MMDP PROJECT ANNUAL PROGRESS REPORT October 1, 2017 – September 30, 2018
Prepared for: Emily Wainwright, AOR MMDP Project, USAID Submitted by: Helen Keller International Date: November 15, 2018
For more information: Kathy Tilford, 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: A trichiasis surgeon examines a woman's eye in the Tigray region of Ethiopia several months after having performed the surgery. (Photo: HKI)
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CONTENTS
ACRONYMS ...... 4
EXECUTIVE SUMMARY ...... 6
KEY PROGRESS INDICATORS ...... 8
GLOBAL PROJECT - TECHNICAL...... 10
BURKINA FASO ...... 31
TRACHOMA ...... 39
LYMPHATIC FILARIASIS ...... 49
CAMEROON ...... 58
TRACHOMA ...... 66
LYMPHATIC FILARIASIS ...... 75
ETHIOPIA ...... 81
TRACHOMA (Oromia) ...... 84
TRACHOMA (Tigray) ...... 99
TRACHOMA (RTI) ...... 109
LYMPHATIC FILARIASIS ...... 111
GLOBAL PROJECT - OPERATIONAL ...... 136
APPENDICES ...... 138
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ACRONYMS AIM Accelerating Integrated Management ASTMH American Society of Tropical Medicine and Hygiene BA Burden Assessment BB Buno Bedele zone BG Beneshangul-Gumuz CBHW Community Based Health Workers CDC US Centers for Disease Control and Prevention CNTD Centre for Neglected Tropical Diseases COR-NTD Coalition for Operational Research on 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) DMT Dedicated Mobile Team DQT Dedicated Quality Team DRS Regional Health Directorate (Direction Régionale de la Santé) DRSP Regional Delegation of Public Health ECU Eye Care Unit EMMP Environmental Monitoring and Mitigation Plan 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 HD Health District 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 Development IAB Illubabora zone IC Infection Control ICTC International Coalition for Trachoma Control IEC Information, Education, and Communication IECW Integrated Eye Care Worker IESO Integrated Emergency Surgical Officer LF Lymphatic Filariasis LQAS Lot Quality Assurance Sampling LSTM Liverpool School of Tropical Medicine M&E Monitoring and Evaluation MDA Mass Drug Administration
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MMDP Morbidity Management and Disability Prevention MMMM Monthly Morbidity Management Meeting MOH Ministry of Health MoST Ministry of Innovation and Technology1 MOU Memorandum of Understanding NaPAN National Podoconiosis Action Network NGO Non-Governmental Organization NTD Neglected Tropical Disease NTTF National Trachoma Task Force ORHB Oromia Regional Health Bureau PFSA Pharmaceutical Fund and Supply Agency PECU Primary Eye Care Unit PHCU Primary Health Care Unit PNLCé National Blindness Prevention Program (Programme National de Lutte contre la Cécité) PNLO National Onchocerciasis Control Program (Programme National de Lutte contre l’Onchocercose) PNMTN National Neglected Tropical Disease Control Program (Programme National de lutte contre les Maladies Tropicales Négligées) QA Quality Assurance RA Readiness Assessment RHB Regional Health Bureau SAFE Surgery, Antibiotics, Facial cleanliness, Environmental improvement SAR Semi-annual Report SECU Secondary Eye Care Unit SNNPR Southern Nations, Nationalities, and People’s Region STTA Short-term Technical Assistance TAB Technical Advisory Board TAP Trachoma Action Plan TAS Trachoma Assessment Survey TEO Tetracycline Eye Ointment TF Trachomatous inflammation- Follicular TIS Trachoma Impact Survey TOT Training of Trainers TPS Traditional Health Practitioners (Tradipraticiens de Santé) TRHB Tigray Regional Health Bureau TSS Trachoma Surveillance Surveys TT Trachomatous Trichiasis TWG Technical Working Group 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
1 Formerly named the Ministry of Science and Technology
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EXECUTIVE SUMMARY The Morbidity Management and Disability Prevention (MMDP) Project2 works at the national and global levels to expand the capacity of ministries of health to provide quality MMDP services for trachoma and lymphatic filariasis (LF) as a part of global disease elimination efforts. The project works to: support service delivery and implement quality assurance measures that contribute to stronger health systems, 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.
In FY18, the MMDP Project continued to work closely with national programs in Burkina Faso, Cameroon, and Ethiopia to strengthen national ownership and global capacity for the scale-up of trachoma and LF care. The project also worked with global partners and experts, including those on the project’s Technical Advisory Boards for trachoma and LF, to leverage field experiences and contribute to the global discussion on capacity building and support for meeting the 2020 elimination goals for trachoma and LF.
The MMDP Project supported 20,813 trachomatous trichiasis (TT) surgeries during the reporting period, advancing ministry of health efforts to meet the trachoma elimination goals. To provide these surgeries, during the reporting period the project screened 584,088 individuals living in endemic areas across the three countries, using a variety of community mobilization and new case-finding strategies. In addition to supporting trachoma elimination planning in the three countries, the project worked with TT surgeons in Burkina Faso and Cameroon on photo taking of TT cases before and after surgery to establish the potential of photos as predictors of TT surgical outcomes.
The project continued its support to ministries of health in project countries in providing quality hydrocele surgery and lymphedema management services. In addition to capacity building efforts focused on the training of 11 hydrocele surgeons3 using the Filaricele Anatomical Surgical Task Trainer (FASTT) training package, the project supported national programs’ training of 89 health staff in pre- and post-operative care of hydrocele patients. In FY18, the project supported 1,077 hydrocele surgeries and the implementation of immediate and 6-12 month post-operative follow- up across the three countries. These follow-up visits are part of the project’s surgical quality assurance activities to assess the presence of recurrence and collect information on patient perceptions of changes in quality of life. Additional LF activities included training 40 health staff in lymphedema management and 796 lymphedema cases in self-care.
The project also supported a range of activities aimed at ensuring a longer-term sustainability of LF morbidity management through health systems strengthening and the integration of activities into the routine health system. One such example is a project-supported workshop in Ethiopia
2 We have used the term “the project” to include the national NTD program, HKI, and all MMDP partners involved in implementation. 3 The use of the word “surgeons” in this document refers to surgical care providers of hydrocele surgery and includes non-physician surgeons.
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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 Innovation and Technology, formerly Ministry of Science and Technology, in Ethiopia in manufacturing the FASTT surgical simulator locally. The project is working with all stakeholders to support the transfer of the FASTT manufacturing technology from the developer in the U.S. to the Ministry of Innovation and Technology in Ethiopia.
The project partnered with WHO/Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) to provide technical support to the LF MMDP Training Workshop for Francophone African countries. The workshop targeted national program managers and MMDP focal points to strengthen their knowledge of LF and capacity to develop LF elimination dossiers.
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 an excellent teaching tool for surgical care providers in LF endemic countries in Africa. Another tool, the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual, developed by the project with International Coalition for Trachoma Control (ICTC) partners, was formally accepted as a preferred practice by ICTC.
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KEY PROGRESS INDICATORS
The two tables below highlight the key achievements from the reporting period against the primary goals of the MMDP Project: building service capacity and increasing services, quality assurance, improving data availability and use, and disseminating best practices. All activities are described in more detail in subsequent sections of the report.
Table 1: Summary of FY18 Support to MMDP Project Countries: Q1-Q4 FY18 Support to MMDP Project Countries: Q1-Q4 Trachoma Achievements LF Achievements 20,813 TT surgeries total (538 BF + 241 CMR + 1,077 hydrocele surgeries (688 BF + 59 CMR 20,034 ETH) + 330 ETH) • 4 TT surgical campaigns (BF) 796 lymphedema cases trained in self-care • 137 TT surgery teams operating, including (ETH) 4 dedicated mobile teams (ETH) • 3 intensified surgical camps and 2 “mini- camps” (ETH) 584,088 people screened total (71,975 BF + 110,521 CMR + 401,592 ETH) 24 TT surgeons trained using HEAD START 11 new hydrocele surgeons trained using (5 BF + 19 ETH) FASTT (5 BF + 6 ETH)
Refresher/debriefing session for 9 TT surgeons 89 health staff trained in hydrocele surgery (7 CMR + 2 ETH) support (2 BF + 87 ETH) 115 people trained in TT campaign/outreach 13 health staff retrained in post-hydrocele management (97 BF + 18 CMR) surgery survey implementation (ETH) 2,835 case finders and community mobilizers 40 health staff trained to conduct trained (700 BF + 799 CMR + 1,336 ETH) lymphedema management trainings (ETH) 1 district4 assessed for burden through a TT-only survey (CMR)
4 Health districts are referred to as districts for the rest of the report.
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Table 2. Key Project Activities (FY18 Q1-Q4)
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 START5 training package Service TT and hydrocele case finding and confirmation, including house-to-house visits and delivery extensive social mobilization activities Provision of hydrocele surgery through intensive camps and the routine health system Provision of TT surgery through multiple operational platforms, including outreach campaigns, dedicated mobile teams, and static site services Provision of equipment and consumables for TT and hydrocele surgery Quality Supportive supervision of TT and LF training and disease management activities assurance Follow-up of operated cases following TT and hydrocele surgery Photo taking of operated eyes to explore predictors of TT surgical outcomes Improve Analysis of TT and hydrocele surgical quality and patient satisfaction data as part of data post-operative monitoring and planning for future capacity building activities availability Review and revision of TT data for decision-making during trachoma action planning and use 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 two MMDP Technical Updates (one featuring the “Training best Trichiasis Surgeons for Trachoma Elimination Programs” manual and the other practices featuring the “WHO Training Package on Morbidity Management and Disability Prevention for Lymphatic Filariasis”) Publishing of the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual as an ICTC preferred practice Support of an LF MMDP workshop for Francophone countries6 Facilitation of the project’s Technical Advisory Board meetings and the 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-NTDs7, ASTMH8, and others
5 Human Eyelid Analog Device for Surgical Training And Skills Reinforcement in Trachoma 6 Benin, Burkina Faso, Cameroon, Republic of the Congo, Cote d’Ivoire, Mali, São Tomé and Príncipe, and Senegal 7 Coalition for Operational Research on Neglected Tropical Diseases 8 American Society of Tropical Medicine and Hygiene
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A surgeon in Cameroon teaches a family member how to apply TEO after the removal of Harande's bandages following his trichiasis surgery the previous day. (Photo: William Nsai/Studio 3)
GLOBAL PROJECT - TECHNICAL
• The MMDP Project worked with International Coalition for Trachoma Control (ICTC) partners to develop a manual titled “Training Trichiasis Surgeons for Trachoma Elimination Programs,” which was adopted as a new ICTC preferred practice. • In partnership with the National NTD Control Program in Burkina Faso, the MMDP Project conducted an independent evaluation of the FASTT Training Package. The evaluation results were well received by the project’s Technical Advisory Board which issued recommendations for the future use of the training package. • The project hosted two technical update webinars on trachoma and LF. The focus of the webinars included the newly-published ICTC surgeon training manual and the WHO Training Package for LF MMDP.
