USAID OFDA Ebola Virus Disease (EVD) in DRC: Strengthening Community Prevention, Response, and Recovery
condomMala
Ebola Virus Disease (EVD) in DRC: Strengthening Community Prevention, Response, and Recovery
Baseline Report
Submitted: 30 January 2020
Revised: 9 March 2020
Prime offeror point of contact: Zaneta Kific Sr. Director, Grants, Contract, and Compliance IMA World Health 1730 M St. NW Suite 1100 Washington, DC, 20036 USA
IMA World Health, OFDA funded EBOLA VIRUS DISEASE in North Kivu and Ituri: Strengthening community prevention, response, and recovery in the Democratic Republic of Congo project Award No. 720FDA20CA00003
Table of Contents Acronyms ...... 3 Background and Project Overview...... 4 Baseline Assessment ...... 5 Baseline Scope: Population, Locations and Timing ...... 8 Methods and Data Sources ...... 8 Limitations ...... 9 Results and Analysis ...... 9 Gender Assessment...... 13 Analysis and Data Use ...... 14 References ...... 14
2 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Acronyms
BCZ Health Zone Management Team CHW Community Health Worker DHIS2/SNIS National Health information system DRC Democratic Republic of Congo EVD Ebola Virus Disease IDP Internally Displaced Person IPC Infection Prevention and Control KAP Knowledge, Attitudes, and Practices NGO Non-Governmental Organization SGBV Sexual and Gender-Based Violence WASH Water, Sanitation, and Hygiene WHO World Health Organization
3 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Background and Project Overview The current outbreak of Ebola Virus Disease (EVD) in Eastern DRC is the second largest outbreak of Ebola and has resulted in 3,390 cases and 2,233 deaths (WHO 2020). The outbreak is occurring during widespread insecurity, impeded access to interior health zones, and increasing distrust of international NGO and relief agencies. This environment presents significant challenges in effective surveillance and monitoring of persons exposed to EVD, dissemination of key messages to reduce risk of transmission and stigma and equipping rural health facilities with essential prevention measures such as WASH, waste management, and effective infection prevention and control (IPC) material and protocols. In October 2018, IMA undertook a rapid assessment of 68 strategic key health facilities. Nearly two-thirds of health facilities had IPC materials; yet most consisted merely of chlorine, gloves, and thermometers. Acceptable amenities for water, incineration, and adequate latrines were found in less than one-third of facilities. The sample of 68 was less than a fifth of operational health care facilities (HFs), indicating a significant gap in IPC coverage in frequently visited facilities where most victims first present (and typically visit several centers in the early stages of their disease). In May 2019, IMA assessed facilities in Nyiragongo, Rutshuru, Rwangoma, and Kibirizi. In these facilities, we discovered that the issue of inadequate IPC supplies and WASH infrastructure persists, as well as additional issues including low understanding of protocols for suspect cases, lack of coordination, and staff turnover. These findings are consistent with those of IPC assessments of health centers in other Ebola affected areas (Pathmanathan 2014; Biedron et al. 2019).
IMA and its partners’ community outreach and mobilization approach will include deploying nurses and CHWs (relais communautaire) from strategic health areas for community-based messaging and enhanced surveillance. The health facility-based IPC approach will include a rapid survey and gender analysis, provision of IPC material and applied protocols, and a monthly support package and checklist to ensure compliance. Cost-efficient, rapid, and appropriate WASH repairs/renovations will be provided to the EVD isolation units of each of the central health centers and comprise (1) light-touch clean water supply repair (2) latrine rehabilitation and repair (3) solid waste incinerator rehabilitation and (4) set aside areas for triage, isolation, PPE donning and doffing, and ambulance evacuation. Since the onset of the outbreak, communities have eschewed health services at local facilities due to the perceived risk of Ebola. IMA and partners will also work to ensure community demand for and access to quality, safe, and comprehensive health services in 6 selected health facilities in priority health areas as part of a scale-up ‘wrap-around’ component. Additionally, community-based WASH projects will help to improve hygiene, reduce virus transmission, and create positive touchstones to link to Ebola prevention and response actors in the health sector.
4 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
The impact of this approach will ensure that high risk and difficult to access health areas and health facilities have the requisite training, financial support, equipment and supplies, and oversight to effectively address the outbreak of EVD while continuing to provide other lifesaving health services; reduce transmission in high risk health-facility areas; provide community-based surveillance and care; ensure contact tracing is appropriately carried out; and reinforce WASH-related and positive behaviors. Curtailment of transmission, reinforced capacity to care, and resilient and engaged communities will help to address the critical gaps in the current EVD outbreak.
