W/H

70-79%

Nb of children W/H<70%

Nb of children with bilateral

oedema

% of children screened with

moderate acute

malnutri.

% of children screened with severe acute

malnutrit.

Target pop. PW/LM

***

Nb of PW/LM screened

Screening coverage%

Nb of PW/LM with MUAC

<21 cm

% of PW/LM screened with

MUAC<21cm****

A B C D E F G H I J K L M N O P Q R= D x 15.7% = F/ E = I/ F = (J + K)/ F = (D x 0.019) = O/ N =Q/ O

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Pregnant women and lactating mothers (PW/LM)Children under 5 years


53

LENGTH (CM) MEDIAN TARGET WEIGHT

MODERATE MALNUTRITION FROM 70 TO 79%

SEVERE MALNUTRITION < 70 %

100% 85% <80% 75% <70% 60% 49 3.2 2.7 2.6 2.4 2.3 1.92

49.5 3.3 2.8 2.6 2.5 2.3 1.98

50 3.4 2.9 2.7 2.5 2.4 2.04 50.5 3.4 2.9 2.7 2.6 2.4 2.04 51 3.5 3.0 2.8 2.6 2.5 2.1

51.5 3.6 3.1 2.9 2.7 2.5 2.2 52 3.7 3.1 3.0 2.8 2.6 2.22

52.5 3.8 3.2 3.0 2.8 2.6 2.3 53 3.9 3.3 3.1 2.9 2.7 2.34

53.5 4.0 3.4 3.2 3.0 2.8 2.4 54 4.1 3.5 3.3 3.1 2.9 2.46

54.5 4.2 3.6 3.4 3.2 2.9 2.5

55 4.3 3.7 3.5 3.2 3.0 2.58 55.5 4.4 3.8 3.5 3.3 3.1 2.6 56 4.6 3.9 3.6 3.4 3.2 2.76

56.5 4.7 4.0 3.7 3.5 3.3 2.8 57 4.8 4.1 3.8 3.6 3.4 2.88

57.5 4.9 4.2 3.9 3.7 3.4 2.9 58 5.1 4.3 4.0 3.8 3.5 3.06

58.5 5.2 4.4 4.2 3.9 3.6 3.1 59 5.3 4.5 4.3 4.0 3.7 3.18

59.5 5.5 4.6 4.4 4.1 3.8 3.3

60 5.6 4.8 4.5 4.2 3.9 3.36 60.5 5.7 4.9 4.6 4.3 4.0 3.4 61 5.9 5.0 4.7 4.4 4.1 3.54

61.5 6.0 5.1 4.8 4.5 4.2 3.6 62 6.2 5.2 4.9 4.6 4.3 3.72

62.5 6.3 5.4 5.0 4.7 4.4 3.8 63 6.5 5.5 5.2 4.8 4.5 3.9

63.5 6.6 5.6 5.3 5.0 4.6 4.0 64 6.7 5.7 5.4 5.1 4.7 4.02

64.5 6.9 5.9 5.5 5.2 4.8 4.1

65 7.0 6.0 5.6 5.3 4.9 4.2 65.5 7.2 6.1 5.7 5.4 5.0 4.3 66 7.3 6.2 5.8 5.5 5.1 4.38

66.5 7.5 6.4 6.0 5.6 5.2 4.5 67 7.6 6.5 6.1 5.7 5.3 4.56

67.5 7.8 6.6 6.2 5.8 5.4 4.7 68 7.9 6.7 6.3 5.9 5.5 4.74

68.5 8.0 6.8 6.4 6.0 5.6 4.8 69 8.2 7.0 6.6 6.1 5.7 4.92

69.5 8.3 7.1 6.7 6.2 5.8 5.0


54

LENGTH<85cm HEIGHT >=85cm

MEDIAN TARGET WEIGHT

MODERATE MALNUTRITION FROM 70 TO 79%

SEVERE MALNUTRITION < 70%

100% 85% <80% 75% <70% 60% 70 8.5 7.2 6.8 6.3 5.9 5.10

70.5 8.6 7.3 6.9 6.4 6.0 5.2 71 8.7 7.4 7.0 6.5 6.1 5.22

71.5 8.9 7.5 7.1 6.6 6.2 5.3 72 9.0 7.6 7.2 6.7 6.3 5.40

72.5 9.1 7.7 7.3 6.8 6.4 5.5 73 9.2 7.9 7.4 6.9 6.5 5.52

73.5 9.4 8.0 7.5 7.0 6.5 5.6 74 9.5 8.1 7.6 7.1 6.6 5.70

74.5 9.6 8.2 7.7 7.2 6.7 5.8

75 9.7 8.2 7.8 7.3 6.8 5.82 75.5 9.8 8.3 7.9 7.4 6.9 5.9 76 9.9 8.4 7.9 7.4 6.9 5.94