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IN BRIEF
During this reporting period, the Morbidity Management and Disability Prevention (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 (Cameroon, Burkina Faso, and Ethiopia) by focusing on capacity building for quality service provision for both trachoma and lymphatic filariasis (LF) interventions. Surgical activities were combined with supportive supervision and patient follow-up to strengthen the programmatic, public health, and clinical aspects of trachoma and LF control programs in the three project countries. Patient follow-up activities focused on reaching the maximum number of patients possible for both trachoma and LF and ensuring the quality of the surgical services provided.
At the global level, the project shared its experiences and lessons learned with Neglected Tropical Disease (NTD) partners through open discussions as well as joint sessions and presentations at the annual Coalition for Operational Research on Neglected Tropical Diseases (COR-NTD) and American Society of Tropical Medicine and Hygiene (ASTMH) meetings. The project partnered with experts from the International Coalition for Trachoma Control (ICTC), the University of North Carolina at Chapel Hill, Johns Hopkins University, Sightsavers, WHO, and others to develop a training guide for trachomatous trichiasis (TT) surgeon trainers (to be used in conjunction with the WHO Trichiasis Surgery for Trachoma manual); this guide 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. In July 2018, the project also organized with WHO, Global Alliance to Eliminate Lymphatic Filariasis (GAELF), and US Centers for Disease Control and Prevention (CDC) an NTD technical update webinar that highlighted the WHO LF MMDP Training Package. In FY18, the project evaluated the Filaricele Anatomical Surgical Task Trainer (FASTT) Training Package and shared results with the LF Technical Advisory Board (TAB) to come up with consensus statements and next steps for the dissemination of the FASTT Training Package.
PROJECT ACTIVITIES
SURGICAL CAPACITY AND HEALTH SYSTEMS STRENGTHENING In 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; the focus on quality assurance also includes infection control and health care waste management. 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
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assurance systems to better suit each country’s existing health system. 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 help them adapt country- specific protocols for surgical audits of trichiasis surgeons.
In partnership with ministries of health, the project has set up quality assurance systems for trachoma and LF interventions that are being implemented in all three project countries. In the specific case of Ethiopia, the Federal Ministry of Health (FMOH) worked closely with the project and the Surgical Society of Ethiopia to set up surgical quality assurance systems that are, in some instances, exceeding the project’s quality assurance standards, which themselves are based on international recommendations. One such example is hydrocele surgery patient follow-up. WHO recommends post-surgical patient follow-up within five days of surgery and related data collection on patient outcomes; WHO also recommends assessing the presence of recurrence, which typically can be attributable to the surgery if it appears 6-12 months after surgery. The FASTT Training Package encourages countries to conduct patient follow-up at additional timepoints, including at seven and 14 days and between one and three months. The FMOH in Ethiopia 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 START9 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. In April 2018, Dr. Bedri provided remote technical support as Dr. Kengmogne led a refresher training of surgeons in Cameroon (please see the Capacity Building and Training sub-section in the Cameroon portion of the report for additional details). This refresher training further refined Dr. Kengmogne’s leadership and technical review skills and was one of the final steps in formalizing his training as a master surgeon trainer.
Unfortunately, the project learned in June 2018 that Dr. Kengmogne accepted a new role that will not allow him to continue working as a TT surgeon or surgeon trainer. In light of Dr. Kengmogne’s departure from TT-related work, the project is working with Dr. Emily Gower to develop and finalize a standardized assessment tool for candidate master HEAD START trainers that will be shared with others in the global community for their potential use as they continue the work of capacity building for TT surgery.
• Short-term Technical Assistance for TT surgery: In the first quarter of FY18, the project provided short-term technical assistance (STTA) to Benin and Cote d’Ivoire by
9 Human Eyelid Analog Device for Surgical Training And Skills Reinforcement in Trachoma
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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 high surgical quality. Outcome assessment activities of TT cases who were operated on during the MMDP Project training were successfully completed in Benin. Further details are presented under the STTA section below.
• 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 TT cases. However, these health care workers are usually not the main target of capacity building interventions. In FY18, the MMDP Project added components to the supportive supervision tool to assess counseling, infection control (IC), health care waste management (HCWM), social mobilization and screening, and data collection by nurses and other health care workers. The information collected through supportive supervision was incorporated into a training of four nurses in campaign organization and management in Cameroon. The aide memoire for TT nurses developed in FY17, based on preferred practices and WHO guidelines, was used during this training and has been routinely incorporated into all similar training activities.
Health Systems Strengthening in Trachomatous Trichiasis
• Benin Trachoma Action Plan (TAP) Follow-up Workshop: As part of the project’s STTA support to trachoma activities in Benin, in December 2017 the project assisted the national program to organize a two-day workshop to identify actionable next steps following the 2015 TAP. Five participants from the national program, three staff from RTI/ENVISION in Benin, and one of the national trainers trained by the MMDP Project attended the workshop. During the workshop, the group developed a draft detailed action plan based on the TAP and on 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.
• Case 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 case follow-up would be integrated into any future surgical management of TT. In both countries, the national programs committed to carrying out case follow-up related to any TT surgery activity. Both countries also committed to following up with cases who had been operated on under the MMDP Project-supported training. Benin confirmed that the national trainer, trained under the MMDP Project, conducted outcome assessments on all cases operated on during the training. The national program in Cote d’Ivoire is leading the follow-up efforts based on discussions with HKI. Additional details are under the STTA section of this report.
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Capacity Strengthening in Hydrocele Surgery
• Training Module for Nurses and Other Health Care Workers: The FASTT Training Package includes patient post-operative care and follow-up guidelines in line with global recommendations. Crucial elements of high-quality patient care that help decrease the risk of immediate post-operative infection are proper hygiene and sterility pre- and peri-operatively and the post-operative sterile change of the dressing. During the reporting period, the project used feedback from the trainings conducted in project countries to update the training module for nurses and other health care workers. Based on this experience and feedback from project countries, the updated FASTT Training Package will include clear recommendations that any FASTT training conducted should include a component on training nursing staff in charge of post-operative care, using the additional training modules available in English and French. These training modules will all be updated in FY19 based on the results of the FASTT evaluation discussed in the Surgical Quality Assurance section below and the WHO Hydrocele Surgery Consultation Report.
• Integration of the FASTT Training Package into Pre-service Curriculum of Medical Students: In February 2018, the project organized through RTI a consultative workshop with representatives of several universities in Ethiopia to introduce the FASTT Training Package and assess the level of interest in and potential mechanisms for the integration of this training package into skills laboratories and the curriculum of medical students. This was an opportunity for the project to continue its advocacy efforts for quality hydrocele surgery and to present its experience to date in developing and using the FASTT simulator and the associated training package. The response was positive, and the workshop was attended by the Surgical Society of Ethiopia who was then tasked to adapt the training package into a medical school syllabus. The MMDP Project reviewed the syllabus and provided technical feedback with the support of Dr. Catherine deVries.
• FASTT Technology Transfer: Ethiopia’s interest in the integration of the FASTT training curriculum into medical schools extended beyond the theoretical part with a request for training on the manufacture of the FASTT surgical simulator. The project met in February 2018 with the Ministry of Innovation and Technology, formerly called Ministry of Science and Technology, to confirm their interest and the Minister of State at the time expressed his full support for this initiative. The project held calls with RTI, Dr. Gower (who developed HEAD START), and the FASTT manufacturer in the United States to discuss the potential way forward in conducting this technology transfer. The MMDP Project has issued a Request for Quotations outlining a two-phased approach for the technology transfer. The first phase will consist of preparing a written document of the FASTT manufacturing process, complete with a list of equipment, ingredients, and suppliers. The second phase is an on-site practical training at the Ministry in Ethiopia to ensure that the local staff have acquired the technical skills and know-how needed to manufacture the FASTT simulator. At the time of the writing of this report, the project had still not received any responses to the Request for Quotations. It should be noted
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that there are two persons in the United States who possess the right skills to produce FASTT and they both have very busy schedules.
Health Systems Strengthening in Hydrocele Surgery
• 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 in the Surgical Quality Assurance section below. The report was shared with the project’s LF TAB. The evaluation highlighted the training package’s potential contribution to health systems strengthening through its focus on quality assurance and patient follow- up and recommended that all members of the surgical team (all those present in the operating room) be included in the FASTT training. Initially the FASTT trainings included only surgical care providers but this was later expanded to include anesthetists. In its updated version the FASTT Training Package will include a specific recommendation to include the whole surgical team involved in providing hydrocele surgery to ensure a homogenous uptake and adoption of preferred practices. As the training package includes potential changes to systemic hospital practices, the evaluation also recommended that hospital leadership (administrators and nurse leadership) participate in the training; this recommendation will be included in the updated package.