Baseline Assessment Objective The overall objective of this assessment is to present baseline data on key project indicators against which the project’s results will be monitored. This baseline assessment will enable IMA to measure the project’s contribution to Ebola prevention and response in the targeted areas. The performance indicators for the project include: Table 1: List of Performance Indicators for the Ebola Prevention and Response project
Sector Name: Health
Objective: Health facilities are improved to adequately and safely respond to the EVD outbreak
Sub-Sector Name: Health Systems and Clinical Support
Indicator 1: Number of health facilities supported.
Indicator 2: Percentage of total weekly surveillance reports submitted on time by health facilities.
Indicator 3: Number of outpatient consultations.
Indicator 4: Number of health facilities rehabilitated.
Indicator 5: Number of health care staff trained.
Sub-Sector Name: Communicable Diseases
Indicator 1: Number of communicable disease consultations.
Indicator 2: Case fatality rates for communicable diseases.
Sub-Sector Name: Reproductive Health
Indicator 1: Number of pregnant women who have attended at least two comprehensive antenatal clinics.
Indicator 2: Number of newborns that received postnatal care within three days of delivery.
5 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Indicator 3: Number of births assisted by a skilled attendant at birth.
Indicator 4: Number of cases of sexual violence treated.
Indicator 5: Number of women in their third trimester who received a clean delivery kit.
Sub-Sector Name: Community Health
Indicator 1: Number of Community Health Workers (CHW) supported (total within project area and per 10,000 population).
Indicator 2: Number and percentage of CHWs conducting public health surveillance
Indicator 3: Number and percentage of community members who can recall target health education messages.
Indicator 4: Custom Number of households visited (reached) by a CHW as part of SBC efforts.
Indicator 5: Custom Number of community members who received an EVD-associated messaged delivered by a CHW.
Indicator 6: Custom Number of church leaders trained and mobilized to champion Ebola prevention messages in their congregations.
Indicator 7: Custom Number of Ebola sensitization songs produced in local languages.
Indicator 8: Custom Number of persons who received a message from a religious leader.
Indicator 9: Custom Number of teachers trained to champion Ebola prevention messages in their schools
Indicator 10: Custom Number of children who received an Ebola awareness message in school from teachers
Sub-Sector Name: Public Health Emergencies of International Concern and Pandemics
Indicator 1: Number of health care staff trained
Indicator 2: Percent of target population who can recall 2 or more protective measures.
Indicator 3: Percent of persons who meet criteria for isolation and are appropriately isolated
Indicator 4: Custom Number of health facilities visited at least once monthly by a representative from the BCZ or IPC Sub-commission.
Indicator 5: Custom Number of target health facilities that follow IPC protocol.
Sub-Sector Name: Pharmaceutical and Other Medical Commodities
6 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Indicator 1: Number of people trained in medical commodity supply chain management.
Indicator 2: Number of health facilities out of stock of any medical commodity tracer products, for longer than one week, 7 consecutive days.
Indicator 3: Custom Number of health facilities supplied with PPE material monthly.
Sub-Sector Name: WASH In Health Facilities
Indicator 1: Custom Number of Water Sources Repaired or Rehabilitated at target health facilities
Indicator 2: Custom Number of Latrines Repaired or Rehabilitated at target health facilities
Indicator 3: Custom Number of Incinerators Repaired or Rehabilitated at target health facilities
Indicator 4: Custom Number of Triage Centers Erected at target health facilities
Indicator 5: Custom Number of Isolation and Changing Rooms Erected at target health facilities
Sector Name: WASH
Objective: Improved WASH infrastructure helps reduce EVD transmission and regain community trust.
Sub-Sector Name: Hygiene Promotion
Indicator 1: Number of people receiving direct hygiene promotion
Indicator 2: Custom Number of people targeted by the hygiene promotion program who know at least 3 of the 5 critical times to wash hands
Indicator 3: Custom Percent of households targeted by the hygiene promotion program whose store their drinking water safely in clean containers
Sub-Sector Name: Water Supply
Indicator 1: Number of people directly utilizing improved water services provided with OFDA funding
Indicator 2: Custom Percent of water points developed, repaired, or rehabilitated with 0 fecal coliforms per 100 ml sample
Indicator 3: Custom Percent of water user committees created and/or trained by the WASH program that are active at least 3 months after training
7 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Baseline Scope: Population, Locations and Timing This baseline assessment looks at key project indicators at the start of the project period (October- November 2019) for the main health areas involved in the outbreak. The 63 health areas included in the assessment are in the north eastern part of the country (Ituri and North Kivu provinces) and account for the majority of EVD cases.