76.5 10.0 8.5 8.0 7.5 7.0 6.0 77 10.1 8.6 8.1 7.6 7.1 6.06

77.5 10.2 8.7 8.2 7.7 7.2 6.1 78 10.4 8.8 8.3 7.8 7.2 6.24

78.5 10.5 8.9 8.4 7.8 7.3 6.3 79 10.6 9.0 8.4 7.9 7.4 6.36

79.5 10.7 9.1 8.5 8.0 7.5 6.4

80 10.8 9.1 8.6 8.1 7.5 6.48 80.5 10.9 9.2 8.7 8.1 7.6 6.5 81 11.0 9.3 8.8 8.2 7.7 6.60

81.5 11.1 9.4 8.8 8.3 7.7 6.7 82 11.2 9.5 8.9 8.4 7.8 6.72

82.5 11.3 9.6 9.0 8.4 7.9 6.8 83 11.4 9.6 9.1 8.5 7.9 6.84

83.5 11.5 9.7 9.2 8.6 8.0 6.9 84 11.5 9.8 9.2 8.7 8.1 6.90

84.5 11.6 9.9 9.3 8.7 8.2 7.0

Measure Height from this point onwards (if to weak to stand then subtract one centimetre)

85 12.0 10.2 9.6 9.0 8.4 7.20 85.5 12.1 10.3 9.7 9.1 8.5 7.3 86 12.2 10.4 9.8 9.1 8.5 7.32

86.5 12.3 10.5 9.8 9.2 8.6 7.4 87 12.4 10.6 9.9 9.3 8.7 7.44

87.5 12.5 10.6 10.0 9.4 8.8 7.5 88 12.6 10.7 10.1 9.5 8.8 7.56

88.5 12.8 10.8 10.2 9.6 8.9 7.7 89 12.9 10.9 10.3 9.7 9.0 7.74

89.5 13.0 11.0 10.4 9.7 9.1 7.8


55

HEIGHT

(cm) MEDIAN TARGET

WEIGHT MODERATE MALNUTRITION

FROM 70 TO 79% SEVERE MALNUTRITION

< 70%

100% 85% <80% 75% <70% 60% 90 13.1 11.1 10.5 9.8 9.2 7.86

90.5 13.2 11.2 10.6 9.9 9.2 7.9 91 13.3 11.3 10.7 10.0 9.3 7.98

91.5 13.4 11.4 10.8 10.1 9.4 8.0 92 13.6 11.5 10.8 10.2 9.5 8.16

92.5 13.7 11.6 10.9 10.3 9.6 8.2 93 13.8 11.7 11.0 10.3 9.7 8.28

93.5 13.9 11.8 11.1 10.4 9.7 8.3 94 14.0 11.9 11.2 10.5 9.8 8.40

94.5 14.2 12.0 11.3 10.6 9.9 8.5

95 14.3 12.1 11.4 10.7 10.0 8.58 95.5 14.4 12.2 11.5 10.8 10.1 8.6 96 14.5 12.4 11.6 10.9 10.2 8.70

96.5 14.7 12.5 11.7 11.0 10.3 8.8 97 14.8 12.6 11.8 11.1 10.3 8.88

97.5 14.9 12.7 11.9 11.2 10.4 8.9 98 15.0 12.8 12.0 11.3 10.5 9.00

98.5 15.2 12.9 12.1 11.4 10.6 9.1 99 15.3 13.0 12.2 11.5 10.7 9.18

99.5 15.4 13.1 12.3 11.6 10.8 9.2

100 15.6 13.2 12.4 11.7 10.9 9.36 100.5 15.7 13.3 12.6 11.8 11.0 9.4 101 15.8 13.5 12.7 11.9 11.1 9.48

