Report on Measles Epidemic Activities Period of Report: February 16, 2018 to February 28, 2019

Home , Ambilobe, Amboangibe, Antseza, Sambava District

USAID COMMUNITY CAPACITY FOR HEALTH PROGRAM

Cooperative Agreement No. AID-687-A-16-00001 June 6, 2016 to June 6, 2021

Submitted to: Dr. Jocelyne ANDRIAMIADANA, AOR USAID/Madagascar in Antananarivo, Madagascar

Prepared by: JSI Research & Training Institute, Inc. USAID Community Capacity for Health Program – Mahefa Miaraka Résidence Lavalley Près Lot IIK 50H Mahatony Alarobia, Antananarivo (101)

This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this report are the responsibility of JSI Research & Training Institute, Inc. (JSI) and do not necessarily reflect the views of USAID or the United States Government.

TABLE OF CONTENTS

Abbreviations 4 Executive Project Summary 5 Project Implementation 6 Financial Expenditures 9 Annex 1. Photo Collage 10

3 Abbreviations

IA Intervention Area

IEC/BCC information, education, communication/behavior change communication

CCDS Commune Commission for Health Development (Commission Communale de Développement de la Santé)

CHV community health volunteer

CSB Basic Health Center (Centre de Santé de Base)

DPEV Directorate of Expanded Program on Immunization (Direction du Programme Elargi de Vaccination)

FKT Fokontany (village)

GOM Government of Madagascar

JSI JSI Research & Training Institute, Inc.

MOH Ministry of Health

SDSP District Health Office (Service du District de Santé Publique)

SBCC social and behavior change communication

USAID United States Agency for International Development

4 Executive Summary During this reporting period, the USAID Community Capacity for Health Program team (the Program), along with other technical and financial partners, continued to take an active part in the Government of Madagascar’s measles epidemic response efforts at the national, regional, district, and commune levels. From February 16, 2019 to February 28, 2019, the Program provided technical, financial, and logistics support to district health management teams to conduct measles investigations in three districts and campaigns in six Program districts. In addition, the Program’s teams participated in regional and district microplanning exercises, as well as taking an active part in overall coordination and monitoring efforts at the national level through the Ministry of Health’s (MOH) crisis unit and sub-committees for campaign response, communication, case management and surveillance to address the epidemic and plan future rounds of targeted measles campaigns. Details of the Program’s support during this period are presented below:

 139 Ministry of Health (MOH) staff, 675 community health volunteers (CHVs), 174 fokontany heads, and 74 members of commune commissions for health development (CCDS) received training on community disease surveillance with a focus on measles.  Technical, financial, and logistic support to 6 district measles campaigns in Menabe and DIANA Regions: Ambilobe, Ambanja, Antsiranana I, Antsiranana II, Mahabo, and Nosy Be districts.  1723 measles cases treated, 1583 children vaccinated, and 9 measles-related deaths were confirmed through Regional and District Health Management Team investigations in 3 districts (Maintirano, Mitsinjo, and Sambava) supported by the Program.  Technical support to Bealanana district, Sofia region for measles campaign micro-planning.  Logistic support for the distribution of medicine from district stores to health centers for the management of measles cases in SAVA region.  Regional radio broadcasts on the importance of vaccinations, vaccination safety, and measles information.

5 Project Implementation Figure 1- Mahefa Miaraka’s Regions and Districts The USAID Community Capacity for Health Program, locally known as Mahefa Miaraka, is a five-year (2016-2021) community-based integrated health program funded by the United States Agency for International Development (USAID). The Program is a collaborative effort between the MOH, USAID, and JSI Research & Training Institute, Inc. (JSI). The Program provides tools and capacity-building training to about 10,000 CHVs, in addition to working with national and local government actors to strengthen the health system and health policies. The Program plays an especially important role in the community-level response to the measles epidemic by mobilizing communities to vaccinate their children and to promptly seek care for measles in coordination with health officials through CHVs, as well as local and traditional leaders.

Mahefa Miaraka operates in 4,885 fokontany (FKT), 456 communes, and 34 districts in the Analanjirofo, Boeny, DIANA, Melaky, Menabe, SAVA, and Sofia regions. Because of this reach, the Program has the potential to provide services to approximately 6.1 million people, or 23.3 percent of the country’s total population (Figure 1).