Estimated Beneficiary Numbers: IMA will target 63 ‘aires de santé’ which represent the majority of recorded EVD cases. Direct beneficiaries are equivalent to the estimated population in the 63 aires de santé (1,300,080). An estimated five percent of these are internally displaced due to ongoing conflict. The estimated number of beneficiaries within the target population are
Targeted Direct Beneficiaries: 284,916 Estimated Number of IDPs: 14,246
These beneficiary numbers are based on:
•number of persons presenting to 76 health facilities (40,493 per quarter or 161,972 per year)
•population of 8 health areas receiving house to house surveillance visits is 122,944
Methods and Data Sources Location and Timing: Data Collection covered all 10 targeted health zones. Apart from the WASH KAP Survey (which was delayed slightly), data were collected between October and December 2019.
1. Rapid Health Facility and Gender Assessment
Baseline data for indicators related to Public Health Emergencies, Pharmaceutical and Other Medical Commodities, and WASH in Health Facilities were collected in November and December, 2019 via a rapid assessment of 76 IMA supported government health center/facilities in the 10 health zones of Rutshuru, Rwanguba, Nyiragongo, Goma, Karisimbi, Beni, Kalunguta, Mabalako, Katwa and Butembo. The assessment included all 76 health facilities supported by IMA. Conducted by IMA and partners with senior health facility staff (usually the head nurse), the survey focused on IPC and WASH to determine priority needs for intervention. Specifically, the assessment looked for the presence (or not) of IPC Material (gloves, gowns, masks, soap, etc.) as well as clean water sources, acceptable latrines, functional incinerator, and the existence of triage and isolation areas (that meet WHO guideline standards) to ensure physical barriers between suspect and other patients. The assessment also included questions on training and facility-based practices related to IPC and Ebola.
The gender related questions included gender make-up of clinic staff, presence of reproductive health services including family planning, the reporting (and, recognition) of gender-based violence and availability of services for Sexual and Gender Based Violence (SGBV) survivors. The data from the assessments were validated/signed off on by Health Zone supervisors.
2. DHIS2/SNIS, Ebola Project Year 1 Data Review, and Literature Review
Baseline data for indicators related to Reproductive Health, Communicable Diseases, and Health Systems and Clinical Support were collected via the DRC Ministry of Health’s DHIS2/SNIS health information management system and onsite health facility data collection. If collected via DHIS2/SNIS, an average for each health facility was calculated using data from the previous 12 months. Then, that 8 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003 was averaged over the 6 health facilities. The case fatality rate baseline was estimated based on previous studies (Portnoy et al 2019; Inglebeen 2019).
Community Health indicator baseline data were collected via IMA’s Award 1 (award 720FDA19CA00004 DRC) Ebola Project database. Original data collection methods for those indicators included focus groups, sign in sheets/rosters, record review, and internal program document review.
3. Knowledge, Attitudes, Practices (KAP) Survey for WASH indicators
Baseline numbers and percentages for select Water Supply and Hygiene Promotion indicators and the Recall of Target Health Education Messages and the Recall of Protective Measures indicators was collected in mid-January 2020. Due to insecurity in the region, the Tearfund baseline KAP survey was delayed slightly and data are just now available (the baseline KAP survey report is included as an attachment). The required sample size for that survey was calculated using a software program based on a confidence level of 95% and a 5% margin of error. Villages were randomly selected to be surveyed through a computer-generated numbering application. A random walk methodology was used to select the households to be surveyed.
Limitations As much of the work for this project is a continuation of work from the previous project, it is difficult to establish a true baseline for indicators that are the same across Award 1 and Award 2, especially those related to IPC and Community Health. For example, 50 facilities included in the recent baseline rapid assessment have already been receiving IMA support for IPC through the first OFDA award. Twenty-five of these facilities were added in April 2019, halfway through Award 1, so an official baseline was not established for them. We also did not collect rapid assessment baseline data on non-IMA supported health facilities, so we will not be able to compare intervention and non-intervention sites on those specific indicators at endline.
Additionally, data for disaggregations (age, sex, disease type) were missing in DHIS2/SNIS for several indicators (ex. number of outpatient consultations). We will be collecting those data disaggregations at health facilities using our own data collection tool moving forward.
The case fatality rate across all communicable diseases across all age groups is difficult to obtain, as it is reported differently in SNIS/DHIS2. The estimate of 7% was obtained by averaging case fatality rates across diseases across several published studies.
