Maternal and Child Survival Program

Guinea

Ebola Response Plan

Quarterly Report Quarter 1, 2015 17 November 2014-30 December 2014

Submitted to:

United States Agency for International Development Cooperative Agreement No. AID-OAA-A-14-00028

Submitted by:

MCSP implementing partners - Jhpiego Save the Children

Submitted 30 January 2015 Revised 10 February 2015 INTRODUCTION

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 24 priority countries with the ultimate goal of ending preventable maternal and child deaths (EPMCD) within a generation. The Maternal and Child Survival Program carries forward the momentum and lessons learned from the highly successful USAID funded Maternal and Child Health Integrated Program (MCHIP), which has made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America and the Caribbean. Under this activity, MCSP interventions build on the development of local training capacity among healthcare providers in Guinea with a focus on competency-based training methods that work to improve both knowledge and skills. These build from previous work specifically on infection prevention practices in health care facilities and a commitment to quality improvement and supportive mentoring and supervision to assist healthcare providers to translate new skills into ongoing practice at their worksites.

In order to contribute to the response to the current Ebola Viral Disease (EVD) epidemic in Guinea and the severe effects on health services, including increased risks for healthcare providers, USAID requested MCSP to develop a workplan to address the infection prevention and control (IPC) practices in facilities, as well as to work with communities to prevent disease transmission. The Ebola Response Project was approved for a period of nine-months from 17 November 2014 to 16 August 2015. The geographic focus areas were determined in collaboration with the National Ebola Response Coordinating Committee (CNLEB), CDC, OFDA and USG supported partners, such as Catholic Relief Services and Save the Children (who is leading Objective 2 in this project).

The focus areas for this project are the capital city of and three rural prefectures, Beyla, Kissidougou and Forécariah. Kissidougou was not originally included in workplan but in the first month, MCSP was requested by CNLEB to add Kissidougou because of the urgent nature of the situation in this area. MCSP is covering 55 target facilities in these areas; three national hospitals (Donka, Ignace Deen, Hôpital Sino- Guinéen), three prefectural hospitals, six communal medical centers (CMC; 6 in Conakry and one in Sinko, Beyla), one socio-medical center (Jean Paul II/ Conakry) and 42 health centers in the three prefectures.

During this past quarter, the spread of the Ebola epidemic was the worst Guinea has seen. In November alone, 522 new cases and 331 deaths were recorded.

The following report presents the activities and achievements of the first six weeks of project implementation.

GOAL AND OBJECTIVES

The goal of the MCSP Ebola Response Project is to: Scale up efforts to prevent and control the spread of EVD to protect and maintain quality reproductive, maternal, newborn, and child health services. The key objectives of this activity are: • Objective 1 – Prevention at facilities: Support healthcare workers and facilities to continue to offer high quality health services in a safe environment by strengthening infection prevention and control (IPC) practices through training, supportive supervision, and complementary monitoring and evaluation.1 • Objective 2 – Ebola virus disease (EVD) prevention within communities: Support communities and their local leaders to combat disease transmission through improved contact-tracing, intensified social mobilization, and technical assistance to district health teams.

RESULTS AND ACTIVITIES BY OBJECTIVE

Objective 1 – Prevention at facilities: Support healthcare workers and facilities to continue to offer high quality health services in a safe environment by strengthening infection prevention and control (IPC) practices through training, supportive supervision, and complementary monitoring and evaluation.

1.1 Active participation of MCSP in national level coordination

The interventions of the MCSP project were quickly integrated into national coordination efforts based on Jhpiego’s active participation in the CNLEB prior to the award of this project. Jhpiego was requested to join the CNLEB several months earlier and Jhpiego committed some of its own funding to key interventions which were quickly bolstered by the award of MCSP to scale up the training of Healthcare Workers in IPC

Highlights this quarter include:

1) MCSP along with partners such as WHO, UNICEF, Plan Guinea, Guinean Red Cross, the National Public Health Institute participated in reflections of the ad hoc committee to address growing reluctance of communities to actions taken as part of the Ebola response and develop a strategy to reduce the intensity and improve community participation. The committee recommended the development of health monitoring committees in all villages and urban communes. A draft of guidelines for implementation, a training plan and an implementation plan were submitted CNLEB for validation.

2) MCSP was closely engaged with the Case Management commission of CNLEB which meets once a week. As part of the commission, MCSP contributed recommendations and guidance to improve protocols for certain interventions including: care provided in Ebola treatment units; management in the community transit centers; and secure burial procedures.

