MMDP PROJECT SEMI-ANNUAL REPORT October 1, 2017 – March 31, 2018
Prepared for: Emily Wainwright, AOR MMDP Project, USAID Submitted by: Helen Keller International Date: May 15, 2018 For more information: Stefania Slabyj, Project Director, [email protected]
THE MMDP PROJECT
The Morbidity Management and Disability Prevention (MMDP) Project is a five-year project funded by the United States Agency for International Development (USAID) with the goal of strengthening national ownership and capacity within a select number of countries to scale up the provision of quality services for the management of morbidity, disability and disfigurement related to trachoma and lymphatic filariasis in a manner that will help to meet disease elimination targets. To achieve this goal, the MMDP Project will focus on the following four intermediate results:
1. Strengthened MMDP data availability and quality for decision-making at the country level. 2. Strengthened support for MMDP implementation scale-up and quality improvement at the country level. 3. Strengthened capacity of MMDP systems within Ministries of Health. 4. Provision of global leadership through building-upon the knowledge and evidence-base for MMDP preferred practices and policy.
The MMDP Project is a global project led by Helen Keller International in partnership with the African Filariasis Morbidity Project and RTI International. The project is funded by the US Agency for International Development under Cooperative Agreement No. AID-OAA-A-11-00054. The period of performance for the MMDP Project is July 22, 2014 through July 21, 2019. The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
Cover photo: Mossi trichiasis patient in Burkina Faso being taken for surgery by son, 2017. (photo: HKI)
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CONTENTS
ACRONYMS ...... 4
EXECUTIVE SUMMARY ...... 6
KEY PROGRESS INDICATORS ...... 7
BURKINA FASO ...... 9
TRACHOMA ...... 12
LYMPHATIC FILARIASIS ...... 19
CAMEROON ...... 27
TRACHOMA ...... 30
LYMPHATIC FILARIASIS ...... 36
ETHIOPIA ...... 40
TRACHOMA (Oromia) ...... 43
TRACHOMA (Tigray) ...... 55
LYMPHATIC FILARIASIS ...... 63
GLOBAL PROJECT ...... 80
PROJECT ACTIVITIES ...... 81
OPERATIONAL ACTIVITIES ...... 96
APPENDICES ...... 98
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ACRONYMS AIM Accelerating Integrated Management CBHW Community Based Health Workers CDC US Centers for Disease Control and Prevention CNTD Centre for Neglected Tropical Diseases CSPS Center for Health and Social Promotion (Centre de Santé et de Promotion Sociale) DFID Department for International Development DGS Central Health Directorate (Direction Générale de la Santé) DMDI Disease Management and Disability Inclusion DMT Dedicated Mobile Team DQT Dedicated Quality Team DRS Regional Health Directorates (Direction Régionale de la Santé) ECU Eye Care Unit EMMP Environmental Monitoring and Mitigation Plan EMMR Environmental Mitigation and Management Report ESPEN Expanded Special Project for Elimination of Neglected Tropical Diseases FASTT Filaricele Anatomical Surgical Task Trainer FHF Fred Hollows Foundation FMOH Federal Ministry of Health FOG Fixed Obligation Grant FY Fiscal Year GAELF Global Alliance to Eliminate Lymphatic Filariasis HCWM Health Care Waste Management HDA Health Development Army HEAD START Human Eyelid Analog Device for Surgical Training And Skills Reinforcement in Trachoma HEW Health Extension Worker HKI Helen Keller International HMIS Health Management Information System HRD Human Resources Directorate IC/HCWM Infection Control and Health Care Waste Management ICTC International Coalition for Trachoma Control IEC Information, Education, and Communication IECW Integrated Eye Care Worker IESO Integrated Emergency Surgical Officer LF Lymphatic Filariasis LFTW Light for the World LSTM Liverpool School of Tropical Medicine MDA Mass Drug Administration MMDP Morbidity Management and Disability Prevention MMMM Monthly Morbidity Management Meeting MOH Ministry of Health MOST Ministry of Science and Technology NaPAN National Podoconiosis Action Network NGO Non-Governmental Organization NTD Neglected Tropical Disease
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NTTF National Trachoma Task Force ORHB Oromia Regional Health Bureau PFSA Pharmaceutical Fund and Supply Agency PHCU Primary Health Care Unit PNLCé National Blindness Prevention Program (Programme National de Lutte contre la Cécité) PNMTN National Neglected Tropical Disease Control Program (Programme National de lutte contre les Maladies Tropicales Négligées) QA Quality Assurance RHB Regional Health Bureau SAFE Surgery, Antibiotics, Facial cleanliness, Environmental improvement SECU Secondary Eye Care Unit SNNPR Southern Nations, Nationalities, and People’s Region SSE Surgical Society of Ethiopia STTA Short-term Technical Assistance TA Technical Advisor TAB Technical Advisory Board TAP Trachoma Action Plan TEC Trachoma Expert Committee TEO Tetracycline Eye Ointment TIS Trachoma Impact Survey TRHB Tigray Regional Health Bureau TT Trachomatous Trichiasis UIG Ultimate Intervention Goal UNC University of North Carolina USAID United States Agency for International Development WHO World Health Organization WoHO Woreda Health Office ZHD Zonal Health Department
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EXECUTIVE SUMMARY In the first half of FY18, the Morbidity Management and Disability Prevention (MMDP) Project continued to strengthen both national ownership and global capacity for the scale-up of trachoma and lymphatic filariasis (LF) care and treatment. During the reporting period, the project made significant achievements, leveraged on-the-ground experience, and strengthened capacity and lessons learned, to support Burkina Faso, Cameroon, and Ethiopia to move closer towards meeting the 2020 elimination goals for trachoma and LF. The MMDP Project supported 10,897 trachomatous trichiasis (TT) surgeries during the reporting period, advancing ministry of health efforts to meet the trachoma elimination goals. This required screening 224,031 individuals living in endemic areas, using a variety of community mobilization and new case-finding strategies. In addition to supporting intensive trichiasis management, the project also supported activities that improved the evidence base for trachoma elimination planning in the three countries. In Burkina Faso, the project supported the national program’s development of a Trachoma Action Plan (TAP). In Cameroon, the project contributed to the national program’s assessment of trichiasis burden through implementation of a TT-only survey in Mada district, and supported coordination between the national program and WHO to make available Tropical Data’s analysis of prior trachoma survey results. The project also increased the three countries’ capacity to provide high-quality hydrocele surgery and lymphedema management services. In collaboration with ministries of health, the project supported the training of 11 surgeons to provide high-quality hydrocelectomies using the MMDP Project-developed FASTT training package. In addition, the project trained 40 health staff on hydrocele surgery support and care. In the first half of the fiscal year, the project supported 536 hydrocele surgeries across the three countries and trained 717 lymphedema patients in self-care. The project also supported a range of activities aimed at ensuring a longer-term sustainability of LF morbidity management in project countries and beyond through health systems strengthening and the integration of activities into the routine health system. One such example is a project- supported workshop in Ethiopia to discuss the inclusion of the FASTT training package in the pre-service training curriculum of surgeons and integrated emergency surgical officers. Another example is the interest of the Ministry of Science and Technology in Ethiopia in manufacturing the simulator locally. The project has been working to prepare for an upcoming LF MMDP training workshop for Francophone African countries. The workshop, sponsored by ESPEN, will strengthen participating countries in their LF technical capacities and in preparing a plan for LF elimination dossier submission to WHO. In the first half of FY18, the MMDP Project continued to develop and refine tools and resources to address challenges in trachoma and LF morbidity management identified by the global community. The project carried out an evaluation of the FASTT training package in Burkina Faso, which found that the training package is a useful tool that provides a comprehensive system for teaching the basics of hydrocele surgery. Another tool, the “Training trichiasis surgeons for trachoma elimination programs” manual, developed by the project with ICTC partners, was formally accepted as a preferred practice by ICTC. In the second half of FY18, the MMDP Project will continue its support to ministries of health to close the gap to meet elimination criteria for both trachoma and LF. The project will continue to distill lessons learned from its practical implementation experience, particularly around piloting the implementation of outcome assessment and surgical audit as two distinct activities; the use of TT-operative photos as potential predictors of surgical outcomes in a programmatic setting; and quality assurance and post-operative follow-up of hydrocele surgery. The project will also plan for the last year of the project and identify the remaining global and local priorities in the global fight to eliminate trachoma and LF that can be accomplished by the end of the project.
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KEY PROGRESS INDICATORS The MMDP Project works at both the national and global levels to expand the capacity of ministries of health to provide quality MMDP services for trachoma and LF as a part of global disease elimination efforts. The project also works to support service delivery and implement quality assurance measures which contribute to stronger health systems, and to improve data availability and use, disseminate best practices, and contribute to advancing the global agenda by sharing experiences and collaborating with local and international partners.
The two tables below highlight the key achievements from the reporting period. All activities are described in more detail in subsequent sections of the report.
Table 1: Summary of FY18 support to MMDP Project countries: Q1-Q2 FY18 Support to MMDP Project Countries: Q1-Q2 Trachoma Achievements LF Achievements 10,897 TT surgeries total 536 hydrocele surgeries • 4 TT surgical campaigns (Burkina Faso) 717 lymphedema cases trained in self-care • 137 TT surgery teams operating, including 4 dedicated mobile teams (Ethiopia) • 3 intensified surgical camps and 2 “minicamps” (Ethiopia) 224,031 people screened total Refresher/debriefing session for three TT 11 new hydrocele surgeons trained using FASTT surgeons (Cameroon) 6 people trained in TT campaign/outreach 27 health staff trained in hydrocele surgery management (Cameroon) support 249 case finders & community mobilizers trained 13 health staff retrained in post-hydrocele (Cameroon) surgery survey implementation (Ethiopia) 1 district assessed for burden through a TT-only Technical/Meeting Support to project- survey (Cameroon) supported countries Technical/Meeting Support to project-supported countries
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Table 2. Key project activities: Q1-Q2
Goal Key Activities
Build service Training in and use of WHO guidelines and standards for TT management, including capacity diagnosis, counseling, surgery and post-surgical follow-up Training in and use of global guidelines and standards for hydrocele management, including diagnosis, counseling, surgery, and post-surgical follow-up Short-term technical assistance to Benin and Cote d’Ivoire to train surgeons and national trainers using the HEAD START training package Training of a Francophone HEAD START master trainer for TT surgery Service Provision of TT surgery through multiple operational platforms, including outreach delivery campaigns, dedicated mobile teams, and static site services TT and hydrocele case finding and confirmation, including house-to-house visits and extensive social mobilization activities Provision of hydrocele surgery through intensive camps and routine health system Provision of equipment and consumables for TT and hydrocele surgery Quality Update of TT supportive supervision tools assurance Exploration of remote technical support as a potential quality assurance strategy for TT surgeon training and surgery Continued implementation of an array of quality assurance measures for TT and hydrocele surgery Improve Analysis of TT and hydrocele surgical quality, patient satisfaction, and data quality as data part of post-operative monitoring availability Review of and revision to TT data for decision-making during trachoma action and use planning Assessment and update of FASTT training package Liaising with WHO’s Tropical Data initiative to facilitate national programs obtaining age- and sex-standardized TT estimates from recent and historical trachoma surveys Disseminate Convening of partners for a MMDP Technical Update featuring the “Training Trichiasis best Surgeons for Trachoma Elimination Programs” manual practices Publishing of the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual as an ICTC preferred practice Planning for an LF MMDP workshop for Francophone countries Facilitation of Monthly Morbidity Management Meetings of the LF MMDP community Dissemination of TT and LF best practices and lessons learned in collaboration with global and local partners at international meetings, including COR-NTDs, ASTMH and others
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TT surgery in the community in Burkina Faso in 2017. (Photo: HKI)
BURKINA FASO
• The MMDP Project conducted four trichiasis outreach campaigns, screening a total of 38,218 people and providing surgery to 288 individuals.
• The project supported the national program in a multi-day Trachoma Action Plan strategic planning meeting to assess progress achieved towards elimination targets, identify gaps and outline next steps.
• The project supported 392 hydrocele surgeries, and conducted 6-12 month follow-up of 61 patients after the surgery to assess clinical and quality-of- life outcomes.
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IN BRIEF In the first half of fiscal year 2018 (FY18), the MMDP Project continued to support intensive trichiasis management services in the Center North and Hauts-Bassins regions. Four trichiasis surgery campaigns took place in the first half of the fiscal year, collectively screening 38,218 people to find 384 confirmed trachomatous trichiasis (TT) cases and provide 288 people with surgery, with additional cases referred to higher-level facilities and counselled as appropriate. The project also implemented outcome assessment and surgical audit activities to follow up 3-6 months after surgery with TT cases operated during last year’s Hauts-Bassins campaigns in June and July 2017. The national program’s multi-day Trachoma Action Plan (TAP) strategic planning meeting took place during the reporting period, with the project providing a facilitator and contributing to the discussion of progress achieved towards elimination targets and the planning of upcoming activities.
Lymphatic filariasis (LF) activities moved forward as well. The project continued supporting hydrocele surgeries in multiple districts (392 surgeries over the course of the reporting period) and conducted a follow-up study of hydrocele surgery patients 6-12 months after surgery. Burkina Faso also hosted the project’s Filaricele Anatomical Surgical Task Trainer (FASTT) evaluation, which resulted in the training of five new hydrocele surgeons in the Center South region. Follow- up of lymphedema patients trained by the project at the end of FY17 took place early in the fiscal year.
PROGRAM BACKGROUND
TRACHOMA
Burkina Faso’s baseline mapping, completed in 2007, provided a crude estimate of over 33,000 individuals with trichiasis. At the start of the MMDP Project, roughly one third of the national burden was estimated to exist in the two project-supported regions of Center North and Hauts- Bassins. However, this epidemiological picture is evolving for two key reasons. First, age- and sex-standardization of trachoma survey data is increasingly yielding lower estimates of burden. This suggests that the data available at the start of the MMDP Project, which were never standardized by age and sex, likely overestimate the backlog. Second, in 2017, 19 trachoma impact surveys (TIS) were completed in health districts across the country (14 were funded by the END in Africa Project and five by the World Bank). These survey results have yielded revised trichiasis estimates for the assessed districts, some of which are targeted by the project. As of the February 2018 TAP meeting, the national program estimates the country’s backlog to be closer to 25,202 cases, although estimates for a number of districts rely on data that have not been standardized by age and sex.
In the Center North region, the project has targeted four of the region’s six districts, as two districts were determined to have 0% TT prevalence at the time of their baseline survey. At the start of the MMDP Project, these four districts collectively had a non-standardized, theoretical
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Ultimate Intervention Goal (UIG) of approximately 6,108 cases, of which roughly 12% were operated or otherwise made known to the health system through the project’s FY16 and FY17 campaigns. However, following the release of preliminary 2017 TIS data for three of these districts, the region’s theoretical UIG at the time of the most recent survey decreased to approximately 1,250 total cases. To date, the project has addressed approximately 20% of this revised burden estimate through its provision of trichiasis management services.
The Hauts-Bassins region, first targeted by the project in FY17, currently consists of eight districts. At the onset, the project targeted the three districts with the highest theoretical UIGs at the time. Collectively, these three priority districts had a non-standardized UIG of 2,184, of which roughly 6% were operated or otherwise made known to the health system through the project’s FY17 campaigns. Of the remaining five districts in the region, one district did not have a TT UIG at either its 2017 or 2010 TIS, indicating that no project intervention was needed. The other four districts had a combined UIG of 782 at the time the project began planning activities in the region and were not prioritized. However, new data made available to the project during the February 2018 TAP indicate several key shifts in the region’s epidemiological landscape. Five of the region’s eight districts have dropped below the TT elimination threshold according to their most recent TIS, leaving only three districts with a theoretical UIG at the start of FY18. Two of these districts have not been surveyed since 2009 and were therefore targeted with project- supported TT-only surveys (see Assessing Disease Burden section) in the FY18 workplan. However, given competing national program priorities following the TAP (several post-mass drug administration (MDA) surveillance surveys have to be completed by the end of June 2018), the project is moving forward with a campaign in these two districts in the second half FY18 rather than implementing TT-only surveys. The third and final district, which has a theoretical, non- standardized UIG of 115 cases, was targeted in Q2 of FY18 (see Trichiasis Management, Including Surgery section). For a summary table of project-supported progress towards the UIG in each targeted district, by fiscal year and in relation to district-level UIGs, see Appendix A (Table A1).
LYMPHATIC FILARIASIS
LF was found to be endemic in all of Burkina Faso’s 63 health districts following the completion of mapping in 2002. The MMDP Project initially used national program estimates to plan LF activities in the two project regions of Center North and Hauts-Bassins. Prior to provision of services, the project compiled burden data from health facilities in the targeted districts to actively identify hydrocele and lymphedema management cases for support in the community.
In the Center North region, the project has conducted hydrocele surgery and/or lymphedema management services in all six districts. During the reporting period, the project conducted 268 hydrocele surgeries. To date, the project has conducted a total of 560 hydrocele surgeries in the region, which represents all of the cases that could be confirmed by a surgeon during project activities and roughly 50% of the regional burden as last estimated by the national program. The 298 lymphedema cases managed to date with project support (in FY17) represent approximately 38% of the national program’s estimated number of cases in the region.
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In Hauts-Bassins, the project has targeted cases from five1 of the regions’ eight districts with hydrocele surgery and/or lymphedema management services. These four districts are estimated to have the highest number of lymphedema and hydrocele cases in the region. The 160 hydrocele surgeries conducted to date under the project represent all of the cases that could be confirmed by a surgeon during project activities and more cases than had last been estimated by the national program. The 83 lymphedema cases managed to date with project support (in FY17) represent approximately 26% of the latest estimated number of cases in the region.
For a summary table of the project’s LF disease management achievements to date, in relation to regional targets and burden estimates, see Appendix A (Table A5).
MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD
TRACHOMA
STRATEGIC PLANNING In the first half of the fiscal year, the project participated in strategic planning meetings to support the preparation for FY18 activities and the development of Burkina Faso’s TAP. Coordination and planning meetings were held with the Regional Health Directorate (DRS) in both the Center North and the Hauts-Bassins regions to review FY17 activities achieved, present the FY18 workplan to stakeholders, and integrate FY18 activities into the districts’ and health areas’ various action plans. The meetings also presented an opportunity to review the Fixed Obligation Grant (FOG) agreement for each DRS (Center North and Hauts-Bassins) and to develop a timeline for the implementation of FY18 activities. The planning and coordination meeting for the Center North was held in Kaya in January 2018, while the Hauts-Bassins meeting was held in Bobo Dilasso in February 2018.
From February 5-9, a TAP development meeting led by the national program was held in Ouagadougou. In addition to supporting the pre-TAP working sessions in January, the project supported Mr. Chad MacArthur to facilitate the meeting while the END in Africa Project supported the meeting costs. The meeting was attended by regional health bureau staff, representatives from the Ministry of National Education and Literacy, the National Program for Water and Sanitation in Burkina Faso, Sightsavers, l’Occitane Foundation, USAID, and HKI MMDP and END in Africa Projects.
The meeting provided an opportunity for the major trachoma actors to come together to take stock of progress made to date and to strategically plan for the coming years leading to elimination. The national trachoma program in Burkina Faso is at a critical point for trachoma elimination, having stopped MDA campaigns in all formerly endemic districts throughout the
1 Only four districts have a functioning operating room, but identified cases from the fifth district of N’dorola were referred to the nearest facility providing project supported hydrocele surgeries.
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country. Additionally, the national program has resources available from USAID and the World Bank to address trichiasis on a large scale. Based on current data, the program has identified the need to conduct 15 surveillance surveys and 16 TT-only surveys to demonstrate elimination criteria have been met. These surveys will continue to not only enrich the evidence-base for demonstrating progress made toward elimination, but also be the inputs from which the program will need to continually revise plans, particularly in targeting districts for trichiasis intervention.
The TAP meeting was held following the availability of results from 19 trachoma surveys conducted the previous fiscal year with support from the END in Africa Project and the World Bank. The week’s discussion focused on each component of the trachoma Surgery, Antibiotics, Facial cleanliness, and Environmental improvement (SAFE) strategy separately, identifying the current status of progress made to date, and the remaining actions needed to arrive at elimination. At the end of the discussion regarding country-specific progress for each SAFE component, the relevant section of the dossier was reviewed. As a final step, the group identified and recorded next steps for each SAFE component, which the national program agreed to finalize and share with the meeting participants.
On March 15, a post-TAP meeting took place to begin finalizing the next steps document. Due to the national program’s participation in MMDP Project campaigns and preparations for the various post-MDA surveillance surveys, the process has been slow. At the time of report writing, the finalization of the document was ongoing.
ADVOCACY Advocacy activities during the reporting period included advocacy days, feedback meetings, and correspondence with local leaders. In February 2018, the project organized a one-day advocacy day in both Orodara and N’dorola health districts in Hauts-Bassins. Since these districts are new to the MMDP Project, the purpose of the advocacy days was to present an overview of the MMDP Project’s activities planned for each district in FY18, provide information on the TT management services that would be provided, and seek the support of district leadership. The meetings were attended by administrative, civil society, traditional, and religious authorities. During the meetings, HKI staff sought the support of the various district leaders to mobilize members of their communities for campaign activities.
The project also held meetings on project implementation outcomes in both regions in January and February to assess the implementation of FY17 activities. The meetings, which were attended by political, traditional and religious authorities, were used to review the successes of the previous campaigns and look at areas for improvement, such as sensitization of community members to increase TT surgery uptake, sources of financing, and the different contributions and expectations of the stakeholders.
To ensure the participation and commitment of community members, letters were sent to political and administrative leaders in Center North and Hauts-Bassins, notifying them of upcoming campaign activities. The letters included information on the TT surgeries that would be provided and encouraged the participation of the leaders and their communities.
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SOCIAL MOBILIZATION AND BEHAVIOR CHANGE Community-level social mobilization activities included the broadcast of radio messages, the use of public criers before and during campaigns, and the distribution of information, education, and communication (IEC) materials.
Using local radio stations, the project disseminated information about trachoma and the project’s activities throughout the target districts. Messages were broadcast in French and in local languages through educational programs and radio magazine shows. In addition, public criers delivered information at the village level about trachoma and the availability of services for trichiasis. The messages delivered included surgery dates, availability of screening services, the source of funding for the surgeries, and who to contact for more information.
The project reproduced and distributed IEC materials developed in previous fiscal years. The table below describes the type and quantity of materials reproduced for FY18 activities.
Table 3. IEC/social mobilization materials messages produced with USAID funding Type of material Brief description of material Target audience Quantity The poster shows an overview of Communities in Poster (trichiasis trichiasis surgery, emphasizing that endemic areas/people 1000 surgery) it can preserve sight. with trichiasis The poster provides an overview of the symptoms of trachoma and Communities in Poster (trachoma and directs those with similar endemic areas/people 1000 TT management) symptoms to go to the health with trachoma center for diagnosis and treatment. The leaflet includes photos and a brief description of the WHO- Leaflet (trachoma defined stages of trachoma. It Health center workers 250 disease stages) includes directive actions based on the stage of the disease. Health center workers Brochure (trachoma Description of trachoma and its and communities in 900 and TT) management endemic areas/people with trichiasis
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CAPACITY BUILDING There were no capacity building activities for trachoma conducted during the reporting period.
ASSESSING DISEASE BURDEN Following the completion of trachoma surveys in 19 districts in 2017, in early FY18 the project worked to obtain updated TT prevalence data for these districts. The National Neglected Tropical Disease Control Program (PNMTN) shared its most recent data during the February 2018 TAP meeting, after which the project updated its TT data tools to align with the data shared.
The project has also been providing support to the PNMTN to develop a protocol for the three TT-only surveys planned for FY18. (Two surveys are planned in the Hauts-Bassins region in N’dorola and Orodara districts, as described in the FY18 work plan, and one survey, in Barsalogho district of the Center North region, was carried over from the FY17 work plan into FY18). The project’s support of these surveys in the first half of FY18 has taken the form of supporting liaising between the PNMTN and Tropical Data to ensure the Francophone protocol that is developed will be in line with World Health Organization (WHO)-endorsed survey standards. Finalization of the protocol and implementation of the surveys is planned for the second half of the fiscal year. The PNMTN, however, also plans to conduct surveillance surveys in 22 districts over the course of FY18. These upcoming surveillance surveys, which are a high priority for the national program, may result in delays to the planned TT-only surveys, depending on the PNMTN’s prioritization of time and human resources.
Finally, the project has continued to track, analyze, and discuss during campaign preparatory meetings the geographic coverage of its TT management services. This geographic coverage data at the sub-district level provides additional documentation of the project’s contribution to reaching the UIG in its targeted regions – particularly in the Center North, where the most TT surgery campaigns have been conducted.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY During the first half of the fiscal year, the project supported the implementation of four TT campaigns (three in Center North region and one in Hauts-Bassins). The first campaign was held in Kaya in January 2018, the second in Boussouma in February 2018, the third in Dafra in March 2018, and the fourth in Kongoussi in March 2018. Across four campaigns, a total of 38,218 people were screened, of which 384 people were confirmed to have trichiasis. Among these confirmed cases, 288 received surgery, 13 were referred to a higher level of care, and 22 refused all services (both surgery and epilation). When surgery was not conducted (because the individual refused or was referred, or was otherwise not recommended to have surgery), those who consented were epilated; however, per current national program guidance, these individuals did not receive epilation forceps.
For FY18, the project continued to use the strategy of performing TT case identification through door-to-door case finding and TT surgeries on the same day. Each TT surgery campaign lasted ten days and started with a preparatory meeting at the DRS. During this meeting, the HKI staff
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and district leadership provided an overview of FY18 campaigns: the number of campaigns planned in each region, the number of cases targeted, the data collection tools to use, and relevant results from the FY17 campaigns. Particular attention was given to the review of the data collection tools to ensure that forms were filled out correctly and completely throughout the campaigns. HKI staff reviewed common mistakes found on the forms and provided tips to avoid them. They also reiterated the importance of correct data to accurately estimate the disease burden for the country and appropriately plan for the provision of services for the districts. At the end of the meeting, each surgery team was assigned a schedule for the campaign.
During the campaigns, the screeners, accompanied by Community Based Health Workers (CBHWs), examined people in their households. The CBHWs serve as guides and interpreters, thus playing a crucial role in introducing the screeners to each household. Also, because they are familiar with the communities, CBHWs were sometimes aware of suspected cases. Due to long distances between households, the screeners and CBHWs often walked for hours to ensure that as many people as possible were screened. Once a TT case was identified, the screeners explained the disease as well as the surgery being offered. The suspected case was then referred to the surgery site, which could either be at a Center for Health and Social Promotion (CSPS) or at another appropriate site in the village, such as a classroom.
At the surgery site, the surgeon confirmed the TT diagnosis and operated on those who consented. After surgery, individuals received post-operative counseling and tetracycline eye ointment (TEO)/Zithromax. At select surgery sites, HKI staff also took photos of the operated eye immediately after surgery as part of a photo-taking activity that is currently being piloted as an additional quality assurance measure. Post-surgical monitoring was conducted at the surgery site on Day 1 by the surgeons, who removed the bandage and assessed the operated eyelid. On Day 8, the CSPS health workers who took part in the campaign conducted post-surgical monitoring. Monitoring operated cases 3-6 months after surgery will take place in the second half of FY18.
Complicated cases, such as those with lower-lid or post-operative trichiasis, were referred to a health facility equipped to handle such cases. Individuals who refused surgery were encouraged to accept epilation. Within the project’s campaign model, refusals are intended to be registered in the health system and receive follow-up from the local head nurse; in practice, however, it is difficult for the project to track the frequency and outcomes of refusal management. As described in the Monitoring & Evaluation section below, in the second half of FY18, the project will explore new management strategies of refusal cases.
On the last day of each campaign, the surgical teams, HKI supervisors, and the district leadership held a debriefing meeting at the district level. In addition to reviewing preliminary campaign results, they assessed remaining drugs and consumables to ensure the appropriate management of stock and to better assess procurement needs for future campaigns.
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COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT Procurement during the reporting period involved primarily:
• Pharmaceuticals for TT surgery: Pharmaceuticals were purchased via the USAID- approved wholesaler (IMRES) and delivered to the country in Q2. The only exception to this was the lidocaine with adrenaline, which was not available from any USAID-approved wholesaler or from the National Medical Pharmacy in Burkina Faso. HKI therefore used private funds to procure the items separately. The project worked with members of its Trachoma Technical Advisory Board (TAB) to adapt a mixing protocol for lidocaine with adrenaline developed by Johns Hopkins University. The protocol was translated into French and shared with the National Program, which is in the process of reviewing the protocol and in the interim decided to proceed using lidocaine only. For the reporting period, lidocaine (without adrenaline) was used during TT surgery campaigns. Drugs purchased in Burkina Faso were purchased from the National Medical Pharmacy, which complies with the national regulations on the management of drugs and is subject to quality control analysis and certification.
• HEAD START surgical simulator parts: HEAD START consumables are procured centrally by the MMDP Global team. In FY18, eight orbits and 150 eyelids were shipped to Burkina Faso to be used for surgeon refresher trainings.