SURGICAL QUALITY ASSURANCE In FY18 the MMDP Project worked with the national programs in the three project countries to further refine the surgical quality assurance strategies supported 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 and the quality assurance tools used in trichiasis surgery have been adapted for use in hydrocele surgery, including for patient follow-up and infection control measures. As noted above, in FY18 the project conducted an evaluation of the FASTT Training Package that provided overall positive feedback as well as recommendations for updating and finalizing it.
Additional TT surgical quality assurance components include the use of supportive supervision, case follow-up, and surgical audits. The project is currently 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: Outcome assessments target operated TT cases 3-6 months after surgery and aim to have 100% of operated cases seen by a qualified surgeon as part of routine follow-up. In FY18 the project worked with each program to develop a strategy for outcome assessments that was then implemented throughout the year. For additional details, please see the Improving Data Availability and Use section below.
• TT surgical audit: The surgical audit focuses on individual surgeon performance. A sample of cases operated on by the surgeon being audited are examined and the resulting information is used for performance improvement as necessary. Continuing the project’s
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emphasis on quality, TT surgeon audits were conducted in all project countries throughout the year. For additional details, please see the Improving Data Availability and Use section below and the Monitoring and Evaluation section of each country-specific report.
• Update of supportive supervision tool: The MMDP Project collected feedback from the three project countries on the use of the supportive supervision tool and the tool is under revision with input from Dr. Gower. When the updated tool is finalized, it will be shared with the three project countries. In Ethiopia, the FMOH developed its own national quality assurance guidelines for trichiasis and the project supports the use of that tool, which is very similar to the project-developed tool. In Cameroon, the supportive supervision data was collected and triangulated with outcome assessment and surgical audit results to define and develop a tailored capacity building plan for TT surgeons, nurses, and other 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 a visit to Cameroon. 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 two national trainers in Cameroon to assist with a refresher training of TT surgeons and of nurses and other 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 with the national trainers, Dr. Bedri worked with the national trainers through Skype and email to develop a curriculum for the training tailored specifically to the participating surgeons. In the second half of the year, the project worked with Dr. Bedri to provide remote supportive supervision during a training of TT surgeons in the Far North region in Cameroon, as he was unable to participate in-person because 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 in February 2018. This training was organized in the context of an independent evaluation of the FASTT Training Package, led by an external evaluator, Dr. deVries. The purpose of the evaluation was to assess the impact of the training package on surgeon skills. The initial plan was to include a pre- and post-training evaluation of surgeon skills. However, in view of ethical concerns raised by the external evaluator on measuring baseline skills of surgeons on live patients, a revised evaluation protocol was developed that excluded the pre-training evaluation component; this protocol was shared with the project’s LF TAB. Based on the comments from the TAB, the project worked with Dr. deVries and the project’s Senior Scientific Advisor, Dr. Gower, who had led an evaluation on HEAD START, 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 2018 TAB meeting. Please
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refer to Operational Research and Facilitating Global Collaboration sections below. The FASTT Training Package will be updated based on the evaluation recommendations and the final WHO Hydrocele Surgery Consultation Report that is expected to be published in the coming months.
• Hydrocele surgery follow-up: In addition to patient follow-up within five days of surgery, in FY18 the project supported hydrocele surgery follow-up with patients within the 6-12 month period following surgery. The purpose of these follow-up visits was to check for recurrence to determine surgical quality and to assess self-perceived changes in patients’ quality of life. This activity took place in all three project countries and data is being compiled for a project write-up on hydrocele surgery (see the Improving Data Availability and Use section below).
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 national trainers) and Cote d’Ivoire (two national trainers). 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 HKI’s 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, including the selection criteria for the TT surgeons and the need for 50 people with TT 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 MMDP Project team of Drs. Bedri and Kengmogne. A total of 14 people with TT were identified for the training, which was considered insufficient for all participants to train on. The training was therefore refocused on the two national trainers to provide them with additional surgical opportunities. At the end of the training, one of the trainees was certified according to WHO guidelines as he was the only one who managed to operate successfully on a sufficient number of cases.
• 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 focused 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 people with TT were operated on during the training. As was the case in Cote d’Ivoire, this resulted in one of the two national trainers being certified due to the limited number of cases available. The project shared with USAID that one of the lessons learned
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from the Cote d’Ivoire and Benin trainings is that low endemicity countries present a challenging situation as 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 that prior to making any commitment for technical support, in-depth discussions with a national program are held to understand the skills and experience available at the country level for TT surgery and the capacity for case mobilization and screening. In addition, depending on the country situation and based on the above experience, the project recommends considering foregoing the two-tiered approach of training national TT surgeon trainers and TT surgeons in favor of one level of training of surgeons; this 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 aligned 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 FY18, the project worked closely with WHO/Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) and other partners including CDC to help plan an LF MMDP Workshop for Francophone countries in Africa, based on a similar workshop that the project organized with partners in Tanzania in 2017. The project participated in all workshop planning meetings and played an important role in translating the training materials into French. The workshop was held in Benin in April 2018 and the project, as part of the organizing team, facilitated several of the sessions. Both Francophone project countries, Burkina Faso and Cameroon, were present; this was an additional opportunity for the project to work closely with staff from the respective national programs to discuss the availability of LF MMDP data, gaps, and planned interventions.
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Table 13. Overview of TT and LF Tool/Resource Development in FY18 Tool FY18 Goal Status Language Trachoma TT Surgeon Training Dissemination in Manual was adopted as an ICTC English and Package English and French preferred practice and is available on the French ICTC and MMDP Project websites. PowerPoint slides and leaflets are finalized and available for dissemination. Presented during HKI technical webinar on February 18, 2018. French version is under final review by the ICTC. Standardized Supportive Dissemination Disseminated to each project-supported English and Supervision Checklists country. French for TT Management Additional internal revision of the tools was ongoing at the end of the fiscal year. New revised version will be utilized in FY19. Laminated support Dissemination Disseminated to each project-supported English and documents for TT country French surgeons, including surgical checklist Aide memoire for Dissemination Disseminated to each project-supported English and nurses trained in TT country. French management support Aide memoire for nurses to train health care workers involved in TT activities (only available in French) Guidelines and support Dissemination Disseminated to each project-supported English and materials for infection country. French control and health care waste management Upgraded TT Surgery In consultation with N/A Video the international trachoma community it was
determined that this was not a priority. National and Master Finalization In consultation with Dr. Bedri and Dr. English and Trainer Assessment Gower, the project is developing and French Tools testing the tools to be shared with the ICTC in FY19.
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Tool FY18 Goal Status Language LF WHO LF MMDP Dissemination Finalized. English and Toolkit Pending WHO clearance. French FASTT Training Package Dissemination Update and finalization pending English, clearance and publication by WHO of French, Hydrocele Surgery Consultation Report. Amharic (written materials) FASTT training Dissemination Finalized; will require review based on English, resources for WHO Hydrocele Surgery Consultation French, nurses/health care Report. Amharic workers (written materials) WHO Hydrocele Dissemination Project was part of WHO Expert English Surgery Consultation Committee and contributed illustrations Report to the report. Pending publication by WHO. LF MMDP Training Dissemination Finalized. Pending clearance and English and Package publication by WHO. French
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, in FY18 the MMDP Project supported the national programs in Burkina Faso and Cameroon in beginning compilation of their historical trichiasis data using the template provided by WHO that is part of the elimination dossier. This support includes coordinating with national programs to ensure that the most recent trachoma impact and surveillance surveys are made available to partners. In Cameroon, the project also liaised extensively with the national program and WHO to facilitate finalization and sharing of age- and sex-standardized TT prevalence estimates for the entire Adamoua region.
The project continues to closely track 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 where TT estimates, despite being age and sex standardized, may contradict other information on TT prevalence. To raise key questions that will help refine elimination planning at the global level, the project has begun to share this data with others in the global trachoma community through fora such as the 2018 ASTMH and Trachoma Scientific Informal Workshop. (See the Disseminating Best Practices section below for details.)
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In Burkina Faso, as part of the discussion and planning around the last mile, the national program organized 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 members of the water and school-health sectors of the ministry of health. 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 that 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 (SAFE) strategy. Following the meeting, the project has continued to support the national program to move 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 occurred in Cameroon in June 2018 with costs shared across the MMDP and ENVISION Projects. The MMDP Project again engaged Mr. MacArthur to facilitate the meeting, which was attended by Sightsavers, WHO representatives, and members of the National Blindness Prevention Program (PNLCé). The meeting addressed components of the SAFE strategy, challenges encountered and expected due to insecurity, epidemiological data, progress towards elimination, and transition planning. Participants also developed action items that the MMDP Project has continued to provide support for. Details can be found under the Cameroon portion of this report.
On the LF front, the MMDP Project continued to work with WHO and partners including the CDC to finalize the LF MMDP Toolkit. The project worked with the WHO LF Focal Point in Geneva to incorporate the new illustrations developed under the MMDP Project and to prepare short descriptions of each toolkit document for posting on the WHO website. The project also supported WHO in the organization and facilitation of the LF MMDP Training Workshop for Francophone Africa in April 2018. This was an opportunity for the project to work closely with Burkina Faso and Cameroon, both in attendance, to examine their existing LF MMDP data, identify potential gaps, and plan ahead for dossier preparation. (As a reminder, the project organized a similar workshop for Anglophone countries in 2017, which Ethiopia attended.)
IMPROVING DATA AVAILABILITY AND USE The MMDP Project continued to collect, review, compile, and analyze data corresponding with its TT and LF indicators; these 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.
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Trachomatous Trichiasis
Piloting new approaches to TT surgery quality assurance through implementation of outcome assessments (previously called centralized follow-up) and surgical audits has been a key monitoring and evaluation priority in FY18.