3) MCSP participated closely in the development of the flipchart to be used by the Health Monitoring Committees, as well as teachers and others engaged in IEC on Ebola. The flipchart has been validated by the MOH, and 500,000 copies were produced with funding from the CNLEB and donors.

1 Note that as per CDC’s guidance, comprehensive IPC initiatives include: 1) training; 2) supportive supervision; 3) provision of IPC- related supplies/equipment; and 4) monitoring and evaluation. Given that USAID is facilitating access to personal protective equipment (PPE), that third element is not explicitly stated in Objective #1 4) A technical working group on IPC was established and now meets weekly. MCSP is an active participant in this group along with USAID, OFDA, CDC, WHO and other partners conducting IPC training such as CRS and HKI. The committee includes a total of 15 organizations and has become one of the most important technical working groups within the CNLEB as the focus of the response has shifted to ending transmission. The group produces weekly information bulletins of the interventions accomplished and results in IPC.

5) MCSP is collaborating with a group of partners - CDC, MSF Belgium, OFDA, WHO - and the Director of the Donka national hospital to put in place triage and screening services at the hospital. Thus far, the Standard Operating Procedures, screening forms, list of materials and consumables, and descriptions of roles and responsibilities within the unit have been developed.

6) As part of the development of the “Zero Ebola in 60 Days” plan led by the Government of Guinea, MCSP participated in a two-day workshop to develop the strategy. Following the validation of the plan by CNLEB, MCSP was chosen to be a member of the technical team that will support the Regional Coordination of the City of Conakry to adopt and operationalize the strategy for implementation.

1.2 Train/update consultant trainers

In the first week of December, Jhpiego conducted2 a workshop to update the skills of 28 trainers on IPC practices with an emphasis on understanding and preventing the transmission of Ebola, along with adult learning skills to train others. These trainers were previously trained as IPC and RMNCH trainers and coaches under the MCHIP program. The five-day training was designed to help the trainers prepare for the updated training program that combines standard IPC and key advice and practices specific to the Ebola virus as a means to strengthen the skills and attitudes of all providers to correctly and consistently implement IPC.

Table 1: Distribution of trainers by cadres and location/facility

Doctors- Doctors- Préfecture and facility Midwives Total Generalist OB/GYN

Conakry (HN, CMC) 5 9 5 19 Dubréka (DPS) 1 1 Faranah (HR) 1 1 Kissidougou (HP) 1 1 DRS Kankan 1 1 HP Kankan 1 1 1 3 Siguiri (HP) 1 1 Nzérékoré (HR) 1 1 Grand Total 9 10 9 28

2 As part of Jhpiego’s commitment to support the Ebola Response in Guinea, Jhpiego had committed its own funding for this activity prior to the award from MCSP, which ultimately benefited the rapid startup of this project.

Session on hand washing, using paint to demonstrate

Session on PPE (Tyvek), preparing for removal

1.3 Conduct site selection, rapid assessment of target sites and preparation for the IPC trainings and supervision

In preparation for implementation in the field, MCSP is conducting baseline assessments of the 55 target health facilities to identify the current level of IPC performance and identify gaps to be addressed through training and coaching on-site support activities. The assessment allowed MCSP to review the availability of materials and consumables for IPC, including PPE and decontamination. The assessment tool was based on the performance standards for IPC that were introduced as part of the Standards-based Management and Recognition (SBM-R) methodology for quality improvement, which was introduced at many of the hospitals and urban health centers covered in this project under the previous MCHIP project. Updates specific to the Ebola virus were included and the number of standards were adapted to the specific service being assessed. The assessments are continuing in the second quarter, and the results will be used for follow-up and coaching visits.

The 29 services of the Donka National Hospital and 23 services of the Ignace Deen National Hospital, including all clinical and support service units, were assessed in December 2014. Among these 52 services: • 20 services (38%) were performing less than 10% of the standards, including eight facilities that were found to perform none • 20 services (38%) were performing between 10% and 26% of standards • 12 services (23%) were performing between 31% and 75%

The team of 18 evaluators, with Jhpiego staff, ready to start the assessment at Donka National Hospital.

Table 2: IPC performance by service at Donka National Hospital

Table 3 : IPC performance by service at Ignace Deen National Hospital

1.4 Conduct training for facility staff

Following the update of trainers and while the baseline assessments were in process, MCSP began training healthcare providers on IPC. With multiple teams of trainers working concurrently, 21 sessions were completed with a total of 503 providers over three weeks, including 328 from Conakry, 100 from Forécariah and 75 from Beyla. Table 4 and 5 provide additional details by health worker cadre, and facility level.

