1. Implementing a Best Practice Measles SIA: Ethiopia’s Experience
Dr Fiona Braka
WHO Ethiopia
Measles Initiative Meeting, Washington DC,
13-14 September 2011

2. Ethiopia: Background
Federal Ministry of Health
Regional Health Bureau
(9 Regions + 2 City Administrations)
Zonal Health Administration
(98 Zones)
Woreda Health Offices
(819 Woredas)
Kebeles/Health Post
(15,000 HP, 1 per 5,000 popln)
Projected population 2010 (census 2007): million
Growth Rate: %
Under-1: % (2.6m)
Under-5: % (11.4m)
Under-15: 45% (35m)
Rural: 83%
Infant Mortality Rate: 75/1000 live-births

3. Measles cases and MCV1 admin coverage in Ethiopia, 1990 - 2010
Catch Up 3

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

5. Second opportunity measles vaccination through SIAs

6. Measles SIAs: 2010-2011 Target: 8.5 million (9 – 47 months)
Phased in 2:
October 2010 (90.8%)
February (9.2%)
Integrated interventions:
OPV (0-59 months)
Vitamin A (6-59 months)
De-worming (24-59 months)
Nutritional Screening (6-59 months and pregnant and lactating women)
2010
2011 6

7. Best Practices SIAs Best Practices “Best Practices”
Activities known to lead to predictably good results without using up too much resources
Based on local realities and challenges
Identified in Ethiopia through:
Extensive review of previous reports
Detailed internal consultations
Experiences from other AFR countries 7

8. Areas of Focus for Best Practices
Coordination
Micro planning and training
Logistics
Advocacy and communication
Resource mobilization
Monitoring and evaluation
Strengthening routine EPI

9. Coordination of the Best Practices SIA- Ethiopia
National Task Force (NTF) with subcommittees led by FMoH
NTF Chaired by FMoH DG
Weekly meetings started 5 months prior to SIAs
~ 7 – 10 people in every meeting
Each meeting for >2hrs == >400 person-hours
Task Forces established at regional, zonal and woreda levels – weekly feedback to NTF 9

10. Micro planning and Training
Emphasis on Kebele level planning with
local knowledge of needs
hard to reach populations
Work with Statistics Agency for best denominators
Focus on training quality
Pre/post testing
Participatory and practical
Schedule based on need not time allotment
Standard agenda
Evidence-based standard training materials: Field guide and translated pocket guides
KAP Survey Findings
Health Workers
(KAP)
86% support the idea of SIAs
55% know the importance of 2nd measles dose
9% know how to estimate vaccine supplies
Community Members
(FGD)
Few knew about SIAs
Most willing to vaccinate children
Major source of health information are HEW and kebele leaders

11. Logistics
Required distribution of logistics 3-4 weeks before implementation
PFSA took on distribution role to Woreda level
Distribution flexibility including transport fleet for emergency distribution
Bundling of supplies

12. Advocacy and Communication
Advocacy visits to Regional Presidents
1-2 months prior to SIA
Joint team: FMoH and partners
Evidence-based messages
Sensitization and engagement of political leaders, Women’s Groups, Pediatric Society, Clinicians
Diverse channels of communication
Mass media: radio/ TV/ billboards, mobile vans
Town criers
Schools (notified via Ministry of Education)
Door to door visits by community volunteers (some places responsible for participation)

13. Resource Mobilization
Government contributions
High level cooperation between EPI partners
Engagement of partners at all levels:
Human resources, transport, social mobilization, logistics
Item
Total Budget (USD)
FMOH
Measles Initiative
Nutrition Partners (EOS)
Global Polio Initiative
To WHO
To UNICEF
Vaccine & injection materials
5,371,901
3,345,097
2,026,804
Operational costs
6,464,204
746,219
2,101,540
1,364,240
1,502,205
750,000
Grand Total
11,836,105
4,658,097
2,776,804
Target population (< 5)
12,859,245
Cost per child $0.92

14. Implementation
High level launch at national level by HE The President and at regional levels by Presidents/ dignified authorities
Approximately 178,320 vaccination teams including 66,870 health workers and more than 72,870 volunteers
Daily monitoring of performance through review meetings and SMS text messaging in phase 2