Results and Analysis NOTE: Baselines and Targets for the following Indicators have been changed from the PMP based on the recent addition of larger, busier facilities for wraparound support: Number of outpatient consultations; Number of communicable disease consultations; All indicators in the Reproductive health subsector. Additional disaggregation data for select indicators can be found in the ART.
Also, many of the targets are for additional facilities, persons or households to those supported/trained/reached in Award 1.
Sector Name: Health
9 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Objective: Health facilities are improved to adequately and safely respond to the EVD outbreak Sub-Sector Health Systems and Name: Clinical Support Baseline Cumulative Target Indicator 1: Number of health 0 6 facilities supported. Indicator 2: Percentage of total 20% 100% weekly surveillance reports submitted on time by health facilities. Indicator 3: Number of outpatient 33,372 34,000 consultations. Male:15,017 Male:15,300 Female:18,355 Female:18,700 Indicator 4: Number of health 0 6 facilities rehabilitated. Indicator 5: Number of health care NA 168 staff trained. Male: 84 Female: 84 Sub-Sector Communicable Diseases Name: Indicator 1: 13,349 (40% of outpatient 13,500 consults) Male Total: 6,075 Male Total: 6,007 Male <5 yrs: 1,883 Male <5 yrs: 1,862 Male >=5: 4,192 Number of communicable Male>=5: 4,145 Female Total: 7,425 disease consultations. Female Total=7,342 Female <5 yrs: 1,782 Female<5 yrs: 1,762 Female>=5: 5,643 Female>=5: 5,580
Indicator 2: Case fatality rates for 7%** 5% communicable diseases. Sub-Sector Reproductive Health Name: Indicator 1: Number of pregnant 1,372 2,058 women who have attended at least two comprehensive antenatal clinics. Indicator 2: Number of newborns that 1,235 1,647 received postnatal care within three days of delivery. Indicator 3: Number of births assisted 2,745 2,760 by a skilled attendant at birth. Indicator 4: Number of cases of sexual 20 22 violence treated. Indicator 5: Number of women in 0 2,058 their third trimester who 10 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
received a clean delivery kit. Sub-Sector Community Health Name: Indicator 1: Number of Community 550 (Award 1 Total) 200 Health Workers (CHW) supported (total within project area and per 10,000 population). Indicator 2: Number and percentage 470 (Award 1 Total) 120 of CHWs conducting public health surveillance Indicator 3: Number and percentage 75% 75% of community members who can recall target health education messages. Indicator 4: Number of households 261,861 (Award 1 Total) 80,000 (additional) Custom visited (reached) by a CHW as part of SBC efforts. Indicator 5: Number of community 399,854 (Award 1 Total) 320,000 (additional) Custom members who received an EVD-associated messaged delivered by a CHW. Indicator 6: Number of church leaders 609 (Award 1 Total) 120 (additional) Custom trained and mobilized to champion Ebola prevention messages in their congregations. Indicator 7: Number of Ebola 11 (Award 1 Total) 5 (additional) Custom sensitization songs produced in local languages. Indicator 8: Number of persons who 629,002 (Award 1 Total) 61,699 (additional) Custom received a message from a religious leader. Indicator 9: Number of teachers 0 216 Custom trained to champion Ebola prevention messages in their schools Indicator 10: Number of children who 0 5,400 Custom received an Ebola awareness message in school from teachers Sub-Sector Public Health Name: Emergencies of International Concern and Pandemics Indicator 1: Number of health care 535 (Award 1 Total) 168 staff trained Male: 84
11 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Female: 84 Indicator 2: Percent of target ND* 75% population who can recall 2 or more protective measures. Indicator 3: Percent of persons who 0%*** 100% meet criteria for isolation and are appropriately isolated Indicator 4: Number of health 47 76 Custom facilities visited at least once monthly by a representative from the BCZ or IPC Sub- commission. Indicator 5: Number of target health 50 76 Custom facilities that follow IPC protocol. Sub-Sector Pharmaceutical and Other Name: Medical Commodities Indicator 1: Number of people trained 154 (Award 1 Total) 158 in medical commodity Male: 79 supply chain Female: 79 management. Indicator 2: Number of health 12 (15%) 4 (<7%) facilities out of stock of any medical commodity tracer products, for longer than one week, 7 consecutive days. Indicator 3: Number of health 50 76 Custom facilities supplied with PPE material monthly. Sub-Sector WASH In Health Facilities Name: Indicator 1: Number of Water Sources 0 Custom Repaired or Rehabilitated 16 at target health facilities Indicator 2: Number of Latrines 0 Custom Repaired or Rehabilitated 22 at target health facilities Indicator 3: Number of Incinerators 0 Custom Repaired or Rehabilitated 17 at target health facilities Indicator 4: Number of Triage Centers 0 Custom Erected at target health 22 facilities Indicator 5: Number of Isolation and 0 Custom Changing Rooms Erected 22 at target health facilities Sector Name: WASH