SUPPORTIVE SUPERVISION Ministry of Health (MOH) and HKI staff in Burkina Faso provide supervision throughout the campaigns. During case finding in villages, they observe screeners’ interaction with and examination of the individuals visited, providing feedback as appropriate. They also support the case finding team to accurately and comprehensively complete the data collection forms. At the surgery site, they monitor the various non-technical components outlined in the project’s supportive supervision checklists and support the surgery team to troubleshoot any issues that arise.
Because surgeries are performed in the field, issues that arise can range from helping to repair broken equipment to having to stand in for the assisting nurse. For example, during the Kaya campaign, one of the surgical tables broke right before surgery. With assistance from HKI staff, the surgeon and the nurse were eventually able to repair the table and proceed with the surgeries. On the same day, while the surgeon was operating on a patient, the nurse was called back to his post for an emergency. HKI staff therefore had to step in and assist the surgeon by holding an additional source of light so he could finish operating.
When technical supervisors are available, they also work with surgery teams to track use of equipment and consumables and plan accordingly for future campaigns. Technical supervision of TT surgeons is provided by the assistant national trainers trained by the project in FY17 to serve both roles. While the goal is for each surgeon to receive technical supervision at least once a year, human resource constraints have made it challenging to have a technical supervisor present at each site during each campaign. Depending on needs, during a campaign, technical supervisors
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are sometimes assigned as the surgeons on the teams and are, therefore, too occupied with case management to provide technical supervision. The project is currently exploring the availability of Dr. Amir Bedri Kello, the project’s primary technical assistance provider for TT surgery, to conduct a training of additional technical supervisors.
SHORT-TERM TECHINCAL ASSISTANCE There were no short-term technical assistance activities for trachoma conducted during the reporting period.
MONITORING AND EVALUATION The project conducted routine M&E activities during the reporting period as part of each campaign. These activities included tracking geographic coverage of TT management services, managing TT surgery data to ensure flow of information from the on-the-ground surgery teams up to the national level, and holding a surgical campaign assessment during the campaign debrief meetings described in the Trichiasis Management section.
In the first quarter of FY18, the project conducted 3-6 month follow-up of the last two TT campaigns of FY17. The campaigns took place in June and July 2017, covering three districts in the Hauts-Bassins region (one campaign covered the district of Dafra, and the other covered the districts of Dandé and Dô). Since the third month following these campaigns fell in FY18, the project carried out 3-6 month follow-up in October 2018 as part of FY17 carryover activities. For this 3-6 month follow-up, the project implemented a two-pronged approach to conducting surgical audit as distinct from “centralized” follow-up (also referred to as “outcome assessment”). As described in the FY18 work plans, this is a new approach for the MMDP Project. The project began piloting this approach in Burkina Faso at the end of FY17 and continued implementing it in FY18 in Dafra, Dandé, and Dô.
For the surgical audit component, the project actively sought out individuals in their home. A portion of those who received surgery during the FY17 campaigns were randomly selected to receive a follow-up visit from a team comprised of a surgeon, representatives from the PNMTN (including a technical supervisor), representatives from the DRS, and HKI staff. There were two teams; one covered Dafra, while the other covered Dandé and Dô. To increase the chances of finding people at home, the teams either called the head nurse assigned to the villages of the selected cases or directly called the person who received surgery. Each team started out by first visiting the health center covering the individual’s village to confirm that the person received Day 8 follow-up, request the post-operative follow-up forms, and be accompanied to the person’s home by a CBHW. Once in a person’s home, the team explained the purpose of the visit, interviewed the person, and conducted a clinical examination of the operated eye(s). Fifty people, representing approximately 34% of the individuals who received surgery during the campaigns, were followed up with through these visits. The results of the clinical examination indicated satisfactory surgeon performance in the most recent campaigns. Based on this analysis of the data, the project determined there was not a need to hold a refresher training of surgeons prior to implementing the first TT campaigns of FY18. The few complications identified were either
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post-operative TT, in which case the individual was referred to a health facility, or granuloma, which were corrected on site by the surgeon who was part of the follow-up team. If the follow- up team determined that an individual’s post-operative TT was severe, the surgeon would epilate the individual before referring the individual.
For the centralized follow-up (or outcome assessment) component, the project worked with national and regional representatives to invite individuals to return to a central location for examination 3-6 months following surgery. The specific location was determined in consultation with local health staff, taking into consideration the distance people could reasonably be expected to travel. From across the two campaigns in Dafra, Dandé, and Dô, 20 patients (in addition to those examined through surgical audit) presented at their designated location, representing approximately 14% of the individuals who received surgery.
Initial implementation of these two activities has already yielded valuable lessons for the Burkina Faso national program. While conducting two distinct activities has resulted in additional people receiving a 3-6 month follow-up examination, reaching 100% of operated cases remains a resource-intensive, logistically complicated endeavor. Decentralized surgical output during campaigns compounds this difficulty, as the project must coordinate with the national program to organize and staff a large number of “centralized” sites to prevent individuals from needing to travel too far. Furthermore, ensuring technical supervision on surgical audit teams remains a challenge, particularly when the presence of the same technical supervisors is also requested for multiple campaigns that are happening during a short period of time. Within a context where MMDP Project-trained surgeons are in high demand, the challenge of limited technical availability is amplified when the same individuals are needed for surgical audit and outcome assessment in addition to campaigns. In the second half of FY18, the project will continue to refine its implementation of both activities, piloting adjustments with the goal to continue to increase the number of people receiving 3-6 month follow-up using the resources available.
In the second half of FY18, follow-up of individuals who have refused surgery will be integrated into surgical audit, when possible. As refusals are not currently documented in a way that facilitates partner, including HKI, access to lists of refusals, the project will need to first explore— in close collaboration with the national program—approaches to systematically share this information.
LYMPHATIC FILARIASIS
STRATEGIC PLANNING The project’s FY18 work plan did not include strategic planning activities for LF. However, based on a request, the MMDP Project shared information on its hydrocele surgery training and implementation activities with the World Bank funded-project in Burkina Faso. The National LF Coordinator confirmed that the hydrocele surgery training activities conducted under the World Bank project used the FASTT national trainers and the FASTT training package. The FASTT
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cartridges were not available at the time of the training but have since been provided to the MOH by the MMDP Project, for future hydrocele surgery trainings under the World Bank project.
ADVOCACY There were no advocacy activities for LF included in the FY18 work plan.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE During the reporting period, the project disseminated information about LF through local radio stations, community health workers, and public criers. Radio messages were broadcast in French and in local languages in the form of radio magazines and educational programs. In addition, public criers and health workers delivered information at the village level. The messages delivered included information on the availability of services for LF including hydrocele surgery dates, availability of screening services, the source of funding for the surgeries, and who to contact for more information.
CAPACITY BUILDING No capacity building activities for LF were included in the FY18 work plan. However, as described under the project’s global activities, in February 2018 Burkina Faso hosted the MMDP Project’s FASTT training and evaluation. A total of five Burkinabe surgeons and one assistant (an anesthesiologist) were trained in hydrocele surgery as part of this activity.
ASSESSING DISEASE BURDEN In FY18, the project continued supporting hydrocele case finding in the Center North region (six districts) and the Hauts-Bassins region (five2 districts), as part of FY17 carryover activities. In addition, in the context of the FASTT training and evaluation conducted in Burkina Faso, a case finding activity was organized in one district in the Center South region to identify hydrocele patients for the training.
In Burkina Faso, LF burden data on suspected hydrocele and lymphedema cases are routinely captured by the health system at the health center level. Health centers register suspected cases who are identified in the community by a CBHW or by health staff when a suspected case self- presents at the health center. The health center then keeps information about these cases on file at the facility but does not systematically transmit the information to other levels of the health system. In districts targeted by the MMDP Project, the project requested these lists from the health centers through the regional health bureaus. The cases identified using this approach are considered “registered” and are summarized in Table 4 below.
In addition, to supplement the hydrocele burden data routinely collected by health centers in targeted districts and to confirm hydrocele cases before surgery, the MMDP Project, through health center staff and the CBHWs, requested that people with symptoms go to their nearest
2 Only four districts have a functioning operating room, but identified cases from the 5th district of N’dorola were referred to the nearest facility providing project supported hydrocele surgeries.
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health center for diagnosis, where hydrocele cases were confirmed by surgeons. The cases confirmed using this method are also summarized in Table 4 below. In some districts, more people self-reported at the health center than had originally been registered as suspected cases through the routine health system.
Table 4. Results of project-supported LF case finding to date: FY17-FY183 Number of Number of Number of suspected hydrocele cases suspected cases of confirmed by lymphedema Region District hydrocele surgeons during cases registered by project-supported registered by health centers active case finding health centers Center North Barsalogho 90 81 22
Center North Boulsa 156 131 201
Center North Boussouma 160 53 614 Center North Kaya 175 200
Center North Kongoussi 267 84 100
Center North Tougouri 230 180 113
Hauts-Bassins Dafra 10 22 22
Hauts-Bassins Dande 2 20 6
Hauts-Bassins Houndé 16 42 44
Hauts-Bassins N’Dorola 38 N/A5 68
Hauts-Bassins Orodara 22 20 174
Center South Saponé6 50 20 N/A Total 1,216 661 1,003
3 The lymphedema cases presented in the table were registered during FY17, with data finalized in FY18. The hydrocele cases presented in the table were registered and/or confirmed during FY17 and FY18. 4 Boussouma does not have a functioning operating room, so cases from that district are referred to Kaya. 5 In N’Dorola, burden data were only collected through the lists the project requested from health centers. As the district did not have a functioning operating room for the project to conduct surgeries, the project did not send surgeons to this location to confirm cases. 6 The burden data presented for Saponé is not representative of the entire district. The data were only collected from 15 health centers in the district, as the goal of the data collection was to identify a sufficient number of hydrocele cases for the training of hydrocele surgeons as part of the FASTT evaluation, rather than to assess the full burden in the district.
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HYDROCELE SURGERY To date, hydrocele surgeries in Burkina Faso have taken place primarily in two regions under the MMDP Project: Center North and Hauts-Bassins. These hydrocele cases are managed through the routine health care system, with the MMDP Project providing assistance in case identification, supervision, provision of drugs and consumables, as well as fees related to the surgical procedure. Patients remained at the health center for an average of three days to monitor surgical wounds and any potential complications. Post-surgical monitoring is described in the Monitoring & Evaluation section.
In the Center North region, the project supported 268 hydrocele surgeries in the first half of FY18. Combined with the 292 surgeries conducted during previous reporting periods, to date the project has supported a total of 560 hydrocele surgeries in the region through the routine health system and as part of hydrocele surgeon training sessions. Through this achievement the project was able to operate all hydrocele cases identified and confirmed through its screening activities.
In the Hauts-Bassins region, as of the end of FY17, the project had supported 56 surgeries through the routine health system and as part of hydrocele surgeon trainings.7 A total of 104 people received hydrocele surgery within the routine healthcare system during the reporting period, representing all cases confirmed by the project in the region to date. In preparation for these FY18 surgeries, the project reviewed the implementation of FY17 LF activities with the Hauts- Bassins DRS. This review led to meetings with teams regarding delays in the execution of hydrocele surgeries in the Hauts-Bassins region. For example, discussions with the teams revealed the high demand for the limited number of sufficiently equipped operating rooms as a key challenge. Following these meetings, the project worked closely with the national programs and the DRS to ensure availability of operating rooms for MMDP Project surgeries. In addition, the project worked with health center staff in the targeted districts to encourage suspected cases to come to the health center specifically when a surgeon was available to confirm and operate cases.
An additional 13 surgeries were conducted in February 2018 in the district of Saponé (in the Center South region) as part of the FASTT training and evaluation. Following the training and evaluation, an additional seven surgeries were conducted with the remaining supplies, resulting in a total of 20 project-supported surgeries in Saponé.
LYMPHEDEMA MANAGEMENT Lymphedema management activities were continued in the Hauts-Bassins and Center North regions as part of the extension of the DRS Hauts-Bassins and Center North FY17 FOGs into FY18. The project completed its distribution of washing kits to the patients trained in lymphedema management in FY17: 298 patients in Center North and 83 patients in Hauts-Bassins. An additional 26 kits were provided to health centers for their activities. During Q1 of FY18, follow-up visits of trained individuals took place as part of the routine health system. Specifically,
7 Although the FY17 APR reported 48 surgeries, additional data were reported by the national program after APR submission.
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CBHWs followed up in the communities with lymphedema patients who had received training and kits from the project, and health center staff conducted follow-up when patients came to the health center. To ensure these activities took place as planned, the MOH and MMDP Project arranged periodic supervision visits, as described in the Supportive Supervision section.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT Pharmaceuticals and consumables used during the reporting period were procured in FY17, except for the purchase of lidocaine with adrenaline. In FY17, the project also procured materials for hydrocele surgeon training, which were then shipped in FY18. 60 cartridges were shipped to Burkina Faso. A portion of the cartridges was used during the MMDP Project’s FASTT training and evaluation, the rest will be used for future FASTT trainings. FASTT consumables are procured centrally by the MMDP Global team.
SUPPORTIVE SUPERVISION During the first half of FY18, a team of PNMTN staff accompanied by a regional surgeon and MMDP Project staff periodically visited operating theaters in the targeted districts in Hauts- Bassins and Center North regions. Since hydrocele surgeries take place through the routine health system, supervision visits were scheduled on an ad-hoc basis. The MMDP Project supervision checklist was not used for every visit, but the general principles of the checklist were always followed. These visits made it possible to summarize accomplishments by operating theater, congratulate the health center staff on their commitments, and document challenges encountered during the management of hydrocele surgeries in the two regions. Supervision visits also provided an opportunity to update the database of operated patients.
In addition, the MMDP Project team, along with national program and regional heath bureau staff, supervised follow up activities of lymphedema cases in both regions during the first half of FY18. As follow-up is conducted within the routine health system, the project was not able to systematically supervise every patient follow-up visit; however, MOH and project staff periodically arranged supervision visits to observe and support health staff as they conducted follow up as part of their routine activities.
SHORT-TERM TECHNICAL ASSISTANCE There were no short term technical assistance activities for LF conducted during the reporting period.
MONITORING AND EVALUATION In November and December 2017, the MMDP Project conducted a follow-up study of individuals who received hydrocele surgery 6-12 months prior. For these surgeries, the project had already collected, compiled, and analyzed follow-up data collected within five days of surgery, which revealed extremely low rates of complications (approximately 2%). This additional six-month follow-up was part of the project’s quality assurance measures, in line with WHO-recommended
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indicators, to assess surgical outcomes. The project also included a quality of life, as perceived by the patient, assessment component.
The study followed up with patients who had received hydrocele surgery through the project between December 2016 and June 2017 (6-12 months prior). A total of 63 patients (37 in the Center North and 26 in Hauts-Bassins) received surgery within this time period and were eligible for follow-up. The project compiled and shared this list of eligible individuals with the health facilities where the surgeries were performed. As the facilities already had the patients’ contact information on file from the time of the surgery, facility nurses and local CBHWs contacted the patients, and gave them a specific appointment time to come to the facility. CBHWs played a valuable role in finding patients, using their networks if the person could not be reached by phone or did not present at the health facility as requested.
All eligible patients were reached, except for one 80-year-old man who had died (unrelated to the surgery). For the 62 individuals who came to the health facility for examination (36 in Center North and 26 in Hauts-Bassins), the medical record was pulled from the facility files, and the person was interviewed and examined. All clinical examinations were conducted by surgeons who, in many cases, had traveled from regional hospitals to the facility specifically for this purpose. Among the 62 examined, one patient (1.6%), who initially had a bilateral hydrocele, had recurrence on one side and was invited back to the hospital for surgery. During the interview, 98% of patients expressed that they were very satisfied and/or would recommend the surgery to others suffering from hydroceles. In addition, 98% of patients reported that they noticed improvements in their ability to conduct daily tasks, and 97% confirmed improvements in their social interactions.
For the hydrocele surgeries that took place in FY18, data from follow-up within five days are still being transmitted from health facilities on a rolling basis and will be summarized in the Annual Progress Report. In addition, the project worked with the national program to review and validate data from the previous year’s LF activities. These data validation sessions were held in Center North on September 25-27, 2017 and in Hauts-Bassins on October 2-3, 2017.
CROSS-CUTTING ACTIVITIES
NTD SECRETARIAT The MMDP Project supported the Neglected Tropical Disease (NTD) Secretariat during the reporting period by supporting telephone and internet services.
ENVIRONMENTAL MITIGATION AND MONITORING PLAN Preferred infection control and medical waste management practices were utilized during the management of hydroceles and TT surgery campaigns in Hauts-Bassins and Center North. Sharps boxes, trash bags, autoclaves, and equipment for decontamination were used at health facilities and surgery sites. When available, biomedical waste incinerators were used at health facilities,
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and hydrocele-related waste was incinerated in accordance with WHO protocols for processing of biomedical waste. When incineration equipment was not available, surgeons were responsible for transporting the waste to a site with an incinerator for proper disposal. In October 2017, the project submitted a revised Environmental Mitigation and Monitoring Report (EMMR) to USAID.
INTEGRATION WITH OTHER DISEASES Case identification and referral within the health system took place for any hernia cases identified during the hydrocele case confirmation.
HEALTH SYSTEMS STRENGTHENING During the reporting period, the MMDP Project contributed to strengthening the health system in Burkina Faso as follows:
• Leadership and Governance: The project’s support for leadership and governance took the form of providing financial resources to the MOH to support its program in FY18, through signing two FOGs with the Central Health Directorate (DGS) and the DRS for the Center North and Hauts-Bassins regions.
• Service Delivery: The project’s support for delivery of trichiasis management services and hydrocele surgery, and its establishment of routine quality assurance practices accompanying these surgeries, help to strengthen Burkina Faso’s ability to deliver effective, safe, high-quality interventions to people suffering from trichiasis and hydrocele.
• Health information: The project’s support of the national program’s management, analysis, and sharing of monitoring and evaluation data related to disease management activities will help to strengthen the MOH’s ability to manage trachoma and LF morbidity.
CHALLENGES AND LESSONS LEARNED • Human resource constraints place significant time demands on a small pool of technical staff who are needed to provide TT surgery, conduct technical supervision of surgeries, and/or participate in post-operative follow-up. The project has responded to this challenge by training additional surgeon trainers and technical supervisors, and by having technical supervisors play a ‘double role’ of both operating and supervising during campaigns with more limited staffing.
• Non-surgical resources are also in high demand, with the national program forced to balance both the MDA and MMDP components of Burkina Faso’s trachoma elimination activities. With so many post-MDA surveillance surveys that must be completed by the end of June 2018, the national program has needed to put certain MMDP Project- supported activities (e.g., TT-only surveys) as second-tier priorities.
• A current global shortage of lidocaine with adrenaline has made it difficult for the project to procure the originally planned quantities. In response to this unforeseen shortage, the
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project collaborated with the Trachoma TAB to develop a protocol for mixing lidocaine and adrenaline, which is currently being reviewed by the national program and national pharmacy staff.
• The length of time required to finalize and disseminate official trachoma survey results has posed a challenge for the project, affecting the project’s ability to plan and implement activities based on the most recent data. As coordinating the analysis and sharing of survey data between the national program and Tropical Data can take a significant amount of time, the project has found that strategic meetings bringing together key stakeholders in person, such as a TAP, are the most successful in facilitating data sharing.
• The MMDP Project’s model of conducting hydrocele surgeries through the routine health system has several important programmatic implications. First, the routine health system has a finite capacity that cannot always meet the full demand for provision of surgeries and post-operative care, particularly if other pressing medical issues must be addressed by the facility at the same time. In response to this challenge, the project has learned that close coordination and more frequent communication with the national program and health facility staff can help ensure facilities prioritize using operating rooms for hydrocele surgery, when appropriate.
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Patient screening tools activity in Sirdjam village in Far North Cameroon, 2017. (Photo: William Nsai/Studio 3)
CAMEROON
• In preparation for its first trichiasis campaign of FY18 the MMDP Project held a refresher training and debriefing session for three TT surgeons, trained six health area nurses and district staff in campaign management, and trained 249 community outreach workers in social mobilization strategies. • Post-operative follow-up of individuals 3-6 months after trichiasis surgery was conducted in two districts, reaching 67 people. • The MMDP Project supported hydrocele surgery and post-operative follow-up for 58 individuals.
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IN BRIEF In the first half of FY18, the MMDP Project engaged in strategic planning, advocacy, social mobilization, capacity building, and disease assessment activities for trachoma and lymphatic filariasis (LF) morbidity management and disability prevention (MMDP).
Related to trachoma, key activities during the reporting period included trainings for surgeons, health area nurses, and community outreach workers. The project also held a series of advocacy meetings with key district, regional, and national stakeholders. These activities were conducted in preparation for the first campaign of the fiscal year, scheduled for April 2018 in Touboro district in the North. In addition, post-operative 3-6 month follow-up visits took place for the two trachomatous trichiasis (TT) campaigns conducted in FY17. The results from this follow-up will be used to shape TT surgeon refresher trainings later in the year. The project also contributed to Cameroon’s assessment of trichiasis burden through implementation of a TT-only survey in Mada district, and by supporting coordination between the national program and World Health Organization (WHO) to make available Tropical Data’s analysis of prior trachoma survey results.
For LF morbidity management, the project continued to provide support for hydrocele surgeries, with 58 surgeries conducted. The project completed all planned surgeries and associated five-day post-operative follow-up by the end of Q1. The project also participated in the national program’s annual national evaluation and planning meeting for integrated control of Neglected Tropical Diseases (NTDs), held in February, which included initial discussions of an integrated strategic plan for the morbidity management of all NTDs, including LF and trachoma.
PROGRAM BACKGROUND TRACHOMA
Cameroon has three regions that have not met elimination criteria for trachoma: the North, Far North, and Adamaoua. In 2016, the trichiasis data collected in the North and Far North during 2010-2012 baseline mapping was standardized by age and sex, resulting in a significant reduction of the estimated country backlog as compared with baseline projections. Standardization of Adamaoua region baseline trichiasis data is still pending (see Assessing Disease Burden section).
When the MMDP Project began providing TT surgeries in FY16, the national remainder against the Ultimate Intervention Goal (UIG) was estimated to be 3,421 TT cases nationally: 2,471 in the Far North,8 808 in the North, and 142 in Adamaoua. However, following the completion of 2017 Trachoma Impact Surveys (TIS) in 13 districts in 2017, and the implementation of two TT-only surveys (one in 2016 and one in 2017), the country’s UIG estimates are currently under revision. While the national program has not yet released new estimates, the preliminary data made
8 This figure reflected the estimated UIG after taking into consideration the TT surgeries that Sightsavers had supported in the Far North prior to the start of the MMDP Project.
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available to the project suggest potentially higher revised UIGs of closer to 3,351 in the Far North and 1,752 in the North, with the Adamaoua data updates still pending.
In the North region, the project has consistently targeted Poli and Touboro districts since FY16. These districts were two of the three districts with TT prevalence above the elimination threshold at the start of the MMDP Project. Following the project’s provision of intensive trichiasis management services, each district conducted a new epidemiological survey (a 2016 TT- only survey in Touboro and a 2017 TIS in Poli). However, the preliminary survey results showed both districts to be above the WHO threshold for elimination, thus warranting further project intervention in FY18. The project is tracking geographic coverage of TT management services in the two districts as interventions are ongoing.
In the Far North region, in FY16 the MMDP Project supported two TT outreach campaigns in the district of Mokolo, one of the four districts that had a remaining UIG at the start of the project. The campaigns resulted in 267 people operated or otherwise made known to the health system. The project did not support any campaigns in FY17 given pending 2017 TIS surveys. Based on the preliminary data recently made available to the project, currently seven districts are estimated to have a remaining UIG. In the second half of FY18, the project is targeting one of these districts, Meri, which has a UIG of approximately 935. The preliminary 2017 TIS data for Meri estimated a UIG of 1,020, but Sightsavers has conducted an estimated 85 surgeries since the survey. For a summary table of MMDP Project-supported progress towards the UIG, see Appendix A (Tables A1 and A2).
LYMPHATIC FILARIASIS
Mapping in Cameroon for LF between 2010 and 2012 determined that 158 of the country’s 181 health districts were endemic. Since then, more than 80% of endemic districts have successfully interrupted transmission of LF. However, data on LF morbidity in Cameroon are limited and inconsistent, highlighting the need for a national plan to identify and manage LF morbidity cases with high quality services. Given the MMDP Project’s focus on the North and Far North regions for trichiasis activities, the project selected these regions to pilot hydrocele surgery and lymphedema management training activities in FY17. The goal of the pilot was to determine key strategies and lessons learned for providing LF MMDP services, to ultimately contribute to a national strategic plan for LF elimination in Cameroon. This pilot included five districts: two in the North (out of 15 LF-endemic districts in the region) and three in the Far North (out of 28 LF-endemic districts in the region).
The project initially selected its pilot districts based on the amount of suspected hydrocele and lymphedema cases identified during FY16 pre-transmission assessment surveys, which the project used as a platform for LF burden data collection in close collaboration with the ENVISION Project. Before beginning disease management activities, the project designed and implemented enhanced hydrocele and lymphedema case finding activities to refine burden estimates prior to delivery of services. This case confirmation identified more hydrocele and lymphedema cases in
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the pilot districts than could be addressed through the project’s provision of services. The project has provided hydrocele surgery to 95 of the 300 cases identified through its enhanced case finding (with 58 of these surgeries conducted during the reporting period); in FY17, the project trained 112 of the 148 identified lymphedema cases in self-care. As the scale of the pilot was not designed to address the full disease burden across all five targeted districts, the remaining cases have been shared with the appropriate health system staff for follow-up outside of the project. For a summary table of the MMDP Project’s LF disease management achievements to date, in relation to current burden estimates, see Appendix A (Tables A5-A6).
MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD
TRACHOMA
STRATEGIC PLANNING During the reporting period, MMDP Project staff participated in strategic planning meetings related to national evaluation and planning for the integrated control of NTDs. In January 2018, the project attended a national-level coordination meeting organized and funded by the national program. The meeting was held to prepare for a larger three-day national evaluation meeting in February funded by ENVISION. That meeting brought together all the key actors involved in the implementation of NTD control activities in Cameroon, including NTD control program managers (onchocerciasis, LF, trachoma, schistosomiasis and intestinal worms), WHO/Cameroon, representatives from partner non-governmental organizations (NGOs)—HKI, Accelerating Integrated Management (AIM), Sightsavers, International Eye Foundation, PersPectives, Good Neighbors, and FAIRMED—and regional health delegates. The main objective of the meeting was to evaluate activities carried out in FY17 and discuss an action plan for FY18; presentations included an overview of NTD activities implemented in each region. During the meeting, the national program introduced AIM as the lead for the development of an integrated strategic plan for the morbidity management of all NTDs, including LF and trachoma. It was noted during the meeting that it would be important for AIM to involve other relevant stakeholders in the development of the plan. Once a first draft is available, key partners, including HKI, will be closely involved in the review. At the time of reporting AIM was still working on the draft. Furthermore, during the second half of the project year, the project will contribute to the integrated strategic plan by sharing lessons learned from its FY17 pilot of LF management activities.
ADVOCACY Advocacy activities during the reporting period included district- and regional-level advocacy meetings. District-level meetings were held in February 2018 with administrative, religious, and traditional authorities in the Touboro district prior to the TT surgery campaign scheduled for April 2018. During the meetings, authorities were informed of campaign objectives, the schedule of the surgical teams, and how they could support field activities. As a result of these meetings,
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local authorities pledged to send public releases to all the heads of villages asking them to provide any assistance needed for the implementation of TT campaigns, especially the mobilization of community members. This assistance could take the form of helping to spread sensitization messages through local channels, including churches, mosques, and markets, to encourage people to attend the community meetings. Similar meetings were held at the regional level with the new North regional delegate, regional governors, and regional-level religious and civil authorities (who committed to sending letters supporting project activities to their district-level counterparts). Approximately 52 people attended these district- and regional-level meetings.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE During the reporting period, information, education, and communication (IEC) tools and materials that were developed and used in the 2017 campaigns were reproduced for the two FY18 campaigns that will take place in the North. The project delivers these materials to the regional delegate’s office, which in turn distributes them to health centers at the district level to disseminate them to the appropriate individuals in the community. The remaining social mobilization activities, including radio spots and community meetings, will begin in Q3.
Table 5. IEC/social mobilization materials messages produced with USAID funding Type of Brief description of material Target Quantity material audience Posters A2 format (59.4 x 42 cm): they include images of TT cases Community 1,500 and awareness messages inviting community members to members be screened for free treatment. The posters were hung in each village at locations where people gather, including markets, public wells and places of worship. Flyers A5 format (14.8 x 21 cm): they include images of TT cases Community 18,000 and awareness messages inviting community members to members be screened for free treatment. The flyers were distributed at the household level. Fact A5 format (14.8 x 21 cm): fact sheets with awareness Outreach 500 sheets messages for community outreach workers to distribute. workers
CAPACITY BUILDING During the reporting period, a two-day refresher/debriefing session for three TT surgeons and a TT surgeon assistant in the North was held in March 2018. This session did not include HEAD START as the surgeons had already participated in a successful HEAD START refresher session in FY17. Results from supportive supervision (in FY17) and 3-6 month post-operative follow-up (in FY18) further confirmed that HEAD START was not necessary, and that the training should focus on TT case management, including the importance of standardizing pre-operative counselling messages; assessing the level of correction “on the table”; health care waste management; and providing supportive supervision specifically of nurses and health care workers during TT campaigns.