Each five-day training included theory sessions accompanied by practical simulations and site visits to practice how IPC should be applied throughout different services of the hospital. During sessions held in Conakry, the Deputy Director of CNLEB, the Director General of Donka National Hospital and the Deputy Director of Ignace Deen National Hospital visited the training sessions to observe the training and encourage the trainers and participants.

Table 4: Distribution of IPC training participants by cadre, by location and by facility

Préfecture/

Type de structure sanitaire

femme - Aide de Santé de Santé Aide (AS)/Infirmier Autre Biologiste Ingénieur Médecin Pédiatre Pharmacien Sage de Technicien laboratoire Total Grand

Beyla 63 1 5 3 1 2 75 Centre de Santé 38 2 40 Centre Médical Communal (CMC) 8 1 2 2 1 14 Direction Préfectorale de la Santé (DPS) 1 1 Hôpital préfectoral 14 1 1 2 18 Poste de Santé 2 2 Forécariah 76 3 3 7 9 2 100 Centre de Santé 34 1 1 1 5 2 44 Direction Préfectorale de la Santé (DPS) 1 1 2 Education 1 1 Hôpital Préfectoral 3 1 3 4 11 Poste de Santé 38 2 1 1 42 Dixinn 89 2 10 77 1 5 1 185 Hôpital National Donka 89 2 10 77 1 5 1 185 Kaloum 65 2 5 1 58 3 7 2 143 Hôpital National I. Deen 65 2 5 1 58 3 7 2 143 Grand Total 293 8 23 1 145 1 9 19 4 503

Table 5: Distribution of trained healthcare workers by facility type and location Type de structure sanitaire Beyla Forécariah Dixinn Kaloum Grand Total Centre de Santé 40 44 84 Centre Médical Communal (CMC) 14 14 Direction Préfectorale de la Santé (DPS) 1 2 3 Centre de Formation Maferenya 1 1 Hôpital (HN, HR, HP) 18 11 185 143 357 Poste de Santé 2 42 44 Grand Total 75 100 185 143 503

1.5 Procure and supply necessary sterilization and sanitation/waste management equipment for trainings

The availability of materials and supplies to implement correct and consistent IPC is essential to breaking the chain of transmission of Ebola and protecting health care workers as they care for clients. A number of partners are helping to contribute materials and supplies to the national pharmacy, including MCSP. MCSP provided 140 locally constructed hand washing units to the Donka and Ignace Deen National Hospitals, so all providers can conduct proper hand hygiene.

Ceremony to present the hand washing units to IPC focal points and superintendant of services at Donka National Hospital, December 23, 2014.

Group photo following the handover of the hand wahsing units at Ignace Deen National Hospital, 29 December 2014.

The local made hand washing units at Donka National Hospital before distribution to the services.

MCSP also provided each of the focus facilities and services with a one-month supply of key materials for IPC including chlorine, trashcans, buckets for setting up instrument decontamination, cleaning materials and personal protective equipment. Some items that are still in short supply include long gloves like those needed for surgery and labor and delivery and disposable gowns.

1.6 Conduct routine quality assurance visits and provide additional follow-up support

At the same time that training sessions were being conducted, MCSP master trainers and supervisors conducted regular visits to the focus facilities to support quality improvement and performance of IPC. Two- thirds of the facilities received supportive supervision visits in the two weeks following the start of training sessions. Findings from the two National Hospitals are presented below.

1) 17 of 23 services received supportive supervision visits at Ignace Deen National Hospital. MCSP supervisors visited with hospital authorities to inform them of the visits, and together they planned the services and staff to be supervised. A plan to strengthen IPC supervision was also discussed with the Director General and the Head Nurse. Over four days, supervisors visited each of the Department Heads to request their adherence to new practices in IPC and support for providers as they complete training. Providers were observed on six key themes:  Washing hands with soap and/or with alcohol-based solution;  Correct preparation of chlorine solution at 0.05%, 0.1% and 0.5%;  Wearing personal protective materials appropriate to the mode of disease transmission;  Correct handling of contaminated materials prior to disposal;  Proper management and disposal of contaminated materials and other waste; and  Participation in triage and screening of clients for Ebola.

Improvements observed during coaching include:  Exam gloves were available in the majority of services;  Providers were observed practicing correct hand washing procedures;  Chlorine solutions were correctly prepared in the majority of services;  The providers who have completed training were engages in implementing IPC procedures in their respective services; and  The providers who completed training had shared information with their colleagues including the action plans for improving IPC.