• The project began working with staff in Burkina Faso, Cameroon, and Ethiopia to develop country-specific approaches and corresponding protocols for surgical audits and outcome assessments that reflect the nuances of the different country contexts. Additional details of these approaches to surgical audits and outcome assessments are presented in the Monitoring and Evaluation subsection of the trachoma portion of each country’s report. Highlights include:
o In Burkina Faso, the project has been piloting outcome assessment as a new, separate activity since the end of FY17. Implementation in FY18 has resulted in an increased proportion of operated cases returning to a centralized location for their 3-6 month follow-up exam as compared with the initial roll-out of the activity at the end of FY17. In addition, the project has supported multiple surgical audits using a protocol that was finalized in June 2018. Please see the Monitoring and Evaluation subsection of the Burkina Faso portion of the report for more details on these activities.
o 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 to actively seek out all operated cases in their homes 3-6 months after surgery. Within this context, the project adjusted its 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. A surgical audit protocol outlining a process for surgeon-based sampling was developed for use when surgical output is high enough to warrant sampling. The revised audit protocol was piloted for three surgeons who participated in the FY18 TT surgery campaigns in the Far North. Please see the Monitoring and Evaluation subsection of the Cameroon portion of the report for more details.
o 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 the first quarter of FY18 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 and project staff attended. 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. For
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a discussion regarding the use of these two quality assurance approaches in Ethiopia, please see the Monitoring and Evaluation subsections of the Ethiopia portion of the report.
• Analysis of data gathered through outcome assessments and TT supportive supervision visits identified surgeons prioritized for surgical audit in Burkina Faso and Ethiopia (Cameroon audited all surgeons in FY18). The project also began the process of revising its existing supportive supervision tools and checklists to facilitate user completion of the materials and increase the frequency of data sharing. Revisions to the checklist will primarily focus on reducing the length so that supervisors can more quickly and comprehensively complete it, particularly in the busy setting of an outreach campaign. The roll-out of revised tools is anticipated in FY19.
• As described in the Semi-annual Report (SAR), the project had also identified the opportunity to support the national program in Burkina Faso in strengthening its approach to systematically documenting refusals to ultimately facilitate continued counseling and provision of opportunities for TT surgical management. Information on refusals was documented throughout the FY18 campaigns, after which it was stored within the routine health system. While theoretically the project could request access to these lists to support follow-up of refusal cases, given the outcome assessments’ ambitious target of reaching 100% of operated cases, in FY18 the project prioritized reaching as many operated cases as possible rather than actively supporting follow-up of refusal cases.
Hydrocele Surgery
• Following all hydrocele surgeries, the MMDP Project encourages follow-up by the routine health system at Day 1-2, Day 3, Day 5, Day 7, Day 14, Month 1-3, Month 6, and Month 12. As an additional quality assurance measure, in collaboration with national programs the project supports verification and systematic documentation of follow-up within five days and within 6-12 months post-hydrocele surgery. The first follow-up assesses any immediate post-operative complications and the latter determines if there is any recurrence and includes questions on self-perceived quality of life changes. The project is conducting this activity in all three countries and will finish compiling and analyzing the data once all follow-up activities are completed. The project plans to prepare a peer- reviewed article providing a comprehensive look at surgical services, patient outcomes within five days of surgery, recurrence in the 6-12 months following surgery, and quality of life changes.
OPERATIONAL RESEARCH The project worked closely with its Senior Scientific Advisor (Dr. 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.
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• 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 work plan support of programmatic research activities on surgical management of postoperative TT. However, delays in confirmation of support from other donors as well as changes in the proposed focus to target 100 people with post-operative TT in Ethiopia postponed in-country activities until FY19. The project presented the work on behalf of Dr. Gower at the NTD NGDO Network meeting in Addis Ababa in September 2018.
• Predictors of TT Surgical Outcomes: To help determine the extent to which photos taken in a programmatic, field-based setting can contribute to identifying risk factors for complications and providing feedback to improve quality of future surgeries, the project piloted taking photos of operated eyelids in FY18. The pilot, under the guidance of Dr. Gower, was implemented in Burkina Faso and Cameroon in a portion of TT surgery campaigns, outcome assessments, and surgical audits. The pilot began with MMDP Project global team members conducting trainings of eight project staff in Burkina Faso (in January 2018) and Cameroon (in March 2018) to take photographs of operated eyes before and after TT surgery. Those trained in photo-taking were individuals who already participate in supervision of TT surgical and post-operative follow-up activities. HKI staff took the photos in Burkina Faso, while in Cameroon HKI staff trained five surgeons and supervisors in the North to help take photos during the pilot.
Over the course of the pilot, a total of 204 operated eyes (101 in Burkina Faso and 103 in Cameroon) were photographed at one or more points in time. A total of 61 eyes were photographed at all three key time points (immediately before surgery, after surgery on either Day 0 or Day 1, and 3-6 months after surgery). The project will conduct a review of the photo-taking activity with Dr. Gower in FY19. The results of the review will inform the project’s potential integration of photo-taking into future campaigns. Initial lessons learned include the following observations:
o Photos can serve as a valuable additional capacity building tool for surgeons. The experience in Cameroon, where the technical supervisor and surgeons reviewed the photos taken as part of their daily debriefs, demonstrated how photos of operated eyes can be used for capacity building purposes. The daily review of photos created an opportunity to provide feedback to surgeons that took place outside of the surgery site but still leveraged visual observations and adult learning principles (e.g., seeing the results of one’s own work). While Burkina Faso’s campaign structure did not lend itself to these types of daily reviews, those involved in the pilot expressed the desire to more immediately see the results captured in the photos as a means of facilitating learning.
o Obtaining high-quality photos requires arranging the surgical site and organizing patient flow in a way that is designed specifically to facilitate photo taking. In both Burkina Faso and Cameroon, field conditions created challenges for photographers. Finding
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good natural lighting proved to be one of the largest environmental barriers to taking a high-quality photo. While the MMDP Project originally instructed surgery teams to integrate photos into surgery campaigns without disrupting the existing structure and processes, experience suggested that the quality of photos could be significantly improved in the future with some adjustments specifically intending to create environmental conditions more conducive to photo taking.
o Clearly defining the role of surgeons during the photo taking process is essential. The project’s contrasting experiences in Burkina Faso and Cameroon highlight the importance of carefully planning how surgeons will integrate into the photo taking process to increase their buy-in and reduce the potential for frustration at the surgery site. In Burkina Faso, HKI non-technical supervisors took the photos during the surgery campaigns. In principle, the concept of taking photos was well received by surgeons, who appreciated being able to see the results and achievements of their work documented. However, the project found that the logistics of taking photos – particularly the need to get close to the person while on the operating table, and the time it took to get a good picture given the lighting conditions – interrupted the usual rhythm and flow of work at the surgical site, often forcing the surgeon to wait for a period of time while the photo was being taken. Showing the photo to the surgeon afterwards (and not taking too many photos at a single site) helped manage potential frustrations, but the practical implications of taking photos were less well received by surgeons. In contrast, this issue did not arise in Cameroon, where HKI staff trained the technical supervisors and surgeons—who are ministry of health staff—to take the photos themselves.
o Capturing a large quantity of high-quality photos may be difficult without integrating additional staff into the surgery team. In Burkina Faso, integrating photo taking into the current model of HKI supervision did not yield a high number of photos per surgeon. The decentralized nature of Burkina Faso’s campaigns sometimes resulted in more surgical sites than HKI supervisors (and camera phones), and teams could not know in advance which sites would have the highest number of operated cases on a given day. In addition, HKI staff could not always take immediate post-operative photos (Day 0) because they sometimes needed to leave the site before surgeries were completed (to return to their hotel before dark for security reasons). In Cameroon, training technical supervisors to take the photos themselves resolved some of these logistical issues, but supervision emerged as a challenge. The one HKI non-technical supervisor at the surgery site often needed to devote his time to other more pressing issues (which often unexpectedly arise during campaigns), which detracted from his ability to directly and continuously observe the photo taking. This experience highlights the need to consider adding additional staff to the surgery team – which is a challenge in light of the human resource and financial constraints that are often present in a programmatic setting.
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o The amount of time that taking photos adds to the surgical process varies based on context. Time to photograph an eye was highly dependent on multiple factors: the environment (e.g., lighting at site), the case (e.g., lateral trichiatic lashes were harder to capture; more severe TT cases had difficulty keeping their eyes open long enough for a photo), and the operation (e.g., how much blood the surgeon had to clean before the post-operative photo could be taken). Among severe TT cases, whose eyes were particularly challenging to photograph, photographers often observed tears resulting from the person trying to keep his/her eyes open despite the discomfort and therefore needed to pause for a break, which further lengthened the time needed.
• 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 were discussed with the project’s TAB during its quarterly meeting in April 2018; these recommendations will be incorporated into an updated version of the FASTT Training Package:
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.
o Based on the recommendations following the FASTT evaluation and its review by the project’s TAB, the FASTT Training Package will be further updated to ensure that FASTT trainings include the surgical team that is present in the operating room, including anesthetists and surgical aids, and not only the surgical care provider.
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DISSEMINATING BEST PRACTICES MMDP Technical Updates:
In February 2018, the MMDP Project organized a NTD technical update featuring the “Training Trichiasis Surgeons for Trachoma Elimination Programs” manual. Dr. Gower (University of North Carolina at Chapel Hill) provided an introduction and background to the webinar. Dr. Bedri (Light for the World) and Sabrina La Torre (Helen Keller International) presented an overview of the manual. Sarah Bartlett and Kim Jensen from Sightsavers introduced 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 with registrants the presentations, a link to the recording of the webinar, and a complete list of questions with responses (as not all questions were addressed during the webinar itself). An exit survey, in which half the webinar participants responded, showed an overall positive response to the webinar; participant noted that the speakers were knowledgeable, the topics presented were relevant as priority issues for trachoma elimination, and the content was relevant to their jobs.
In July 2018, the MMDP Project organized a second NTD technical update for FY18 featuring the “WHO Training Package on Morbidity Management and Disability Prevention for Lymphatic Filariasis.” Speakers included Dr. Jonathan King (WHO), Dr. Didier Bakajika (WHO/ESPEN), Dr. Suma T.K (Government T. D. Medical College Hospital - India), Dr. Charles MacKenzie (GAELF), and Ms. Caitlin Worrell (CDC). The presentations included a description of the global LF situation and the LF elimination goals, a description of the training package and its content, and an overview of several field experiences using the LF MMDP training package. The webinar was well-received; of the 201 registrants, 88 participated during the live webinar. The webinar included an exit survey with preliminary results showing positive feedback. Following the live webinar, the project provided the presentations, webinar recording, and other materials to all those who registered.