101.5 16.0 13.6 12.8 12.0 11.2 9.6 102 16.1 13.7 12.9 12.1 11.3 9.66

102.5 16.2 13.8 13.0 12.2 11.4 9.7 103 16.4 13.9 13.1 12.3 11.5 9.84

103.5 16.5 14.0 13.2 12.4 11.6 9.9 104 16.7 14.2 13.3 12.5 11.7 10.02

104.5 16.8 14.3 13.4 12.6 11.8 10.1

105 16.9 14.4 13.6 12.7 11.9 10.14 105.5 17.1 14.5 13.7 12.8 12.0 10.3 106 17.2 14.6 13.8 12.9 12.1 10.32

106.5 17.4 14.8 13.9 13.0 12.2 10.4 107 17.5 14.9 14.0 13.1 12.3 10.50

107.5 17.7 15.0 14.1 13.3 12.4 10.6 108 17.8 15.2 14.3 13.4 12.5 10.68

108.5 18.0 15.3 14.4 13.5 12.6 10.8 109 18.1 15.4 14.5 13.6 12.7 10.86

109.5 18.3 15.5 14.6 13.7 12.8 11.0


56

HEIGHT

(cm) MEDIAN TARGET

WEIGHT MODERATE MALNUTRITION

FROM 70 TO 79 % SEVERE MALNUTRITION

< 70%

100% 85% 80% 75% 70% 60% 110 18.4 15.7 14.8 13.8 12.9 11.04

110.5 18.6 15.8 14.9 14.0 13.0 11.2 111 18.8 16.0 15.0 14.1 13.1 11.28

111.5 18.9 16.1 15.1 14.2 13.3 11.3 112 19.1 16.2 15.3 14.3 13.4 11.46

112.5 19.3 16.4 15.4 14.4 13.5 11.6 113 19.4 16.5 15.5 14.6 13.6 11.64

113.5 19.6 16.7 15.7 14.7 13.7 11.8 114 19.8 16.8 15.8 14.8 13.8 11.88

114.5 19.9 16.9 16.0 15.0 14.0 11.9

115 20.1 17.1 16.1 15.1 14.1 12.06 115.5 20.3 17.3 16.2 15.2 14.2 12.2 116 20.5 17.4 16.4 15.4 14.3 12.30

116.5 20.7 17.6 16.5 15.5 14.5 12.4 117 20.8 17.7 16.7 15.6 14.6 12.48

117.5 21.0 17.9 16.8 15.8 14.7 12.6 118 21.2 18.0 17.0 15.9 14.9 12.72

118.5 21.4 18.2 17.1 16.1 15.0 12.8 119 21.6 18.4 17.3 16.2 15.1 12.96

119.5 21.8 18.5 17.4 16.4 15.3 13.1

120 22.0 18.7 17.6 16.5 15.4 13.20 120.5 22.2 18.9 17.8 16.7 15.5 13.3 121 22.4 19.1 17.9 16.8 15.7 13.44

121.5 22.6 19.2 18.1 17.0 15.8 13.6 122 22.8 19.4 18.3 17.1 16.0 13.68

122.5 23.1 19.6 18.4 17.3 16.1 13.9 123 23.3 19.8 18.6 17.5 16.3 13.98

123.5 23.5 20.0 18.8 17.6 16.5 14.1 124 23.7 20.2 19.0 17.8 16.6 14.22

124.5 24.0 20.4 19.2 18.0 16.8 14.4

125 24.2 20.6 19.4 18.2 16.9 14.52 125.5 24.4 20.8 19.6 18.3 17.1 14.6 126 24.7 21.0 19.7 18.5 17.3 14.82

126.5 24.9 21.2 19.9 18.7 17.5 14.9 127 25.2 21.4 20.1 18.9 17.6 15.12

127.5 25.4 21.6 20.4 19.1 17.8 15.2 128 25.7 21.8 20.6 19.3 18.0 15.42

128.5 26.0 22.1 20.8 19.5 18.2 15.6 129 26.2 22.3 21.0 19.7 18.4 15.72

129.5 26.5 22.5 21.2 19.9 18.6 15.9 130 26.8 22.8 21.4 20.1 18.7 16.08


57

OBSERVER’S CHECKLIST FOR ASSESSING QUALITY OF EOS ACTIVITIES Region_________; Zone_________; Woreda__________; Kebele________; EOS post_______; Name of the observer___________; Signature__________; Date: __/__/__

SUBJECT YES NO COMMENTS A Social mobilisation 1 Is the catchment population aware of :