2) 27 of 29 services received supportive supervision visits at Donka National Hospital. Improvements observed during coaching include:  Trashcans were available in all services visited and were well maintained (not overflowing);  Providers appeared motivated to make changes and had started to clean and sanitize their work areas;  Providers were washing hands following the correct steps.;  Buckets were available with decontamination solution and high-level disinfection;  Posters on hand washing were visible in some services (emergency, radiology, internal medicine, nephrology, trauma, neurosurgery, oncology, plastic surgery, cardiology and Diabetes service);  In the visceral surgical unit, which did not have a safety box for sharps, providers created their own safety boxes;  Services had received (and were using) the hand washing stations donated by MCSP.

A notable observation that demonstrated superior commitment was that the superintendent for the pediatrics service had bought two pairs of cleaning gloves with his own money for the cleaner.

1.7 Communications support as a tool for referral, logistics management and mentoring During each of the training sessions, an orientation is given on the mobile mentoring program using cell phones. 99% of participants agreed to participate in the program and provided their phone numbers. The objective of this activity is to promote knowledge retention for IPC through text messages on the topic.

Objective 2 – Ebola Virus Disease (EVD) Prevention within Communities: Support communities and their local leaders to combat disease transmission through improved contact-tracing, intensified social mobilization, and technical assistance to district health teams. (Entire section revised)

2.1. Social and behavior change communication (SBCC) and sensitization on EVD prevention and hygiene promotion in affected sub-prefectures, through public health committees and radio messages.

Conakry: No activities took place in Conakry during the reporting period.

Kouroussa Prefecture: No activities took place in during the reporting period.

Beyla Prefecture: In Beyla, where Save the Children intervenes only for this project, the main activities in December were related to hygiene promotion and radio sensitization. Specifically during the reporting period the following was conducted:

• A first hand-washing promotion session took place in Beyla, reaching eight participants which were key community members. The session focused on the necessity to regularly wash hands with soap and water. • Every Thursday since start-up in Beyla, radio messages have been broadcast on the local community radio station focusing on health promotion using standard UNICEF and communication working group messages to support efforts to prevent and treat Ebola (three messages till end of December).

2.2. Sensitization for civil society groups and Community Health Worker (CHW) Associations:

Conakry: The main area of intervention for the Ebola Virus Disease (EVD) sensitization of civil society organizations is in Conakry where a total of 58 organizations are to be sensitized and trained on EVD. Concretely, thirty CHWs from six civil society organizations representing CHWs in Conakry received training and undertook visits to health worker treatment centers.

Trainings included topics such as: “Combating hostile words and reactions by individuals and groups: understanding and explanation, not orders", which aims to promote an informed response to the prevention and management of the Ebola virus. The training methodology is interactive, question-and-answer based, and encourages an open and taboo-free environment in which participants can learn both the technical aspects of the disease, and the necessary medical response – this both validates and underlines the Ebola health messages that have been implemented in Guinea.

The primary targets for the trainings included staff from both primary and secondary, public and private health structures, medical students, laboratory assistants, doctors, nurses, traditional healers, actors, and organized community associations (who return to their communities to share what they learn from the training).

The training content focused on clarifying the less understood aspects of Ebola, such as the epidemiological context, the role of the immune system in fighting the disease, what medical procedures are conducted in the Ebola Treatment Centers (ETC), and other practical considerations such as:

o How to question patients who have been in contact with the dead or the diseased, and the importance of training on how to remove gloves after being in contact with the body fluids of an Ebola patient. o Numerous questions on means of preventing infection at an ETC. o How to provide support to community treatment centers. o An in-depth session on infection control measures to be taken in both public and private health facilities (targeting all professional categories). o How participants should report information back to their associations. o A training report advocated at the national coordination level for comprehensive training on Ebola to be provided to both the public and private medical sectors, including all professional categories, especially students, who are most frequently on the front line of medical consultations.

An awareness-raising session in Kouroussa

Kouroussa Prefecture: In Kouroussa 19 sensitization sessions were conducted in December, drawing approximately 385 adults (265 women and 96 men) and 24 children (5 girls and 19 boys) (see Table 6 below) with messages on how to avoid transmission and how best to respond to cases of Ebola in the community.

The World Health Organization’s (WHO) Ebola messages, depicting modes of transmission and key methods of prevention, were translated into the two local Malinke dialects: N’ko and Malikou, to allow for a stronger understanding and uptake of the messages.

Save the Children also participated in sensitization sessions targeting community resistance to the Ebola surveillance in five communities: Lorombo, Dura, , and Komola, Koura.

