Report on the Third Round Zithromax Distribution of Konso SPW s1

Report on the Third Round Zithromax Distribution campaign in North Ari Woreda of South Omo zone, as part of Orbis Rural Eye Care South Omo project, SNNPR, Ethiopia

Kassahun Mengistu

North Ari MDA Coordinator November, 2016. 1. Introduction Trachoma is the world’s leading cause of eye infections but preventable blindness, affecting mankind since antiquity. An estimated 8 million people are already blind or visually impaired because of the disease, and 84 million have active infection and need treatment. More than 10 percent of the world’s population is at risk of blindness due to trachoma, which has incapacitated families and communities for centuries in the poorest regions of Africa, Asia, the Middle East, and in some parts of Latin America, Australia, and Asia. Sub-Saharan Africa has the highest burden of the disease of which Ethiopian has the highest magnitude. The disease is caused by repeated infection by the bacterium Chlamydia trachomatis. Trachoma is spread through contact with infected people (discharge from the eyes and nose can easily transmit the disease). Flies that seek out the red, sticky eyes caused by trachoma can also transmit the disease from person to person. The disease generally occurs in poor dry and arid rural communities where people have limited access to water, sanitation, and primary health care.

Trachoma is the second leading cause of Blindness in Ethiopia next to Cataract. According to the national blindness, low vision and trachoma survey conducted in 2006 trachoma accounts 11.5% of all blindness and 7.7 of people with low vision. It is estimated that over 138,000 people are already blinded by trachoma2.

The prevalence of active trachoma (AT) in children age 1-9 is 40% for the whole country ranging from 0.5% to 62.6% in different regions of the country. It is fourfold higher in rural children than urban due to poor sanitation and water supply. Over 9 million children aged 1-9 years have active infection in Ethiopia.

Trachomatous trichiasis (TT), a chronic form of trachoma is estimated to be 3.1% for the country. This means there are estimated 1.3 million people age 15 and above who are in immediate risk of blindness unless treated urgently.

According to the national survey, the prevalence of active trachoma and TT in SNNPR are 33 % and 2% respectively. However, from the district based baseline trachoma surveys conducted in other ORBIS supported rural projects in SNNPR, the prevalence of both active and blinding trachoma (active trachoma between 22- 54% and TT between 1.1 and 6.4%) are by far higher than the regional findings as indicated in the national survey. The prevalence of active trachoma in North Ari woreda among children aged between 1-9 years according to the woreda based survey conducted in 2013 G.C reported to be 25.53% whereas the trachomatous trichiasis rate among people aged above 15 years appears to be 0.57%. Orbis International Ethiopia has been implementing the WHO recommended SAFE strategy in South Omo project to control and eliminate trachoma over the last 3 years through capacity building of the local health worker through training, provision of supplies and medical equipment to eye care services. Establishing of SECU and PECUs in different districts were the main activities for the last 1year years. In 2013 ORBIS has done a baseline survey to determine the prevalence of active trachoma and Trachomatous trichiasis in eight woredas of the zone and came up with the results of these prevalence ranging from ( active trachoma. 20.53- 20.15% and TT, 0.57-1.09%) which needs public health intervention through mass drug administration. Therefore, trachoma is found to be a public health problem in these woredas as the prevalence of the two indicators is high above the WHO cut off point. Hence, trachoma is till a major public health concern and need an immediate trachoma intervention program. Following these findings and as per the recommendation of WHO, Zithromax distribution program was planned in these woredas including North Ari woreda.

Table1. Summary of trachoma survey findings in North Ari woreda of South Omo Project

Prevalence of Active Prevalence of TT S.No. Woreda Trachoma in 1-9 yrs in >15 yrs 1 25.53% 0.57%

Back ground of North Ari Woreda North Ari woreda is located in the South part of Ethiopia and inhabited by Ari people who speak Arigna languages respectively. The area is located in the SNNPR South Omo Zone, approximately 810Km South of Addis Ababa and 87 Km from South Omo Zone Jinka town. The total population for woreda based on 2014 census population progration is 86,577 and woreda composed total 35 kebeles. Ethnic group living in the woreda Ari 98 percentage & others 2% - weather condition :- Dega 85% Weynadega13% and Kolla 2%

- The most socio economic status of woreda has formed farmer’s 97% merchant 1% and civil servant 2%.