MMDP Project Presentations at Global Meetings:
In November 2017, the MMDP Project participated in the Annual Meeting of COR-NTD, held in Baltimore, Maryland. The project jointly led a break-out session with the Kilimanjaro Centre for Community Ophthalmology, Sightsavers, and the University of North Carolina at Chapel Hill on “Post-trichiasis surgery follow-up at 3-6 months: Experiences and lessons learned,” which was very well-received. In addition, the project made two presentations in the context of the Innovations Lab session: “FASTT: A Surgical Simulator for Hydrocele Surgery” and “MMDP Toolkit to Address Lymphatic Filariasis Disease” (the latter jointly with CDC).
The project had a strong presence at the ASTMH Annual Meeting in Baltimore, Maryland in November 2017. The project led a join symposium with UNC on “Follow-up tools for surgical quality assurance”; this included presentations from all three project countries. The project also gave additional oral presentations. The topics presented at ASTMH were as follows:
• TT screening and active case finding – An opportunity for eye health programs: A case study of the MMDP Project in Burkina Faso
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• Experiences from Burkina Faso and Cameroon: Quality assurance using hydrocele surgery follow-up tools
• Follow-up on hydrocele surgery quality outcomes: The experience of the Surgical Society of Ethiopia (RTI submission under the MMDP Project in Ethiopia)
• Outcomes of a Pilot Hydrocele Surgery Camp in Ethiopia (RTI submission under the MMDP Project in Ethiopia)
• Supportive Supervision for Trichiasis Surgery
In addition, the project had poster presentations on the following topics:
• 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 Cameroon
In March 2018, the MMDP Project was invited to present at the NTD NGDO Network’s Disease Management Disability and Inclusion Working Group meeting. The project participated remotely and presented on the trachoma- and LF-related MMDP indicators collected under the project. The presentation generated an active discussion and questions from the audience members.
In April 2018, the project’s Associate Director of NTDs attended the ICTC meeting on Transition Planning for Trachoma Elimination in London, England. This was an opportunity for the project to participate in this important discussion and to provide input on draft tools to assist countries in transitioning planning for all components of the trachoma SAFE strategy.
In June 2018, the project’s Senior Technical Advisor attended the GAELF meeting in New Delhi, India and was invited by the GAELF secretariat to lead the report preparation and presentations of the MMDP working groups in collaboration with the Centre for Neglected Tropical Diseases (CNTD)/Liverpool School of Tropical Medicine (LSTM).
The project participated in the NTD NGDO Network meeting in Addis Ababa, Ethiopia in September 2018. The Senior Technical Advisor presented on behalf of WHO a rapid-fire presentation on the Training Package on MMDP for LF. The Associate Director of NTDs presented on the surgical management of post-operative trichiasis on behalf of Dr. Gower. The project also participated in the ICTC and the LF NGDO Network meeting which included presentations on the project’s work.
The MMDP Project provided support for a peer reviewed article, "A Delphi consultation to assess indicators of readiness to provide quality health facility-based lymphoedema management services," that was published in the September 2018 issue of the PLOS Neglected Tropical Diseases journal.
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Training Trichiasis Surgeons for Trachoma Elimination Programs Manual:
In FY18, in close partnership with Dr. Bedri, the Kilimanjaro Centre for Community Ophthalmology, and other global experts, the MMDP Project finalized this training manual as an ICTC preferred practice. The MMDP Project also finalized a French translation of the manual and submitted it to ICTC for review. The French version is currently available, and a finalized version will be uploaded on the ICTC website in the near future.
The LF MMDP Training Package:
The project worked closely with WHO and partners to finalize the LF MMDP Training Package. The package had initially been developed for training national LF focal points and other national program staff in the South East Asia Regional Office, and the MMDP Project, in close collaboration with WHO, CDC, GAELF, and others adapted it for use in the regional LF MMDP workshop that it organized for Anglophone Africa in 2017.
In the months leading up to the WHO/ESPEN Regional LF MMDP Training workshop for Francophone countries, the project worked with partners including CDC on further updating and translating all the modules in the training package into French. In the months following the workshop the project worked closely with all partners to finalize the training package in English and French for submission to WHO for final clearance. Following the MMDP Project webinar mentioned above, WHO confirmed that they had received preliminary clearance for the training package. WHO had also requested the project to prepare a facilitator’s guide that would be a companion to the LF MMDP Training Package and a draft was developed and submitted to WHO. The project subsequently worked with CDC on comments received on the facilitator’s guide and at the time of the writing of this report the finalized version had been submitted to WHO for final review and clearance. WHO also requested that an additional module be developed for the LF MMDP Training Package, focused on the integration of LF MMDP activities into national public health systems. The project developed this module, shared it with WHO, and further refined it and resubmitted it based on feedback received. It is currently undergoing a final review at WHO.
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. 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 was invited to facilitate parts of the WHO/ESPEN Regional LF MMDP Training workshop for Francophone Africa and organized a webinar with global experts in LF from WHO, CDC, GAELF, and Government T. D. Medical College Hospital - India.
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Additional activities in support of facilitating global collaboration include:
• Trachoma Scientific Informal Workshop, November 2018, New Orleans, Louisiana: The project will be participating in the upcoming meeting and submitted the following abstracts in August 2018. All were accepted for presentation: o Trichiasis Case Finding in Burkina Faso: The MMDP Project's Experience o Trichiasis Case Finding in “The Last Mile”: The MMDP Project's Experience in Cameroon o Photographing operated TT cases to explore predictors of surgery outcomes: The MMDP Project's experience in a programmatic setting
• Monthly Morbidity Management Meetings of the LF MMDP Community (MMMM) and ad hoc meetings of the TT MMDP Community: As in previous years, in FY18 the MMDP Project facilitated and served as the secretariat for the MMMM. The MMMMs are led by WHO and include representatives from HKI, CDC, AFMP, 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. MMMM meetings were held in October and December 2017 and January, March, April, May, June, July, and August 2018. No meeting of the ad hoc Global TT Coordination Meeting took place during the reporting period; the project is using other international meetings and its quarterly TAB meetings to engage with the TT community.
• MMDP Project Technical Advisory Boards – TAB meetings: During the reporting period, the project reinitiated its TABs. As presented in the FY18 work plan, the project created two technical advisory boards, one focused on each disease. The LF TAB also welcomed a new TAB member, Emily Toubali (USAID). All the TAB members who also serve as consultants on the project confirmed they will volunteer their time on the TAB.
The first of the Trachoma TAB quarterly meetings was held in December 2017 with members electing Dr. Gower as the chair. Two additional meetings were organized in April and September 2018 and provided an opportunity for the project to discuss its activities including photo taking of TT cases.
The first quarterly meeting of the LF TAB was held in December 2017 with members electing Dr. Charles Mackenzie as the chair. Two additional meetings were organized in April and September 2018 and provided an opportunity for the project to discuss the FASTT evaluation and next steps. The LF TAB reviewed the FASTT evaluation report and developed consensus statements that are pending finalization.
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A female trichiasis screener examines a woman's eye for signs of trichiasis while conducting door to door screening in Dandé district, Burkina Faso. (Photo: HKI)
BURKINA FASO
• The MMDP Project trained 11 surgeons and conducted seven trichiasis outreach campaigns during which a total of 71,975 people were screened and 538 individuals received surgery.
• 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 688 hydrocele surgeries and conducted 6-12 month follow-up of 276 patients after surgery to assess clinical and quality-of-life outcomes.
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IN BRIEF
In FY18, the Morbidity Management and Disability Prevention (MMDP) Project continued to support intensive trichiasis management services in the Center North and Hauts-Bassins regions. Seven trichiasis surgery campaigns were conducted, collectively screening 71,975 people to find 701 confirmed trachomatous trichiasis (TT) cases and provide 538 people with surgery, with additional cases referred to higher-level facilities and counselled as appropriate. The project10 also implemented outcome assessment and surgical audit activities to follow up 3-6 months after surgery with TT cases operated during two of last fiscal year’s Hauts-Bassins campaigns and during six of this fiscal year’s Center North and Hauts-Bassins campaigns. To ensure the quality of trichiasis surgeries provided during the campaigns, the project trained five surgeons, two assistant national trainers who subsequently supervised FY18 activities, and 92 health workers.
The national program’s multi-day Trachoma Action Plan (TAP) strategic planning meeting took place in February 2018, with the project providing a facilitator and contributing to the discussion of national 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 (688 surgeries in FY18) in operating blocks in ten health districts11 and conducted a follow-up study of hydrocele surgery patients 6-12 months after surgery. Burkina Faso also hosted the independent evaluation of the project’s Filaricele Anatomical Surgical Task Trainer (FASTT) training package, which was based on the training of five hydrocele surgeons in the Center South region. Follow-up of lymphedema patients trained in self-care 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 an estimate of over 33,000 individuals with trichiasis. Since then, trachoma surveys—along with provision of intensive management service in select districts—have resulted in a revised epidemiological context. As of the February 2018 TAP meeting, the national program estimated the country’s backlog to be closer to 25,000 cases (although estimates for some districts rely on data that have not been standardized by age and sex). Figure I below shows the change in the estimated Ultimate Intervention Goal (UIG) by district since baseline.
10 We have used the term “the project” to include the national NTD program, HKI, and all MMDP partners involved in implementation. 11 Health districts are referred to as districts for the rest of the report.