Beyla Prefecture: Meanwhile in Beyla, 80 participants (22 women, and 58 men) (see Table 6) took part in sensitization sessions addressing EVD.

Table 6: Attendance at sensitization sessions Attendees Area Sessions Total Men Women Girls Boys Kouroussa 19 265 96 5 19 385 Beyla 3 58 22 0 0 80 Total 24 323 118 5 19 465

2.3: Contact-tracing and surveillance in affected sub-prefectures:

Conakry: No activities are planned in Conakry under this objective.

Beyla Prefecture: No activities took place in this first quarter.

Kouroussa Prefecture: To assist with the nationwide efforts to establish public health committees or comités de veille villageois (CVV) in every district of Guinea with the goal of improving community-level surveillance and creating additional interlocutors with communities, Save the Children recruited a Communication & Mobilization Supervisor was recruited to support the Direction Prefectural de la Santé (DPS) in establishing CVV. Additionally, Save the Children supported the DPS with contact-tracing in the prefecture by helping supervise CHWs that are involved in this type of surveillance.

Overall for December, Save the Children established and trained 70 CVV, in collaboration with the prefecture, as directed by the National Coordination in the Fight against Ebola. Since then Save the Children has positioned itself nationally as the lead NGO in overseeing the set-up, training, and functioning of CVV in five prefectures, including Kouroussa and Beyla.

Generally, a CVV is made up of up to seven members per committee. In Kouroussa then a total of 462 members (387 men and 75 women) received training in which the objectives were to: o Empower CVV with the knowledge and skills necessary to perform their roles and responsibilities. o Strengthen the communities’ capacity to conduct active Ebola surveillance at the grass-roots level.

Specifically, the trainings focused on the roles and responsibilities of CVV, Ebola prevention, data collection methods and tools (using two simple tools developed by Save the Children), active surveillance of Ebola cases i.e. monitoring any movement of people in the community, and the use of boites à images job aids.

2.4: Coordination and technical support to the Direction Prefectural de la Santé (DPS) to help manage the EVD response at prefecture level:

Conakry: No activities are planned in Conakry under this objective.

Kouroussa Prefecture: No activities are planned in Kouroussa prefecture under this objective.

Beyla Prefecture:

Save the Children quickly determined that the DPS of Beyla need additional technical support despite a national EVD coordinator having been deployed and WHO field an expert. Initially actions to support the DPS in their day-to-day functioning consisted of the following:

• Distributions of soap and chlorine to support efforts to scale-up handwashing. • Provision of fuel to ensure that the two prefectural ambulances were actually able to move around and be able to transport Ebola patients from communities to the next Ebola treatment center in N’zérékoré. • Provision of fuel to allow the DPS generator to run, thereby enabling the prompt entry of data collected in the region and providing electricity necessary for the transmission of Ebola messaging through local radio in Beyla.

Table 7: Indicators Related to Objective 2 Kouroussa Beyla Indicators Notes () (Nzérékoré region) Number of contacts traced 182 132 by the MoH Contacts traced for 21 100% 100% days (%) In addition to the WHO training received, on-the-job training was Number of CHWs trained 70 CVV 0 provided during supervision visits Number of CHWs 0 0 Already supported by WHO supported Number of radio Every Thursday, broadcast by messages/sensitization 0 3 Beyla rural radio broadcasts

Next Steps:

All activities will continue in the coming quarter as originally proposed.

Objective 1:

It is expected that all of the IPC training will be completed in Quarter 2. Post-training follow-up will continue while the trainings are being conducted.

In addition to the original request for support to strengthen IPC among healthcare workers, the CNLEB has requested support to mobilize faculty and students at the Faculty of Medicine to increase their engagement in the fight to end Ebola. MCSP is investigating opportunities add these activities into the current project and/or include it in future funding.

At the suggestion of USAID Guinea, Jhpiego is preparing a concept note for submission to OFDA for the extension of IPC training to additional prefectures, including support for waste management and decontamination equipment.

Objective 2:

All activities will launch in the coming quarter (January – March) as originally proposed and immediate plans include: • Scale-up of SBCC efforts in Conakry, Kouroussa, and Beyla • Launch of 30 CVV in Beyla, including formation and training • Maintaining the support for contact-tracing and DPS technical assistance in Kouroussa and Beyla • Provision of a follow-up training for all CVV in the Kouroussa region, focused on their activities in the communities in order to: o Check that the two sets of monitoring tools provided by Save the Children are being used and completely correctly. o Ensure that the CVV are working effectively.