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In addition to the refresher/debriefing session for surgeons, the project organized trainings of health area nurses and community outreach workers. The two-day health area nurses training was held in March. Four health area nurses and two staff from the Touboro health district participated. Health area nurses are responsible for organizing all campaign activities at a health center. This includes holding community meetings, training community outreach workers, monitoring social mobilization activities, and helping with the actual surgery process. The training was based on key training manuals recommended by the International Coalition for Trachoma Control and included aide memoires developed by the MMDP Project in FY17 as support materials. The training covered surgery site organization, pre- and post-operative training, and post-operative monitoring. In addition, the project reviewed and analyzed the data collected through supportive supervision activities to date and tailored the refresher training to focus on topics identified as areas for improvement. As a result, the training emphasized preferred practices related to patient counseling, patient flow management, infection control, and management of biomedical waste.
The community outreach workers training consisted of four sessions held March 8-10 in the health areas of Mbang Ray, Dompta, Djom, and Mafare, which are targeted for surgery campaigns. A total of 249 community outreach workers were trained in Touboro district. The main objective of the training was to provide community outreach workers with the skills required to implement social mobilization and sensitization activities. More specifically, the trainees learned how to disseminate the following information in very simple terms in local languages: symptoms of trachoma, risks associated with TT, and the advantages and availability of TT surgeries. They were also trained in the mobilization, counselling, and referral of people for post-operative appointments. The trainings were led by the health area nurses previously trained by the project. The methodology used consisted of plenary discussions, group discussions, and role-playing. Supervision of the activity was provided by joint teams of staff from HKI and the Regional Delegation from the North.
ASSESSING DISEASE BURDEN In the first half of FY18, the project supported the National Blindness Prevention Program (PNLCé) to update Cameroon’s trichiasis disease burden data in several key ways. While data discussions with the national program have been ongoing throughout the life of the project, the release of updated data in recent months, as described below, highlights the significant progress that was achieved during the reporting period. Collectively, these updated data sets will inform the PNLCé’s ongoing planning for elimination and contribute significantly to the preparation of Cameroon’s upcoming Trachoma Action Plan (TAP), to be held in the second half of FY18.
In Q1 of FY18, the MMDP Project supported a TT-only survey in Mada district in the Far North, collaborating closely with the PNLCé and WHO’s Tropical Data. Mada was selected for a TT- only survey because the district’s TT data had not been updated since its 2010 baseline survey, as its initial TF prevalence was not high enough to trigger MDA activities. Updating the initial baseline TT prevalence (of 0.40% among the total population) enables the PNLCé and MMDP Project to determine whether intensive TT management activities are still needed in the district
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to achieve elimination. Although the TT-only survey was targeted in the project’s FY17 work plan, a Tropical Data-certified trainer was not confirmed until the very end of FY17. Therefore, the survey took place in the first quarter of FY18. In October 2017, the project supported the PNLCé in its collaboration with Tropical Data to develop a protocol for the survey, and in November 2017, supported a TT-only survey training of eight graders and eight recorders. The survey team engaged in data collection throughout the month of November, under MOH and MMDP Project supervision. The project also liaised extensively with the PNLCé and WHO to facilitate access to, and dissemination of, Tropical Data’s analysis of the survey data. These results showed an age-and sex-standardized TT prevalence of 1.26%, indicating the need for intensive TT management services. The project, therefore, chose to move forward with the two Mada TT campaigns tentatively planned in Cameroon’s FY18 work plan.
Also during the reporting period, the project facilitated collaboration between the Cameroon PNLCé and WHO to share Tropical Data’s final analysis of TT-only survey results from Touboro district. Although the MMDP Project completed this TT-only survey in October 2016, the project was only able to access preliminary results during FY17. The final results were made available to the project in January 2018 and indicated a TT prevalence of 0.77%. During this same time period, the project supported the PNLCé to access an additional data set: Tropical Data’s analysis of the TT prevalence data generated by the 2017 TIS.
Finally, the project has been supporting the PNLCé in requesting Tropical Data’s retrospective analysis of three additional data sets—Adamaoua region’s baseline survey results, the 2014 TIS results, and the 2015 TIS results—to have data standardized by age and sex. The project provided assistance developing a data dictionary for the Adamaoua baseline data, which was finalized and shared with the PNLCé in January 2018. Once the Adamaoua baseline data are age and sex standardized, the project will assess whether two TT-only surveys will take place in the region as tentatively planned in the FY18 work plan.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY There were no TT surgery campaigns during the reporting period. The first TT campaign is planned for April 2018 in Touboro district in the North region.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT Procurement during the reporting period involved primarily:
• Pharmaceuticals for TT surgery: Pharmaceuticals were purchased via the USAID- approved wholesaler (IMRES). The only exception to this was lidocaine with adrenaline, which was not available by any USAID-approved wholesaler; therefore, HKI procured the item with private funds. To ensure the quality of lidocaine with adrenaline procured locally in-country, the team purchased them from the national pharmacy, which follows the national drug guidelines and management in Cameroon.
• HEAD START surgical simulator parts: HEAD START consumables were procured centrally by the MMDP Project global team. During the reporting period, eight orbits and
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100 eyelids were shipped to Cameroon for use during the upcoming surgeon refresher training in the Far North.
SUPPORTIVE SUPERVISION Joint teams from HKI and the North Regional Delegation supervised both the health area nurse training and the community outreach worker training that took place in Touboro. The goal of this supervision was to verify the effectiveness and quality of the training sessions. Specifically, supervisors ensured that the appropriate cadre of health worker attended each training, topics and content covered aligned with the training objectives, and trainers used the appropriate methodology (including hands-on and role-playing exercises). Supportive supervision of TT management activities will be conducted as part of routine campaign activities in the second half of the fiscal year.
SHORT-TERM TECHNICAL ASSISTANCE During the reporting period, Dr. Amir Bedri Kello provided support to the national trainers to develop a tailored refresher training plan for the refresher/debriefing session for TT surgeons in the North (see Capacity Building section). Due to the security situation, which prevented external consultants from traveling in the region, Dr. Bedri provided this technical support remotely. He participated in skype sessions with the project team, and reviewed and analyzed surgeon performance data to help develop the refresher training plan. Dr. Bedri also began working remotely with the national trainers to develop a training plan for a Q3 training of TT surgeons in the Far North.
MONITORING AND EVALUATION The project began the fiscal year by supporting 3-6 month follow-up for the two TT campaigns conducted in FY17. As described in the FY18 work plan, the project is shifting its approach to 3- 6 month follow-up by working to incorporate both outcome assessment and surgical audit as two distinct activities. In the low-burden context of Cameroon, however, recent campaigns have not yielded a sufficient number of surgeries to enable auditing at least 20 patients per surgeon, as is the current preferred practice for surgical audit. To address this challenge, the project is employing an integrated approach incorporating both surgical audit and outcome assessment principles. In line with the surgical audit principle of objectivity, a technical supervisor provided oversight to ensure surgeons accurately assessed and reported complications, and to use the activity as an opportunity for surgeon learning. In keeping with the objective of outcome assessment, which aims to provide a 3-6 month exam to 100% of people receiving surgery, all operated cases were invited to return to a centralized location—in this case, a health center— to receive a follow-up exam. The follow-up team then sought out those who did not come to the health center.
In October 2017, the project conducted 3-6 month monitoring in Poli district. A total of 34 people received surgery in FY17 as part of the project’s May 2017 campaign. The follow-up team attempted to reach all of these individuals and was ultimately able to find and examine 26 people
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(76% of those receiving surgery). During March 15-21, 2018, the project supported another follow-up activity in Touboro district, where the project had held its second and final FY17 campaign in September 2017. Forty (74%) of the 54 people who received surgery during that campaign were examined by the follow-up team. Out of the 40 individuals examined during this activity, 25 people (63%) arrived at the health center, while the remaining 15 people (38%) were found and examined in their homes. This experience indicates that inviting individuals to return to a health facility is a feasible approach to reaching cases 3-6 months after surgery, but further outreach—and possibly home visits—remain necessary to ensure 100% of cases receive this critical follow-up examination. During FY18 campaigns, the project will build off this experience to refine its strategies for following up with those receiving surgeries, with the dual goal of reaching as many people as possible and systematically auditing the performance of all surgeons operating under the project. As additional follow-up activities are conducted, the project will be able to better compare the data collected at health centers with the data collected in cases’ homes, in order to identify any trends in outcomes and to gauge the effectiveness of various strategies for encouraging cases to self-present at a health facility.
Based on indications of relatively low complication rates from these two follow-up activities, the project determined in collaboration with the PNLCé that additional training on HEAD START was not needed in the North prior to the start of FY18 campaigns. However, the project will continue to closely monitor the performance of surgeons throughout the rest of the fiscal year, recommending additional practice on HEAD START if needed.
In addition to these quality assurance activities, following the FY18 release of updated TT prevalence data in select districts (see the Assessing the Disease Burden section), the MMDP Project began supporting the PNLCé to organize TT data in advance of the upcoming workshop to develop a national TAP. To inform the discussions planned during this workshop and to support the PNLCé in preparing its trachoma elimination dossier, the project has begun compiling the TT data that will be needed as part of dossier submission, using the WHO template. The project aims to discuss these data with the PNLCé and Sightsavers early in Q3, in advance of the TAP.
Finally, prior to the first TT surgery campaign of FY18, the project made minor updates to its data collection tools. Several registry updates were made to address issues raised in FY17, such as the need to clarify which eye is referenced when post-operative signs and symptoms are recorded. The project also adapted its data collection processes to ensure the appropriate data continue to be captured as the project’s strategies, particularly those for case finding, continue to evolve. Recent changes also included updating the geographic coverage tool so that it reflects the administrative re-organization of health areas within project districts that took place at the end of FY17. The project will continue to monitor coverage of TT management services during all FY18 campaigns.
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LYMPHATIC FILARIASIS
STRATEGIC PLANNING During the reporting period, the project participated in the annual national evaluation and planning meeting for integrated control of NTDs, as described above in Trachoma Strategic Planning. Based on the content of the yet-to-be-drafted AIM’s integrated strategic plan for the morbidity management of NTDs, the MMDP Project will adapt its FY18 work plan activities to support the national program in developing priority actions and drafting a strategic plan for LF morbidity management accordingly.
ADVOCACY There were no advocacy activities for LF included in the FY18 work plan.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE There were no social mobilization and behavior change activities for LF included in the FY18 work plan.
CAPACITY BUILDING/TRAINING There were no capacity building activities for LF included in the FY18 work plan.
ASSESSING DISEASE BURDEN There were no disease burden assessment activities for LF included in the FY18 work plan.
HYDROCELE SURGERY A total of 58 people received surgery in Q1 of FY18 across five districts in the North and Far North. Surgeries were performed in Ngong and Bibemi health centers in the North, and Kar- Hay, Kaele and Guidiguis health centers in the Far North. During the reporting period, the health district hospital, where surgeries took place, coordinated with the district’s health centers to plan surgeries for confirmed cases. Confirmed cases had been identified during community meetings held in FY17. Their diagnosis was first confirmed by a health area nurse, then officially confirmed by a surgeon. Once a schedule with surgery dates and times had been established for Q1 of FY18, the health centers worked closely with community outreach workers to communicate the appointments to the confirmed cases, who arrived at the hospital the evening before their surgery to check in and start the pre-operative case management process.
LYMPHEDEMA MANAGEMENT There were no lymphedema management activities included in the FY18 work plan.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT There were no commodity supply management and procurement activities for LF included in the FY18 work plan.
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SUPPORTIVE SUPERVISION The hydrocele surgeons trained in June 2017 received close technical supervision during the hydrocele surgeries conducted in September 2017. In this first phase of surgeries, a FASTT master trainer observed each surgeon, providing technical supervision and targeted technical feedback. Once the surgeons demonstrated sufficient improvement in the areas identified, they independently conducted surgeries from October to December 2017, with non-technical supervision carried out jointly by HKI and Regional Delegation teams. This non-technical supervision included ensuring the required consumables and drugs were available, that data was collected properly, and that patients were not required to pay for the project-supported surgery.
SHORT TERM TECHNICAL ASSISTANCE There were no short term technical assistance activities for LF included in the FY18 work plan.
MONITORING AND EVALUATION Beginning in FY17, the project supported hydrocele surgeries in the five district hospitals of Ngong, Bibemi, Kaele, Guidiguis, and Kar-hay. As described in the Hydrocele Surgery section, a portion of these surgeries initially planned for FY17 were carried out in the first quarter of FY18. As part of this hydrocele case management, the project continued to support health staff to conduct post-operative follow-up within five days of surgery. To ensure high quality of data reported by district hospitals, the MMDP Project organized on-site review of the raw data collection forms, cross-checking various forms against each other and working with hospital staff to address any inconsistencies. Of the 95 patients receiving project-supported surgery in FY17 and FY18, 100% received follow-up within five days following surgery. In total, nine of the 95 patients were diagnosed with complications within five days post-surgery. Additional care was provided to all patients with complications, and they were kept under observation at the hospital until the complications were resolved.
Prior to the start of the surgeries, the project conducted an “Obstacles to Surgery” study in September 2017. The survey was integrated into the case identification activity described in the Hydrocele Surgery section, in the districts of Bibemi (North region) and Kar-Hay (Far North region). The survey sought to identify potential obstacles that may prevent individuals from seeking or receiving hydrocele surgery. During the reporting period, the project synthesized and analyzed the data. In summary, a total of 86 individuals were interviewed about their knowledge of health facilities that provide hydrocele surgery, means of transportation to these facilities, and initial thoughts on the costs and other factors that could influence the decision to have surgery. Less than one third of the respondents (31%) said they would be capable of covering all costs associated with the surgery. Of the remaining 59 respondents, 44 (51%) reported that they would be able to cover only those costs related to transportation and food associated with the surgery—leaving 15 people (17%) who reported being unable to support any of the costs. In addition, some respondents identified fear as a potential obstacle—specifically, fear of erectile dysfunction or of becoming sterile following surgery, fear of dying or the operation hurting, or fear of how others might perceive them after the surgery. Key findings from the report will be shared with LF stakeholders, including the MOH, to inform the country’s strategic planning.
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CROSS-CUTTING ACTIVITIES
NTD SECRETARIAT As discussed in the Trachoma Strategic Planning section above, the project participated in two central-level meetings during the reporting period. During the meetings, participants reviewed FY17 NTD activities, including those of the MMDP Project, and developed detailed implementation plans for FY18 activities.
ENVIRONMENTAL MITIGATION AND MONITORING PLAN Preferred infection control and medical waste management practices were utilized during the hydrocele surgeries conducted in five districts in the North and Far North. All the health facilities used biomedical waste incinerators, and hydrocele surgery-related waste was incinerated in accordance with WHO protocols for processing of biomedical waste. In October 2017, the project submitted a revised Environmental Mitigation and Monitoring Report to USAID.
Data collected through supervision visits conducted during a previous TT campaign and related to infection control and health care waste management were analyzed. Specific issues and challenges observed (such as nonsystematic segregation of contaminated and non-contaminated waste in the operating room, or related to sterilization process) were discussed and reviewed during the refresher training for TT surgeons and the training for nurses organized prior to the first campaign planned for April FY18.
INTEGRATION WITH OTHER DISEASES Case identification and referral within the health system took place for any hernia cases identified during the hydrocele case confirmation.
HEALTH SYSTEMS STRENGTHENING In FY18, the project contributed to strengthening the heath system in Cameroon as follows:
• Leadership and Governance: MMDP Project support for leadership and governance took the form of providing financial resources to the MOH to support its program in FY18, through the signing of two FOGs with the PNLCé and the Regional Health Directorate (DRS) for the North region.
• Health workforce: The project’s training of surgeons and health area nurses contributes to further human resource development of the health system staff in Cameroon. The supportive supervision activities provided under the TT and LF programs also contribute to strengthening health workforce capacity.
• Health information: The project’s continuous collaboration with the national program to share monitoring and evaluation data related to disease management activities, and to access updated survey data assessing the trichiasis disease burden, will help strengthen Cameroon’s health information system and inform future MOH planning.
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CHALLENGES AND LESSONS LEARNED • The security situation in Cameroon continues to present a challenge to project activities, limiting the ability of consultants to provide support in the areas targeted during TT campaigns. To ensure continued support and oversight of training and capacity strengthening activities, the project supported Dr. Amir’s provision of remote technical assistance for the Q2 Touboro trainings and is continuing to explore how this remote support can be effectively used to support additional project activities.
• The project has found that coordinating with multiple points of contact across the national program and Tropical Data to share the latest trachoma survey data can take a significant amount of time. The project has learned that strategic meetings that bring all the key stakeholders together in person, such as a TAP, are the most successful in facilitating sharing of data.
• The MMDP Project’s model of conducting hydrocele surgeries through the routine health system means working with a limited human resource pool. For example, MMDP Project- trained nurses were sometimes not available during all phases of project activities. In response to this challenge, the project has learned that close coordination and more frequent communication with the national program and health facility staff can help ensure that project-trained staff are available for the pre- and post-operative care that accompanies hydrocele surgery. In addition, the project will continually assess the availability of trained human resources and determine any additional training needs.
• Hospital staff should be closely involved in hydrocele surgery planning activities, including scheduling of surgeries, to ensure that patient beds are available for all operated patients until discharge, with a provision for extra time for potential complications.
• The results of the “Obstacles to Surgery” study in Cameroon reveal that the most important barrier to patients seeking surgical care is cost. This information will be taken into consideration in the background information used to prepare the country’s strategic plan of action.
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Physician confirming hydrocele condition as part of a hydrocele surgical camp in Ginir hospital, Bale Zone, Oromia, Ethiopia, 2017. (Photo: Abrham Tilahun/Lael Photo and Video Art)
ETHIOPIA
• Despite insecurity during the reporting period, a total of 185,813 people were screened and 10,609 people received trichiasis surgery through static sites, outreach campaigns, and dedicated mobile teams. • The MMDP Project supported 86 hydrocele surgeries and trained 717 people with lymphedema in self-care. • The MMDP Project adapted implementation strategies to respond to insecurity in project areas through the innovative use of trichiasis surgery minicamps.
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IN BRIEF In the first half of fiscal year 2018 (FY18), the MMDP Project supported the Federal Ministry of Health (FMOH) to advance its commitment for morbidity management activities through the adoption of national guidelines and policies. In December 2017, the FMOH adopted national guidelines for supportive supervision, surgical audit, and outcome assessments to monitor the quality of trichiasis (TT) surgery. These guidelines ensure a minimum standard in conducting these activities, to ensure quality services are provided to the people of Ethiopia. Additionally, the Head of the Oromia Regional Health Bureau (ORHB) wrote a letter to the region’s hospitals, health centers and health posts stating that free treatment for hydrocele and lymphedema should be provided to all patients needing these services. This letter was a result of an MMDP Project- supported meeting in February 2018 to review progress made towards providing services to hydrocele patients and to plan services in Oromia for the upcoming months.
In addition to these positive leadership steps by the FMOH and ORHB, a few challenges also arose. In Oromia, the primary challenge was insecurity, which disrupted all health programming and made planning TT surgery camps difficult or impossible in some areas, particularly in Borena, Bali and West Harerghe zones. Months of protests and unrest culminated in the declaration of a state of emergency on February 17, 2017 following the resignation of the Prime Minister. However, despite the insecurity, Fred Hollows Foundation (FHF) closely monitored the situation, and when local situations were calm, implemented surgical activities. By doing this, FHF reached 96% of their trichiasis surgery target for the reporting period.
In Tigray, the main challenge to the MMDP Project was an ophthalmic clinical officer’s training course that recently began at Mekelle University. Of the 17 active TT surgeons in MMDP Project areas, five enrolled in this training course to further their careers. To counter this, Light for the World (LFTW) proposed a new activity to train more TT case finders to sweep house-to-house, ensuring a more efficient use of the remaining TT surgeons’ time during outreach. In addition, LFTW held discussions and made an agreement with Mekelle University to utilize the TT surgeons enrolled in the training on weekends, following the case searches during the rest of the week. This approach appears to be working well, as numbers of surgeries have increased each month since this strategy was implemented. Overall, despite this difficulty, LFTW reached 76% of its target for the reporting period.
For lymphatic filariasis (LF) activities, RTI focused on two areas: 1) planning and mainstreaming activities and 2) supporting the Gambella region to begin implementation of hydrocele surgery services. RTI supported the planning meeting in Oromia discussed above and organized a meeting with several universities to discuss mainstreaming the Filaricele Anatomical Surgical Task Trainer (FASTT) surgical simulator into the medical colleges’ skills laboratories. This proposal was met positively by the participants, and the project will further efforts to this end in the remaining half of the fiscal year. For hydrocele service provision, RTI, in partnership with the Surgical Society of Ethiopia (SSE), provided refresher training to six surgeons and integrated emergency surgical officers (IESOs) in three hospitals in Gambella. During the reporting period a total of 86 hydrocele surgeries were conducted.
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PROGRAM BACKGROUND
TRACHOMA
Ethiopia’s national backlog of TT cases was estimated by the World Health Organization (WHO) at 693,037 individuals in March 20169. The FMOH committed to addressing the entire backlog through the “Ethiopian Initiative to Clear the TT Backlog: Fast Track to the Elimination of Fast Track Initiative.” With support from numerous partners, the FMOH and respective regional health bureaus (RHBs) of Amhara, Oromia, Tigray, and Southern Nations, Nationalities and Peoples’ (SNNP) regions have begun implementing this initiative. The USAID-funded MMDP Project supports the regions of Oromia and Tigray. Based on the ultimate intervention goal (UIG) data in the 2015 National Trachoma Action Plan (TAP), the MMDP Project plans to address 11% of the overall UIG in the country. During the reporting period, the project10 reached cases from 142 woredas (113 in Oromia and 29 in Tigray). (see also Appendix A, Tables A1 and A2):
• In Oromia, baseline mapping estimated more than 200,000 TT cases in the whole region; the MMDP Project-supported area spans ten of twenty zones with an estimated UIG of 54,782 at the beginning of the project11. In the first half of FY18, the project reached 8,342 persons with TT surgery; combined with the FY16-17 output, a total of 35,046 individuals have been operated (64% of the estimated UIG)12.
• In Tigray, the MMDP Project is targeting 31 woredas across five zones in FY1813. At the start of the project, the estimated UIG was 22,272. In FY18, 2,267 individuals have been operated to date; cumulatively, over the course of the project, 17,194 individuals have received surgery, or 77.2% of the estimated UIG14.
LYMPHATIC FILARIASIS
Initial country-wide mapping to measure LF endemicity was conducted in 2013, then updated in 2015 with confirmatory remapping of select woredas that identified 70 woredas as LF-endemic. In 2017, redistricting resulted in one additional LF-endemic woreda, bringing the total number to 71. Since mapping did not establish the LF morbidity burden for each of these woredas, the
9 http://www.trachomacoalition.org/GET2020/ 10 The MMDP Project currently supports 131 woredas in Oromia (increased from 115 in the FY18 work plan due to redistricting) and 31 in Tigray. It should also be noted that cases operated during the reporting period came from four woredas not designated as MMDP Project-supported areas in Oromia. These four woredas are accounted for in the 142 woredas. 11 Due to redistricting that occurred during FY17, the number of zones increased from eight to ten. 12 A total of 38,488 individuals have been operated or otherwise made known to the health system in Oromia (managed through epilation, referred, or refused), which is approximately 70.3% of the UIG; however, Ethiopia only utilizes persons operated when calculating progress against the UIG. 13 As described in the FY18 work plan, LFTW has expanded to the non-urban areas of the six woredas of Mekelle, which increased the number of woredas receiving project support from 25 woredas spanning four zones to 31 woredas spanning five zones. 14 A total of 17,900 individuals have been operated or otherwise made known to the health system in Tigray, which would equal approximately 80.4% of the UIG reached, should Ethiopia begin to utilize these figures in its calculations.
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FMOH established a goal of conducting burden assessments in all LF-endemic woredas by 2020. The MMDP Project has supported burden assessments in 36 (51%) of these woredas.
Prior to MMDP Project activities, LF morbidity management activities had only been conducted in a small percentage of the country’s LF-endemic woredas. Since FY17, the MMDP Project has targeted nearly half of the country’s total endemic woredas for hydrocele surgery and lymphedema management activities (see Appendix A, Tables A5 and A6). The woredas targeted in FY18 span three regions: Beneshangul-Gumuz, Oromia, and Gambella. In the project’s fourth region, Tigray, all known hydrocele cases received project-supported surgery in FY17. The 86 hydrocele surgeries conducted to date in FY18, combined with the 417 conducted in FY17, represent approximately 34% (503/1,492) of the total hydrocele surgery needs in these four regions as estimated by the burden assessments. However, to date, only 14% of the FY18 target has been reached. The 650 individuals with lymphedema trained in self-care in FY18, combined with the 599 trained in FY17, represent roughly 127% of the cases targeted by the project as part of the feasibility study and 7% (1,249/17,586) of the total estimated number of cases (see Lymphedema Management section below).
MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD
TRACHOMA (Oromia)
STRATEGIC PLANNING Zonal IECW TT surgery performance review and planning meeting The objectives of the Integrated Eye Care Workers (IECW) performance review and planning meetings were to review the progress of TT surgery performance, identify major accomplishments and challenges, learn from the previous period’s work, and develop plans for the remaining period. These meetings were supported by FHF through institutional funding.
The review and planning meetings provided an opportunity to assess the progress of TT surgery, identify associated problems and develop an action plan for the subsequent performance periods. TT surgery performance in the selected woredas were presented and discussed at each meeting. These meetings were planned to be implemented in the 10 MMDP Project-supported zones for 530 participants with an average number of 53 participants in each zone. The participants included RHBs Neglected Tropical Disease (NTD) team, Zonal Health Department (ZHD) heads and NTD focal persons, ICEWs, Primary Health Care Unit (PHCU) Directors where IECWs are stationed, Woreda Health Office (WoHO) head/deputy head, woreda NTD focal persons and FHF staff. To date, these meetings have been held in eight zones with the meetings held in each zonal capital.
High-performing IECWs and woredas reporting the strongest TT surgery performance shared lessons learned from implementation of outreach activities and factors that contributed to their achievements. Aseko and Shirka woredas of Arsi, Guba Koricha woreda of West Harerghe, and
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Dugda Dawa woreda of Borena zones were among the woredas which shared lessons that enabled them to achieve high TT surgery performances. The success factors attributed to high TT surgery performance in these woredas were the commitment of IECWs and woreda health offices (health office heads, NTD focal persons) and strong coordination between IECWs, woreda health offices, health extension workers (HEWs), kebele structures and community leaders.
Major challenges identified that contributed to low TT surgery performance were also discussed during the meeting. These included the long-standing social unrest in the region, frequent turnover of health sector leaders, and inaccessibility of some kebeles due to poor road infrastructure.
Another key topic discussed was the increasing inaccessibility of patients living in remote areas. IECWs also expressed concern that there is low TT case turnout in some areas even where there has been an increased focus on social mobilization and case finding. FHF and the ZHD continued to stress the need for active case finding and coordinating activities closely with kebele leaders.
Due to the social unrest in Oromia, travel across the woredas and zones was banned for several weeks at various times during the reporting period, therefore, the IECWs were not able to carry out planned outreach activities. Moreover, political leaders, health sector leaders, and the community at-large were focused on issues related to the insecurity, including support to the internally displaced. These challenges have led to a decrease in performance in quarter two (Q2), however, once the areas are secure, the IECWs will start to conduct outreach again.
At the end of the performance review and planning meetings, each woreda developed a woreda- specific action plan that incorporated lessons learned from other woredas. Specifically, the plans detailed the roles and responsibilities of woreda health office heads, NTD focal persons, PHCU directors and IECWs. Most of the action plans incorporated the reactivation of the woreda-level workers to closely monitor TT surgery activities, strengthening social mobilization using kebele and community structures and town criers, and TT case finding by HEWs.
FHF plans to complete the remaining zonal IECW performance review and planning meetings in April 2018.
ADVOCACY Zonal-level advocacy meetings The objective of advocacy meetings is to create an opportunity for administrative and political leaders to understand the burden and socioeconomic impact of trachoma, highlight the ongoing TT interventions, and subsequently foster greater ownership and leadership by the zones. These meetings were funded by FHF through institutional funding. FHF planned to conduct 10 zonal level advocacy meetings in FY18 with an average of 54 participants per zone, for a total of 540 participants.