15. Multiple Data Sources (Tigray)
Monitoring
Pre campaign assessments (3-4 weeks and 1 week prior to SIA) and feedback given to address gaps
Different methods utilized to monitor performance:
Methods: Daily review meetings (with administration), supervision
Data Sources: Administrative, rapid convenience monitoring, independent monitoring
Improving data flow through use of SMS text messaging
Multiple Data Sources (Tigray)

16. Administrative follow-up measles SIAs coverage. Ethiopia.
97% polio
>95% coverage:
- 81/95 (85%) Zones
- 740/ 814 (91%) Woredas
93% measles
Admin coverage,
Admin coverage,
>=95%
90-94%
80-89%
<80% 16

17. Independent Monitoring Assessment of Woreda Performance
Proportion of Children missed in Evaluated Woreda
Woredas Reaching Targets for
Measles Vaccination
Polio Vaccination
>10%
106 (27%)
107 (27%)
5-10%
67(17%)
79 (20%)
<5%
222 (56%)
209 (53%)
Source of data: Post SIA Independent monitoring, 395 Woredas sampled
Note: Poor quality finger markers compromised the independent monitoring process in many areas 17

18. Evaluation of the SIA 1. Post SIA coverage survey
To assess coverage estimates for all interventions
80 woredas in the 2 phases of the SIA; 4,420 children
2. Best practices evaluation
To determine best practices implemented and their effect on coverage
20 woredas
3. Strengthening of routine EPI through the SIA
4 regions: 8 zones; urban and rural representation
4. Impact assessment

19. Post SIA Coverage Survey, 2010-2011
Phase 1: 87.8%
Phase 2: 93.1%
Limitations: assessment of finger marking compromised by quality of markers and timing of phase 1 survey; non availability of screening card in some areas 19

20. Best Practices Evaluation
Best practice activities
P-value
Measles Coverage
Polio Coverage
Vitamin A coverage
De-worming coverage
Presence of enough vaccine carriers
0.044
0.005 -
Appropriate cold chain
0.018
Use of multiple locally available channels
0.048
0.041
Task force meeting at all levels
0.023
0.02

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

22. Survey Sites: 4 Regions; 2 zones/ region; urban & rural
Impact of Measles SIAs on the Routine Immunisation System, Ethiopia. KAP Surveys Pre-SIA (6wks) vs Post-SIA (2wks)
Survey Sites: 4 Regions; 2 zones/ region; urban & rural
Addis Ababa
Oromiya
SNNPR
Somali
Pre-SIA
Post SIA
Post-SIA
Monitoring chart up to date
50%
63%
35%
99%
100%
60%
64%
Health facilities with adequate functional cold chain
83%
26%
22%
32%
14%
80%
Health facilities with adequate safety boxes
92%
96%
93%
Health workers who know the use of additional doses of measles immunization
75%
46%
74%
76%
27%
87%
Health workers who know the correct site of measles vaccine injection
94%

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

24. Major Lessons Learned
Early identification of best practices at the country level
Strong federal government leadership and ownership
Micro planning should be bottom up
Include both technical and administrative officials
Adjustments after submission should be shared back down
Evidence-based social mobilization and training materials
Interpersonal communication (door-to-door where feasible) is effective
Daily intra campaign monitoring is essential for real-time results to ensure all children are reached.
Routine Immunization strengthening should be included in all aspects of planning, implementation and review, especially maintaining coordination structures

25. Future Perspectives for Measles Elimination in Ethiopia
Consideration of wider age group for the next SIA in view of ongoing transmission
Local resource mobilisation for measles control efforts based on SIA experience
Partnerships forged and strengthened
Routine system strengthening
Use of SIA Coordination structures for future SIAs and routine EPI activities such as new vaccine introduction
Pre-SIA registration of target children and identification of hard to reach populations useful for subsequent SIA and RI
Capacity building of PFSA in logistics management
Local partnerships for RI and SIAs

26. Acknowledgement FMOH (Neghist Tesfaye) Balcha Masresha Meseret Eshetu
Pascal Mkanda
Gavin Grant
Sisay Gashu
Luwei Pearson
Tirsit Assefa
Habtamu Belete
Yodit Hailemariam
Halima Dao
David Brown
Kathleen Wannemuehler
Theresa Diaz
Edward Hoekstra
Mitike Molla
National SIA Task Force
MEDCO

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