- Clean water coverage 80%

- Health facility coverage by infrastructure 100%, j.e Health center 4, and Health post 35 in number.

- Health coverage by standard service requirement i.e. Health center technical staff total 65 in number, from total technical staff 4 IECW and at health post 71 HEW.

2. Goal To eliminate blinding trachoma from North Ari woreda as part of South Omo rural eye care project.

2.1 Objectives - To implement “A” components of SAFE strategy to suppress the recurrences of AT by treating pool of infection. - To reduce the high prevalence of AT 25. 53% and TT 0.57% to below 10% and 1% respectively after consecutive mass drug administration for the eligible population of the woreda. - To create awareness within the community on trachoma and SAFE strategy.

3. Eligible/target:

Zithromax is safe and recommended by Pfizer for all individuals except for children less than 6 months and those hypersensitive for Zithromax (Macrolides). However, the FMOH does not recommend for mothers in their first three months of pregnancy too. Tetracycline eye ointment (TOE) will replace Zithromax for those who are not eligible for Zithromax. The eligible population for Zithromax and TEO eye ointments is residents of the woreda.

Target of coverage ITI recommends that MDA coverage with Zithromax above 90% of the eligible population can be considered as a success in eradication of trachoma as “A” component of SAFE strategy. However, the level of our success is to work against 98% and above for effective elimination of AT. 4. Methods and instruments/logistics  A two days sensitization/ advocacy , training on the cause, transmission prevention modes of treatment and public health aspect of trachoma and detailed techniques of the planned mass drug distribution workshop was successfully conducted involving officials from North Ari woreda health offices and administrative leaders .  Supervisors for the distribution, distribution teams composed of health extension workers, health workers, community health agents recruited from the woreda and Peasant Association Leaders were participants of the workshop. Trachoma control and prevention activities that have been implemented over the last 1year, the current status of trachoma and all aspects of MDA were presented and discussed in detail.  The planning exercise included detailed budget for the Zithromax distribution (determining the number and the duration of the distribution for each Kebele per woreda, the corresponding budgets and dates for each activities were cleanly outlined per woreda).  All logistics necessary to conduct the distribution were prepared and obtained to the woreda health offices before the start of distribution. These included delivery of registration books, Zithromax tablets and POS, 1% Tetracycline eye ointments, height measuring sticks, colored dosage guides, distributer’s dress (special attire with trachoma message), Zithromax distribution manuals prepared in Amharic language, different Zithromax reporting and summary formats, transferring budget for Zithromax distribution to woreda finance and economic development office on time, determining the number and duration of vehicles to the woreda and availability of vehicles on time.  All the necessary human resource required to the woreda for the Zithromax distribution was determined for each Kebele during the micro-planning meeting. Assignments of health workers were based on the accessibility and the population size of each Kebele and also on the number of available of health workers (HOs, nurses, HEW and others). Moreover, on average one supervisor was assigned to closely follow every three kebeles during the distribution. However, the catchments area for each supervisor may vary depending on the local situation. Dates for distribution have been determined and the distribution takes 6-7 days on average with small variation. 5. Composition of distribution team  99 teams and 18 supervisors were assigned prior to the distribution in the Woreda. Each team is composed of three individuals, Health extension worker/Health worker, Community Health Agent/, Kebele Leader/ Peasant Association Leader. 99 HEWs, 99 HDA, 99 PALs 99 HWs, 18 supervisors, 2 who facilitators and 1 woreda coordinators participated during the distribution.  Health education messages and community sensitization about trachoma and Zithromax distribution dates have been announced on daily basis before and during the distribution days locally. .  Posters, leaflets have been posted and distributed ahead of the distribution date. Banners were also used to inform people about the campaign. Based on the population size, the amount of needed drugs, human resource, number of teams and supervisors and all other required logistics have been determined (84144).