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In the reporting period, FHF conducted five zonal advocacy meetings in Illubabora, Arsi, West Harerghe, East Shewa and Buno Bedele zones; meetings were held in the respective zonal capitals. Meeting participants included: ORHB NTD coordinators, ZHD heads, NTD focal persons, zonal administrators and political affairs chiefs, woreda administrators and political affairs chiefs, woreda women’s and children’s affairs heads, and WoHO heads/deputy heads.
Although FHF aimed to conduct all the advocacy meetings during the reporting period, ongoing social unrest in much of the region led administrative and political leaders to prioritize the restoration of security over health programming. Additionally, various government initiatives, such as the launching of a six-week environmental conservation campaign in all woredas, were also prioritized over TT surgery advocacy meetings.
In the five zones that completed the advocacy meetings, zonal health offices requested the participation of IECWs in the meetings. IECW participation strengthened the discussions since they could share lessons and challenges faced while implementing TT surgery outreaches and camps. Additionally, the participants brainstormed how the various administrative and political leaders could support activities. The advocacy meetings were jointly led by political and health sector leaders to create a sense of leadership and accountability for the health sector staff. The advocacy meetings in Arsi and Illubabora were immediately followed by TT surgery minicamps. FHF began implementing smaller surgery camps in response to the Ethiopian government’s ban on large-scale campaigns due to insecurity in the region. The recent declaration of a State of Emergency across Ethiopia makes it difficult to schedule future advocacy meetings, but FHF plans to finish advocacy meetings before May 2018.
Woreda level Advocacy meetings The woreda-level TT surgery advocacy meetings have the same general objectives as the zonal- level advocacy meetings and were planned for ten woredas, and were supported by FHF institutional funding. Woredas are prioritized based on high estimated number of cases and need for an intensified camp. The advocacy meetings are held immediately before intensified TT camp activities start.
During the reporting period, FHF implemented six out of the ten planned woreda-level advocacy meetings. Meeting participants include HEWs, kebele leaders, IECWs, PHCU directors, woreda health office leaders and NTD focal persons. Approximately 700 participants were estimated to participate; thus far 702 participants have participated in the six woreda-level advocacy meetings. The meetings highlighted TT surgery progress, shared lessons learned and enabled the development of detailed action plans to implement intensified TT surgery camps in the woredas. Lessons learned from areas where there is successful coordination between HEWs, kebele leaders, PHCUs, and IECWs, such as Munesa and Gololcha woredas where the kebele leaders actively support the HEWs in case finding, were documented and will be used to promote similar coordination in other woredas.
In all meetings, the community leaders have agreed that more TT cases could have been screened if the kebele leaders worked more closely with HEWs. The HEWs also admitted that they were
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poorly engaged in TT case findings for various reasons: lack of commitment on their part, lack of support from PHCUs and kebele leaders and expectation of per diem payment, which is given under vaccination programs. The large program area with limited telecommunications and transportation makes it difficult for the IECWs to be in continual contact with kebele leaders and HEWs across the district. Activities, such as the intensified surgical camps and minicamps, which are supported in areas with high numbers of cases, provide an opportunity for advocacy and engagement with kebele leaders. At the end of each advocacy meeting, a micro-plan was developed by participants for each kebele with clear roles and responsibilities for the planned TT surgery intensified camps and routine TT surgery outreach services. HEWs and kebele leaders also agreed on their roles in social mobilization and case finding and committed their support for the intensified camps and routine surgical outreach. The remaining five woreda-level advocacy meetings will be held where intensified camps can be planned in Q3-Q4; this will be highly dependent on the security situation.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE In FY18, FHF planned to disseminate TT messages to inform community members about TT surgery services by radio in collaboration with the Oromia broadcasting network to reach 17 million people residing in the zones supported by the MMDP Project. The radio spots in Afan Oromo encourage individuals with TT to seek out surgical services and communities to refer cases to HEWs and IECWs for surgical services. These messages are the same as developed last year. FHF has not developed an overall social mobilization and behavioral change strategy separate from what is detailed in the annual work plan.
Given that more than 70% of TT cases in Ethiopia are women, the messages are prepared by female actresses and focus mainly on encouraging women to seek the services. The messages also ask that those women who have had TT surgery encourage women with unoperated TT to present for surgery. The radio broadcasts aired twice a week starting from July 2017 through the end of March 2018 and were supported by FHF institutional funding.
CAPACITY BUILDING
FHF plans to conduct three categories of trainings in FY18: a training for 40 new IECWs, a refresher training for 22 IECWs and TT case screening and counseling training for 260 HEWs.
Training of TT Surgeons, Evaluation and Certification The training for new IECWs will focus on replacing those IECWs who have left their posts due to promotions, education, and other commitments. FHF conducted an assessment to determine whether IECWs were still posted to MMDP Project sites and whether the posted IECW was still conducting TT surgery activities. The assessment determined that 21/125 IECWs left their posts or stopped working on TT surgeries. FHF planned to organize an IECW training early in quarter two (Q2), but the training was postponed due to insecurity. Although FHF started the IECW training in late March 2018 at Yabelo Hospital in Borena zone, only the theoretical session was
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finished by the end of the reporting period. The training will be fully reported on in the next reporting period. The activity will be supported by both MMDP Project and FHF funds.
IECW refresher training The IECW refresher trainings address surgical skill gaps identified during supportive supervision and TT surgical quality audits. By the end of February 2018, FHF identified only one of eight IECWs audited with poor surgical outcomes with a need for a skill refresher. The IECW will be refreshed in late April, at the same time as another IECW identified in FY17 who has not yet received retraining15. Insecurity and transportation challenges have delayed the surgical audits, and the majority are planned for Q3 (see Monitoring & Evaluation section). With the recent deployment of a dedicated quality team (DQT) and planned supportive supervision in the upcoming months, FHF will continue with audits and supervision to identify any IECWs with skill gaps and will organize any needed refresher trainings.
HEWs case screening and counselling training FHF planned to train 260 HEWs on TT case screening and counseling in woredas that did not receive this training in FY17. The aim of the training is to build the skill of HEWs to identify TT cases, provide counseling and refer patients to the surgical sites.
The HEWs’ training was not conducted during the reporting period because the health staff have been unable to travel to the woredas and organize the training due to insecurity. Additionally, experience has shown that the productivity of HEWs increases if the training is immediately followed by an intensified TT surgery camp or minicamp. FHF plans to train HEWs in alignment with upcoming TT surgery camp activities during Q3.
ASSESSING DISEASE BURDEN A trachoma impact survey was conducted in the woreda of Metu, in Illubabora Zone, with support from the ENVISION Project. The age adjusted TF prevalence in children 1-9 years is 0.16% and the TT prevalence in adults 15 years and above is 0.03%. Since the district is now under the threshold for elimination for both TF and TT, project-supported TT surgical services will stop and FHF will work with the zonal and woreda government to hand over any remaining TT surgeries.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY FHF planned and implemented a combination of three TT surgery delivery approaches to achieve the MMDP Project FY18 target of operating 18,560 patients. The service delivery strategies include: static and outreach services by the IECWs, dedicated mobile teams (DMTs), and intensified surgical camps. TT surgeons use the Trabut surgical method throughout the MMDP Project-supported areas. During the reporting period, a total of 8,342 patients received TT
15 In the FY17 SAR2 report, FHF stated that 12 IECWs were yet to be provided supervision/refresher. This was a misstatement since 1 has left the program, 10 had a minimum of 2 directly observed surgeries during supervision activities/skill assessment in Q3 and Q4 2017 and were not recommended for skill refresher. One IECW still needs refresher training.
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surgery. This is 45% (8,342/18,560) of the annual target and 96% (8,342/8,724) of the reporting period target. To put this into context, since the start of the MMDP Project, FHF has supported 35,046 TT surgeries, 64% of the estimated UIG.
In terms of quarterly progress, FHF achieved TT surgery performance of 123% (4,783/3,898) of the planned target for Q1; however, insecurity decreased performance to 74% (3,559/4,826) in Q2. MMDP Project zones with better security conditions during the reporting period, such as East Shewa, Guji and Bunobedelle, performed 38% of TT surgeries (3,275/8,724). West Harerghe and Bale zones, on the other hand, which have the highest estimated number of cases to operate but experienced much more insecurity, only accounted for 19% (1,675/8,724) of the surgeries conducted. FHF will continue to monitor the security conditions and take advantage of breaks in the insecurity to conduct program activities.
While working to enhance TT surgical output utilizing all TT surgery provision strategies, FHF has tried to reach most villages to make TT surgery services available. Accordingly, FHF has reached 1,697 kebeles out of 2,752 (62%) of the total kebeles found in all MMDP Project- supported woredas.
IECW Static Sites and Outreach IECWs are stationed at woreda-level PHCUs and conduct TT surgeries in their respective health facilities (static services), as well as during outreach activities. FHF plans for each IECW to perform two, three-day outreach sessions per month, including travel, surgery and post-operative follow-up activities. However, FHF has been flexible in the implementation of the schedule and duration of the outreach based on the fact that most outreaches are organized in distant and remote areas where cases are found, and, therefore, three days is not always enough. In some woredas, IECWs have stayed for weeks to conduct TT surgeries before returning home. Most outreach activities are organized at health posts, schools or farmer training centers.
In FY18, FHF planned for the IECWs to conduct 7,520 TT surgeries by static and outreach service. During the reporting period, 3,181 TT surgeries were performed by IECWs during outreach activities, and 96 TT surgeries were performed through static services, for a total of 3,277 TT surgeries. In total, 44% (3,277/7,520) of the annual surgery target has been met. During the reporting period, approximately 61% (76/125) of the IECWs were found to be surgically active in any given month. As mentioned above, FHF plans to train 21 IECWs to replace those no longer active (see Capacity Building section).
Despite the continued unrest and public protest in most MMDP Project-supported areas in Oromia, FHF cluster offices and zonal technical advisors have been carefully monitoring the situation and continue to support IECWs to provide TT surgical services. FHF-supported IECW performance reviews are a platform to review performance and have leveraged the support of health sector leaders to achieve the targets despite the challenging operating environment.
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Dedicated Mobile Teams (DMTs) DMTs consist of two TT surgeons and one coordinator to provide TT surgical services in woredas with high estimated numbers of cases. DMT TT surgeons conduct a high volume of TT surgeries, support case management and provide mentoring to IECWs during intensified camp activities. During this reporting period, a fourth DMT was added. During the reporting period, 20% (1,000/5,040)16 of the planned DMT surgeries for the year were conducted; however, this does not count their contribution during the intensified camps, as the intensified camp data are aggregated by camp and not segregated by surgeon type.
The newly established DMT is stationed at Bale Robe hospital in Bale zone and is expected to provide TT surgery in the remote and nomadic pastoralist parts of this zone. To recruit this team, a vacancy announcement was made by Bale Hospital and a practical examination was used during the recruitment process, supervised by FHF staff. The individuals selected were previously trained and certified TT surgeons. One was an IECW in Bale Zone and the other was an ophthalmic nurse from East Shoa. This DMT commenced TT surgery in February 2018 after receiving a two- day orientation training by FHF staff and RTI’s Quality Assurance (QA) Officer.
To counter the lower than planned productively of DMTs caused by insecurity, FHF relocated DMTs to woredas in the MMDP Project area with better security. For example, the Shashemene DMT was mobilized to Gechi woreda of Bunobedelle zone which currently has no active IECW. Additionally, the DMT in West Harerghe was relocated to Arsi zone to support TT surgical activities.
To improve the performance of DMTs, FHF paid for and organized a day-long DMT performance review meeting in January in Addis Ababa for all DMTs, cluster coordinators, zonal NTD technical advisors, and program managers to come together and undertake an in-depth review of the DMT performance and prepare an action plan for the remaining period. The biggest challenges are the limited participation of the kebele leaders during social mobilization and the expectation of payment by these leaders (both per diem and salary). The identified challenges were taken up by FHF cluster coordinators to discuss with zonal and woreda health officers.
Intensified TT Surgical Camps FHF planned to perform 6,000 TT surgeries through the intensified TT surgical camp strategy in the five zones with the largest estimated number of TT cases (Bale, Borena, Arsi, West Arsi, and West Harerghe zones). However, insecurity in the region forced FHF to become innovative when intensified camps could not be conducted. This led to implementing smaller “minicamps” since security measures from the government did not allow the convening of large-scale campaigns except in Bunobedelle, Illubabora and Guji. The intensified camps and minicamps bring together DMTs and IECWs not only to operate on high volume of TT surgeries but also provide an opportunity for experienced DMT surgeons to provide mentoring and coaching to IECWs on
16 This does not include surgeries conducted by DMT members during intensified camps.
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surgical skills. This is accomplished by assigning a DMT to travel to a specific woreda and work directly with the IECWs.
Of the ten planned intensified camps for the reporting period, FHF was able to accomplish the following: full-scale intensified camps in Bunobedelle zone (one camp in three woredas), Illubabora zone (one camp in four woredas), and Guji zone (one camp in two woredas); as well as minicamps in East Shewa zone (one minicamp in seven woredas) and Arsi zone (one minicamp in 19 woredas) during the reporting period.
During the reporting period, a total of 4,065 TT cases were operated through the intensified camp and minicamp strategies (68% of target).
Patient Counseling Counseling for TT cases is primarily provided by the HEWs and the TT surgeon (IECW or DMT) to ensure that the patient is given the necessary information before deciding to undergo TT surgery. The HEWs screen and counsel the patient at home, health post, or at community gathering areas to encourage them to visit IECWs or DMTs to receive surgical services. The surgeon is responsible for counseling the patient on the importance of surgery, the procedure, the risk if not treated, and other information before surgery. Post-surgery, the TT surgeon counsels the patient to return for the next day and then seven to 10 days and three to six months following the surgery. Patients are given appointment reminder cards for these follow-up visits. The surgeon also counsels the patient on how to take care of the surgical wound.
If an individual refuses surgery, he or she is counseled by the TT surgeon on the importance of TT surgery and the individual’s contact information is shared with HEWs trained in counselling. HEWs will then visit these cases one to two times to provide further counseling on the surgery.
Patient Referrals and Refusal Management During the reporting period, 4% (391/9,219) of individuals with confirmed TT were found to need referral services to secondary or tertiary eye care units. Referrals include patients with high blood pressure and other medical complications, post-operative TT, lower eyelid TT, and pediatric TT. Approximately 4% (403/9,212) of the TT patients with confirmed TT refused surgical services. Individuals were first counseled by the IECW. If the individual refuses, the HEWs trained in counseling by the MMDP Project and kebele leaders continue to counsel the individuals. Following refusal of the surgery, the IECW links the refusal cases to the HEWs. The HEWs, in collaboration with kebele leaders, are trained to continually advise the cases on the importance of having surgical management using influential persons in the community and relatives. Anecdotal evidence from discussions with program staff show reasons for refusal include 1) fear of surgery, 2) not wanting surgery during farming season, 3) not wanting surgery before social commitments, such as weddings or funerals, or 4) having no one to accompany them to surgery.
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Epilation In this reporting period, FHF commenced epilation services only through the DMTs in cases where individuals with few lateral lashes were refusing surgery. Only DMTs offered these services as they are highly-skilled and able to provide epilation if the individuals continue to refuse surgery after counseling. Nine TT patients were provided epilation in lieu of surgery. FHF limits the support for epilation to individuals with TT who have less than five inverted lateral eyelashes and have refused surgery after counseling. Individuals with more lashes are not offered epilation and are counseled to receive surgery. It is important to note that these individuals were not counseled on epilation outside of the surgical setting due to mandate from the FMOH not to encourage the practice of epilation, and the FMOH does not support the distribution of forceps to individuals who refuse surgery.
TT case registers and reporting forms capture reasons for referral, refusals and epilation. The register also provides details regarding referral cases so the IECW can provide referral papers and record feedback received from the hospitals that managed the cases. Refusals who were provided epilation are linked to trained HEWs for further counseling to accept TT surgery. No data are available as to whether any of these patients later opted for surgery.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT In FY18, FHF planned to procure 24 types of commodities for the MMDP Project-supported zones, and a combination of FHF and MMDP Project funds were used to procure TT supplies during the reporting period. FHF supports the purchase of items that are considered restricted commodities per U.S. government regulations, and, therefore, all drugs purchased in FY18 were purchased with non-MMDP Project funds.
FHF typically conducts bulk procurement once or twice a year. Occasionally, shortages of items at the Pharmaceuticals Fund and Supplies Agency (PFSA) at the time of bulk procurement or unanticipated needs will require another procurement. A commodity stock balance report is tabulated monthly and communicated to FHF program staff by the store keeper.
In terms of challenges, until 2018, Zithromax had not been given post-surgery; however, the FMOH has agreed that Zithromax will be used post-surgery and requested it through its 2018 Zithromax application, which was approved by the trachoma expert committee (TEC). In addition, the lack of some supplies, such as tetracaine, lidocaine with adrenaline and blades, in the local market is a chronic challenge. For example, although RTI provided FHF with tetracaine for the first half of FY18, FHF had a difficult time finding mre and only located enough to last until the end of June. FHF will plan procurement in Q3 to cover the remaining need; in the future, FHF will mitigate this challenge by starting the procurement process early and by communicating frequently with RTI if challenges are faced.
SUPPORTIVE SUPERVISION FHF organizes supportive supervision for TT surgeons to ensure IECWs are observed while conducting surgery and assessed on their ability to manage the TT surgery program in their
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respective areas. In FY17, FHF trained the following: 24 individuals on supportive supervision; 12 ophthalmologists, ophthalmic nurses, and cataract surgeons from six hospitals on direct surgical supervision; and 12 zonal NTD focal persons and zonal NTD technical experts on the operational side of TT case management. Supervisory teams consist of the FHF TT surgery supervisor and TT surgery quality coordinator, as well as trained supervisors from secondary eye care hospitals and zonal health offices.
During the reporting period, FHF planned to provide supportive supervision to 40 IECWs (in Arsi, East Shewa, West Arsi, Bale and Borena zones), but due to insecurity, was only able to provide supportive supervision to 21 IECW (12 in Arsi and 9 in East Shewa zones). Over the course of the project year, FHF plans to visit each IECW at least once through supportive supervision and surgical audits.
The MMDP Project supportive supervision checklist was used to collect information pertaining to TT surgery: patient counseling, data management, operative procedures (pre, intra and post), infection prevention and instrument processing. Supervisory visits included: 1) discussions with IECWs, PHCU directors, NTD focal persons and patients; 2) observation of surgical procedures, infection prevention precautions, and 3) review of case registration books.
The main finding of the supervisory visits in Arsi zone is that all IECWs visited have maintained the required standard levels in patient counseling, recording and reporting, surgical technique, operative procedures and infection prevention. The team also observed that adequate TT surgery commodities are available at health facilities. Furthermore, most districts visited have prioritized TT surgery interventions in the woreda.
The supervision teams also identified low TT surgery performances in some woredas due to difficulty in organizing outreach activities in very remote villages and the availability of vehicles. In certain woredas, such as Digelu Tijo of Arsi zone, political and health sector leaders provided little support for community mobilization and integration of TT surgery with other health activities. Another persistent challenge is competing priorities that take up some of the IECWs’ time.
The findings of the supportive supervision visits are communicated directly to the IECWs during the visit and any issues are immediately addressed by the supervision team. Each supervisory visit is also recorded in a report detailing the findings and recommendations for subsequent actions. The supervisory team also provides feedback to PHCU directors and WoHOs, and actions, where required, are agreed to at all levels. One recommendation was to continue the organization of zonal level advocacy meetings to garner the support of the administrative and political leaders. Integration of TT surgical services with other health services at the community level (community health days, immunization outreach) was found to be a missed opportunity. The supervision team recommended presenting the supervision findings during the advocacy meetings and IECWs’ performance review and planning advocacy meetings.
In MMDP Project-supported areas, FHF will continue to utilize the MMDP Project supportive supervision checklist until the newly introduced FMOH supportive supervision guidelines have
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been rolled out (see below in FMOH/NTTF Surgical Audit Guidance). Feedback that FHF continues to receive regarding the supportive supervision checklist by government staff is that the MMDP Project supervision checklist was found to be too detailed, not user friendly, and time-consuming for routine use. The supervisors felt that too much time was spent filling out the form and not enough time working on the specific challenges of the individual being supervised. FHF plans to continue to conduct supportive supervision in the second half of FY18.
SHORT-TERM TECHNICAL ASSISTANCE No external short-term technical assistance is planned in Oromia in FY18.
MONITORING AND EVALUATION Surgical audits FHF uses surgical audits as another tool to evaluate TT surgeon performance and quality. If the outcomes of the patients operated by the surgeon are poor, FHF will evaluate the surgeon while operating during a supportive supervision visit, and when recommended by the supervisor, a skills refresher training tailored to the individual surgeon to improve their surgical skills will be held.
During the reporting period, eight IECWs were audited by FHF and TT surgery supervisors (three in Arsi, one in West Arsi, and four in East Shewa zones) and one IECW was audited by the new DQT in West Arsi (see below); 63 patients received followed-up as part of these audits. Surgeons who have never been audited were prioritized, including IECWs who had performed high numbers of TT surgeries, had high number of refusals, or were recommended from supervisory visits. In the FY18 workplan, FHF had based its plans around the number of patients to follow-up, per previous MMDP Project guidance, and planned to include 1,248 patients during the audits; to date, 5% have been reached (63/1,248). The main reasons for the low output against planned targets are the delayed establishment of the DQT and the insecurity, limiting the ability to move around the woredas and zones.
Dedicated Quality Team In Q2, FHF hired a full-time DQT which includes a qualified TT surgery supervisor and a coordinator. The TT surgery supervisor is an optometrist, certified TT surgeon and trainer of IECWs and has been employed by FHF as a DMT surgeon since 2014. The DQT coordinator is responsible for organizing the surgical audit activities and communicating with zonal health departments, woreda health offices, IECWs, HEWs and community leaders before and during the activity. This individual was formerly an IECW in West Arsi zone and is a public health officer by training. Shashemene hospital hosts the team as it is a referral hospital with a secondary eye care unit located relatively in the center of the MMDP Project zones. FHF, in collaboration with the RTI QA Officer, trained the DQT. The training included an overview of the MMDP Project and discussion on trachoma, TT and the surgical audit protocol. The training took place both in the classroom and the field, where an audit was conducted with FHF’s TT surgery quality coordinator. Following theoretical orientation and practical support, the DQT started field work the last week of February 2018, accompanied by the FHF surgical quality coordinator.
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Now that the DQT is in place, the pace to conduct the audits will increase, and FHF will also intensify the use of government staff from hospitals to support additional audits.
Current Surgical Audit Framework The current methodology used for surgical audits is:
1. IECWs are prioritized and selected for audit using the following criteria: operated on low or high number of surgeries, identified as needing extra supervision during the training or during supervisory visits, and reported many refusals; 2. A sample of 15% of patients within the 3-6 month post-operative window are randomly selected using data from the surgeon’s logbook; 3. The surgical audit team travels house-to-house with the IECW who performed the surgeries, a local guide, and, if possible, the woreda NTD coordinator, to conduct the audit; 4. Patients are examined by the TT supervisor for post-operative TT, eyelid margin abnormality, granuloma, and patient satisfaction. If a patient is not available, this is noted on the data collection form and another patient is visited. 5. If the audited IECW is found to have greater than 10% post-operative TT, granuloma or eyelid margin abnormality, the IECW is scheduled for a skills evaluation by a supervisor. The skills evaluation includes direct observation of a minimum of two TT surgeries and feedback from the supervisor, who may then recommend the surgeon for a full skills refresher training. 6. The skills refresher training is a five-day practical training delivered by a TT surgery supervisor. As part of the refresher training each IECW is expected to operate a minimum of five eyelids under strict supervision.
FMOH/NTTF Surgical Audit Guidance The FMOH/NTTF held a two-day meeting in December 2017 to introduce, discuss, and adopt new guidelines on surgical quality. FHF plans to follow the new guidelines for surgical quality audits following the national training and roll-out of the activity. The FMOH guidelines will require a change in patient sampling: instead of randomly sampling 15% of patients, the FMOH guidelines calls for a lot quality assurance methodology, wherein up to 40 patients per surgeon may be included in the audit.
3-6 Month Outcome Assessments As part of the MMDP Project, FHF plans for IECWs to conduct 3-6 month post-surgery outcome assessments for all operated cases. During counseling after surgery and during the one-day and 7-14 day follow-ups, surgeons advise the patients to return 3-6 months after surgery. Patients are given appointment cards to remind them of the follow-up visit. Supportive supervision and outcome assessment reports show that 146 patients were followed up passively (individuals report to the health facility where the IECW is stationed 3-6 months after surgery) by eight surgeons, and no complications were reported. However, it should also be noted that the outcome assessments are conducted by the surgeon who conducted the surgery; therefore, the
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data may be biased. Therefore, FHF relies heavily on supervision and surgical audit findings to determine surgeon skill level. Some reasons why patients do not attend these 3-6 month follow-up visits have been anecdotally captured by IECWs: the patients did not recall the appointment period and had to travel far to the health facility or appointment sites. During IECW review and planning meetings, these follow- up visits were discussed, and FHF determined that IECWs who have good counseling skills and are well-known by their patients were more likely to have patients attend the 3-6 month follow- up visit. This topic will continue to be discussed during review and planning meetings and supportive supervision visits.
TRACHOMA (Tigray)
STRATEGIC PLANNING Regional-level Strategic Planning Meeting On December 5, 2017, in collaboration with the Tigray Regional Health Bureau (TRHB), LFTW facilitated a strategic planning meeting in Mekelle and, of the 75 participants anticipated, 72 participants from the TRHB, zonal and woreda administrations (including zonal social affairs), woreda health offices and eye care units attended the meeting. The main absentee was a representative from the women and children’s affairs who was unable to participate due to conflicting priorities. The objective of this meeting was to discuss the challenges and lessons learned from FY17, plan for the remainder of the year, and better understand how to reach cases with TT services to achieve the estimated remaining UIG in FY18.
During the meeting, discussions focused on the FY16 and FY17 TT surgery performance and challenges, TT surgery targets for FY18, number and distribution of available certified TT surgeons working in the MMDP Project-supported woredas, approaches for case identification, and findings from the pilot house-to-house case identification strategy in Department for International Development (DFID)-supported project areas. Participants agreed on action points to meet the FY18 targets. To meet the targets, it was determined that changes to two main areas were necessary: strengthening political commitment and revision of the current case-finding strategy.
The case-finding strategy in MMDP Project areas to date has focused on mass mobilization, which does not reach everyone and does not convince all those it does reach to present during outreach. To revise the strategy, participants proposed scaling up the systematic house-to-house case finding strategy in MMDP Project areas where there are hard-to-reach cases and a high estimated number of cases. LFTW held a one-day training to train case finders to carry out this work, and thus far, 12 kebeles from two woredas were selected to try out the systematic house-to-house case finding strategy. A total of 238 TT cases were confirmed. Of these, 217 agreed to undergo surgery, 20 minor cases were epilated, and one case refused all services. Further analysis will be conducted in Q3 to determine whether this strategy identified more cases than would have been found using the previous outreach strategy.
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Strategic Planning Meetings at Zonal Level In FY18, LFTW planned to conduct three one-day meetings in the Central, North Western, and Eastern zones of Tigray. In December 2017, TRHB and LFTW conducted these meetings as planned. A total of 240 participants out of 246 planned attended, including representatives from TRHB, TT surgeons, zonal administrations, eye care units (ECUs), WoHOs and health centers. Although representatives from cultural associations and disabled people organizations, woreda women and children affairs offices were invited, they did not attend due to conflicting priorities. The main objective of these meetings was to develop detailed zonal- and woreda-level implementation plans to reach the remaining cases and to work towards trachoma elimination.
Presentations focused on the trachoma elimination strategy, with a specific focus on zonal and woreda-level progress over the last year. In addition, an orientation was given on a planning tool, adapted from the International Coalition for Trachoma Control (ICTC) TAP template, to be used for district-level microplanning by each district team. Using the planning tool, the breakout groups calculated the TT backlog and UIGs of a specific district. Additional information in each plan included the number of TT surgeons available, the number of surgeries a surgeon can perform per day, the number of outreach days that a surgeon can conduct per month and planned steps to carry out the systematic case-finding strategy described above.
Additionally, there was also a discussion on how to fill the human resources gap given that five of the 17 active certified surgeons in the MMDP Project zones were enrolled in the ophthalmic officer training at Mekelle University. The solution was to agree with the University to continue to utilize the surgeons during times that did not conflict with their coursework. Looking forward to FY19, 19 new diploma-level ophthalmic nurses are expected to graduate from Mekelle University and could possibly trained to serve as TT surgeons.
Zonal-level Quarterly Monitoring Review Meetings In FY18, LFTW planned to conduct quarterly one-day performance review meetings in the three zones. These meetings were postponed due to other government meetings and are rescheduled for the first week of April 2018.
ADVOCACY Advocacy Meetings for Political Leaders at the Zonal Level In FY18, LFTW planned to conduct three one-day zonal level advocacy meetings with participants from all five MMDP Project zones. Despite consensus by TRHB officials and political leaders on the importance of the meeting, this meeting has been repeatedly postponed due to other meetings and conferences. At the time of report writing, it has been scheduled for the first week of April 2018.