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Figure 1: UIG at Baseline Survey (as of 2007) and at Most Recent Survey
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To date, the MMDP Project has supported TT management in two regions: Center North and Hauts-Bassins. Roughly one third of the national trichiasis burden was estimated to exist in these regions at the start of the project. Both regions have since generated revised trichiasis data through a combination of project-supported outreach campaigns that reduced the remaining UIG and additional trachoma surveys that produced new prevalence estimates. Figure 2 below shows the change in districts above and below the WHO trichiasis elimination threshold over time.
In the Center North region, the project has supported four of the region’s six districts (Boussouma, Kaya, Kongoussi and Barsalogho) as the other two districts (Boulsa and Tougouri) were determined to have 0% TT prevalence at the time of their baseline survey. At the start of the MMDP Project, the four districts supported by the project collectively had a non- standardized, theoretical UIG of approximately 6,108 cases. Out of these 6,108 cases, 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 Trachoma Impact Survey (TIS) data, the region’s theoretical UIG at the time of the most recent survey decreased to approximately 1,250 total cases spread across the same four targeted districts. To date, the project has addressed approximately 35% of this revised burden estimate through its support of TT management services. Extensive efforts in Boussouma district have addressed nearly the entire theoretical UIG in that district. The remaining three endemic districts are targeted in FY19.
The Hauts-Bassins region, first targeted by the project in FY17, consists of eight districts. The project initially targeted the three districts with the highest theoretical UIGs at the time activities began (Dafra, Dandé and Do).12 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. However, new data made available to the project during the February 2018 TAP indicated that five of the region’s eight districts (Dandé, Do, Houndé, Karangasso Vigue, and Lena) had dropped below the TT elimination threshold according to their most recent TIS—leaving only three districts (Dafra, N’dorola, and Orodara) with a combined theoretical UIG of 247 at the start of FY18. To date, project-supported campaigns have addressed approximately 70% of this estimated burden, with only one district (Orodara district) calculated to have a remaining UIG that warrants intensive TT outreach according to current estimates. Orodara is targeted in FY19 with a goal of addressing the district’s entire remaining theoretical UIG.
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).
12 Of the remaining five districts in the region, one district (Houndé) did not require provision of intensive TT management services. The other four districts (Karangasso Vigue, Orodara, N’dorola, and Lena) were not prioritized given their comparatively lower UIGs.
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Figure 2: Districts Above TT Elimination Threshold at Baseline Survey (as of 2007) and at Most Recent Survey
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LYMPHATIC FILARIASIS
LF was found to be endemic in all of Burkina Faso’s districts following the completion of mapping in 2002. Figure 3 below shows endemicity using the current number of districts (70 districts, increased from 63 at the time of baseline mapping).
Figure 3: LF Endemicity (as of 2002) and MMDP Project Intervention Areas in Burkina Faso
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The MMDP Project initially used national program estimates to plan LF activities in the two project regions of Center North (six districts) and Hauts-Bassins (eight districts). Prior to conducting burden assessment (BA) activities and prior to provision of services, the project compiled burden data from health facilities in the targeted districts to actively identify the hydrocele and lymphedema management cases that would receive support. Figure 4 below illustrates this contribution towards identifying cases, placing it within the broader national context using the burden data available to the project.
Figure 4: Districts with LF Burden Assessments
Before beginning disease management activities, the project supported assessments of select health facilities providing hydrocele and/or lymphedema services (shown in Figure 5 below). In August 2018 the national program informed the MMDP Project that they would be conducting additional health facility assessments in the coming month. At the time of writing of this report the activity was completed, and the national program was working on analyzing the data for a write-up that will be shared with the project.
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Figure 5: Health Facility Assessments for LF Services13
Following its health facility assessments, the project began supporting disease management services. Over the life of the project, a total of 1,028 hydrocele surgeries have taken place and 381 lymphedema patients have been trained in self-care. Specifically:
• In the Center North region, the project has conducted hydrocele surgery and/or lymphedema management services in all six districts. To date, the project has supported a total of 829 hydrocele surgeries (537 during the reporting period) and training in self- care of 298 lymphedema cases (all in FY17) in the region.
• In Hauts-Bassins, the project has targeted cases from five of the regions’ eight districts (Dafra, Dandé, Houndé, Orodara and N’dorola) to support the provision of 187 hydrocele surgeries (131 during the reporting period) and training of 83 lymphedema cases in self-care (all in FY17).
13 The national program in Burkina Faso conducted a health facility assessment in August 2018. The assessment looked at the quality of health services offered for LF in seven health districts across seven regions and the results will be available in FY19.
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• As part of the independent evaluation of the FASTT Training Package that the project conducted in the Center South region in Burkina Faso in February 2017, a total of 20 patients were operated on by the participants during and after training.
For details regarding the overall disease burden in each region, see the LF Assessing Disease Burden section. For a summary table of 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 FY18, the project participated in strategic planning meetings to support the implementation of trichiasis management campaigns, the development of Burkina Faso’s TAP, and the development of an FY19 work plan. 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, present the FY18 work plan to stakeholders, and integrate FY18 activities into the districts’ and health areas’14 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-Dioulasso in February 2018.
On February 5-9, 2018 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 Mass Drug Administration (MDA) campaigns in all formerly endemic districts throughout the 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
14 Health area refers to a district sub-division.
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the evidence-base for demonstrating progress made toward elimination but will also provide the national program with information needed to continually update plans, particularly in targeting districts for trichiasis intervention. The week’s discussions 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, 2018 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 delayed. At the time of writing this report, the finalization of the document was ongoing. In FY19, the national program requested support for a follow-on meeting with a focus on the dossier in order to have dedicated time to supplement the work conducted in March 2018.
On August 7-8, 2018 a workshop to finalize and validate the FY19 work plan was held in Ouagadougou with representatives from HKI, the National Neglected Tropical Disease Control Program (PNMTN), the Hauts-Bassins and Center North regional health offices, Sightsavers, and USAID. The group discussed and agreed on priority activities for FY19. Discussions also centered on activities beyond the MMDP Project, namely post-operative follow-up for both trachoma and hydrocele surgeries and the completion of elimination dossiers (LF and trachoma).
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 districts in Hauts-Bassins. Since these districts had not previously received TT support from 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 and received 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 2018 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 regions, notifying them of
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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.
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 Brief description of material Target audience Quantity material The poster shows an overview of Communities in Poster (trichiasis trichiasis surgery, emphasizing that it endemic areas/people 1000 surgery) can preserve sight. with trichiasis The poster provides an overview of the Poster (trachoma Communities in symptoms of TT and directs those with and TT endemic areas/people 1000 similar symptoms to go to the health management) with trachoma center for diagnosis and treatment. The leaflet includes photos and a brief description of the WHO-defined stages Leaflet (trachoma of trachoma. It includes directive Health center workers 250 disease stages) actions based on the stage of the disease. Health center workers Brochure Description of trachoma and TT and communities in (trachoma 900 management. endemic areas/people and TT) with trichiasis
CAPACITY BUILDING Regular technical supportive supervision of TT surgeons during TT case management activities in the field is a key factor in ensuring the quality of surgeries performed. To provide optimal support in technical supportive supervision, and to conduct supervisions in a systematic way, it is essential to have a sufficient number of adequately trained supportive supervisors. To that end, the project
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supported a training of three new technical supervisors (also referred to as assistant national trainers) from May 2-6, 2018 in Kaya in the Center North. The training was led by two assistant national master trainers with support from Dr. Amir Bedri Kello. The main objective was to ensure that the trainees have the technical competency for performing and supervising TT surgeries and the ability to address challenges encountered by surgeons to ensure regular technical supportive supervision visits during TT campaigns. Dr. Bedri facilitated the training, supervised the assistant master trainers and led sessions on supportive supervision. Topics covered included an overview of trachoma in Burkina Faso, the principles of supportive supervision, the role of a supervisor, and preferred practices in the management of TT. The training also included theoretical and practical HEAD START sessions, as well as surgeries on TT cases at the Kaya regional health center. Out of the three surgeons trained, two were retained as technical supervisors and each provided technical supervision in subsequent project activities.
This training workshop also provided an opportunity for Dr. Bedri to reinforce the capacity of the already trained assistant national master trainers. Dr. Bedri observed the trainers as they gave presentations, led the HEAD START sessions, and provided supportive supervision during the TT surgeries. Throughout each of those phases of the training, he provided real-time feedback to the trainers and intervened when corrective actions were needed. During the debriefing session, the two assistant national master trainers noted that it was a great opportunity for them to not only improve on their surgical and supportive supervision skills but also to practice teaching and working with colleagues as a team.
In April 2018, the project supported a one-week training for five TT surgeons in the Center North region. The training was led by two assistant national master trainers. The one-week training included theoretical and practical phases covering surgical technique on both HEAD START and TT cases. Sessions focused on surgical management of TT, infection prevention measures, counselling techniques, data collection and analysis, referral of non-TT cases, and management of drugs and consumables. Out of the five surgeons trained, three were certified.15
In FY18, the MMDP Project expanded TT management activities to the districts of Orodora and N’dorola in the Hauts-Bassins region. To ensure the success of TT surgery campaigns in these new districts, the project trained health workers and district staff who play a key role in the provision of trichiasis management services. On April 4-6, 2018 the project supported a training for district and Hauts-Bassins DRS staff on preferred practices for organizing a campaign. Two representatives from the Orodora district, two representatives from the N’dorola district, and one representative from the Hauts-Bassins DRS participated in the training. Topics covered were trachoma elimination strategies, general information on trachoma, trachoma manifestations, TT management, treatment of complications, filling out data collection tools, supervision, and counseling.
In addition, the project supported the training of 92 nurses and health center staff on trichiasis diagnosis, post-operative follow-up, advocacy, social mobilization, organization of surgical sites,
15 Due to the low number of TT cases available for the practical phase of the training, a second session was organized in July to find more TT cases to certify the previously trained surgeons.
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data collection, counseling, and management of refusals. At the community level, the project trained a total of 350 Community Based Health Workers (CBHWs) and 350 community guides in Orodora and N’dorola on trachoma manifestations and treatment, social mobilization, the role of the CBHWs in case management, and the detection and referral of suspected cases. The trainings were held in each district’s health center. Additionally, the project supported information sessions for 141 Traditional Health Practitioners (TPS) focused on their role in TT management and the implementation of surgical campaigns.