 One MDA coordinator with one vehicle was actively involved in the whole period of the distribution.  A manual is prepared in English to help trainer (woreda coordinator) trainees in undertaking the Zithromax distribution.  Registration books of 50 pages were used during the census to enter data of the distribution.  Budget for fuel for motor cycle was allocated for the woreda.

 The use of mobile/wireless cell phone was very vital in effective communication between teams, their supervisors, woreda officials, and ORBIS staff. Where there is no network connection, messengers were used to pass information to the general public and the needed personnel. .  Role and Responsibilities HEWs/HWs:  Calculate the required drugs per their catchments area and receive the drugs from the woreda pharmacy store  Reconstitution of Zithromax suspension  Administering Zithromax tabs and POS and providing 1 % Tetracycline eye ointment for the beneficiaries  Documenting the drug provided to the beneficiaries on the registration book  Daily follow up of the drug balance and reporting to the supervisors for immediate action  Compiling and reporting the data at the end of the distribution Role and Responsibilities CHAs:  Health education on trachoma and Zithromax before and during the distribution  Measuring height of individuals and reporting to the HEW/HW for drug administration  Ensuring clean water is always available at the distribution site  Collection of used bottles  Participation during community mobilization Role and Responsibilities of Kebele Leaders/Peasant Association Leaders:  Community Mobilization and sensitization  Trace residents in their Kebele who did not appear in the distribution site.  Select appropriate sites for drug distribution team in each Kebele of the woreda Role and Responsibilities of Kebele supervisors  Supervising the overall activities of the distribution team  Provision of technical support to the distribution team  Provision of drug and water in case of shortage  Follow up of the drug balance on daily bases  Compiling and reporting at the end of the distribution  Make sure the drug balance is correct at the end of the distribution  Daily monitoring and feedback as to how the distribution is reaching every resident through going into the village and interviewing the residents weather they received Zithromax or not and comparing to the daily report Role and Responsibilities of Community Mobilizes:  Community mobilizes are woreda officials including the administrators, cabinet members and other influential community figures.  They started mobilizing the community members starting one week prior to the distribution dates and during the time of distributions.  Moved to priority areas depending on local situations.  Made the local leaders participate fully on the distribution with great attention. Role and Responsibilities of temporarily recruited distribution coordinator/MDA consultants  Provide pre-Zithromax distribution training to distribution team members in the stated woredas.  Provide continuous supportive supervision and technical support during the period of Zithromax distribution in the Woreda.  Oversee the proper final accounting of the Zithromax balances against the issued and the distributed quantities.  Submit detailed Zithromax distribution report as per the standard reporting format provided by ORBIS Ethiopia, including; the pre-Zithromax distribution training, for each woreda at the completion of the distribution program.  Submit Estimated Zithromax Distribution Cost (Specifically for Per-diem paid to the distribution team, supervisors, etc) for the Woreda.

6. Achievements 1. Coverage and drug utilization  The Target population of the woreda was 86,577.  The community acceptance of drugs was impressing and distributing teams were found performing well at their duty sites from all aspects.  Out of a total of 86,577., target population, 84679 people were treated in 35 kebeles of woreda making the coverage 98% . Table 1.Reporting sex distribution

Ttable -2 .Drug report  Overall, 227642 tablets of Zithromax , 85110 ml of Zithromax POS and 3667 tubes of 1 % Tetracycline eye ointments were dispensed (see table above.)  Drugs were handled with care and dispensed with caution and hence the wastage was very minimal.  It was believed that health information was passed to those residents who took the drugs 84679 people  Measuring sticks, laminated dose guides, registration books and balance at hand drugs collected back to woreda store. On the top of this, drugs physical Inventory and bin cards were also adjusted. .  Finance  The budget transferred to the woreda to conduct the pre distribution training and the actual distribution was ETB 911,903