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SOCIAL MOBILIZATION AND BEHAVIOR CHANGE HEW and HDA Network In addition to the radio spots, LFTW uses the existing TRHB health service system to create awareness of TT surgery availability. This network is structured in the following manner: one Health Extension Worker (HEW) is responsible for 30 Health Development Army (HDA) leaders; each HDA leader is responsible for six HDA members; and one HDA member is responsible for communicating with five households. In FY16 the MMDP Project trained more than 3,000 HEWs and HDAs on trachoma elimination strategies and case identification counseling and referral. LFTW has encouraged HEWs and HDAs to integrate trachoma prevention and TT surgery messages during their regular health-related meetings with community members, community gatherings and household visits. These TT messages include that TT surgeries are free and available.
MDA and Regional-level Comprehensive Eye Health Project Linkage Previous years have shown that integrating MMDP Project activities with other diseases, such as cataract campaigns, has led to effective and efficient service delivery. LFTW and TRHB have agreed to integrate MMDP Project activities with the existing regional-level comprehensive eye health services directly financed by LFTW. During MMDP Project TT surgery outreach, other eye diseases such as cataract and, glaucoma are also identified and referred to the nearest secondary eye care units (SECUs) by the outreach teams. Other minor cases, such as eye infections, that require medical treatment on site are also treated.
Mass drug administration (MDA) will be conducted in all trachoma-endemic districts in April 2018, and LFTW plans deploy all TT surgeons to the drug distribution sites for screening and TT surgeries.
Radio Spots To mobilize the community for TT surgery services and to create awareness around trachoma, radio activities were planned for FY18 utilizing the local radio station Dimtsi Woyanie. This radio station has the potential to reach to every kebele in Tigray. The contract was signed in March 2018 with MMDP Project funding and will support the broadcast of radio spots three days a week for 13 consecutive weeks, beginning in March. The MMDP Project-supported radio spot was produced by the International Trachoma Initiative country office in collaboration with Dimtsi Woyanie and the TRHB communication office. It was pre-tested and broadcast in FY17; in FY18, a short message that encourages already operated cases to return for follow-up was added through funding from the MMDP Project. The key messages of these radio spots are that TT surgery provision is free and that people should attend outreach camps when these are held near their community.
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CAPACITY BUILDING Refresher Training for TT Surgeons During the first week of March 2018, LFTW planned to conduct a five-day refresher training for all 17 TT surgeons trained and certified in FY16 and still active17. This training did not take place due to the TRHB banning any trainings or meetings during the reporting period due to other priorities. The refresher training has been rescheduled for the first week of April. Although several surgeons are now enrolled in a training course at Mekelle University, they will still take part in this training to maintain their surgical skills.
New TT Surgeon Training When developing the FY18 workplan, LFTW took into consideration the overall 13% attrition rate of TT surgeons over the past two years in both MMDP Project and DFID-supported areas. In addition, Mekelle University planned to introduce an ophthalmic officer training course, which was presumed would attract TT surgeons for career advancement, although LFTW had assumed that the FMOH would deploy newly graduated optometrists to Tigray to fill current staffing gaps. With this in mind, LFTW planned to train five new TT surgeons in FY18 with MMDP Project support. However, so far the FMOH has deployed only one new optometrist to MMDP Project zones, and, therefore, the training is postponed for the foreseeable future.
ASSESSING DISEASE BURDEN With support from the ENVISION Project, twenty-two MMDP Project-supported woredas were scheduled for trachoma impact surveys in FY18, although none have taken place to date. As MDA is planned for late April 2018, the impact surveys will likely take place in early FY19.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY In FY18, LFTW is supporting the TRHB and FMOH to reach 5,981 cases in the MMDP Project- supported areas of Tigray region (Central, North Western, Eastern, Western zones, and the non-urban areas of six woredas of Mekelle zone), which was the estimated number of all remaining cases at the time of FY18 work planning. Surgery is conducted by ophthalmic professionals (not IECWs) based in secondary and primary eye care units. In the MMDP Project- targeted zones, there are 24 trained and certified TT surgeons, although only 17 have been actively operating. LFTW provides TT surgery services using both static and outreach services.
Static services are provided at two secondary and eight primary ECUs in the five targeted MMDP Project zones, each of which has at least one trained and certified ophthalmic nurse. The FY18 surgery target for static services is 221, based on the small number of patients who present at ECUs given the distance from their homes. For outreach, TT surgeons travel from the ECUs to health centers and health posts in the communities per a pre-determined schedule. Through outreach, 5,760 patients are targeted for services.
17 A total of 18 TT surgeons were trained and certified in FY16; however, one since resigned.
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During the reporting period, static sites accounted for 4% (92/2,267) of all surgeries; the other 2,175 patients were reached through outreach services. A total of 241 outreach campaigns were organized, reaching 314 kebeles at least once (196 kebeles in Central zone, 74 in North-Western, 29 in Western, 10 in Mekelle, and 5 in Eastern zone). Though the number and length of outreach visits vary, on average, each surgeon conducted outreach for five days per month. For the reporting period the goal was to conduct 2,991 surgeries, and the project reached 76% of that goal despite having fewer TT surgeons available. However, the house-to-house systematic case finding approach appears to be proving its effectiveness, as the number of cases has increased each month since implementing the strategy. One concern for continuing this house-to-house strategy is the cost and the project’s ability to reach all targeted areas with this strategy in the available budget.
Pre-Surgery Screening and Counseling TT surgeons conduct health education to patients before conducting screening. The messages include a general overview about trachoma and its complications, different management options (surgery or epilation) and encourages the patient to accept the recommended management strategy for any eye condition found.
After the group health education session, TT surgeons screen the suspected cases to confirm TT. During the reporting period, a total of 2,418 cases were confirmed from screening 30,128 individuals. Those with minor conditions that can be treated on site are treated; others are referred to care at the ECUs. Patients with confirmed TT but with only one or two lateral trichiatic eyelashes are counseled for epilation. For patients with confirmed TT needing surgery, patient counseling is then provided using the standard MMDP Project patient counseling format which is adopted from the ICTC outreach manual.
After surgery, patients are asked to return the next day for patch removal by the surgeon. During this follow-up, patients are encouraged to come back to the outreach site seven days post-surgery for removal of the silk sutures, which will be removed by either the TT surgeon or by a trained outreach coordinator. All patients who underwent TT surgery received post-operative counseling, had their patch removed, and were assessed for complication by the surgeon on the day after the surgery; all patients had their sutures removed and were again examined for complications seven days after the surgery by the TT surgeon or trained clinical nurse at the outreach site.
Refusals and Epilation Patient are only offered epilation in two cases: if there are one or two lateral trichiatic eyelashes not touching the cornea or a patient refuses to undergo surgery. During the reporting period, a total of 151 patients were counseled for epilation. Of those, 120 were offered epilation because they refused surgery, and 73 accepted epilation. The most commonly cited reason for refusing surgery and epilation was because they preferred surgery, but at a more convenient time (for example, after the harvest). For those who agree to epilation, the TT surgeons conduct the epilation, as it is against FMOH policy to provide epilation forceps to a TT patient. When epilation is performed, the surgeon tells the patients that it is a temporary solution and surgery will
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eventually be needed. Those undergoing epilation are encouraged to contact the ECU for the next outreach campaign.
The main reasons for refusing surgery were fear, unwillingness to be operated during farming/harvesting seasons, social commitments (such as weddings), and lack of relatives to bring the patient back home after surgery. The refusal rate during the reporting period was 4.9%, similar to last year. While the rate has not increased, LFTW believes that the last cases to reach will be harder to reach in terms of geography and willingness to accept services, and will continue to monitor the data.
Tracking Refusal and Epilation Cases Lists of TT patients who were epilated and those who refused both surgery and epilation were given to the outreach coordinators for continuous follow up and counseling18. The outreach coordinators then provided their lists to the respective case finders based on the patient address for continuous follow up and counseling.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT The TRHB submits requests for consumables and other items to LFTW. The list of consumables to be procured is then checked by the procurement team at LFTW and the Director Eye Health/NTDs to ensure alignment with WHO guidelines and quality. Quantities are also checked in line with the projected targets for the period. Once this is confirmed and approved by the Director, LFTW provides approval to TRHB. The request is sent to the Mekelle branch of the PFSA to provide the available specifications and unit costs. Items procured are then stored at the TRHB drug store, which is managed by a pharmacist. When items are not available at PFSA, they are procured using a competitive bidding process led by LFTW.
The ECUs where the TT surgeons are based submit validated stock requisitions to the TRHB store pharmacist. These are based on the expected number of TT surgeries to be conducted in their catchment areas. The TRHB store pharmacist then delivers the requested items to the ECUs. Once the ECUs receive the drugs, the items are kept at the ECUs’ drug stores, which are managed by pharmacists or pharmacy technicians. The TT surgeons then withdraw the supplies from the ECU drug store upon formal request. The TT surgeons report back the utilization of supplies to the ECU store pharmacist after outreach campaigns are completed. The ECU pharmacist reports the drug balance to TRHB.
For FY18, the necessary consumables were procured in advance by RTI and LFTW, with the exception of restricted commodities. These restricted commodities were purchased during the reporting period with LFTW institutional funding.
During the FY17 Zithromax quantification workshop, the TRHB applied for post-operative Zithromax aligned with the planned FY18 TT surgery target. Accordingly, post-operative Zithromax was approved by the TEC and transported from the national PFSA located in Addis
18 LFTW does not yet have data on the number of these individuals followed up and is determining how best to track this.
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Ababa to the regional PFSA hub located in Mekelle. Unfortunately, the regional PFSA hub delivered the post-operative Zithromax to the woredas instead of the ECUs where the TT surgeons are located. In some cases, the woredas provided the post-operative Zithromax to patients; however, the registry does not capture this information, so the quantity provided is not available. After discussing with FMOH, the drug is being collected by the TRHB drug store to be re-distributed to the ECUs.
SUPPORTIVE SUPERVISION There are currently nine supportive supervisors who are trained cataract surgeons, ophthalmic officers, or senior ophthalmic nurses. Seven of the nine are senior government employees from the three SECUs with many years of experience. Two of the supervisors are LFTW seconded staff.
The supportive supervisors were trained by the MMDP Project in FY16 and received refresher training in FY17. Supportive supervisors are assigned to specific geographic areas within the MMDP Project-supported area. This creates a sense of responsibility, as the supportive supervisors are then accountable for that specific area.
The supervisors use the MMDP Project supportive supervision checklist to assess the quality of services and adherence to WHO and FMOH guidelines, as well as the effectiveness of the static and outreach strategies. The FMOH checklist is based on the MMDP Project checklist; therefore, no specific adaptation is anticipated. In addition to the checklists, supportive supervisors also fill in the database for easy access, analysis and use of findings from supportive supervision visits.
During the reporting period, 40 technical visits to outreach and static sites were conducted by the supportive supervisors for a total of 81 days spent in the field at outreach sites (health posts and health centers). In general, surgical practice is strong since all TT surgeons in Tigray are certified ophthalmic nurses or optometrists. The main issues found during these visits include incomplete registration forms, poor patient counseling, and poor community mobilization in some outreach sites.
SHORT-TERM TECHNICAL ASSISTANCE No external short-term technical assistance is planned in Tigray in FY18.
MONITORING AND EVALUATION Surgical Audits In FY18, LFTW plans to audit 14 surgeons. Initially LFTW planned to begin surgical audits at the beginning of the fiscal year to use the findings to provide input for the refresher training of TT surgeons. However, the final version of the national quality assurance guidelines was not released until December 2017, and, LFTW waited until these guidelines were available. In January 2018, supervisors, trained by LFTW NTD/Eye Health Director in FY16 (and refreshed by the Director in FY17) began carrying out the surgical audits using the methodology from the FMOH guidelines. The method is a change from previous years with sampling based on patients operated by a
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specific surgeon, rather than by geographical area, which should provide more reliable information about specific TT surgeon performance.
During the reporting period, LFTW conducted audits for five surgeons. For the five TT surgeons audited, a total of 133 people with 200 operated eyelids were examined. The result of the audit shows that post-operative TT is ≤5% in all surgeons and therefore have “acceptable” results per the FMOH guidelines.
The main challenge with the FMOH guidelines is the number of eyelids that need to be examined per surgeon: the auditor/supervisor needs to examine up to 40 eyelids operated within the previous 3 to 6 months, which may require sampling patients from many districts. This has shown to require a significant investment in time and human resources, as it has taken approximately 10 days to audit each surgeon.
3-6 Month Outcome Assessments In FY18, in addition to counseling operated patients to return after 3-6 months for follow-up, LFTW began to provide patients with an appointment card to be used as a reminder to the patient. District health office trachoma focal persons, outreach coordinators and case identifiers were also asked to mobilize patients for 3-6 month outcome assessment by information registered in the TT surgery registration book. Patients are asked to return to the outreach sites so that the surgeon or the supervisor can assess the outcome of the surgery. When organizing an outreach, LFTW uses surgeons from the closest ECU; however, occasionally, surgeons from other MMDP Project-supported zones are utilized. Thus, the outcome assessment may or may not be conducted by the surgeon who performed the surgery. So far, during the reporting period only 126 patients returned to the outreach sites. Positive outcomes (no post-operative TT, eyelid margin abnormality, or granuloma) have been reported. However, there is some concern of bias in the reporting, particularly when it is the surgeon who performed the surgeries reporting the outcomes. The project is continuing to advocate for a technical supervisor to be present.
Zonal and Regional Program Coordinators’ Monitoring Visit LFTW program and zonal coordinators have regular monthly visits to the ECUs and WoHOs to discuss and provide feedback to officials on the identified gaps and strengths of TT surgery outreach and progress against targets. In addition to woreda health offices and ECUs, the coordinators visit the woreda and zonal political administrations to discuss with political leaders any outstanding issues.
LFTW Director Eye Health/NTDs Technical Assistance and Monitoring Visits LFTW’s Director Eye health/NTDs planned two technical assistance and monitoring visits for FY18. The first was originally scheduled for November 2017, but due to scheduling conflicts took place in January 2018 in the Central and North-Western zones of Tigray. The director attended three outreach campaigns and provided technical support for six TT surgeons and two supportive supervisors during his three-day visit. In addition to providing technical support while TT surgeons conducted surgery and supportive supervisors provided supervision, he also attended the one-day post-operative follow-up at the outreach sites. During TT surgeon’s refresher
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training planned for April 2018, the findings from the follow-up visits will be used to tailor the five-day training. After the training, the director will also conduct a second follow-up visit as per the workplan to ensure the learnings from the training are properly implemented.
LYMPHATIC FILARIASIS
STRATEGIC PLANNING Hydrocele Surgery Planning and Performance Review Meeting For FY18, RTI had originally planned to support the FMOH conduct a national hydrocele surgery planning and performance review meeting to set goals for 2018. However, after the workplan was approved, the FMOH determined that it would not hold this meeting. Instead, RTI worked with the ORHB to organize a regional hydrocele planning workshop with MMDP Project funding, given the low output over the previous year.
This workshop was held in Adama on February 6, 2018. The meeting was presided over by the Deputy Head of the ORHB, and the regional NTD focal point. In attendance were a total of 44 individuals, including medical directors, general surgeons and IESO) from six hospitals; 14 zonal- and woreda-level focal persons; Zeina Sifri, Senior Technical Advisor for the MMDP Project at Helen Keller International (HKI); one representative from the SSE; and five staff from RTI Ethiopia, including RTI’s Chief of Party, Technical Advisor, MMDP Program Manager, MMDP Project Manager and Data Manager.
During the meeting, the following presentations were made and discussed: • High-level summary of the national and regional-level NTD programs; • Global MMDP Project highlights by HKI; • The estimated LF morbidity burden and how to address this burden; • Experiences in hydrocele surgery, and challenges in ensuring hydrocele surgery availability, including the continued political instability; • Development of hydrocele surgery plans by the hospitals, zonal- and woreda-level NTD focal persons to reach the patients identified during the burden assessments; • Efforts by the RHB to ensure free treatment for all hydrocele and lymphedema patients.
In follow-up to the last point, the RHB has issued a letter stating that all services for LF-related morbidity would be available free of charge to patients. These services include transportation of patients, hydrocele surgery, lymphedema management and other related costs19.
Additional action points from the meeting include: • Ensuring burden assessment findings are provided to the respective hospitals and zonal- and district-level NTD focal points; • Auditing and sharing the status of surgeons trained on hydrocele surgery;
19 Per the hydrocele surgery protocol, all patients undergoing surgery are admitted to the hospital for three days; however, the letter from the hospital only specifies admission on an “as needed” basis.
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• Finalizing the memorandum of understanding between RTI and the hospitals targeted for hydrocele surgery support in FY18; • Planning surgery weeks by hospital and setting dates by which each hospital/zone aims to operate the known cases; • Identification of sites with high burden and planning for minicamps and conducting readiness assessments in those hospitals; • Holding a follow-up meeting in June to discuss progress.
Consultative Workshop on Inclusion of FASTT Hydrocele Surgery Training in Medical School Pre-Service Training In FY18, RTI planned to hold a one-day consultative workshop to introduce the FASTT training package to representatives of several universities in Ethiopia and discuss mechanisms for integrating the training package and simulator into skills laboratories and the curriculum of these universities’ medical colleges. The long-term objective is to provide students with a standardized approach, based on the latest WHO hydrocele surgery guidelines, to learn hydrocele surgery during their pre-service training, in an effort to ensure all patients in Ethiopia with hydrocele receive quality surgery.
On February 5, 2018, with MMDP Project funds, this workshop was held in Addis Ababa and attended by a total of 16 participants, including representatives from the Universities of Addis Ababa, Gondar, Jimma, Debretabor, Mekelle, and Hawassa, and St. Paul Millennium Medical College. In addition to the university representatives, Zeina Sifri from HKI; Sarah Martindale and Jan Douglass from the Centre for Neglected Tropical Diseases (CNTD) at Liverpool School of Tropical Medicine (LSTM); Dr. Asrat Mengiste from the National Podoconiosis Action Network (NaPAN); Drs. Andualem Deneke and Dereje Gulilat from the SSE and Addis Ababa University; and Dr. Fikreab Kebede, Sharone Backers, Teshale Yadeta and Haile Kassahun from RTI attended.
The discussion during the workshop focused on the hydrocele burden in Ethiopia, experience in hydrocele surgery, the FASTT training package, and approaches to integration. The universities indicated their interest to include the FASTT training package into the surgeon/IESO curricula and agreed that the SSE would lead the integration process. The MMDP Project will support any future meetings or workshops to move the process forward.
The first step is to provide the Ministry of Science and Technology (MOST) the physical and chemical properties of the FASTT cartridges, which will help to forecast the scope of integration and time the process will take. In conjunction with the workshop with the universities, RTI and HKI met with MOST on February 7, 2018 in Addis Ababa to discuss the potential to produce FASTT bases and cartridges locally. The delegation met with the MOST State Minister, Professor Afework Kassu, who gave his support to this collaboration and assigned an expert to support this effort. At the time of the writing of this report, the MMDP Project is working with Ho’s Art, the FASTT manufacturer, to discuss the details of the possibility of this technology transfer and legal counsel to ensure there are no intellectual property issues. The MMDP Project will fully document the process of the integration of the FASTT training package and curriculum, and it could possibly serve as a resource to other countries.
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Consultative Workshops on Inclusion of Lymphedema Management in the Comprehensive Pre-Service Training of Nursing Curriculum In the FY18 workplan, RTI included support to the Human Resource Development (HRD) Directorate at the FMOH to conduct two workshops to integrate lymphedema management into the pre-service nursing curriculum. Although these workshops have not taken place, on October 10, 2017, Dr. Fikreab Kebede, RTI Senior Technical Advisor, visited the FMOH and met with the Nursing Initiative Coordinator at the HRD and the NTD team regarding possibilities of integration. A consensus was reached that a discussion would be held during a national nursing curriculum revision meeting that the Directorate was planning to hold in November 2017; however, this meeting has not taken place.
A wider consultative meeting was held on January 25, 2018 with the NTD and HRD teams at the FMOH during which inclusion of lymphedema management and other case management of NTDs was discussed. In addition to integrating lymphedema management, the NTD team extended the initiative to include the clinical management aspects of other NTDs. RTI was further asked to draft the curriculum on lymphedema management. RTI provided a concept draft to the FMOH team to consider; a further draft will be provided for HKI’s input once discussions continue. RTI is also discussion with Jhpiego the mainstreaming process as Jhpiego leads the Human Resources for Health Project.
Participation in National Trachoma Taskforce and LF/Podoconiosis Technical Working Group RTI attended the NTTF meeting on October 20, 2017 to review progress and outstanding issues on the draft national guidelines for TT surgery service supervision, outcome assessments and surgical audits. The meeting identified further editorial work and requested members of the drafting team. RTI has reviewed and provided feedback on these documents, and provided technical support in developing and finalizing the supportive supervision guidelines, ensuring the inclusion the infection control and healthcare waste management (IC/HCWM).
To this end, a national consultative workshop was conducted in Adama from December 7-9, 2017. RTI was represented by Teshale Yadeta (MMDP Manager), Asrat Gebretsadik (TT Quality Assurance Officer) and Dr. Fikreab Kebede. The team further facilitated and supported regional teams in action planning exercises for implementing the guidelines. The consultative workshop was attended by approximately 90 participants from the RHBs, implementing partners, tertiary and secondary eyecare units, universities, and the Ethiopia Ophthalmic Society.
In addition, Dr. Fikreab Kebede of RTI, participated in the NTTF meeting held on January 4, 2018 at the FMOH. Participants discussed the need to develop training manuals to guide implementation of TT surgical audits and manage post-operative TT. The NTTF assigned the Training and Quality Assurance committee to develop these manuals.
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ADVOCACY RTI did not plan any advocacy-related activities in the MMDP Project FY18 workplan.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE Messaging on LF MMDP
LF Tool Printing
New Hope manual
In FY16, the “New Hope” manual, a CDC manual on lymphedema management, was adapted to the Ethiopian context, including translation into Amharic, and was pre-tested. In FY17, this manual was translated into Tigrigna and Oromiffa. Additionally, RTI planned to print the New Hope Toolkit to give to all lymphedema patients in MMDP Project-supported areas. During the reporting period, RTI printed 14,731 copies in three languages. Of those printed, a total of 8,985 have been distributed to the woreda health offices and health centers (960 of the Amharic version; 7,920 Oromiffa and 105 Tigrigna), and these tools are provided to the patients once they are enrolled for lymphedema management services.
Post-hydrocele surgery flash cards
In FY17, RTI collaborated with the SSE and the FMOH to develop post-hydrocele surgery patient care flash cards in Amharic, Oromiffa and Tigrigna. The flash card is designed as reference information for the patient and as a teaching tool for the clinical healthcare workers and HEWs following hydrocele surgery. During the reporting period, the MMDP Project produced 269 Amharic versions and 712 Oromiffa versions of the flash card.
Lymphedema management flash cards
The lymphedema management flash card was drafted in FY17, although not finalized. The flash card will be finalized in FY18, after the planned feasibility study (see Lymphedema Management section) is completed.
Mobilization of Patients for Hydrocele Surgery In FY18, the MMDP Project planned to use both community-based mobilization through the HEW and HDA network and radio spots, for a total of 48 days of broadcasting, to mobilize patients for hydrocele surgery.
For seven days prior to the FASTT training that took place from December 25-29, 2017 at Gambella hospital, the Gambella RHB and the Gog and Abobo woreda health offices conducted social mobilization through radio spots. The radio spots were the same as those used in FY17 in Beneshangul-Gumuz with translation by the RHB into the local language, Agnuwa. Experts from the Regional Education Bureau translated the messages and reviewed them for acceptability in terms of religious, cultural, and social values; formal pre-testing was not conducted. The messages
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emphasized that the surgery is provided free of charge. The radio spots were broadcast once per day to five woredas.
In addition, HEWs, HDAs, and woreda- and kebele-level administrative leaders mobilized patients for the hydrocele surgery campaign. The rest of the radio spots will be utilized in Oromia and Beneshangul-Gumuz in campaigns planned in the next reporting period.
Assessing the Effectiveness of Radio Spots In FY18, RTI planned to ask patients presenting for hydrocele surgery how they learned about the availability of hydrocele surgery services by administering a short questionnaire to patients as part of intake. However, with the novelty of surgery in Gambella, RTI determined that this activity will take place in the next reporting period.
CAPACITY BUILDING Training of Hydrocele Surgeons In FY18, the MMDP Project planned to support national efforts to expand surgical services for hydrocele to the Gambella region with trainings for six surgeons and/or IESOs from three hospitals (Gambella, Tepi, and Mizan Aman). Two separate trainings were planned: one at Gambella Hospital (with two surgeons/IESOs targeted) and one at Mizan Aman University hospital in Southern Nations, Nationalities, and People’s Region (SNNPR), with two surgeons/IESOs each targeted from Tepi and Mizan Aman Hospitals, which serve populations in the LF-endemic districts in Gambella region.
During the reporting period, the training at Gambella Hospital took place from December 25-29, 2017 and one surgeon and one IESO were trained. The training at Mizan Aman University hospital took place from February 12-17, 2018 and two surgeons and two IESOs (one of each cadre from both Mizan Aman and Tepi hospitals) were trained.
The four-day trainings each consisted of one day of classroom lecture and training on the FASTT surgical simulator and three days of practical training on patients. The materials that were used included the MMDP Project-developed training curriculum and the FMOH’s Hydrocele Surgery Handbook. Refresher Training of Clinical Workers on Post-Hydrocele Surgery Survey In FY18, RTI planned to conduct a 9-12-month follow-up survey of patients operated on during the first hydrocele surgery campaign in Assosa, Beneshangul-Gumuz in FY17 and who also previously participated in a survey within five days following their surgeries. The objective of these surveys is to assess surgical outcomes and to better understand the long-term impact of the surgery on the patient’s quality of life. As it has been a year since that survey, RTI determined that a refresher training should be held to ensure the clinical workers conducting the survey remember the protocol. The refresher training for the clinical workers was held on February 18, 2018 in Assosa town. A total of 13 (five female) clinical workers participated in the training.
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The main challenge of this training was that there was not adequate time for the practical sessions. The training in Tigray did not take place during the reporting period and is planned for April 2018, to be immediately followed by the survey. The survey was meant to include patients from Oromia as well; however, due to insecurity in Oromia during the Day 5 data collection period, that follow- up was not possible. RTI will consider including Oromia in the 9-12 month survey if the security situation allows.
Training of Clinical Workers in Lymphedema and Post-Hydrocele Surgery Management During the reporting period, RTI planned to train 42 clinical workers in Beneshangul-Gumuz, Oromia, and Gambella to provide both lymphedema management and post-hydrocele surgery management. These plans slightly shifted for two reasons: 1) per USAID guidance that lymphedema activities begin after the conclusion of the feasibility study; and 2) the training of hydrocele surgeons in Gambella necessitated training for clinical healthcare workers to care for hydrocele patients at the proper intervals post-surgery (five, seven, 14 and 30 days; six and 12 months). Therefore, in conjunction with the FASTT training in Gambella, a one-day training was held on December 25, 2017 for a total of 13 (one female) clinical workers from the Gog, Abobo, and Itang woredas. The training was conducted by the SSE and focused exclusively on post- hydrocele surgery care for the reasons listed above.
On February 12, 2018, an analogous training took place in Mizan Aman in conjunction with the FASTT training at that hospital. A total of 13 clinical healthcare workers (five female) participated from the Dimma, Godere and Mengesh woredas of Mejang zone and two hospitals in SNNPR (Mizan Aman and Tepi). The inclusion of the hospitals in SNNPR is due to the proximity to the LF-endemic districts of Gambella.
The principal lessons learned during this training and from previous experience is that certain factors enable the clinical workers to conduct this follow-up, including:
• Commitment and ownership from the Head of the RHB to provide patients food and accommodation for post-surgery visits. Patients generally stay near the hospital until day 7 post-surgery and return for day 14 and one-month follow-up visits. The woreda health offices or NTD focal persons take responsibility to arrange these logistical details; • PHCU and trained clinical workers’ commitment to provide the post-operative care on the proposed dates and forgo participation in competing activities; • Monitoring of follow-up from RHB NTD focal persons and RTI regional technical advisor; • Clear information provided to the clinical workers on the number of patients to whom they will provide follow-up care and the specific follow-up activities, as well as the contact information for each patient.
Once the lymphedema management feasibility study has been completed, RTI will determine further training needs for clinical healthcare workers for lymphedema management.
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ASSESSING DISEASE BURDEN No LF disease burden assessments were planned in FY18.
HYDROCELE SURGERY In FY18, RTI plans to support 600 hydrocele surgeries. To date, 86 patients have been operated, mostly in Gambella region.