ASSESSING DISEASE BURDEN Two TT-only surveys were planned in the Hauts-Bassins region (N’dorola and Orodara districts) in the FY18 work plan, as these districts have not been surveyed since their baseline mapping in 2009. An additional TT-only survey in the Center North region was included as part of FY17 carryover activities for Barsalogho district, where a revised TT estimate is needed but no future surveys will be conducted based on the MDA schedule. However, given competing national program priorities following the 2018 TAP, implementation of these three TT-only surveys was delayed to allow for completion of a set of trachoma surveillance surveys (TSS) taking place in 2018. The project therefore focused on supporting the PNMTN in drafting a TT-only protocol for these surveys and liaising between the PNMTN and Tropical Data to help ensure the protocol aligns with WHO-endorsed survey standards. Finalization of the protocol was still ongoing as of the end of FY18. Due to these delays, the project moved forward with a campaign in N’dorola and Orodara districts in the second half of the fiscal year (see Trichiasis Management section).
Project activities also included coordinating with the PNMTN to receive updated TT prevalence data for the 19 districts16 that conducted a TIS in 2017 and for the 10 districts17 that conducted a TSS in 2018. The PNMTN and partners, including the MMDP Project, began to compile all available trachoma data into the WHO Excel template that will be submitted with Burkina Faso’s dossier. In addition, the project has continued to monitor the geographic coverage of its TT management services data at the health area level to provide additional documentation of progress towards reaching the UIG.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY In FY18 the project supported the implementation of seven TT campaigns (five in the Center North region and two in the Hauts-Bassins region). A total of 71,975 people were screened, of whom 701 were confirmed to have trichiasis. Among these confirmed cases, 538 received surgery, 48 were referred to a higher level of care, and 47 refused all services (both surgery and epilation). When surgery was not conducted (because the individual refused, 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.
16 The districts surveyed were Dedougou, Tougan, Sindou, Nongr-Massom, Zabre, Boussouma, Kaya, Kongoussi, Leo, Nanoro, Reo, Tenado, Po, Fada N’Gourma, Gayeri, Manni, Pama, Houndé, and Sebba. 17 The districts surveyed were Manga, Saponé, Kombissiri, Bittou, Garango, Tenkodogo, Ouargaye, Bogande, Koupela, and Pouytenga.
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Campaigns took place according to the following timeline:
• In the Center North region:
o January 2018 campaign in Kaya district
o February 2018 campaign in Boussouma district
o March 2018 campaign in Kongoussi district
o April 2018 campaign in Kaya district
o May 2018 campaign in Boussouma district
• In the Hauts-Bassins region:
o March 2018 campaign in Dafra district
o April 2018 campaign in Orodara and N’dorola districts
Each TT surgery campaign lasted ten days and started with a preparatory meeting at the DRS. During this meeting, HKI staff and district leadership provided an overview of the number of campaigns planned in each region, the number of cases targeted, the campaign’s data collection tools, and results from previous campaigns. At the end of the meeting, each surgery team was assigned a schedule for the campaign.
Throughout FY18, the project continued to use the strategy of conducting door-to-door case finding and surgeries on the same day. During the campaigns, screeners—accompanied by 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. In addition, the CBHWs were sometimes already aware of suspected cases because they are familiar with the communities. Due to long distances between households, the screeners and CBHWs often walked for hours to screen as many people as possible. 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 health center or at another appropriate site in the village, such as a classroom.
At the surgery site, a surgeon confirmed the TT diagnosis and operated on those who consented. All surgeries in FY18 were conducted with lidocaine without adrenaline18 due to a global shortage of lidocaine with adrenaline. After surgery, individuals received post-operative counseling and tetracycline eye ointment and Zithromax. Post-surgical monitoring was conducted at the surgery site on Day 1 by the surgeon, who removed the bandage and assessed the operated eyelid. On Day 8, the health center workers who took part in the campaign conducted post-surgical
18 See Commodity Supply Management and Procurement section for more details
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monitoring. Monitoring operated cases 3-6 months after surgery took place as described in the Monitoring and Evaluation section.
Complicated cases, such as those with lower-lid TT, those with post-operative TT, and individuals with TT under 15 years of age are 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 to receive follow-up from the local head nurse.
At select surgery sites, HKI staff took photos of operated eyes immediately before and after TT surgery as part of a pilot to generate additional information regarding using photos taken in a programmatic setting to predict surgical outcomes. For details on the pilot, which was also conducted in Cameroon, see the Operational Research section of the Global APR.
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 determine procurement needs for future campaigns.
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 with 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 training.
SUPPORTIVE SUPERVISION The Ministry of Health (MOH) and HKI staff in Burkina Faso provide supervision throughout the campaigns and during trainings. The goal of supervision during trainings is to verify the effectiveness and quality of the sessions. Specifically, supervisors (MOH and HKI staff) ensured
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that the appropriate cadre of health worker attended each training, topics and content covered aligned with the training objectives, and trainers used the appropriate training methodology.
Supportive supervision of TT management activities is conducted as part of routine campaign activities to ensure that social mobilization activities, case finding, counseling, and the organization of surgery sites are conducted based on preferred practices. During case finding in villages, the supervisors 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.
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. 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 are sometimes assigned as the surgeons on the teams and are, therefore, too occupied with case management to provide technical supervision. This year the project enlisted the support of Dr. Bedri to train and certify two additional technical supervisors (see Capacity Building section) to ensure that TT surgeons receive technical supervision at each campaign.
SHORT-TERM TECHNICAL ASSISTANCE Short term technical assistance in FY18 consisted of Dr. Bedri supporting the training of three new technical supervisors and reinforcing the capacity of the already trained assistant national master trainers (see Capacity Building section).
MONITORING AND EVALUATION Contributing to quality assurance of TT surgery has continued to be an M&E priority. Outcome assessments and surgical audits play an important role in ensuring surgical quality.19 As described in the FY18 work plans, implementation of these two distinct activities is a new approach for the MMDP Project. Burkina Faso first piloted the approach at the end of FY17 and has continued implementation throughout FY18. The following outcome assessments and surgical audits took place in FY18 with project support:
19 The project adapts its terminology as needed to maintain alignment with the language used in the global trachoma community and therefore currently uses the terms outcome assessment and surgical audit. The FY18 Burkina Faso work plan, however, refers to “centralized case monitoring” rather than “outcome assessment” and “evaluation of surgery and epilation quality” rather than “surgical audit.”
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• October 2017: outcome assessment and surgical audit in Dafra district (following up on surgeries from the previous fiscal year’s June 2017 campaign20)
• October 2017: outcome assessment and surgical audit in Dandé and Dô districts (following up on surgeries from the previous fiscal year’s July 2017 campaign)
• June 2018: outcome assessment in Kaya district (following up on surgeries from the January/February 2018 campaign that took place during the reporting period) and surgical audit of two surgeons
• June 2018: outcome assessment in Boussouma district (following up on surgeries from the February 2018 campaign that took place during the reporting period)
• July 2018: outcome assessment in Kongoussi district (following up on surgeries from the March 2018 campaign that took place during the reporting period)
• August 2018: outcome assessment in Dafra district (following up on surgeries from the March 2018 campaign that took place during the reporting period)
• August 2018: outcome assessment in Orodara and N’dorola districts (following up on surgeries from the April 2018 campaign that took place during the reporting period)
• September-October 2018: surgical audit of two surgeons
For outcome assessments, the project worked with national and regional representatives to invite all 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. Across all outcome assessments, a total of 245 cases self-presented at their designated location for examination by a surgeon. The percentage of operated cases who self-presented for examination varied from 6% at the very beginning of the fiscal year to as high as 74% later in the year following continued refinement of the follow-up process.21 The number and proportion of cases receiving outcome assessments has dramatically increased since the project’s initial pilot of the activity due to two key adjustments: increasing the amount of time spent at each outcome assessment site to allow people to come later in the day and providing phone credit to district representatives to facilitate their support in contacting community health workers and patients the day of the outcome assessment. Other factors affecting follow-up rates included weather conditions and whether the person had someone to accompany them to the follow-up examination.
For surgical audits, a new protocol was developed that 1) adjusts the project’s previously implemented sampling strategy so that it is now surgeon-based, 2) assures the audit team composition reflects current global preferred practices, and 3) narrows the scope of the follow-
20 Since the 3-6 month follow-up period for the June and July campaigns fell in FY18, the project carried out these follow- up activities as part of FY17 carryover activities. 21 Calculations exclude operated cases targeted as part of surgical audit.
MMDP Project FY18 Annual Progress Report – Burkina Faso (October 1, 2017 – September 30, 2018) 47
up interview so that it focuses most heavily on verifying and assessing surgeon performance. After a sample of each audited surgeon’s operated cases was selected to receive a follow-up visit, the audit team actively sought out these individuals in their homes. Each audit team was comprised of a surgeon, representatives from the PNMTN (including a technical supervisor), representatives from the DRS, and HKI staff. 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 had received surgery. Each team started out by first visiting the health center covering the individual’s village to confirm that the person had 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). A total of 134 people having previously received surgery were examined in their homes after being actively sought out by a team.22
The results of these outcome assessments and surgical audits were used on a rolling basis to inform project-supported activities. Analysis of the results from the October 2017 follow-up examinations indicated satisfactory surgeon performance in the most recent FY17 campaigns and determined there was not a need to hold a surgeon refresher training prior to implementing the first TT campaigns in FY18. Similarly, the results from the June-August, 2018 outcome assessments following FY18 campaigns revealed that group surgeon refresher trainings were not needed for FY19; rather, the project will continue to monitor individual surgeon performance and provide capacity building as needed through surgical audits and ongoing supportive supervision. Two surgeons audited in June 2017 were recommended for close supportive supervision which will be provided by the assistant national trainers in the next campaigns planned for FY19. A surgical audit conducted in September for two additional surgeons was ongoing at the end of the reporting period. The recommendations from that audit will be incorporated into FY19 activities.