1.1 The EOS date 1.2 Target age group 1.3 Purpose of EOS 1.4 Post location 2 Are hard to reach areas identified? How? 3 Is the post clearly identified (by banners or posters) 4 Are supportive staffs mobilising and directing clients B Post organisation and management 1 Enough space at the EOS post 2 Good crowed control 3 Service provided on first-come first served bases 4 Is the post well organised with an order flow of clients 5 Is the number of staffs assigned according to the micro plan (7 per post) 6 Is the average number of children receiving the service per day according to the microplan 7 Are there enough tally sheets at the post, including screening registration book 8 Does the team report to its supervisor on daily basis C Acute malnutrition screening 1 Availability of supplies for screening

1.1 A wooden stick of 110 cm 1.2 MUAC tapes 1.3 Length measuring board 1.4 Salter scale of 25 kg 1.5 Weighing pants 2 Screening practices

2.1 A wooden stick cut at 110 cm is used to rapidly select the children less than 5 year 2.2 Bilateral oedema is checked properly 2.3 MUAC measurement is taken only for children that are able to walk 2.4 MUAC is measured properly 2.5 Children that do not walk are directly sent for W/H measurements 2.6 Salter scale is re-adjusted to zero with the empty weighing pants hanging before each weighing

2.7 The child is placed undressed in the pants or weight of the clothes is deducted from the measurement

2.8 Each day, the scale is checked using a known weight to guarantee good functioning


58

2.9 85 cm is used as a cut off to take standing or lying position measurements 2.10 Height/length measurements is taken in correct position 2.11 Weight/Height measurements is correctly interpreted

D Vitamin A supplementation 1 Supplies availability

1.1 Vit. A capsules of 100,000 UI 1.2 Scissors 1.3 Wipes or towel to clean oil off hands 1.4 A container to dispose used capsules 2 Supplementation practices

2.1 Does the provider ask whether the child has received Vit A during the last month 2.2 Does the provider give the correct dose for age 2.3 Does the provider open, administer and dispose the capsules correctly 2.4 Are hands clean and free of oil 2.5 Does the provider make sure the child is calm before giving 2.6 Does the provider check to see that the child swallows the drops and is alright 2.7 Does the recorder record the dose on the tally sheets 2.8 Does the provider give parent messages about receiving Vit.A 2.9 Does the provider tell the parent when to bring the child again for Vit.A 2.10 Is the Vit.A kept out of the sunlight/freezing 2.11 Are the empty capsules disposed into a container

E De-wormimg Adequate Albendazole available Does the provider give the correct dose for age

F Measles Vaccination 1 Availability of supplies

1.1 Vaccine 1.2 AD syringes 1.3 Mixing syringes 1.4 Cold boxes 1.5 Vaccine carriers 1.6 Safety boxes 1.7 Adrenaline 2 Vaccination practices

2.1 Does the injection technique conform to the national guideline 2.2 Are vaccines stored in vaccine carriers with at least 2 frozen ice packs 2.3 Does vaccinator dispose of used syringes into a safety box 2.4 Does vaccinator dispose of used syringes without recapping 2.5 Is there a system of replenishing ice packs for the post


59

Correction of the test “Evaluate yourself” page 24 Questions A and B: W/H Percentage of the Median calculation and interpretation Child W/H %

(cm) Weight

(kg) Percentage of median

Nutritional status

1 85 9.2 Between 75 and 80% MM – moderate malnutrition 2 88 7.9 Less than 70% SM – severe malnutrition 3 100 14 More than 85% Normal 4 102 16.5 More than 100% Normal 5 106 11.2 Less than 70% SM - severe malnutrition 6 79 8.9 More than 80% Normal

Question C: 1- b 2- c 3- b 4- b 5- a Question D:

Indicators Nutritional status #persons screened and referred

W/H >= 80% Normal 9, no referral 70% =< W/H < 80% Moderate 1, referral to SFP W/H < 70% Severe 1, referral to nutrition unit Bilateral Oedema Severe 1, referral to nutrition unit PW/ LM: MUAC < 21cm Moderate 1, referral to SFP PW/ LM: MUAC >= 21cm Normal 3, no referral

Total screened 16 *Pregnant Women=PW; Lactating Mothers=LM

SFP: supplementary feeding programme

NOTE: the child with oedema has to be registered in the row “bilateral oedema”. Do not registered him in the row “W/H >= 80%” not to register the same child twice.

ENHANCED OUTREACH STRATEGY (EOS) - WHO · children 6-59 months of age in the 11 regions of the country (Ethiopian Health and Nutrition Research Institute, 1996). The situation is

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