Since October 2018, Madagascar has experienced a serious measles epidemic with 79, 6991 measles cases reported to February 28, 2019. Consequently, the Program’s efforts and resources have been mobilized to assist the MOH in its efforts to prepare for and fight against the epidemic, especially as the epidemic spread to all regions of the country. The Program continues to take an active part in national coordination meetings on the measles epidemic response with the Directorate of the Expanded Program on Immunization (Direction du Programme Elargi de Vaccination or DPEV), and in weekly crisis committee meetings for the conduct and monitoring of the first two phases of the national measles campaign. In addition, since the beginning of the epidemic, the Program has provided technical, financial and logistic support to regional and district health management teams for measles campaigns in 8 districts (Ambanja, Ambilobe, Antalaha, Antsiranana I, Antsiranana II, Mahabo, Morandava, and Nosy Be) and community field investigations in 5 districts, with 6 of these campaigns and 3 of the field investigations taking place during this reporting period. In further support of the measles epidemic response, the Program has also trained MOH district health management teams, health center heads, members of local health coordination committees, Fokontany heads, and community health volunteers on community surveillance, including identification and referral of measles cases. Under the direction of DPEV’s Social Mobilization Committee, the Program also contributed to the development of radio messages on measles and the importance of vaccination in light of the current outbreak.

Details of the Program team’s measles response activities from February 16, 2019 to February 28, 2019 are presented in the following sections of this report.

1 Ministère de la Sante Publique, Situation de La Lutte Contre La Rougeole à Madagascar, February 28, 2019. 6

Intervention Area 1 (IA1): Community Engagement and Ownership of Health Services

1. Vaccine preventable diseases (including measles) response training for community health volunteers (CHVs)

One of the Program’s most important contributions in the GOM’s measles response is training community leaders at the commune and fokontany (cluster of villages) levels, CHVs, and the GOM’s health service providers at the regional, district, and commune levels to respond to the epidemic. As a result of these trainings, community actors are able to: 1) educate their community about the measles epidemic, including measles signs and symptoms, the importance of vaccination, why seeking prompt care is important, and the timing of vaccination sessions; 2) identify and list unvaccinated children and coordinate with the CSB to ensure vaccination of all children between six months to nine years of age; 3) identify and refer measles cases for treatment at the CSB; and, 4) report any measles-related deaths in the community to the head of the Fokontany and the CSB.

From February 16 to February 28, 2019 the Program trained 139 district health management team and health center staff, 675 CHVs, 174 Fokontany chiefs, and 74 commune leaders on the measles epidemic and response (case signs, referral, and reporting). Since the beginning of the outbreak the Program has oriented and trained a total of 10,292 individuals on the measles epidemic for the identification of unvaccinated children and measles cases, as well as the referral of cases for treatment at the CSB (figures shown in Table 1).

Table 1 Trainers, Providers, and Coordination Structures Trained (October 1, 2018 to February 28, 2019)*

Trainers and Providers Community Total Regional District health health Health Regions Commune Village office office Center CHVs leaders heads officials officials Staff (CSB) (EMAR) (EMAD) Analanjirofo 0 0 35 1 263 39 338 Boeny 0 0 25 0 182 64 271 DIANA 7 12 199 62 1,155 338 1,773 Melaky 0 0 59 20 578 181 838 Menabe 0 9 91 37 1,070 524 1,731 SAVA 0 4 128 34 1,326 320 1,812 Sofia 1 9 190 97 2,783 449 3,529 TOTAL 8 34 727 251 7,357 1,915 10,292

* Training totals for February 2019 will be finalized mid-March 2019

2. Referral of suspected measles cases to CSB

CHVs screen cases and refer suspected measles cases. The Program routinely monitors how many suspected measles cases CHVs report to CSBs. During the reporting period, CHVs also conducted health education sessions to inform their community about signs of suspected cases and the need for

7 community members to report suspected cases immediately to CHVs and/or the CSB. In the month of January 20192, CHVs had identified and referred 2,235 cases of measles for treatment.

Intervention Area 2 (IA2): Behavior Change and Health Promotion

1. Broadcast messages on measles and the importance of vaccination through local radio stations

As part of its social behavior change and communication (SBCC) approach, the Program contracts with 23 regional radio stations to broadcast radio programs developed by the MOH several times per week. These media activities are designed to improve the public’s knowledge about measles and the current epidemic and encourage them to adopt best prevention and treatment practices, especially vaccinating their children.

