STOP 34 Mission Report-Ethiopia Field Report From June 1st – August 31, 2010 By Ugo Enebeli Sarah Hubka Dean Seneca Abednego Yeboah
STOP 34
Mission Report-Ethiopia
Field Report
From June 1st – August 31, 2010
By
Ugo EnebeliSarah Hubka
Dean Seneca
Abednego Yeboah
Outline
Mission- STOP 34
Background
AFP, Measles, and NNT Surveillance
Expanded Program on Immunizations
Challenges
Recommendations
Conclusions
STOP 34 Mission
•The main mission was to conduct epidemiological surveillance surrounding Polio (AFP), Measles and NNT.
•Review the Expanded Program on Immunizations to assist the administration of vaccinations in accordance with WHO intentions.
•Provide sensitization regarding surveillance and vaccination of the above mentioned diseases.
Background Ethiopia is a landlocked country located in the north eastern
part of Africa.
An estimated population of 79 million according to the most recent national census
86% of the population lives in rural areas.
There are approximately 195 government run hospitals, 1,362 health centers, and 12,488 health posts.
During our assignment we supported:◦ Total of 12 Zones Supported
◦ Total of 103 Woredas Supported
◦ Total of 196 Health Facilities Visited
Places Visited
ZoneWoreda Health
Offices Visited
Health Facilities,
Hospitals, Health
Posts Visited
Clinics
(private)
Holy Water Sites,
Traditional
Healers Visited
Individuals
Sensitized
Eastern (Tigray) 7 17 0 0 38
Guji 14 18 1 0 186
Jima 17 27 3 0 184
Mekele 1 7 0 0 18
Metekel 7 17 0 0 89
North Shoa 10 14 0 0 207
North Wello 10 21 0 0 52
South Gonder 13 21 0 0 289
Southern
(Tigray)2 5 0 0 12
Wag Hamira 6 13 0 0 38
West Gojjam 7 12 0 0 201
West Shewa 9 11 0 1 175
TOTALS 103 196 4 1 1489
AFP, Measles and NNT Surveillance“Strengths”
Most health workers are knowledgeable of AFP, measles, NNT case definitions and specimen collection procedures.
Case definitions posters are visibly displayed in vantage points for health workers.
WHO officers performed regular ACS visits and provide continuing support to woredas and health facilities
Most woredas have a recently trained designated surveillance focal people
0
5
10
15
20
25
30
35
Ethiopia: Expected vs. Reported cases of AFP
in Zones visited by STOP 34 Weeks 23 and 33
Expected AFP
Reported
Week 23
Reported
Week 33
0
1
2
3
4
5
6
Ethiopia NP AFP Rates of Zones Visited by
STOP 34: Week 23 vs Week 33
NP AFP
Wk 23
NP AFP
Wk 33
0
20
40
60
80
100
120
Ethiopia AFP Stool Adequacy Rates in Zones
Visited by STOP 34 Week 23 vs Week 33
Stool
Adeq.
Wk 23
Stool
Adeq.
Wk 33
0
100
200
300
400
500
600
700
800
Ethiopia: Expected vs. Reported Measles
Cases in Weeks 16 and 33 in Zones Visited
by STOP 34
Expected
Measles
Reported
Week 16
Reported
Week 33
0
5
10
15
20
25
Ethiopia: Measles Detection Rates in Zones
visited by STOP 34 Weeks 16 vs 33
Det Rate
Week 16
Det Rate
Week 33
0
20
40
60
80
100
120
Ethiopia: Adequacy Rates Measles in Zones
Visited by STOP 34 Week 16 vs 33
Adeq Rate
Week 16
Adeq Rate
Week 33
2 missed suspected cases of AFP; 133 missed suspected cases of measles; 7 missed suspected cases of NNT
Lack of logistics to support surveillance, forms, specimen supplies, designated vaccine carriers, etc…
Insufficient knowledge amongst many health workers of the reporting requirements for AFP, measles and NNT.
Limited feedback on submitted specimen samples. Case files are not available at many health facilities nor
woreda offices; not existent for the previous three years Few zonal or woreda IDSR FPs had a plan for visiting
sites and ACS was not evident in the registers
AFP, Measles and NNT Surveillance“Challenges”
Expanded Program on Immunizations“Strengths”
Adequate supply of basic EPI logistics, AD syringes, safety boxes, mixing syringes, etc…
Most health facilities have a refrigerator
Most sites observed good injection safety practices
Most health centers maintain refrigerator temperatures between 2 and 8 degrees Celsius, when monitored
• The cold chain was not consistently maintained in many facilities due to kerosene shortages, power outages, and staff transitions or staff absence during training
• Insufficient vaccine management, inadequate recording of vaccine usage, expired VVM, expired vaccines, no wastage monitoring
• There was poor data management, analysis and interpretation; many of the Vaccine Monitoring Charts were outdated
• Vaccines are administered in unsanitary conditions.
• Improper waste disposal
Expanded Program on Immunizations“Challenges”
RecommendationsGeneral Improve the conditions of the health
facilities by making them clean and orderly.
Woredas and health facilities would benefit from cross-training multiple staff to perform different key roles within their organization.
Increased supportive supervision
Increase training in EPI, AFP, measles and NNT surveillance and refresher training should be available on a quarterly basis.
RecommendationsSurveillance Institute Active Case Search at all levels
Ensure that all supplies and materials are available for investigation and reporting
Ensure individual case investigation files for AFP, measles and NNT are completed and inventoried for the last three years
Decrease the time to allow results from National Lab to reach all zones, woredas and health facilities in a timely manner
RecommendationsEPI Vaccine monitoring charts should be completed and updated
monthly
Health facilities should work toward a strong defaulter tracing mechanism to ensure dropout rates are <10%
Increase frequency and number of staff trained who work on the cold chain maintenance
Woredas and all health facilities should take a weekly inventory of vaccine supply and record type of vaccine, number of vials, VVM stage, and expiration date
Vaccine wastage rate should be calculated and recorded monthly
Repair and/or replace non-functional refrigerators, provide spare parts, and needed supplies as necessary
All health facilities should have an effective, safe, and appropriate waste management system such as a functional incinerator or shallow pit that is burned when full
Conclusion
STOP Team 34 identified gaps in surveillance during the two field missions. Active case search (ACS) was most lacking in many zones. Also identified weaknesses in EPI, particularly cold chain and vaccine management. The team was able to educate many facility staff about the importance of ACS and the need to frequently monitor vaccine stock.
Acknowledgements World Health Organization, Ethiopia Federal Ministry of Health, and
U.S. Centers for Disease Control and Prevention (CDC).
All of the Staff at the WHO EPI Office (including Dr. Pascal Mkanda, Dr. Fiona Braka, Dr. Kasahun Mitiku, Dr. Sisay Gashu, Dr. Gavin Grant, Dr. Teklay Kidane, Dr. Ayisheshem Ademe, Mr. Tesfaye Bedada, and Mr. Dawit Getachew, Ms. Welansa Belayneh, Ms. Meseret Fikru, Ms. Selamawit Bogale, Mr. Hanok Kebede and Mr. Behailu Demissie), the medical surveillance officers in the zones we visited, and the others who supported us during our time in Ethiopia
We would like to thank the regional, zonal and woreda EPI/IDSR focal persons for their support during our field missions.
We would also like to thank our WHO drivers, Mesele,YohannesKimfe, Fisseha, Tadesse,andYeseph for their safe driving, sound judgment and translation.
Lastly, we would especially like to thank the health workers in each woreda, kebele, and community we visited. Their efforts are truly appreciated and are vital in the fight against polio, measles, and neonatal tetanus.