Hydrocele surgery in MMDP Project-supported areas is conducted through two approaches: 1) a campaign approach, utilizing the HEW/HDA network and radio spots to mobilize many patients for surgery during a specific period, and 2) routine services, in which hospitals themselves reach out to patients or patients self-report. The method of hydrocele surgery recommended by the MMDP Project is resection, and the majority of patients received surgery through this method (81/86). The remaining patients were operated through the eversion technique, which is recognized by WHO, as these were minor cases and the surgeons judged that this technique was appropriate for those cases.
During the reporting period, two hydrocele surgery camps were held, one each at Gambella and Mizan Aman hospitals, following the trainings of hydrocele surgeons held at each hospital (see Capacity Building section). During the reporting period, the importance of the woreda health offices was underlined in mobilizing patients for surgery, as they were the primary drivers for these efforts in Gambella. They were also instrumental in ensuring that patients had a place to stay and food to eat after their release from the hospital until Day 7 post-surgery, ensuring patients received the proper follow-up care.
While RTI has only reached 14 % of its annual target to date, this was primarily due to supporting Gambella to institute services. The second half of FY18 will be focused on supporting Oromia and Beneshangul-Gumuz to conduct hydrocele surgery campaigns, particularly now that the former has commitment from the RHB and plans for campaigns by hospitals. With the plans from the hospitals, an additional 321 patients are targeted for surgery by early July 2018 in Oromia alone. In Beneshangul-Gumuz, two campaigns are planned in May 2018 targeting approximately 100 patients total. Additional campaigns will be planned and conducted as needed in Q4.
One lesson learned is to not rely entirely on the burden assessment findings to recruit patients to seek surgical services. Although the overall number of cases in Gambella region discovered through the burden assessments was low (69), only 56% of those operated during the camps were identified during the burden assessments. RTI will look further into the origin of these patients to determine where those missed are coming from. Additionally, RTI will further examine the radio messages’ effectiveness in the second half of FY18.
Hospital Readiness Assessments In November 2017, a team from RTI and the SSE conducted hospital readiness assessments in three hospitals: Gambella hospital, which serves the LF-endemic districts in the northern part of Gambella region, and two hospitals in the SNNPR region that serve populations in the LF-endemic districts in the southern part of Gambella region (Mizan Aman University Teaching Hospital and
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Tepi Hospital). The objective of these assessments is to evaluate whether a given hospital has the proper staffing, facilities, equipment/instruments, laboratory services, medication, spaces for consultation and waiting areas (for patients prior to surgery), and meal services.
To conduct the readiness assessments, the team adapted the draft World Health Organization MMDP situation analysis tool for LF. In addition, the team conducted a facility observation and interviewed key staff (hospital management, operating room, pharmacy and laboratory). The team also evaluated the operating rooms, waiting rooms, training halls, and IC/HCWM practices and sites. Based on the findings, the team concluded that the hospitals were of sufficient quality to hold the planned FASTT trainings and subsequent campaigns. Key observations include: Pre-Camp Screening No pre-camp screening exercises took place as in FY17; instead, the burden assessment data, along with social mobilization via HEWs/HDAs and the radio, were utilized to inform patients of the campaigns.
Patient Counseling and Pre-Surgical Care The day before surgery, surgeons screened patients using the MMDP Project pre-operative assessment form in consultation with the FMOH and SSE. Patients were then offered voluntary HIV testing alongside other basic laboratory tests (urinalysis, haemoglobin, and blood group). All patients were then observed swallowing pre-operative antibiotics. Prior to surgery, patients signed a written consent form to undergo surgery following counseling on the surgical procedure and possible complications and risks.
Patient Follow-up Per FMOH guidelines, patients should be hospitalized until Day 3 following the surgery to ensure a surgeon follows up with each patient prior to discharge, and to ensure one aseptic change of dressing prior to patient discharge. Following discharge, patients return home under the care of clinical healthcare workers trained to recognize post-operative complications, treat minor post- operative complications and refer patients back to the hospital when required, perform sterile changes of dressing, and report their findings. The clinical healthcare workers follow-up the patients at days 5, 7, 14, 30 and 60, as well as at 6 and 12 months.
LYMPHEDEMA MANAGEMENT The FY17 workplan included a study to examine the feasibility of providing community-based lymphedema management services, and NaPAN was selected to assist with this work. The general objective of this study is to compare two community-based lymphedema management interventions (a basic package of care, or “non-intensified,” and an “intensified” model) to provide evidence for decision-making to scale up LF MMDP services in all endemic districts in Ethiopia. At the time of the writing of this report, the FMOH expressed to RTI and HKI that the delays in carrying out the study are holding up its ability to scale-up lymphedema services in Ethiopia.
As originally planned the feasibility study would compare the two approaches for lymphedema managements. In the six MMDP Project intensified woredas, lymphedema patients are provided
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with a kit of basic supplies (soap, ointment, towels) to enable them to perform the required washing. The clinical workers training patients receive supportive supervision for three consecutive months and two quarterly visits from NaPAN staff. In the six woredas of the non- intensified arm, no kits are provided to the patients and supervision to the clinical workers is left to the health system. The feasibility study could not be completed in FY17 and this activity was carried over into FY18.
To conduct the evaluation of the two models, a number of activities first needed to be completed, some of which have taken place but not all. The status of the various activities required in order to conduct the feasibility study are listed below:
1. Training of clinical healthcare workers (FY17). While only twelve districts were selected as part of the feasibility study of the two different models, in FY17 a total of 207 persons were trained in 32 woredas20 (41 persons trained from intensified woredas), including clinical health care workers stationed at woreda-level health centers. Additional trainees included staff from district hospitals, woreda health offices and NTD focal persons. During the training, the clinical workers were taught about LF; care for patients with lymphedema, as well as counseling, provision of patient follow-up, referrals, and reporting. Support materials utilized during the training include the FMOH’s MMDP guidelines for LF and podoconiosis and NaPAN’s manual on psychosocial and economic rehabilitation for LF and podoconiosis patients.
2. Communication activities to inform people with a swollen leg that care is available at the local health center (FY17-18). This included health education sessions on lymphedema sessions and care at the health centers, production of a poster on LF and podoconiosis (due to co-endemicity of the diseases and the FMOH’s approach to integrate care for lymphedema due to both conditions), and broadcast of radio/television programs. These communication activities were conducted and paid for by the health system.
3. Train patients to care for their lymphedema (FY17-18). To date, 1,316 patients in the intensified arm have been trained to conduct self-washing (599 in FY17 and 717 in FY18). In the non-intensified areas, the data have not yet been collected.
4. Provide patients in the intensified arms with basic supplies (bandages, Vaseline, soaps, basins, and towels) free of charge (FY17). A total of 26 health centers received these supplies to provide to patients and buckets for each health center to use for demonstration during patient visits. At the time of the writing of the report, NaPAN is working to collect information regarding the distribution to the patients, and this will be reported on in the next reporting period.
20 Clinical healthcare workers were trained in 32 woredas in FY17; however, RTI and NaPAN recognized that this would be too many woredas for an evaluation. Therefore, six woredas were selected for “intensified” intervention, described above. All other woredas (26) implemented “non-intensified” intervention, but only six of these were selected for inclusion in the evaluation.
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5. Cascade training to health extension workers to be supervised by the RHBs and zonal health departments at the PHCU and the PHCU to observe cascade to the health center level (FY17-18). This was accomplished in the intensified arm. Cascade training was not supported by the MMDP Project in the non-intensified arm.
6. Supportive supervision by NaPAN monthly (for three months) has been conducted in all 26 health centers in the six woredas in the intensified arm (FY17-18). One of two quarterly supportive supervision visits were conducted in the woredas in Oromia and Tigray. The second quarterly visits are planned for April 2018 in those regions. In Beneshangul-Gumuz, the first quarterly visit is planned for April 2018. As a note, NaPAN is not providing any supportive supervision to the non-intensified woredas; RHB and zonal health departments are to conduct supportive supervision.
7. The protocol for the evaluation has been drafted and comments from the project’s LF Technical Advisory Board (TAB), including USAID, have been received and are under review (FY18).
Once the protocol has been revised, NaPAN will proceed to collect data to evaluate the two models. Dependent on comments from the TAB, this may include:
• A review of medical charts to determine the number of visits each lymphedema patient made to the health center, the drugs/supplies received, and the clinical outcomes recorded (number of acute attacks experienced during the previous month);
• Focus group discussions with patients to assess whether patients understand the treatment procedures, their perceptions of the feasibility of continuing adherence to the washing and their perceived impacts of the intervention;
• Key informant interviews with clinical healthcare workers and decision-makers in the woredas, zones and regions regarding the feasibility of providing community-level lymphedema services;
• Costing data from the study will be compiled to better understand the investments required to offer these services at scale.
One of the lessons learned in conducting the activities is that RTI had not recognized from the outset the level of mentoring to partner staff required to ensure the overall success of the study. For example, in the future, RTI would want to oversee the development of a data collection framework for all information that will be relevant to the study. As an example, all patients in the “intensified intervention” woredas were to receive a kit with basic supplies. The supplies were delivered to the health centers and assumptions were made that each patient would receive them. However, there was no tracking system to ensure that each patient received a full kit. Although NaPAN is working to collect patient-level distribution on its supervisory visits, RTI will work to ensure that in future activities, these systems will be agreed upon prior to implementation.
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COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT During the reporting period RTI worked with partners FHF and LFTW to determine FY18 needs and procured the necessary consumables for surgeries. RTI also procured 21,450 tubes of tetracycline eye ointment (TEO) through the USAID-approved wholesaler, IDA, for FY19 activities. As the procurement was conducted in tandem with the procurement for the ENVISION Project, the TEO has not yet shipped to Ethiopia. Given past experience, the procurement was done early so that the TEO is available at the beginning of the FY19 fiscal year and surgeries are not delayed. For hydrocele surgeries in Gambella, CNTD-LSTM provided payment directly to Gambella hospitals (and is currently making payment to Mizan Aman hospital) to cover the cost of restricted items utilized during the surgery.
Additionally, RTI received HEAD START supplies from HKI and has since distributed some of these items to LFTW and FHF. The main difficulty noted during the reporting period was the unavailability of certain items, such as surgical blades; however, by repeatedly checking with the PFSA, enough were located for activities during the reporting period.
SUPPORTIVE SUPERVISION Supportive Supervision of Hydrocele Surgeons by SSE Consultants The SSE conducted two visits to hospitals during the reporting period: one to Assosa hospital in preparation for and during the October 2017 USAID-HKI field visit to Assosa hospital. As this visit was not organized as a supportive supervision visit but rather to prepare for the visit, recommendations were not generated. The second visit took place in March 2018 to Pawe hospital in Beneshangul-Gumuz.
Although the full report is not yet available, a key strength noted was that surgeries were done in Pawe General Hospital by the FASTT-trained hydrocele surgeon and IESO per the resection technique steps detailed in the FMOH’s hydrocele surgery handbook. Additionally, all patients were provided with preoperative antibiotics and full-body baths prior to surgery. Surgeons operated in keeping with the project infection prevention protocol as per WHO recommendations. Finally, all patients were registered in operating room registry books provided by the MMDP Project.
The visits also noted that patients were operated and discharged on the day of surgery, rather than being hospitalized for three days as per FMOH and MMDP Project guidelines. RTI has discussed this with the hospital, and the hospital agreed to the three-day hospitalization. A memorandum of understanding is being signed to this effect.
Supportive Supervision to Clinical Workers Providing Lymphedema Management Services by NaPAN Consultants The training of clinical workers on lymphedema management and supervisions activity is on hold until the feasibility study is conducted (see Lymphedema Management section).
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Supportive Supervision to LFTW and FHF RTI’s QA Officer regularly conducted supportive supervision visits to both Tigray (LFTW) and Oromia (FHF) for TT surgery campaigns and quality assurance activities (e.g. surgical audits). Below are summarized findings from the supervision conducted during the reporting period. During his supportive supervision visits, the QA Officer provides immediate feedback to TT surgeons, PHCU directors and other relevant personnel to ensure they are aware of any issues. The QA Officer also discusses his findings with either FHF or LFTW staff present during the supervision and regularly shares findings with both FHF and LFTW offices in Addis Ababa.
Strengths identified by the QA officer during the supportive supervision visits include:
• HEWs properly referred cases to the campaigns; • House-to-house screening by nurses and HEWs during outreach contributed to a strong mobilization of cases; • Magnifying loupes were used for screening; • Surgeons provided good counseling, filled out forms and registers correctly and provided informed consent to the patients; • In some of the woredas there was strong commitment from the kebele and zonal leaders, as they worked together to organize outreach activities; • All equipment, supplies, and medications were present, including tetracaine and Zithromax; • Eyelids were correctly labeled pre-operatively; • Proper aseptic technique and sterility practices were maintained pre-, intra- and post- operatively;
Areas for improvement identified by the QA officer during the visits include:
• In some cases, surgeons were overloaded by work and had no assigned assistants; • IEC materials were not always available for social mobilization; • Although the surgeons had magnifying loupes, they were often old and had a narrow working area and short distance; • Hand sanitizer was not always present during patient screening; • In some instances, surgical hand washing was not properly done by the surgeons due to lack of a water system in the health center; an immediate recommendation was to collect water via jerrycans to use for handwashing before surgery; • Problems with final waste disposal. For example, incinerators were not fenced properly, and some waste materials were seen outside the incinerator.
SHORT-TERM TECHNICAL ASSISTANCE No short-term technical assistance was requested in FY18.
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MONITORING AND EVALUATION Tracking LF MMDP Interventions: Hydrocele Surgery The MMDP Project utilizes a standard set of reporting tools for hydrocele surgery, including:
• Medical history form, which is filled out by the examining surgeon; • Hydrocele surgery register, which is filled out by the surgeon in the operating room; • Post-operative patient follow-up form, which is filled out by the surgeon on Day three post-surgery and afterwards by clinical workers at a health center level, and, • Hydrocele surgery performance reporting form to be compiled by each hospital and sent to the RHB and then from the RHB to the FMOH.
For hydrocele surgery, assessments and follow-up are completed at hospital and health centers, and the RHB submits hydrocele surgery performance reports to the FMOH. At present, RTI collects information from the hospitals that conducted hydrocele surgeries and uses this information to harmonize with the national integrated NTD database. These data are not yet reported through the health management information system (HMIS) as planned.
Post-hydrocele Surgery Follow-up Survey In FY17, the MMDP Project conducted a survey five days post-surgery among patients operated during the first hydrocele camps conducted in Beneshangul-Gumuz region to determine the clinical outcomes of the surgery and establish information regarding patients’ quality of life and economic situation. The project sought to follow-up at least 30% of patients operated (53/175 patients); a total of 68 patients were followed-up. RTI aimed to follow-up the same 68 patients at the 9-12-month post-surgery benchmark to determine clinical status and whether the patients perceived any quality of life or economic changes. The survey took place in February 2018. Each data collector required between two to seven days to complete the survey to reach the targeted number of participants, and 63/68 patients were located and surveyed. At the time of report writing, the data analysis is ongoing and will be shared in the next reporting period.
During the reporting period, an analogous survey was planned in Tigray but did not take place. It will take place in May 2018, immediately after the refresher training for clinical workers on the data collection tool (see Capacity Building section). As noted above, should security improve, the survey will also be conducted in Oromia.
CROSS-CUTTING ACTIVITIES
NTD SECRETARIAT No financial support is provided directly to the FMOH or RHBs by any partner. Technical support was supplied during the above-described activities and during meetings.
FY19 MMDP Project Work Planning Meeting (Planned) The FY19 MMDP Project workplan meeting is planned for June 7-8, 2018.
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ENVIRONMENTAL MITIGATION AND MONITORING PLAN In all health centers, there is an infection control and patient safety team. This team is responsible for all infection control activities, injection safety and disposal of healthcare waste. Additionally, infection control and waste management is monitored during routine supervision activities for the MMDP Project. During the reporting period, two of FHF’s supportive supervision visits and 99 of LFTW’s assessed all areas of the EMMR monitoring. Additionally, all supportive supervision led by RTI’s QA Officer for TT surgery utilizes the MMDP Project supportive supervision checklist, which includes IC/HCWM, and IC/HCWM sessions are included as part of trainings. For example, during this reporting period, the hydrocele surgery trainings and the refresher training for the data collectors for the 9-12 month post-hydrocele surgery follow-up training included IC/HCWM sections, and there is a section on this in the ongoing TT surgeon training in Oromia. The LFTW Director Eye Health/NTDs pays close attention to IC/HCWM during his technical assistance visits and IC/HCWM is consistently prioritized by supportive supervisors in Tigray, utilizing the MMDP Project supportive supervision checklist. In addition, the FMOH recognized the importance of IC/HCWM and included it in the supportive supervision checklist for TT surgery. Additionally, one aspect of the hospital readiness assessments for hydrocele surgery is to determine the availability of infection control and waste management facilities: the assessment requires the teams to determine whether autoclaves and incinerators are present and how non-hazardous waste is disposed.
INTEGRATION WITH OTHER DISEASES FHF FHF has previous experience integrating TT surgery with other activities, such as cataract surgery and MDA campaigns. Specifically, in East Harerghe (a DFID project zone) TT surgery was integrated with cataract surgery campaign supported by the Himalayan Cataract Project in 2017. This approach was attempted in Bale zone in October 2018 but could not be carried out successfully because of the instability in the zone during the time of the activity. Currently, FHF is working with Arsi ZHD to integrate TT surgery with MDA campaigns.
LFTW LFTW and the TRHB have agreed to integrate MMDP Project activities with the existing regional level comprehensive eye health services directly financed by LFTW. During cataract campaigns organized at hospitals, the team plans not only for cataract surgeries but also for TT surgery. As an example, during the cataract campaigns in Axum and Adigrat hospitals, in December 2017 and February 2018, respectively, approximately 130 TT patients were operated.
LFTW and TRHB have also tried to integrate refractive error services with MMDP Project activities. Although in DFID-supported areas LFTW tried unsuccessfully to couple refractive error screening in school with screening for TT in those communities, LFTW has plans to integrate refractive error screening with TT screening at the community level to ensure that the comprehensive eye care package is available to patients.
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RTI Per FMOH guidelines, lymphedema management is conducted holistically: there is no distinction between lymphedema due to podoconiosis and lymphatic filariasis in terms of care. Therefore, the ongoing lymphedema management as part of activities for the feasibility study will likely reach both types of lymphedema patients.
HEALTH SYSTEMS STRENGTHENING SERVICE DELIVERY • Trichiasis management: Direct medical service provision for TT patients is provided in static and outreach settings by trained and certified TT surgeons. Government-employed TT surgeons provide TT surgery from static sites, with the training and systems established enabling ongoing provision of care beyond the life of the project. Outreach activities provide service delivery closer to the patient, making services more accessible.
• 3-6 month surgical quality audits: Examination of TT surgery patients 3-6 months following the surgery to assess the quality of services provided is conducted by experienced eye care professionals. Follow-up trainings are provided when findings from these assessments reveal a need for skills refreshers. Feedback provided by supervisors allows TT surgeons to continue to develop their skills.
• Community mobilization and awareness raising: Activities that raise the awareness of community members, such as radio spots and social mobilization by HEWs, help to ensure those in need of the services are aware of their availability, now and into the future.
• The MMDP Project’s support for hydrocele surgery ensures that hydrocele cases have access to services. The trainings for surgeons and clinical healthcare workers (for post- hydrocele surgery follow-up and management) as well as the hospital readiness assessments ensures that these services are of high quality. Since the MMDP Project also fully supports the cost of the surgery (including patient travel, laboratory work, consumables, in-patient hospitalization for three days, and follow-up care), the services are affordable to patients.
• Purchase of the consumables and medications required for TT and hydrocele surgery ensures their availability for the services provided through the MMDP Project.
• The TRHB has developed a plan to establish an NTD unit within the regional health structure to push for improved mainstreaming of NTD activities. Although this unit is still being formed, the MMDP Project has helped to build the capacity of various cadres of TRHB personnel in TT surgery, monitoring and evaluation, project planning, financial management, and behavior change. These cadres are all working in different levels of the health system so that these skills can then be transferred to other areas of work not necessarily linked to MMDP activities.
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• With referral linkages in Tigray, the trachoma outreach campaigns have been used to identify and refer major eye disease to the nearby SECUs, strengthening the links between the PHCUs and higher-level care and increasing the number of major eye disease managed at the SECUs and hospitals. For instance, between January and December 2017, over 6,000 cataract surgeries were conducted, and a substantial number of patients had been referred during TT outreach campaigns.
HEALTH WORKFORCE • Experienced eye care professionals provide supportive supervision to TT surgeons on all aspects of TT surgery, providing TT surgeons the opportunity to improve skills.
• The consultative workshop on inclusion of FASTT hydrocele surgery training in medical schools’ pre-service training is a step towards ensuring that the medical schools have a surgical simulator for their skills labs, which will help ensure medical students understand how to perform the resection technique.
• The training of the six hydrocele surgeons to serve the Gambella region ensures the availability of a cadre of surgeons with standardized training to provide high-level care to patients in that region.
HEALTH INFORMATION • The reporting structures are aligned with the HMIS pathway and the system allows decision makers to have access to reliable, usable, understandable and comparative data. TT surgery provision is currently captured in the HMIS.
LEADERSHIP/GOVERNANCE • Advocacy meetings facilitated by the ZHD and WoHO provide an opportunity for all stakeholders, such as administrative bodies and local leaders, to understand service delivery and allow a platform for inclusion in the development of activities at a local level.
• The hydrocele surgery planning and performance meeting provided an opportunity to engage the leaders of the ORHB to better understand the burden of hydrocele in the region and to plan services. It also provided the Head of the ORHB with information and a platform to announce that the ORHB and the hospitals would take leadership within the region to ensure both hydrocele and lymphedema patients would receive free care.
• LFTW strives to promote increased ownership and leadership of the MMDP Project interventions by the TRHB leadership by enabling the TRHB to lead on key decisions related to project implementation and in terms of human and other resources management. One way in which this is accomplished is through fixed obligation grants, which encourages implementation of rigorous governance measures to ensure transparency of the use of resources and enables them flexibility to make decisions regarding financing of activities in accordance with the milestones.
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CHALLENGES AND LESSONS LEARNED • In Oromia, recurrent social unrest in almost all parts of the region was the greatest challenge during this reporting period and hindered movement within the region. This has affected FHF’s performance of surgery, supportive supervision, and surgical audits in most zones. As political leaders’ and sectors’ attention was primarily focused on issues related to the instability, the TT surgery program was not a priority. In addition, the recent replacement of numerous political leaders and health sector managers at the woreda level has been a challenge, as FHF needs to orient these new stakeholders to the project.
• In Tigray, the main challenges revolved around quality assurance activities. For outcome assessments, although HDAs and HEWs actively encourage operated patients to come to a central point for follow-up, only 126 patients presented. To address this, LFTW modified the radio messages to include information about follow-up and has added additional days to TT surgeon outreach plans to ensure they have time to examine operated patients. Additionally, the FMOH guidelines for surgical audits have proven to be very time- consuming; it has taken an average of 10 days to conduct a surgical audit for one surgeon, and this makes it difficult for the supervisors to conduct supportive supervision.
• A lesson learned in Tigray is that the house-to-house case-finding strategy, immediately followed by a camp, appears to be quite effective, though expensive. LFTW is planning to implement this strategy in hard-to-reach areas teams may only be able to access once and areas with high numbers of estimated cases to operate.
• Some follow-up visits to hydrocele surgery patients were not conducted as planned. To remedy this issue, RTI plans to map clinical workers to hydrocele surgery patients to ensure each understands which patients he or she is responsible for following up with.
• During this reporting period, 18 patients operated for hydroceles in Beneshangul-Gumuz were released on the same day. RTI will continue discussions with the hospitals on the importance of hospitalizing patients until Day 3 and determine the support required by the hospitals, if any, to adhere to this protocol.
• The FMOH’s push to move MDA towards an integrated approach has taken up a great deal of the FMOH, RHB, and partners’ time, leaving less time for the MMDP Project. It has been decided that Beneshangul-Gumuz and Gambella will move forward with integration, while Oromia will not. While RTI envisions that this issue will still preoccupy much of FY18, we believe the impact will lessen in FY19.
• The delay in the feasibility study has delayed expansion of lymphedema management to other woredas as per the approved workplan. Funds earmarked within the FMOH for expansion have been reprogrammed as a result.
UPDATE ON FY18 IMPLEMENTATION TIMELINE See the attached timelines.
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LF community case identification and referral in Far North, Cameroon, 2017. (photo: William Nsai/Studio 3)
GLOBAL PROJECT
• The MMDP Project worked with the International Coalition for Trachoma Control (ICTC) partners to develop a manual titled “Training trichiasis surgeons for trachoma elimination programs”. This guide is a companion to the WHO yellow manual, “Trichiasis Surgery for Trachoma”, and a new ICTC preferred practice. • In partnership with the National NTD Control Program in Burkina Faso, the MMDP Project conducted an evaluation of the FASTT training package. The evaluator provided recommendations to update it and supported its widespread use. • The project’s Technical Advisory Boards for trachoma and LF held meetings to provide guidance on key project activities.
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IN BRIEF
During this reporting period, the MMDP Project continued to provide technical and programmatic support to national governments and the international community. The project provided support for health systems strengthening in project countries by focusing on capacity building for quality assurance of service provision for both trachoma and LF interventions. Surgical activities and capacity building, combined with supportive supervision, patient follow-up and in the case of trichiasis, surgical audits, all contributed to strengthen the programmatic, public health and clinical aspects of trachoma and LF control programs in Burkina Faso, Cameroon and Ethiopia. At the global level, the project shared its experiences and lessons learned with NTD partners through open discussions as well as joint sessions and presentations at the annual COR- NTD and American Society of Tropical Medicine and Hygiene (ASTMH) meetings. The project partnered with experts from ICTC, University of North Carolina (UNC) at Chapel Hill, Johns Hopkins University, Sightsavers, WHO and others to develop a training guide for TT surgeon trainers (to be used in conjunction with the WHO Trichiasis Surgery for Trachoma manual), which has been endorsed as an ICTC preferred practice. The project hosted and jointly organized a technical webinar on the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual, along with a presentation by Sightsavers on its TT Patient Tracker. The project also evaluated the FASTT training package, which will be updated based on the evaluation findings and recommendations from a recent WHO consultation on hydrocele.
PROJECT ACTIVITIES
SURGICAL CAPACITY AND HEALTH SYSTEMS STRENGTHENING In the first half of FY18, the MMDP Project continued its work supporting surgical initiatives for trichiasis and hydrocele surgery in the three project countries, as well as in Benin and Côte d’Ivoire. The project’s focus on quality assurance of surgical activities includes capacity building and supportive supervision initiatives which are complemented by a rigorous patient follow-up system that records patient outcomes and assesses whether any retraining of surgeons is needed. During the reporting period, the project discussed with each of the country national programs the challenges encountered conducting quality assurance measures and how to adapt quality assurance systems to better suit each country. One such example is the project’s efforts to follow-up with a higher proportion of operated TT cases through outcome assessments. The project is also working closely with the countries to adapt and help them adopt country-specific trichiasis surgical audit protocols.
In partnership with ministries of health, the project has put in place quality assurance measures that are being used systematically in all three project countries. In Ethiopia, the Federal Ministry of Health (FMOH) is working with the project to set up quality assurance systems that are in some instances exceeding the project’s quality assurance standards, which are based on international recommendations. One such example is hydrocele patient follow-up. WHO recommends countries collect patient information within five days of surgery and the number of
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patients with recurrence (which is typically attributable to the surgery if it appears 6-12 months after surgery). In its FASTT training, the MMDP Project encourages countries to conduct patient follow-up at additional timepoints, including at seven and 14 days and between one and three months. The FMOH has adopted all of these follow-up points. The project’s advocacy to routinely include quality assurance measures, and its demonstration of their feasibility, contribute to strengthening the countries’ delivery of these interventions within the existing health structure.
Capacity Strengthening in Trachomatous Trichiasis
• Training of a Francophone HEAD START master trainer for TT surgery: In addition to the activities conducted at the country level, the project continued its efforts from FY17 to increase the cadre of Francophone HEAD START master trainers beyond Dr. Amir Bedri Kello. Following a training of national trainers in Cote d’Ivoire in early FY18, the project supported Dr. Bedri to mentor Dr. Kengmogne while he was supervising the training of four surgeons in Cote d’Ivoire. On that occasion, Dr. Bedri also assessed the progress Dr. Kengmogne has made since the FY17 training and discussed with him the areas that required further practice. The project is planning additional mentoring opportunities for Dr. Kengmogne that align with Dr. Bedri’s visits to Cameroon in the second half of FY18. In collaboration with its Senior Scientific Advisor Dr. Emily Gower, the project is utilizing remote supervision to provide opportunities for Dr. Bedri to remotely supervise Dr. Kengmogne in his work as a national trainer in Cameroon. Finally, the project is working with Dr. Emily Gower to develop a standardized assessment tool for potential HEAD START master trainers that could be used by others in the global community.