During the reporting period, CHVs also conducted health education sessions to inform the community on communicable diseases, specifically on measles signs and the need for community members to seek immediate care for suspected cases from CHVs and/or the CSB3. In addition, CHVs took part in identifying unvaccinated children in their fokontany during measles campaigns and investigations conducted by district health management teams.

Intervention Area 3 (IA3): Health Service Planning, Management, and Governance  From February 16 to February 28, 2019 the Program actively took part in micro-planning for measles campaigns in six Program districts and provided technical, financial, and logistics support to the measles vaccination teams and community mobilizers in Ambilobe, Ambanja, Antsiranana I, Antsiranana II, Mahabo, and Nosy Be districts. In addition, the Program provided technical support to Bealanana district, Sofia region for measles campaign micro- planning (planning for Phase 3 of the campaign). .  In Morondava, the Mahefa Miaraka team participated in advocacy meetings, financially supported communication efforts (including local radio broadcasts), financially supported district and regional supervisors, and coordinated the transport of vaccines and commodities to three CSBs. In addition, the regional and district teams supported strategic decision- making throughout the campaign by providing technical input during daily debriefings, including analysis of campaign results and managing the process of identifying unvaccinated children in communities. The campaign targeted 287,764 children between the ages of six months to nine years for vaccination. Five of the six districts achieved greater than 95 percent coverage of this target.4 Only Antsiranana I (87.1% coverage) achieved less than the 95% coverage target. The lower coverage was due in part to the closure of several schools for holidays, the refusal of certain schools to allow vaccinators on their premises, and refusals by parents. The Mahefa Miaraka team has actively worked with the Regional Health Management Team to enlist the Regional Prefect to broadcast messages over local radio on the importance of vaccinating children against the measles. In addition, the Prefect will meet with school administrators in order to convince them of the need to vaccinate their students. With the support of the Regional Prefect and the reopening of schools, the District Health Management Team and its partners aim to achieve the 95% coverage rate by early March.

2 Most recent community data available from CHV monthly reports dates from January 2019. 3 Figures for February will be available as of the next update report, March 1 – 15, 2019. 4 District Health Office administrative records as reported by MOH on March 4, 2019. 8

 In addition to campaign activities, the Program supported three community field investigations in response to suspected measles cases. During these investigations CHVs, in collaboration with district health offices and CSBs, treated 1723 measles cases, vaccinated 1583 children, and confirmed 9 measles-related deaths: o In Boeny, the Program provided technical and financial support to the Mitsinjo District Health Management Team to conduct measles investigations and response in Ambararatabe fokontany, Antseza commune. Mahefa Miaraka supported the complete listing and treatment of 97 measles cases and the vaccination of 140 children 6 months to 9 years. o In Melaky, the Program provided financial and logistic support to the Mantriano District Health Management Team for measles investigation and response for the complete listing and treatment of 1581 measles cases in the district, vaccination of 631children 6 months to 9 years, and confirmed 7 reported measles-related deaths. o In SAVA, the Program conducted joint investigation and response activities with the district health management team in Andravitokana fokontany, Amboangibe commune, Sambava district. Mahefa Miaraka supported the complete listing and treatment of 45 measles cases, vaccination of 812 children 6 months to 9 years, and confirmed 2 reported measles-related deaths. In addition, the team supported the transport of medicines from the districts to health centers (CSBs), and collaborated with CSB heads to mobilize CHVs to identify non-vaccinated children.

Financial Expenditures* (October 1, 2018 to February 28, 2019)

ITEMS Current Period (USD) Training Measles Investigation (District) Campaign Activities (mobilization and vaccination teams, supervision, communication)

TOTAL

*Total financial expenditures from this report may change due to the fact that financial reports for the activities in question will not be finalized until March 2019. 4** Funds allocated under activity 3.3.3.1 of the FY2019 Workplan, “Provide support as needed to DRSP for emergency health response” total . In FY2019 the funds expenditure for both plague and measles response activities are quickly approaching the annual total approved for this activity, with approximately spent.

9 ANNEX 1: Photo Collage of Measles Campaign Activities February 2019

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