12 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Objective: Improved WASH infrastructure helps reduce EVD transmission and regain community trust. Sub-Sector Hygiene Promotion Name: Indicator 1: Number of people 0 43,808 receiving direct hygiene promotion Indicator 2: Number of people 28% 21,904 Custom targeted by the hygiene promotion program who know at least 3 of the 5 critical times to wash hands Indicator 3: Percent of households 24% 50% Custom targeted by the hygiene promotion program whose store their drinking water safely in clean containers Sub-Sector Water Supply Name: Indicator 1: Number of people 0 9,000 directly utilizing improved water services provided with OFDA funding Indicator 2: Percent of water points 0 100% Custom developed, repaired, or rehabilitated with 0 fecal coliforms per 100 ml sample Indicator 3: Percent of water user 0 100% Custom committees created and/or trained by the WASH program that are active at least 3 months after training ; **Please see note about case fatality rate in the Limitations section. *** There was no established isolation unit in any of the 76 facilities at the onset, the baseline could in effect be ‘zero’
Gender Assessment Evidence from the 2014-2016 in West Africa indicates that women and girls are particularly vulnerable to the indirect impacts of Ebola ranging from lost livelihoods and education (through school closures), to reduced access to, and utilization of, maternal, sexual, and reproductive health services (Gatiso 2018; Jones et al 2016). More directly, the increase in sexual violence and gender-based violence during complex emergencies, including disease outbreaks, has been documented (Gill and Fannigan 2015).
13 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
In order to monitor SGBV in the targeted health areas, and to better understand the impact of the Ebola outbreak on women and girls, we have included gender related questions in the rapid assessment of the 76 facilities. Key results are summarized below.
26% of health facilities surveyed do not have separate toilets for males and females
62% of health facilities surveyed do not offer services/care for survivors of sexual and gender- based violence
76% of health facilities surveyed do not have a protocol in place for combating sexual and gender-based violence
63% of health facilities surveyed do not have staff trained according to the national protocol to receive and treat cases of sexual violence
Only 34% of the health facilities surveyed have PEP (post exposure prophylaxis) kits available for cases of sexual violence
48% of health facility staff are female
Analysis and Data Use Data obtained from the baseline study has already been used to refine targets for this award. Additionally, data from the rapid assessment provides guidance for topics that need special attention during IPC trainings (ex. proper use of sterilization equipment), as well as which facilities may need additional supportive supervision for IPC control.
References WHO 2020. Ebola Virus Disease: Democratic Republic of Congo External Situation Report 74. Available at https://www.who.int/publications-detail/ebola-virus-disease-democratic-republic-of-congo-external- situation-report-74-2019.
Pathmanathan et al. 2014. Rapid Assessment of Ebola Prevention and Control Needs- Six Districts, Sierra Leone, October 2014. MMWR 63(49).
Biedron et al. 2019. Evaluation of Infection Prevention and Control Readiness at Frontline Health Care Facilities in High-Risk Districts Bordering Ebola Virus Disease–Affected Areas in the Democratic Republic of the Congo — Uganda, 2018. MMWR 68(39).
Portnoy, A. et al. 2019. Estimates of case-fatality ratios of measles in low-income and middle-income countries: a systematic review and modelling analysis. Lancet 7(4):PE472-481.
Ingelbeen, B. et al. 2019. Recurrent Cholera Outbreaks: Democratic Republic of Congo, 2008-2017. Emerging Infectious Diseases 25(5).
WHO. Data quality review: a toolkit for facility data quality assessment. Module 1. Framework and metrics W.H. Organization, Editor. 2017: Geneva.
Gatiso. TT, et al. PLoS Negl Trop Dis. 2018;doi.org/10.1371.
14 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery
Award No. 720FDA20CA00003
Jones SA, Gopalakrishnan S, Ameh CA, et al ‘Women and babies are dying but not of Ebola’: the effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone BMJ Global Health 2016;1:e000065.
Risso-Gill, I. and Fennegan, L. 2015. Children’s Ebola Recovery Assessment: Sierra Leone. Accessed November 15th, at https://www.savethechildren.org/content/dam/global/reports/emergency- humanitarian-response/ebola-rec-sierraleone.pdf
15 IMA World Health, OFDA funded EBOLA VIRUS DISEASE in DRC: Strengthening community prevention, response, and recovery