• Short-term technical assistance for TT surgery: In Q1 of FY18, the project provided short-term technical assistance (STTA) to Benin and Cote d’Ivoire by training national trainers and surgeons using the HEAD START training package. The training was also an opportunity for the project to discuss recommended supportive supervision approaches to support surgical quality. Prior to the trainings, the project confirmed with the national programs that they were on-track to screen and identify the required number of TT patients for each of the trainings, but in both instances, this proved to be a challenge as they fell short of the goal. Further details regarding these trainings are presented under the STTA section.
• TT capacity strengthening activities for nurses and health care workers: One of the lessons the project learned through its interventions is that nurses and health care workers are crucial to the successful implementation of MMDP interventions, as they contribute to the overall quality of the service delivered to the patients. However, these health care workers are usually not the main target of capacity building interventions. In FY18, the MMDP Project added other components to the supportive supervision tools to be able to fully assess and identify potential gaps in knowledge, attitude or practices of the nurses and health care workers: counseling, infection control, health care waste management (HCWM), social mobilization and screening, data collection. The information
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collected through supportive supervision is fed back into the training to ensure that it is adapted to meet the specific needs of the nurse trainees. In addition, the aide memoire for TT nurses developed in FY17, based on preferred practices and WHO guidelines, is being used during training activities. During the reporting period, the project used the aide memoire in a training of four nurses in campaign organization and management in Cameroon.
Health Systems Strengthening in Trachomatous Trichiasis
• Benin Trachoma Action Plan follow-up workshop: As part of the STTA support in Benin, the project supported the national program to organize a two-day workshop in December 2017 to identify practical next steps based on the 2015 TAP. The workshop was attended by five participants from the national program, three from RTI/ENVISION, and one of the national trainers trained by the MMDP Project. During the workshop, the group developed a draft detailed action plan based on the TAP and global recommendations. Also, as part of the workshop the group defined key activities related to essential components of a TT intervention. Additional details regarding the workshop are provided under the STTA section of this report.
• Patient Follow-up activities: As part of the STTA provided to the national programs in Benin and Cote d’Ivoire, the project worked closely with the national trainers and the national coordinators to ensure that patient follow-up would be integrated into any future surgical management of TT. In both cases, the national programs committed to carrying out patient following up related to any TT surgery activity. Both countries also committed to following-up with patients who had been operated on under the MMDP Project- supported training. The project is working closely with both countries to ensure this follow-up takes place.
Capacity Strengthening in Hydrocele
• Training module for nurses and health care workers: The FASTT training package includes patient post-operative care and follow-up guidelines in line with global recommendations. One of the crucial elements of high-quality patient care that helps decrease the risk of infection is proper hygiene and the post-operative sterile change of the dressing. During the reporting period, the project used feedback from the trainings conducted in the project countries to update the training module for nurses and health care workers. In the second half of FY18, the project will further update the module by incorporating recommendations from the FASTT evaluation report and the WHO consultation on hydrocele surgery.
Health Systems Strengthening in Hydrocele
• FASTT evaluation report recommendations: In the first half of FY18 the MMDP Project conducted an independent evaluation of the FASTT training package. Details are included under the Surgical Quality Assurance section below. The main conclusion of the
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evaluation is that the FASTT training package is a useful teaching tool for teaching the basics of hydrocele surgery for health staff in charge of operating on hydrocele patients. Specific recommendations related to health systems strengthening include inviting the entire surgical team (anesthetists and support staff) to a FASTT training. In previous FASTT trainings, support staff have participated in the theoretical part of the training but not the training on the FASTT simulator or surgery on patients. Based on the evaluation recommendation, the project will revise the FASTT training package to include this as a standard practice. As the training package includes potential changes to systemic hospital practices, the evaluator recommended that hospital leadership (administrators and nurse leadership) participate in the training to be able to support at a hospital level the planning and provision of hydrocele surgery services.
SURGICAL QUALITY ASSURANCE In the first half of FY18, the MMDP Project worked with the national programs in the three project countries to further refine the surgical quality assurance strategies used by the project. The use of the HEAD START surgical simulator led to the development and use of the FASTT simulator for hydrocele surgery training in FY17. In FY18 the project conducted an evaluation of the FASTT training package to assess its impact on surgeon skills. Additional TT surgical quality assurance components include the use of supportive supervision, patient follow-up and surgical audits, and the project is in the process of revising these tools based on its TT surgical management experience. In addition, the remote supervision tool developed on a pilot basis in FY17 was further refined in FY18 for use in upcoming TT activities.
• TT surgical outcome assessment: In the first half of FY18, the project strengthened post-operative outcome assessments of TT patients at 3-6 months post-surgery. Outcome assessments target the patient and aim to have 100% of operated trichiasis cases seen by a qualified surgeon as part of routine follow-up. Building from past experience using surgical audits, the project sought to have each program develop a strategy for independent outcome assessments to test and refine over the course of the year. Country-specific examples of how this effort was rolled out is described in more detail in the Improving Data Availability and Use section.
• TT surgical audit: Continuing the project’s focus on quality, surgical audits of trichiasis surgeons continued in all project countries in the first half of the year. The surgical audit focuses on individual surgeon performance, focusing the cases selected for follow-up more narrowly on a single surgeon. As with outcome assessments, the approaches used for surgical audits vary across project-supported countries, as surgical output, total number of active surgeons, and geographic distribution of populations influence the country- specific approaches to surgical audits. Country-specific approaches to and outcomes of audits are detailed in the M&E subsection of the trachoma portion of each country’s report.
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• Update of supportive supervision tool: The MMDP Project collected feedback from the three project countries on the use of the supportive supervision tool, which is under revision with input from Dr. Gower. The updated tool is in the process of being finalized and will be shared with the three project countries. In Ethiopia, the FMOH is finalizing its own national quality assurance guidelines for trichiasis, and the project’s supportive supervision tool is in-line with these guidelines. In Cameroon, the supportive supervision data was collected and triangulated with the 3-6 month follow-up results to define and develop a tailored capacity building plan for TT surgeons, as well nurses and health care workers.
• Remote technical support: In FY17, the project explored the possibility of providing remote technical support in response to a recommendation made by the HEAD START master trainer, Dr. Bedri, following an in-country visit. Initial work using remote support in FY17 led to the recommendation to continue to try to utilize this method to provide technical feedback. In FY18, the project facilitated Dr. Bedri’s provision of remote support to national trainers in Cameroon to assist with a refresher training of TT surgeons and of nurses and health care workers. Through email and Skype calls, Dr. Bedri assisted in the analysis of results from supportive supervision and 3-6 month follow-up of operated TT cases. Following this co-review, Dr. Bedri worked with the national trainer through Skype and email to develop the curriculum for the training. In the second half of the year, the project will work with Dr. Bedri to provide remote supportive supervision during a training of TT surgeons in the Far North in Cameroon, as he will be unable to participate in-person as the area is inaccessible to foreigners due to insecurity.
• FASTT hydrocele surgery training package evaluation: In partnership with the National NTD Control Program in Burkina Faso, the MMDP Project organized a FASTT hydrocele surgery training as part of an evaluation of the FASTT training package, led by an external evaluator, Dr. Catherine deVries. The purpose of the evaluation was to assess the impact of the training package on surgeon skills. However, in order to address potential ethical concerns about measuring baseline skills of surgeons (without intervention or correction by the evaluator), a revised protocol that excluded the pre- training evaluation component was developed and shared with the project’s LF Technical Advisory Board (TAB). Based on the comments from the TAB, the project worked with Drs. deVries and Gower to revise the protocol and questionnaires. The finalized evaluation materials were shared with the LF TAB and the evaluation was conducted in February 2018. The evaluation report was submitted by Dr. deVries and shared with the project’s LF TAB in March 2018 for discussion during the April TAB meeting.
The report concluded that the FASTT training package is a useful teaching tool that provides a comprehensive system for teaching the basics of hydrocele surgery: pre-op evaluation, intra-operative considerations, instruments, instrument care, and post- operative wound care, for health staff in charge of operating on hydrocele patients. Specific recommendations related to health systems strengthening include inviting the entire surgical team (anesthetists and support staff) to a FASTT training. In previous
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FASTT trainings, support staff have participated in the theoretical part of the training but not the training on the FASTT simulator nor surgery on patients. Based on the evaluation recommendation, the project will revise the FASTT training package to include this as a standard practice. As the training package includes potential changes to systemic hospital practices, the evaluator recommended that hospital leadership (administrators and nurse leadership) participate in the training to be able to support at a hospital level the planning and provision of hydrocele surgery services. Based upon the evaluation results, the evaluator recommended, “As the FASTT training package is the most up-to-date and comprehensive curriculum available for training and continuing medical education for surgeons performing hydrocele surgery, encourage its immediate use and develop a means to alert users of available updated materials (e.g., via a WhatsApp message or website with a link to the project materials).”
• Hydrocele surgery follow-up: In addition to patient follow-up within five days of surgery, in FY18 the project conducted hydrocele surgery follow-up of patients within the 6-12 month period following surgery to assess for recurrence and confirm surgical outcome. The project continued to collect this data during the reporting period. In the second half of FY18, the project will analyze this data, and the results will be shared with local and global partners.
SHORT-TERM TECHNICAL ASSISTANCE As part of its scope, the MMDP Project responds to technical assistance requests from ministries of health and global partners for TT- and LF-related activities. In the first half of FY18, in consultation with USAID, the project conducted a follow-on training to a FY17 regional training of four national TT surgeon trainers from Benin (two) and Cote d’Ivoire (two). There were several challenges in carrying out both STTA requests, and the project shared with USAID a lessons-learned document highlighting the specific challenges encountered, lessons learned and proposed solutions.
• National training of TT surgeons, Cote d’Ivoire: The project worked with the HKI country office and the national program in Cote d’Ivoire to carry out a national training of TT surgeons in Buna District, Cote d’Ivoire in October 2017. The preliminary planning activities were coordinated with the national program and key requirements for the training were shared with the national program, including the selection criteria for the TT surgeons and the need for 50 patients for the surgery component of the training. The two national trainers previously trained under the MMDP Project in FY17 led the training of four TT surgeons, with support from the MDDP Project team of Drs. Bedri and Kengmogne. A total of 14 patients were identified for the training, which was insufficient for all participants. Therefore, the training was refocused on the two national trainers to provide them with additional surgical opportunities.
• National training of TT surgeons, Benin: Based on the training experience in Cote d’Ivoire and the skill level of the two national trainers, the project discussed with USAID
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and proposed to focus the Benin training on strengthening the surgical capacity of the two national trainers. With USAID concurrence, the TT surgery training was conducted in Tchaourou district in December 2017. Nine patients were operated on during the training. The project shared with USAID that one of the lessons learned from the Cote d’Ivoire and Benin trainings is that low-endemic countries present a challenging situation, where it may be difficult to identify potential trainers that meet the required selection criteria of having robust TT surgical experience. Following the Benin and Cote d’Ivoire STTA activities, the project recommends in-depth discussions with a national program to understand the skills and experience available at the country-level for TT surgery and the capacity for patient mobilization and screening, prior to any commitment for technical support. In addition, depending on the country situation and based on the above experience, the project recommends considering foregoing the two-tiered approach of national TT surgeon trainers and TT surgeons in favor of one level that may prove to be sufficient in some contexts, particularly where the national trichiasis burden is low.
• Benin Trachoma Action Plan follow-up workshop: As discussed under the Health Systems Strengthening section, project discussions with the NTD Coordinator revealed that although Benin had a TAP, no additional action steps had been conducted since its development in 2015. In December 2017, the project worked with the national program to organize a workshop that was attended by five members of the national program, three staff from RTI/ENVISION and one of the national trainers trained by the MMDP Project. By the end of the workshop the participants had developed a draft detailed action plan, based on the TAP and in accordance with preferred practices and global recommendations. The feedback from this activity was very positive and the national program was grateful for the work that led to a roadmap to help them reach the elimination goal.
• LF MMDP Workshop for Francophone Africa: In partnership with WHO-Expanded Special Project for Elimination of Neglected Tropical Disease (ESPEN), Global Alliance to Eliminate Lymphatic Filariasis (GAELF), and US Centers for Disease Control and Prevention (CDC), in FY17, the MMDP Project led an LF MMDP workshop focused on six Anglophone countries. In FY18, the project was invited by ESPEN to help organize and facilitate a similar workshop for Francophone countries in Africa to take place in April 2018. As part of planning activities during the reporting period, the project participated in calls for workshop facilitators and shared the modules that were used in the Anglophone workshop the previous year.
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Table 6. Overview of TT and LF Tool/Resource Development in FY18 Tool FY18 Goal Status Language Trachoma TT Surgeon Training Package Dissemination The manual was adopted English and as ICTC preferred practice French PowerPoint slides and leaflets finalized and available for dissemination Presented during HKI technical webinar - Feb. 18 French version under translation Standardized Supportive Supervision Dissemination Disseminated English and Checklists for TT Management Additional internal revision French of the tools New revised version will be utilized in FY18
Laminated support documents for TT Dissemination Finalized English and surgeons, including surgical checklist French (included in TT training package)
Aide memoire for nurses trained in TT Dissemination Disseminated English and management support and to train health French care workers involved in TT activities (only available in French)
Guidelines and support materials for Dissemination Disseminated English and infection control and health care waste French management
Upgraded TT Surgery Video In consultation with the international trachoma community it was determined that this is not a current priority. National and Master Trainer Assessment Finalization In consultation with Drs. English and Tools Bedri and Gower, the French project is developing and testing the tools to be shared with the ICTC LF WHO LF MMDP Toolkit Dissemination Revising/finalizing English and Pending WHO clearance French FASTT Training Package Dissemination Evaluating/finalizing English and French FASTT training resources for nurses/ Dissemination Finalizing English and health care workers French
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SUPPORTING GLOBAL ELIMINATION PLANNING Accurate TT estimates at the district level remain integral to the ability of countries to plan the interventions needed to reach WHO’s elimination criteria, particularly in low endemicity countries. As described in the country-specific sections of this report, the MMDP Project is playing a key role assisting the national program in Cameroon by liaising with WHO’s Tropical Data initiative to calculate age- and sex-standardized TT estimates from historical surveys. The project is also closely tracking the relationship between survey data and on-the-ground observations (e.g., data on screening, surgical output, and geographic coverage). Through this data collection and analysis, the project aims to support national programs to document the efforts that have taken place in districts where TT estimates, despite being age and sex standardized, may contradict other information on TT prevalence. As the project works in districts that are reaching the ‘last mile,’ the project is well positioned to raise key questions in the global trachoma community that will help refine elimination planning at the global level.
In Burkina Faso, as part of the discussion and planning around the last mile, the national program supported a TAP workshop in February 2018. The meeting was supported by the MMDP and the END in Africa Projects. The MMDP Project engaged Mr. Chad MacArthur to facilitate the meeting, which was attended by the l’Occitane Foundation, Sightsavers, and included participation from members of the water and school-health sectors of the ministry. The meeting provided a forum to discuss progress made to date on achieving the elimination criteria for both interruption of transmission and trichiasis. The meeting included a review of the epidemiological data for trichiasis, including provisional categories to help prioritize districts: those in need of immediate service provision, those in need of a TT-only survey and those which will receive revised estimates to better inform decision-making within the coming year. As part of the meeting, the participants prepared a list of action items pertinent to each component of the Surgery, Antibiotics, Facial cleanliness, and Environmental improvement strategy. Following the meeting, the project has continued to support the national program to move the action items forward, specifically, data entry into the WHO elimination dossier template and trichiasis service provision in priority areas. A similar trachoma action planning meeting is planned in Cameroon for the second half of FY18 with costs shared across the MMDP and ENVISION Projects.
On the LF front, the MMDP Project continued to support WHO to finalize the LF MMDP Toolkit. The MMDP Project worked with the WHO LF Focal Point in Geneva to incorporate the new illustrations developed under the MMDP Project and develop short descriptions of each of the toolkit documents for posting on the WHO website. At the request of WHO, the project developed a facilitator’s guide to conduct a LF MMDP workshop similar to the ones carried out in SEARO and Tanzania. The draft guide is currently under review by WHO.
Following the planned April 2018 WHO-ESPEN LF MMDP workshop for Francophone countries, the project will discuss with the Burkina Faso national program next steps to begin preparing the LF MMDP elimination dossier. In Cameroon, the project will support in the last half of FY18 a LF strategic planning workshop with local and global partners.
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IMPROVING DATA AVAILABILITY AND USE The MMDP Project continued to collect, review, compile, and analyze data corresponding with its TT and LF indicators, which are summarized in Appendix A. In addition to summarizing project activities and results, these indicators have enabled the project to strengthen its internal programmatic feedback loops and engage in evidence-based decision-making. For example, as described in the country-specific sections of this report, the project has relied on its 3-6 month post-TT surgery outcome data to determine the nature and timing of FY18 surgeon training activities.
Trachomatous Trichiasis
Piloting new approaches to TT surgery quality assurance, through the implementation of outcome assessments (previously called centralized follow-up) and surgical audits as two distinct activities, has been another key M&E priority in FY18. The project began working with staff in Burkina Faso, Cameroon, and Ethiopia to develop country-specific approaches and corresponding protocols that reflect the nuances of the different country contexts.
• In Burkina Faso, the project has been piloting outcome assessment as a new, separate activity since the end of FY17. Initial implementation has resulted in 20 additional people receiving an examination 3-6 months after surgery during the reporting period, yet the majority of those who receive this important follow-up exam are successfully reached only when the project actively seeks them out in their homes. Early lessons learned by the project highlighted the time- and resource-intensive nature of outcome assessment in the Burkina Faso context, as surgical outreach sites are often widely geographically dispersed. As a result, the team must organize, staff, and supervise many “centralized” follow-up sites within a single district. For surgical audits, a new protocol is under development that 1) adjusts the project’s previously implemented sampling strategy so that it is surgeon-based, 2) assures the audit team composition reflects current global preferred practices, and 3) narrows the scope of the follow-up interview so that it focuses most heavily on verifying and assessing surgeon performance. The new protocol will be piloted in Q3, although the limited availability of surgeons and technical supervisors (who are the same individuals participating in TT surgery campaigns and outcome assessments) poses a challenge to staffing surgical audit teams.
• In the low-burden setting of Cameroon, the number of individuals receiving TT surgery during a campaign is often small enough that it is feasible for the project to actively seek out all operated cases in their homes 3-6 months after surgery. Within this context, the project is revamping its 3-6 month questionnaire components to align with current preferred practices for both outcome assessments and surgical audits, so that the activity may fulfill the objectives of both activities to the greatest extent possible when surgical output is very low. A surgical audit protocol outlining a process for surgeon-based sampling is also under development for use when surgical output is high enough to warrant sampling. The revised approach will be piloted during the 3-6 month post-operative window for the campaigns conducted during FY18.
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• In Ethiopia, the project’s roll out of its FY18 approach coincided with the FMOH’s unveiling of a comprehensive and integrated approach to TT surgical quality assurance. To ensure alignment with the FMOH’s national guidelines, the project paused its piloting of new processes during Q1 and instead provided feedback on the draft guidelines the FMOH shared with partners for review. In December 2017, the FMOH convened a meeting to discuss the guidelines that was attended by project staff in Ethiopia. Following this meeting, the global project team began working with in-country partners to develop practical implementation strategies for surgical audits and outcome assessments based on FMOH guidelines and current best practices shared by the international trachoma community.
• Analysis of data gathered through TT supportive supervision tools will take place primarily in the second half of FY18, as Q1 and Q2 were focused on revising the project’s existing tools and checklists to facilitate user completion of the materials and increase the frequency of data sharing. The project will rely primarily on the data generated from the revised checklists to analyze the data as described in the FY18 work plan, with special emphasis on linking supportive supervision results with post-operative outcome data, to the extent possible.
• The project has also begun planning the details of its exploration of TT surgery refusals. As described in the FY18 work plan, this activity was initially envisioned as compiling qualitative data on refusals at the time that refusals are documented, with the goal of identifying, understanding, and, to the extent possible, addressing the underlying reasons in each country-specific context. However, as part of the discussions that took place during the Q2 TAP in Burkina Faso, the project identified the opportunity to support the national program in strengthening its approach to systematically documenting refusals. In FY18, the project will prioritize supporting a clear system to identify and document TT case refusals within the existing health system. Proper case refusal management should enable the health system to know where TT case refusals are for continued counseling and provision of opportunities for TT surgical management.
Hydrocele
• MMDP Project guidance is that all patients undergoing hydrocele surgery receive a follow- up within five days post-surgery, as recommended by WHO. The project has used lessons learned from TT surgery quality assurance to conduct patient follow-up 6-12 months post-hydrocele surgery, including questions on quality of life changes. The project is conducting this activity in all three countries. Once the data is compiled and analyzed the project plans to prepare a comprehensive document looking at surgical services, patient outcomes within five days of surgery and recurrence in the 6-12 months following surgery. The document will be finalized later in the project year.
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OPERATIONAL RESEARCH The project worked closely with the project’s Senior Scientific Advisor, Dr. Emily Gower, WHO and Sightsavers to conduct operational research activities in an effort to develop and share technical guidance related to MMDP in support of USAID’s portfolio.
• Surgical management of post-operative TT: Based on discussions with the WHO Trachoma Medical Officer Dr. Anthony Solomon and Dr. Gower, the project included in its FY18 workplan support of programmatic research activities to develop a training curriculum on surgical management of postoperative trichiasis. The proposed project support relies in part on preliminary activities conducted by Dr. Gower, in collaboration with Dr. Merbs from Johns Hopkins University. These preliminary activities encountered delays and the project is in regular contact with Dr. Gower with regards to the revised timeline. At this stage no set dates have been shared for the proposed activities that could be supported by the project, including surgeon trainings on a pilot basis. In the meantime, Dr. Gower has also approached several donors with a proposal to help support the surgical management of post-operative TT activities and there has been no conclusive feedback yet. Dr. Gower is working to obtain IRB approval from UNC to facilitate the surgical work once activities start. The MMDP Project’s involvement is currently on-hold pending further discussions with USAID regarding the project’s future involvement.
• Predictors of TT surgical outcomes: In Q2 of FY18, eight project staff in Burkina Faso and Cameroon received training in taking photographs of operated eyes immediately before and after trichiasis surgery. The photos will be used to generate additional information regarding potential predictors of surgical outcomes in a programmatic setting, and to help facilitate unbiased assessment of surgical outcomes during outcome assessment and surgical audits. MMDP Project global team members provided the trainings (which took place in January in Burkina Faso and in March in Cameroon), which included detailed planning for the roll-out of the pilot for the first TT campaigns of the year. Those trained in photo-taking were individuals who already participate in supervision of TT surgical and post-operative follow-up activities. During the reporting period, Burkina Faso piloted the photo-taking with a sample of 55 operated cases during its first four campaigns, the results of which the project is currently assessing. In Cameroon, MMDP Project staff trained five surgeons and supervisors in the North in photo-taking, using the post-operative follow-up in Touboro district in March 2018 as an opportunity for informal practice. The photo-taking pilot will take place during the first FY18 TT campaign, planned for Q3. The quality and quantity of photos collected, and the logistics of taking photos within each country’s campaign model, will inform the project’s potential integration of photo-taking into future campaigns.
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• Evaluation of the FASTT training package: As discussed above, the MMDP Project worked with Dr. deVries to lead the evaluation of the FASTT training package during a training in Burkina Faso. The evaluation report provided the following recommendations that will be discussed with the project’s TAB during its quarterly meeting in April 2018.
o Integrate technical updates into the FASTT videos and training materials to be consistent with the 2017 WHO consultation on surgical management of hydrocele surgery. o Consider including entire surgical teams, including anesthetists and support staff, as participants in the FASTT training. Also, as systemic hospital practices may need to change to incorporate the recommendations in the FASTT training package, it may be important to engage hospital leadership (administrations and nurse leadership) in the training. o As the FASTT training package is the most up-to-date and comprehensive curriculum available for training and continuing medical education for surgeons performing hydrocele surgery, encourage its immediate use and develop a means to alert users of available updated materials (e.g., via a WhatsApp message or website with a link to the project materials). o Encourage the use of the evaluation tools included in the FASTT training package to evaluate participant skills on the FASTT simulator and on patients.
DISSEMINATING BEST PRACTICES Scientific Leadership The MMDP Project worked closely with its local and global partners, to prepare and submit abstracts and presentations for conferences. The project is also working on white papers and manuscripts for publication in peer-reviewed journals. They include the following:
• Annual Meeting of the Coalition for Operational Research on Neglected Tropical Diseases, November 2017, Baltimore, Maryland: (accepted) o Breakout session: Post-trichiasis surgery follow-up at 3-6 months: Experiences and lessons learned (joint with Kilimanjaro Centre for Community Ophthalmology, Sightsavers, UNC) o Innovation Lab sessions: ▪ FASTT: A Surgical Simulator for Hydrocele Surgery; ▪ MMDP Toolkit to Address Lymphatic Filariasis Disease (joint with CDC)
• ASMTH Annual Meeting, November 2017, Baltimore, Maryland: (accepted) o Symposium: Follow-up tools for surgical quality assurance o Abstracts for oral presentations ▪ TT screening and active case finding, an opportunity for eye health programs: Case study of the MMDP Project in Burkina Faso ▪ Outcomes of a Pilot Hydrocele Surgery Camp in Ethiopia (RTI submission under the MMDP Project in Ethiopia)
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o Abstracts for posters: ▪ Management of the quality of trichiasis surgery services in a community setting in Cameroon: Implementing a quality assurance approach ▪ Confirming Trachomatous Trichiasis prevalence: Pilot TT-only survey in Touboro health district in North Cameroon
• Submissions to the 2018 ASTMH Annual Meeting: (submitted, awaiting feedback) o Symposium: Health Systems Strengthening through Capacity Building and Service Delivery for Hydrocele Surgery: Case studies from Africa and Asia. Submitted in collaboration with Center for Neglected Tropical Diseases (CNTD)-Liverpool School of Tropical Medicine (LSTM) o Abstracts for oral and poster presentations (to be determined): ▪ Quality of Life Changes and Post-Operative Follow-Up of Hydrocele Surgery Patients ▪ Community-based approach to identify hydrocele cases: Results of a pilot in five health districts in Cameroon ▪ The “last mile” of trichiasis management in Cameroon: Aligning implementation and epidemiological data at the threshold of trachoma elimination ▪ Identification of barriers to hydrocele surgery: Case study of the Bibemi and Kar-Hay health districts in Cameroon ▪ Strengthening the quality of trachomatous trichiasis surgical services: Using an integrated supportive supervision approach
• The MMDP Project is preparing case studies, peer reviewed articles, white papers, and grey literature on the following topics: o Experience in TT case finding across countries; o Experience offering epilation counseling for TT cases that refuse surgery; o LF situation analysis, burden assessment and health facility assessment experiences across the project countries; o Hydrocele surgery and post-operative follow-up; and o FASTT evaluation results.
• Manual for trainers titled “Training Trichiasis Surgeons for Trachoma Elimination Programs”: As described above, in FY18 the MMDP Project finalized this training manual as an ICTC preferred practice in partnership with global partners. The MMDP Project also finalized a French translation of the manual and submitted it to ICTC for review. We anticipate the French version will be available by the end of FY18.
• MMDP Technical Updates: In February 2018, the MMDP Project organized a NTD technical update featuring the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual. An introduction and background was provided by Dr. Emily Gower
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 94
(UNC at Chapel Hill). An overview of the manual was presented by Dr. Amir Bedri Kello (Light for the World) and Sabrina La Torre (Helen Keller International). Sarah Bartlett and Kim Jensen from Sightsavers presented on the Trichiasis Surgery Patient Tracker: A common application. More than 50 people registered for the webinar, and 30 logged into the platform at the time of the webinar. Following the live presentation, the project shared the presentations, a link to the recording of the webinar, and a complete list of questions with responses (as all questions were not able to be addressed during the webinar itself) with registrants. An exit survey, in which half of webinar participants responded, showed an overall positive response to the webinar, and that participants felt the speakers were knowledgeable. Participants also responded that the topics presented were relevant as priority issues to trachoma elimination and that the content was relevant to their jobs.
• NTD NGDO Network – Disease Management Disability and Inclusion Working Group (DMDI): The MMDP Project presented remotely on the trachoma and LF-related indicators collected under the project to the DMDI meeting in the UK in March 2018. The presentation was well received and followed by an active discussion and questions from the audience members.
FACILITATING GLOBAL COLLABORATION During the reporting period, based on internal discussions and discussions with USAID, the MMDP Project intensified its collaboration efforts to raise the visibility of the project with local and global partners and to create opportunities for additional partnerships. This effort has not only increased the project’s visibility and transparency within the global community, but also has led to potential new partner initiatives in both trachoma and LF. A few examples of these new initiatives include the project’s discussions with Sightsavers on its TT patient tracker app, and the webinar that the project organized with global technical TT experts. On the LF front, the project submitted a joint symposium application with CNTD-LSTM for hydrocele surgery and health systems strengthening, and the project is currently discussing with Sightsavers its work in hydrocele surgery. The project will continue to contribute to global conversations on MMDP through presentations and discussions on lessons learned as highlighted under the Improving Data Availability and Use and Disseminating Best Practices sections.