. Monitoring and Evaluation  The progress of the distribution was monitored daily at Kebele and village level and challenges, best practices and other experiences were communicated with respective Kebele and woreda supervisors.  Daily communication about the progress of the distribution among supervisors, distribution teams, and MDA Coordinator was the standard during the whole period of the distribution. 7. Challenges  Failure of supervisors and teams to provide qualitative and reliable report data. In principle, drug balance, person treated and target population data should be in line with that of registration books. However, significant gaps were on crosschecking these data during report collection. The main problem here is the concerned were not voluntary to work according to the principle. There was tiresome dealing made so that teams will collect back the registration books and drugs balance at hand to woreda store. They resist saying we did not do in such away on previous MDA. There was erasing and falsifying of recorded drugs from registration.  Poor drug control of teams and supervisors.  Census registration books at some kebeles lack households’ contents and recording  Mismatch of BBF drugs (tabs & POS) on bin cards and actual amount counted at woreda store.  In some Kebeles there was out migration from rural to semi urban and absence of some household members.  Some Supervisors & Health Proportional’s were seen to have low commitment.  There was misconception & resistance not to take drug like Ottle, Gelila and Kelete kebele, Garshino and Melt kebele  Some Kebeles were hard to reach inaccessible areas / to address with Vehicles and supervision was difficult like Hamersha, Garshino Gimja, Lelo and Chilsha.  Misunderstanding to calculate right amount of drugs per catchment areas were observed in few Kebeles  Some Supervisors were not committed & did not follow their daily responsibilities.  There was no daily distribution team discussion after work and plan for next day in most kebeles  During previous census time those individuals out of the kebeles for a long time were registered. 8– Action taken  Conducted house to house re-visit to confirm the presence of missed household members.  Using personal messengers to communicate with teams in hard to reach areas and to have daily reports  Health education for misconceptions and to start medication provision from Kebele leaders  Creating ownership.  Dealing with Woreda Administrator & Woreda Health office about challenges  Using all means of transportation to supervise Kebeles.  Cross check and inform the team to use daily plan and evaluate at the end of the day.  Cross checking final report with registration book and keeping data quality by counting and refill gaps during data collection.  The ORBIS vehicles arrived early at duty station, where it was required most to distribute logistics and transport personnel to the different distribution sites.  Every 2 day woreda command post meeting and provision of feedbacks to kebeles low performance 7. Lesson Learnt and the way forward

 Health education is a core component of Zithromax distribution. In future distribution program, health leaning materials like leaflets, posters, banners and others methods should be recommended. The community sensitization and advocacy workshop was very productive and should continue in future programs. The use of the local FM radio in North Ari very vital in propagating the right information throughout the distribution period.  Drugs adequacy shall be secured ahead of distribution to avoid inconveniences.  The involvement of WoHO must be there on micro plan development.  Unlimited follow up and team coaching must be there to make qualitative and reliable MDA. It also needs attentions of zonal officials.  Early distribution schedule notification and budget transfer greatly favors the smooth distribution. It also helps in making effective and early budget liquidation for partners. 8. Recommendations 1. Measuring sticks and laminated dose guides should be rearranged as per the revised Program Manager’s Manual for Zithromax distribution. 2. There must be post MDA distribution evaluation at woreda level with woreda officials and Kebele supervisors to address gaps found and strengths for coming distribution. It has great inputs on short and long term M&E. 3. For coming pre-campaign woreda health office and South Ommo ORBIS project should do on attitude of the community for effective and efficient MDA achievement which was attention on this post campaign meeting 9. Acknowledgment I would like to extend my heartfelt appreciation to the organization ORBIS International Ethiopia South Omo project & partners listed below for their invaluable contribution in the 3rd nd round Zithromax distribution in North Ari Woreda. Woreda administrators, Woreda health offices, CHAs, HEWs Kebele leaders and HWs as well as the community at large

10. References 1. North Ari woreda census survey findings, 2013 2. National trachoma survey, 2005/2006 3. Orbis international Ethiopia different previous survey documents