• Global Trichiasis Scientific Meeting: Although a date has yet to be set, the MMDP Project has reconfirmed to Dr. Anthony Solomon of WHO its continued readiness to help support a global trichiasis or trachoma scientific meeting, as per WHO needs.
• Monthly Morbidity Management Meetings of the LF MMDP Community and ad hoc meetings of the TT MMDP Community: In FY18, the project facilitated and served as the secretariat for the Monthly Morbidity Management Meetings of the LF Community (MMMM). No meeting of the ad hoc Global TT Coordination Meeting took place during the reporting period, and the project is using other international meetings and its quarterly TAB meetings to engage with the TT community.
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The MMMMs led by WHO include representatives from HKI, CDC, African Filariasis Morbidity Project, GAELF, Government T.D. Medical College Hospital-India, the Malaria Consortium, RTI, and USAID, with new members in FY18 including CBM, CNTD-LSTM, and Sightsavers. MMMMs were held in October and December 2017 and January, March and April 2018.
During the reporting period, the project reinitiated its TABs. As presented in the workplan, the project created two technical advisory boards, one focused on each disease. The LF TAB also welcomed a new TAB member, Emily Toubali (USAID LF Consultant). All of the TAB members who also serve as consultants on the project confirmed that they will volunteer their time on the TAB.
The first of the quarterly meetings of the Trachoma TAB was held in December 2017. During the meeting, the TAB elected Dr. Gower as the chair, and proposed and agreed on its terms of reference for the TAB. The meeting focused on discussion of the main FY18 trachoma activities planned for the project. The member participation was strong and discussions focused on several points raised, namely the lidocaine with adrenaline shortage and proposed research activities. Following the TAB meeting, the project reached out to TAB members to obtain their technical feedback on a standard operating procedure to mix lidocaine with adrenaline. In the interim, the Burkina Faso national program that does not have access to pre-mixed lidocaine with adrenaline has decided to conduct surgery using lidocaine only.
The first quarterly meeting of the LF TAB was held in December 2017. It followed the same format as the trachoma TAB meeting and the nominated chair was Dr. Charles Mackenzie. TAB members actively participated in discussions on the upcoming project activities. Following the meeting, the project reached out to the TAB members to obtain feedback on a number of planned activities, including the 6-12 month protocol for hydrocele surgery patient follow-up, a lymphedema management feasibility study protocol, and the FASTT evaluation protocol.
OPERATIONAL ACTIVITIES
HUMAN RESOURCES During the reporting team, the project hired Geri Kemper as a Program Associate. This position was created as a result of the project team restructuring that occurred in late FY17.
TRAINING AND PROFESSIONAL DEVELOPMENT No global team training or professional development opportunities were funded by the MMDP Project during the reporting period.
PROJECT MEETINGS During the reporting period, monthly project team meetings were transitioned to weekly team meetings, focusing on FY18 country and global work plans and project updates.
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CENTRAL-LEVEL PROCUREMENT Central-level procurement of supplies for FY18 trichiasis management and LF MMDP activities took place throughout the reporting period. Details are provided in Table 7 below. The project was not able to identify a USAID-approved wholesaler to provide lidocaine 2% with 1:100,000 adrenaline. As a result, the project procured the specific drug with organizational funds. As Burkina Faso did not have a supplier with lidocaine with adrenaline (pre-mixed), during the reporting period surgeries were conduct only with lidocaine (without adrenaline), as recommended by the Burkina Faso national program. HKI purchased the lidocaine in Burkina Faso with organizational funds.
Furthermore, due to the unavailability of TT surgery drugs from IMRES and the timing of the campaigns, HKI purchased with organization funds the drugs needed for the first few campaigns in Burkina Faso, so as not to delay TT campaigns.
Table 7. MMDP Project Headquarters Procurement (USAID-supported) HEAD START FASTT Pharmaceuticals
Burkina Faso 150 eyelids; 8 orbits 60 cartridges Various (via IMRES)
Cameroon 100 eyelids; 8 orbits - Various (via IMRES) Ethiopia 576 eyelids; 36 orbits - - DC Office 120 eyelids; 10 orbits 15 cartridges -
REPORTS TO USAID The MMDP Project submitted the FY17 Environmental Mitigation and Monitoring Reports for Burkina Faso, Cameroon, and Ethiopia in October 2017. The FY17 Annual Progress Report, covering October 1, 2016 – September 30, 2017, was submitted in November 2017. Additionally, informal monthly updates on project activities were shared with USAID throughout the fiscal year.
FY18 WORK PLANS A draft FY18 work plan and budget for the three MMDP Project countries and the global activities was submitted to USAID on August 1, 2017. The revised work plan and budget based on USAID feedback and comments was approved by USAID on December 5, 2017.
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APPENDICES
APPENDIX A – MMDP PROJECT SUMMARY DATA TABLES Trachoma (tables A1-A4) • LF (tables A5-A8) • Other Project Activities (table A9)
APPENDIX B – FY18 SEMI-ANNUAL REPORT IMPLEMENTATION TIMELINES
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Trachoma Table A1. TT Management Services: Targets vs. Actuals by Project Area For each geographic area the MMDP Project has targeted with trichiasis management services, the following table summarizes how project achievements relate to the area’s UIG. • The project’s trichiasis management activities support progress towards the elimination threshold of a prevalence of TT unknown to the health system of less than 1 case per 1000 total population. The project therefore tracks the number of people receiving trichiasis surgery and the number of cases otherwise made known to the health system. The number of cases otherwise made known to the health system is defined as all known cases of individuals who refuse surgery or are referred by the project for surgery due to either lower eyelid trichiasis or an age of less than 15 years. (Referrals due to post-operative TT are not included, to avoid counting the same individual more than once.) • As the epidemiological data used to calculate the UIG change with each new trachoma survey, the UIG will be updated as needed in future reports to reflect the most recent estimates. The calculation of the Remainder against the UIG considers all TT surgeries since the most recent survey, including those conducted by other implementers. • UIG data for Ethiopia include data only from woredas covered by the MMDP Project.
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Table A2. TT Management Services: Geographic Context
For additional details, please refer to the following country-specific notes: Burkina Faso • Although all four districts in the Center North with a UIG were originally planned for project intervention in FY16, the coup d’état in September 2015 resulted in delays and the project’s inability to conduct activities as planned.
Ethiopia • In Oromia, the MMDP Project’s area of coverage encompassed 115 woredas with a UIG at the time of FY18 work planning. However, due to redistricting that took place at the beginning of FY18, this number of project-supported woredas increased to a total of 142. The Oromia woredas not within the MMDP Project’s area of coverage are towns or are supported by another partner. • In Tigray, the project currently targets 31 woredas spanning five zones (increased from 25 woredas targeted in FY17, and 22 woredas targeted in FY16).
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Table A3. MMDP Project Achievements: Trichiasis Management (USAID-supported) The following table provides a breakdown of the intensive trichiasis management services provided by the MMDP Project. Please note the following: • The number of people confirmed with TT does not always equal the number of people who received surgery, were referred for surgery, or refused surgery. Some individuals are lost to follow-up and not formally tracked by the project. • Referrals: The project refers to a higher-level facility post-operative or lower-lid trichiasis cases as well as those <15 years old with TT. • Epilation: Individuals are reported as receiving epilation counseling only if they were provided with a pair of high-quality forceps, as recommended in the WHO Second Global Scientific Meeting on Trachomatous Trichiasis report. The project supports each Ministry of Health’s official stance on epilation. The project will continue to advocate for the adoption of the recent WHO guidance regarding epilation as an alternative trichiasis management strategy. • Number of people receiving surgery or otherwise made known to the health system: As the project’s trichiasis management activities support progress towards the elimination threshold of a prevalence of trichiasis unknown to the health system of less than 1 case per 1000 total population, the project tracks the number of people receiving trichiasis surgery and the number of cases otherwise made known to the health system. The number of cases otherwise made known to the health system is defined as all known cases of individuals who refuse surgery or are referred by the project for surgery (due to either lower eyelid trichiasis or an age of less than 15 years). Referrals due to post-operative TT are not included, to avoid counting the same individual more than once.
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Table A4. MMDP Project Achievements: Trichiasis Training (USAID-supported)
The following table provides a breakdown of the MMDP Project’s trichiasis training activities to date21. • The table does not include FY15, as the year was a period of start-up and therefore did not have external trainings provided by the MMDP Project. Two national trainers in Cameroon began training at the very end of FY15, which is captured in FY16 data due to the timing of reporting cycles. • Recipients of surgeon refresher trainings are defined below as those who receive both an initial training and a second training from the project. • Certification of TT surgeons by the MMDP Project follows the guidelines included in the WHO Trichiasis Surgery for Trachoma (2nd Edition) surgeon training manual. National trainers are included in the number of TT surgeons certified if they are certified as part of the national trainer training process. In some cases, individuals are already certified at the time of their national trainer training and therefore are not included in the number certified. In addition, TT surgeons receiving refresher training are already certified and therefore not included in the number certified. • Supervision training includes training of technical and non-technical supervisors. When supervision training is incorporated into national trainer training, individuals trained in both capacities are counted in both table rows.
21 In Ethiopia, the cost of the FY17 training of 2,050 TT case finders (HEWs/HDAs trained by LFTW) was shared between the MMDP Project and ENVISION funds. In addition, the FY17 training of the 268 outreach coordinators in campaign management was financed by the Tigray Regional Health Bureau, with the MMDP Project providing technical support. MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 102
Lymphatic Filariasis
Table A5. LF Disease Management Services: Targets vs. Actuals by Project Area
The table below summarizes the project’s LF disease management achievements to date in relation to regional targets and current burden estimates. Burden estimates represent data from only those districts targeted by the MMDP Project.
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Table A6. LF Disease Management Services: Geographic Context
The table below provides an overview of the districts the MMDP Project has targeted with direct provision of LF disease management services (i.e., hydrocele surgeries and/or lymphedema management training for individuals with lymphedema). FY15 and FY16 are excluded from the table because the MMDP Project did not begin directly providing LF disease management services until FY17.
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 104
Table A7. MMDP Project Achievements: LF Training (USAID-supported)
The following table provides a breakdown of the MMDP Project’s LF training activities to date. • The table does not include FY15, as the year was a period of start-up and therefore did not have external trainings provided by the MMDP Project. • Supervision training includes training of technical and non-technical supervisors. When supervision training is incorporated into national trainer training, individuals trained in both capacities are counted in both table rows. • Health staff trained in hydrocele surgery support include other operating room team members (e.g., anesthesiologists) and/or nurses trained in hydrocele surgery follow up.
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Table A8. MMDP Project Achievements: Additional LF MMDP Activities (USAID-supported)
The table below summarizes additional LF MMDP activities conducted to date.
• LF Burden Data Collection: The districts reported are those in which the project has supported the collection of LF burden data, which includes support in the form of supervision and/or additional technical support. FY15 is not included in the table for Burkina Faso and Ethiopia because the project did not begin supporting LF burden data collection in those countries until FY16.
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Table A9. MMDP Project Achievements: Other Project Activities (USAID-supported)
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 107
Appendix B – FY18 Semi-annual Report Implementation Timelines
Global
FY18 Global Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S
KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Capacity Strengthening HEAD START Remote Technical Support C C C C C C I I I I I I FASTT Hydrocele Surgery Training C Health Systems Strengthening Training of a Francophone HEAD START C S Master Trainer Resource/Tool Development C C C C C C I I I I I I Updating FASTT hydrocele surgery video based on latest WHO recommendations I I I I I I from hydrocele consultation WHO Hydrocele Surgery Consultation C
Surgery costing exercise I I I I Short Term Technical Assistance HEAD START National Training of TT C C Surgeons (Benin and Cote D'Ivoire) Assessment of HEAD START TT Surgeons training in Benin
Regional HEAD START Training
FASTT Training and Assessment C FASTT ToT Workshop and the training of 8 hydrocele surgeons Contribute towards the WHO impact of
HEAD START on TT recurrence study Supporting Global Elimination Planning Technical support to WHO in developing standardized LF MMDP Workshop package & C Facilitator's Guide Technical support to WHO for Francophone C C LF MMDP Workshop Technical support for review of French S S S version of the LF MMDP Toolkit
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 108
Global, cont.
FY18 Global Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Improving Data Availability and Use Maintain the project’s robust M&E system C C C C C C I I I I I I Document results of 3-6 month follow-up S S S and surgical audits Analysis of data gathered through supportive S S S supervision activities Document reasons for refusal of TT surgery S S S Operational Research Surgical Management of Post-Operative TT: S S S Oculoplastic surgeon training Predictors of TT surgical outcomes C C C I I I I I I Disseminating Best Practices MMDP Technical Updates C S S Scientific Leadership NNN S COR-NTDs C ASTMH C Facilitating Global Collaboration Global Trichiasis Scientific Meeting 3 S TAB Meeting TT / TAB Meeting LF C C S S Monthly Morbidity Management Meetings of the LF MMDP Community and ad hoc C P C C P C S S S S S S meeting of the TT MMDP Community Operational Activities Project Meetings C C C C C C S S S S S S Reports to USAID C C C C C C S S S S S S FY19 Work Plans S Central-Level Procurement Consumables (HEAD START, FASTT) and C C S S S S Pharmaceuticals
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 109
Burkina Faso
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning PNMTN 2019 annual action plan S Workshop for the development of the S FY19 MMDP Project work plan Workshop to finalize the FY 19 MMDP S Project work plan Quarterly coordination meetings C C PNMTN technical and steering C committee workshops Meeting with the PNMTN to develop the C C trachoma elimination dossier Meeting on managing residual TT cases P (scale-down) Advocacy Meeting on project implementation outcomes in the Centre-Nord and Hauts- C C Bassins regions Advocacy days in the Orodara and C N’dorola health districts Informing the administrative and political C C C S S authorities in the areas of intervention Social Mobilization and Behavior
Change Initiatives IEC materials C C C Local media C C C S S Public criers C C C S S Capacity Building/Training Training for two national assistant S trainers / supervisors Training for TT surgeons using the HEAD S START surgical simulator Training for DRS and HD teams on preferred practices for organizing a S grassroots campaign
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 110
Burkina Faso, cont.
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Capacity Building/Training Training for CSPS health workers on S diagnosis and postoperative follow-up CBHW training on case-finding and S referral Information sessions for traditional health S practitioners (THPs) Assessing the Trachoma Disease
Burden
Evaluation of the achievement of the UIG C C C S S in the Centre-Nord TT-only survey P P Trichasis Management, Including
Surgery Pre-surgery TT case-finding C C C S S Equipment and supplies for the surgical C C C S S team
Campaign preparatory meeting with the C C C S S ECD members and ICPs
Preparatory meeting with the TT C C C S S screening and surgery teams Surgery camps C C C S S Managing refusal cases C C C S S Postoperative follow-up C S S S S Treatment of referred TT cases C C C S S Supportive supervision during the surgery C C C S S campaigns
Data collection and transmission during C C C S S TT surgery campaigns Commodity Supply Management and
Procurement Procure drugs and consumables C C C C
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 111
Burkina Faso, cont.
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Supervision Training sessions for two assistant S master-trainers Training sessions for TT surgeons S Training sessions for DRS and DS teams on preferred practices for organizing a S grassroots campaign Training for CSPS health workers on TT S diagnosis and postoperative follow-up CBHW training on case-finding and S referral To supervise the meetings of information S to the profit of tradipraticians (TPS) Information sessions for traditional health S practitioners (THPs) TT surgical campaign C C C C C Equipment and consumables management C C C C C Short-Term Technical Assistance in
Trachoma Develop TT-only survey protocol P Postoperative TT management training P Support for trainers to train assistant S S national-trainers M&E Managing cases of reluctance or refusal C C C Passive patient monitoring at the health C S S S S center 3-6 months post-surgery Evaluation of surgery and epilation quality C S S S S Surgical camp assessment meeting C C C S S Validation sessions P S Geographic coverage of TT treatment C C C S S services TT surgery data management C C C S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 112
Burkina Faso, cont.
FY18 LF MMDP Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning Advocacy Social Mobilization and Behavior Change Initiatives Disseminate awareness messages via local media C C C C C C Capacity Building/Training Assessing the LF Disease Burden Active data collection C C C C C C Hydrocele Surgery Hydrocele cases identification C C C C C C Provide hydrocele surgeries at district operating C C C C C C blocs Post-operative monitoring C C C C C C Data collection and transmission C C C C C C Lymphedema Management Patient monitoring C C C Data collection C C C LF Commodity Supply Management and
Procurement Procurement of the pharmaceutical products and consumables for hydrocele surgical teams C C C Develop kits for pharmaceuticals and C C C consumables Ensure provision of pharmaceuticals and C C C consumables at all levels Supervision ICP quarterly supervision of CBHWs C Annual supervision of the DRS teams C Management of pharmaceuticals and C C C C C C consumables Supervise the CHR operating room team C C C C members Supervise the CMA operating room teams C Home-based lymphedema treatment C C C C C Waste Management C C C C C C
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 113
Burkina Faso, cont.
FY18 LF MMDP Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Short-Term Technical Assistance in LF M&E Biannual supervision of the ECDs C Management of data on lymphedema management and hydrocele surgery C C C C C
Data validation sessions P
FY18 Cross Cutting Activities Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed NTD Secretariat Office supplies C C C IT equipment C C C Communications C C C C C C S S S S S S Environmental Mitigation and Monitoring Plan Mitigate harmful environmental impacts and ensure that infection prevention C C C C C C S S S S S S measures are followed Integration with other diseases Disseminate the practices and the outcomes/experiences during project S S S S S S implementation Health System Strengthening
Communications and Media Relations
Planned Subawards to Local Organizations and/or Governments
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Cameroon
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4 O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning North Region - Mid Term Evaluation Meeting S Far-North Region - Mid Term Evaluation S Meeting North Region - Regional Planning and S Evaluation Meeting Far-North Region - Regional Planning and S Evaluation Meeting National Evaluation and Planning Meeting C FY19 Work Plan Development Meeting S Coodination Meeting at regional and national C S S level Trachoma elimination working group S meetings Advocacy North region - Advocacy meeting at regional C Level - with Regional Governor
North region - Advocacy meeting at district C Level -Touboro Health District
Far-North region - Advocacy meeting at S regional Level - with Regional Governor
Far-North region - Advocacy meeting at S district Level - Meri Health District Social Mobilization and Behavior
Change Initiatives Revision and Production of IEC Material C C C Community meetings for the first TT S campaign (North & Far-North) Community meetings for the second TT S campaign (North & Far-North) Production and diffusion of Radio - TV S magazine prior to the first TT campaign Production and diffusion of Radio - TV S magazine prior to the second TT campaign
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 115
Cameroon, cont.
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4 O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Capacity Building/Training Refresher of TT surgeon in the North region C Refresher of TT surgeon in the Far-North S region
Professional development and remote S S technical support for technical supervisors
Training of TT supervisors in the - Regional & P District level Far-North region Training of Health Area nurses first campaign C North (Touboro) Training of Health Area nurses second S S campaign North (Touboro) Training of Health Area nurses first campaign S Far-North (Meri) Training of Health Area nurses second S S campaign Far-North (Meri) Training of community members first C campaign North (Touboro) Training of community members second S S campaign North (Touboro) Training of community members first C campaign Far-North (Meri) Training of community members second S S campaign Far-North (Meri) Assessing the Trachoma Disease
Burden TT only survey in Mada district in the Far C North Trichasis Management, Including
Surgery TT Campaign 1 - 2nd Quarter in the Far- S S North & North TT Campaign 2 - 3rd Quarter in the Far- S S North & North Commodity Supply Management and
Procurement Procurement C C C C C C
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 116
Cameroon, cont.
FY18 Trichiasis Work Plan Implementation Timeline Q1 Q2 Q3 Q4 O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Supervision Supervision of Community meetings prior to the first S TT campaign (North & Far North) Supervision of Community meetings prior to the S S second TT campaign (North & Far North) Supervision of Social Mobilization activities prior to C S the first campaign (North & Far-North) Supervision of Social Mobilization activities prior to S S the second campaign (North & Far-North) Supervision of refreshment of TT surgeon in the C S North & Far North Supervision of health area nurse training prior to the C S first TT campaign (North & Far-North) Supervision of health area nurse training prior to the S S second TT campaign (North & Far-North) Supervision of community outreach workers prior to C S the first TT campaign (North & Far-North) Supervision of community outreach workers prior to S S the second TT campaign (North & Far-North) Supervision of the first TT campaign (North & Far- S S North) Supervision of the second TT campaign (North & Far- S North) Short-Term Technical Assistance in Trachoma Technical Assistance for the development of the S S S FY19 MMDP Workplan Technical Assistance for the Drafting of the C C C S S S S S S elimination Dossier M&E Production of datas collect tools C C C TT Camapign 1 - 3-6 month post TT follow up in S Touboro TT Camapign 1 - 3-6 month post TT follow up in S Meri 3-6 month post-TT follow up in Poli C Surgical Audit North & Far-North S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 117
Cameroon, cont.
FY18 LF Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning Workshop for the documentation of lessons P learned from FY17 LF activities Workshop for the development of National P Strategic Plan for LF Morbidity Management Prepatory workshop #1 prior to the development of National Strategic Workplan P for LF Morbidity Management Prepatory workshop #2 prior to the development of National Strategic Workplan P for LF Morbidity Management Workshop for the validation of National P Strategic Plan for LF morbidity management Advocacy Social Mobilization and Behavior
Change Initiatives Capacity Building/Training Assessing the LF Disease Burden Hydrocele Surgery Hydrocele Surgeries in North and Far North C C C Districts Lymphedema Management LF Commodity Supply Management and Procurement Supervision Supervision of hydrocele surgeries C C C Short-Term Technical Assistance in LF M&E
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 118
Cameroon, cont.
FY18 Cross Cutting Activities Work Plan Implementation Timeline Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed NTD Secretariat Participation of HKI Staff in coordination C C C C C C S S S S S S meeting at all levels Workshop for the development of trachoma elimination dossier Environmental Mitigation and Monitoring Plan waste management activities C C C S S Integration with other diseases Community mass NTD drug administration campaigns Cataract data collection Health System Strengthening Human resources C C C C C C S S S S S S Health information C C C C C C S S S S S S Funding C C C C C C S S S S S S Governance C C C C C C S S S S S S Service offering C C C C C C S S S S S S
Planned Subawards to Local Organizations and/or Governments
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 119
Ethiopia
FY18 Trichiasis Work Plan Implementation Timeline FHF Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning Zonal IECW Perfomance Review and C C C C C S Planning Meetings1 Advocacy Zonal level advocacy meetings C C C C S S Woreda level advocacy meetings C C C C S S Social Mobilization and Behavior
Change Initiatives Community mobilization and awareness C C C C C I S S S S S S raising to prepare for TT surgery Capacity Building/Training Training of TT Surgeons, Evaluation and P S S S Certification IECW skills refresher training HEWs case screening and counselling P S S training: Assessing the Trachoma Disease
Burden N/A Trichasis Management, Including
Surgery Dedicated mobile teams C C C C C S S S IECW static sites and outreach C C C C C I S S S S S S Intensified TT surgical camps C C C S S S S Patient counseling C C C C C I S S S S S S Refusal management C C C C C I S S S S S S Referral management C C C C C I S S S S S S Commodity Supply Management and
Procurement Commodity supply management and C C S S procurement Supervision Monthly supportive supervision P P P C C S S S S S S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 120
Ethiopia, cont.
FY18 Trichiasis Work Plan Implementation Timeline FHF Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Short-Term Technical Assistance N/A M&E Reporting C C C C C I S S S S S S Post-Operative Follow-up C C C C C I S S S S S S Surgical audits P P C C C S S S S S S S Data validation P P P P P I S S S S S S
FY18 Cross Cutting Activities Work Plan Implementation Timeline Q1 Q2 Q3 Q4 O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Environmental Mitigation and Monitoring Plan Implementation of environmental C C C C C I S S S S S S Mitigation and Monitoring Plan
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 121
Ethiopia, cont.
FY18 Trichiasis Work Plan Implementation Timeline LFTW Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning Strategic planning meetings at regional level C Strategic planning meetings at zonal level C Quarterly monitoring review meetings at P S S S zonal level Advocacy Advocacy meetings for the political leaders at S zonal level Social Mobilization and Behavior
Change Initiatives MDA and regional level comprehensive eye C C C C C C S S S S S S health project linkage with TT surgery
Radio spots P C S S S S S S
Capacity Building/Training
Refresher training for TT surgeons P S
New TT surgeon training P S S S S S S Assessing the Trachoma Disease
Burden N/A Trichiasis Management, Including
Surgery Static site TT surgery services C C C C C C S S S S S S Outreach services C C C C C C S S S S S S Patient counseling C C C C C C S S S S S S Refusals management C C C C C C S S S S S S Case referral C C C C C C S S S S S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 122
Ethiopia, cont.
FY18 Trichiasis Work Plan Implementation Timeline LFTW Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Commodity Supply Management and
Procurement Commodity supply management and C C S S procurement Supervision Monthly supportive supervision C C C C C C S S S S S S Short-Term Technical Assistance N/A M&E Reporting C C C C C C S S S S S S 3-6 month post-surgery passive follow-up C C C C C C S S S S S S Surgical Audits P P P I C C S S S S S S Surgical quality assurance and post op follow C C C C C C S S S S S S up LFTW Director Eye Health/NTDs technical P C S assistance and monitoring visits
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 123
Ethiopia, cont.
FY18 Cross Cutting Activities Work Plan Implementation Timeline LFTW Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Environmental Mitigation and Monitoring Plan Implementation of Environmental C C C C C C S S S S S S Mitigation and Monitoring Plan Integration with other diseases Integrating TT Surgery into regional comprehensive eye health project and F&E C C C C C C S S S S S S project Health system strengthening Supportive Supervision and Training for TT C C C C C C S S S S S S Surgery Surgical Audits P P P S C C S S S S S S Supporting the FMOH and TRHB to C C C C C C S S S S S S strenghten its referral system Planned Subawards to Local P P P C Organizations and/or Governments
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 124
Ethiopia, cont.
FY18 Trichiasis Work Plan Implementation Timeline RTI Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning Participation in National Trachoma C C Taskforce (NTTF) Advocacy N/A Social Mobilization and Behavior
Change Initiatives N/A Capacity Building/Training N/A Assessing the Trachoma Disease
Burden N/A Trichiasis Management, Including
Surgery N/A Commodity Supply Management and
Procurement
Purchase tetracycline eye ointment (FY19) C S S
Supervision Supportive Supervision for TT Surgery C C C C C S S S S S S Surgical Audits for TT Surgery C C C S S S S S S M&E N/A
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 125
Ethiopia, cont.
FY18 LF Work Plan Implementation Timeline RTI Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Strategic Planning
Hydrocele Surgery Planning and Performance C S Review Meeting
Consultative Workshop on Inclusion of FASTT Hydrocele Surgery Training in Medical School C Pre-Service Training Consultative Workshops on Inclusion of Lymphedema Management in the P P Comprehensive Pre-Service Training of Nursing Curriculum
Participation in LF/Podo Technical Working C C Group (TWG) meetings
Advocacy N/A
Social Mobilization and Behavior Change
Initiatives
LF Messaging--Printing of Materials C
Assessing the Effectiveness of Radio Spots S S S
Airing of Radio Spots C S S S S S Patient Mobilization by HEWs C C C C C S S S S S S
Patient Counseling C C C C C S S S S S S Reporting Follow-up C C C C C C S S S S S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 126
Ethiopia, cont.
FY18 LF Work Plan Implementation Timeline RTI Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Capacity Building/Training Training of Hydrocele Surgeons C C Refresher Training of Clinical Workers on C S Post-Hydrocele Surgery Survey Training of Clinical Workers in Lymphedema C C S and Post-Hydrocele Surgery Management Assessing the LF Disease Burden N/A Hydrocele Surgery Hydrocele Surgery C C C C C I S S S S S S Lymphedema Management Lymphedema Management S N/A LF Commodity Supply Management and
Procurement Hydrocele Surgery Supervision Supportive supervision for hydrocele surgeries C C C S S S S S S
Supportive supervision to clinical workers C P C C C C S providing LF management services Joint FMOH supervision with NaPAN P S Short-Term Technical Assistance in LF N/A M&E Tracking LF MMDP Interventions: hydrocele C C C C C I S S S S S S surgery Post-hydrocele surgery follow-up survey C S Feasibility Study (NaPAN) S S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 127
Ethiopia, cont.
FY18 Cross Cutting Activities Work Plan Implementation Timeline RTI Q1 Q2 Q3 Q4
O N D J F M A M J J A S KEY: (C) Completed; (I) In-process; (S) Scheduled; (P) Postponed Environmental Mitigation and Monitoring Plan FY19 MMDP workplanning meeting S Implementation of Environmental Mitigation and C C C C C I S S S S S S Monitoring Plan Integration with other diseases N/A Health System Strengthening (HSS) N/A Communications and Media Relations Publications I S Case study development on TT surgery outcomes S S Planned Subawards to Local Organizations and/or Governments NaPAN C C C C C C S S S
MMDP Project FY18 Semi-Annual Report (October 1, 2017 – March 31, 2018) 128