For the complications identified during these activities, individuals were referred to a health facility if found to have either post-operative TT or eyelid margin abnormality. If a person was found to have severe post-operative TT, the surgeon would epilate the individual before providing a referral. Cases of granuloma were typically corrected on site by the surgeon who conducted the exam.
Implementation of outcome assessments and surgical audits as two distinct activities has consistently resulted in additional people receiving a 3-6 month follow-up examination. However, 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
22 When surgical output resulted in fewer than 20 people in the same district receiving surgery from the surgeon being audited, the audit targeted all operated cases (rather than a sample).
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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.
Also, during the reporting period, the project conducted routine M&E activities during each campaign. These activities include tracking geographic coverage of TT management services, managing TT surgery data, and assessing activities during the debrief meetings held after each campaign. Follow-up of refusal cases during outcome assessments and surgical audits did not take place as planned in order to prioritize reaching as many operated cases as possible.
LYMPHATIC FILARIASIS
STRATEGIC PLANNING The project’s FY18 work plan did not include strategic planning activities for LF. However, based on a request from the MOH, 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 trained under the MMDP Project and the FASTT Training Package. FASTT 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, including those planned under the World Bank project. In 2019, the PNMTN plans to renew its five-year strategic plan for LF. While no exact dates have been set for this activity at this time, the national program has started working on a first draft.
ADVOCACY No activities were planned under this section for FY18.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE In FY18, the project disseminated information about LF MMDP services 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 surgical care providers were trained in hydrocele surgery using the FASTT Training Package as part of this activity. An additional two
MMDP Project FY18 Annual Progress Report – Burkina Faso (October 1, 2017 – September 30, 2018) 49
anesthetists, who were part of the surgical team, participated in the training sessions but did not practice on the surgical simulator.
ASSESSING DISEASE BURDEN In FY18, the project continued supporting hydrocele case finding in the Center North region (six districts) and the Hauts-Bassins region (five23 districts), as part of FY17 carryover activities (see Table 4 below for districts). In addition, in the context of the FASTT training and evaluation conducted in Burkina Faso, a case finding activity was organized in the district of Saponé in the Center South region to identify hydrocele patients for the training.
As summarized in the table below, several methods have been used to collect LF burden data in Burkina Faso. Prior to 2006, LF burden data were collected by the national program during MDA. More recently, 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 identified by a CBHW at the community level 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” 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 worked with health center staff and CBHWs to request that people with symptoms go to their nearest health center for diagnosis. Those who self-presented were examined by a surgeon, who confirmed hydrocele cases. The cases confirmed using this method are also summarized in Table 4 below. As shown in the table, in some districts, more people self- reported at the health center than had originally been registered as suspected cases through the routine health system.
23 Only four districts have a functioning operating room but cases identified in the fifth district of N’dorola were referred to the nearest facility providing project supported hydrocele surgeries.
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Table 4. LF Burden Data in Project-supported Regions Hydrocele Lymphedema # suspected # cases # suspected # cases # cases cases Region District per cases confirmed per registered by PNMTN registered by by surgeons PNMTN health data health centers in FY1824 data centers25 Barsalogho 276 90 81 84 22
Boulsa 156 131 201 586 361 Center Tougouri 230 180 113 North Boussouma 160 53 914 6126 278 Kaya 175 200
Kongoussi 403 267 84 68 100
Center North total 2,179 1,078 537 791 689
Dafra 26 10 26 40 22
Dandé 27 02 26 03 06
Houndé 100 16 49 49 44
N’Dorola 38 10 68 Hauts- 51 35 Bassins Orodara 22 20 174
Do 15 14 Districts not Districts not Districts not Karangasso targeted with targeted with targeted with 04 08 Vigué project support for project support project support LF for LF for LF Léna 04 02
Hauts-Bassins total 227 88 131 151 314 Center Saponé27 -- 50 20 -- N/A South Total 2,406 1,216 688 942 1,003
24 Hydrocele case confirmation by surgeons took place with project support during FY17 and FY18. The table above includes case confirmation data from the FY18 reporting period. 25 The project collected suspected lymphedema cases data from health centers during FY17, with data finalized in FY18. 26 Boussouma does not have a functioning operating room, so cases from that district are referred to Kaya. 27 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 Hydrocele surgeries in Burkina Faso have taken place primarily in two regions under the MMDP Project: Center North and Hauts-Bassins. These hydrocele cases have been managed through the routine health care system, with the MMDP Project providing assistance in case identification, supervision, provision of drugs and consumables, and support of fees related to the surgical procedure. In FY17, the project used local media to deliver information to communities about hydrocele as well as the treatment method and locations where treatment can be sought. In addition, public criers encouraged any person suffering from a hydrocele to identify themselves to health workers to be registered, and receive information about when, where, and how to seek treatment. As a result, the 688 cases operated in FY18 with project support had been previously identified in FY17.
During the reporting period, the project supported 537 hydrocele surgeries in the Center North region (for cases identified in the districts of Barsalogho, Boulsa, Tougouri, Boussouma, Kaya, and Kongoussi). Combined with the 292 surgeries conducted during previous reporting periods, to date the project has supported a total of 829 hydrocele surgeries in the region through the routine health system and as part of hydrocele surgeon training sessions. For a summary table of hydrocele surgeries to date, by fiscal year and by region, see Appendix A (Table A5).
In the Hauts-Bassins region, as of the end of FY17 the project had supported 48 surgeries through the routine health system and as part of hydrocele surgeon trainings. In FY18, a total of 131 men received hydrocele surgery through the routine health system (in the districts of Dafra, Dandé, Houndé, Orodara, and N’dorola). In preparation for these FY18 surgeries, the project had reviewed the implementation of FY17 LF activities with the Hauts-Bassins DRS. This review led to meetings with operating room teams regarding delays in the execution of hydrocele surgeries planned in the Hauts-Bassins region. When discussions with the teams revealed a high demand for the limited number of sufficiently equipped operating rooms as a key challenge, the project worked closely with the national program and the DRS to ensure that operating rooms were made available for MMDP Project surgeries.
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 by the trained surgical care operators with the remaining supplies, resulting in a total of 20 project-supported surgeries in Saponé.
As per standard project procedure, after hydrocele surgery all operated patients remained at the health center for an average of three days to monitor surgical wounds and any potential complications. The project also supports the active follow-up of operated cases 6-12 months following surgery. Post-operative monitoring is described in more detail in the Monitoring & Evaluation section.
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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 routine activities. During Q1 of FY18, follow-up visits of trained individuals took place as part of the routine health system. Specifically, 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. A total of 60 cartridges were shipped to Burkina Faso. Some of the cartridges were used during the MMDP Project’s FASTT training and evaluation and the rest will be used for future FASTT trainings. FASTT consumables are procured centrally by the MMDP Global team.
SUPPORTIVE SUPERVISION In 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 consistently for every visit, but the general principles of the checklist were always followed. These visits made it possible to summarize accomplishments by operating theater, provide on the spot feedback and 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. 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 No activities were planned under this section for FY18.
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MONITORING AND EVALUATION M&E activities for LF in FY18 focused on follow-up of hydrocele surgery. Following all surgeries, the project encouraged follow-up at Day 1-2, Day 3, Day 5, Day 7, Day 14, Month 1-3, Month 6, and Month 12 as conducted by the routine health system. As an additional quality assurance measure, in collaboration with the national program, the project supported implementation of several distinct follow-up activities in FY18. These quality assurance activities focused on verifying data from post-operative follow-up of hydrocele patients within 5 days of surgery and conducting patient interviews and clinical exams specifically 6-12 months after surgery.
Since project-supported hydrocele surgeries take place within the routine health system, data from follow-up within five days of surgery are provided by health facilities and then synthesized at the regional level before being shared with the MMDP Project. Given challenges encountered in systematic and complete data transmission in FY17, in FY18 the project supported additional measures to ensure more complete reporting of follow-up data from this time period. Specifically, the team conducting the 6-12 month follow-up activities (described further below) used the follow-up as an opportunity to cross check the available data on the follow-up within 5 days of surgery, since the methodology included reviewing patients’ medical records. Using this approach, a total of 658 patients had their follow-up data (from within 5 days of surgery) reviewed and the results showed a low rate of complications (less than 2%) in this group.
The later 6-12 month post-operative period is a critical time window in which clinical postoperative outcomes can be linked to the quality of surgery provided. The 6-12 month follow- up supported by the project aimed to identify any case of recurrence and assess patients’ perceptions of changes in their quality of life. Two rounds of 6-12 month follow-ups took place in FY18. Each round of follow-up included both regions (Center North and Hauts-Bassins), targeted all operated patients who were in the 6-12 month post-operative period, and adhered to a protocol developed with support from the project. To implement the activity, lists of individuals having received surgery during the appropriate time period were shared 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 to give them a specific appointment time to come to the facility. CBHWs played a valuable role in finding patients and often used their networks if the person could not be reached by phone or did not present at the health facility as requested. For each patient who came to the health facility for examination, the medical record was pulled from the facility files, and the person was interviewed and examined. All clinical examinations were conducted by MMDP Project trained surgeons who, in many cases, had traveled from regional hospitals to the facility specifically for this purpose.
The first round of follow-up took place in November and December 2017. A total of 63 patients who had received surgery through the project 6-12 months prior (between December 2016 and June 2017) were targeted. All targeted patients were reached except for one person who had died of causes unrelated to the surgery. The clinical examinations revealed that among the 62 patients, one (1.6%) had a recurrence. This was a patient who was initially operated on for a bilateral hydrocele, had recurrence on one side, and was invited back to the hospital for surgery.
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During the interviews to gather information on patients’ perceptions of the surgery and changes in their quality of life, 98% of patients expressed that they were very satisfied and/or would recommend the surgery to others; 98% of patients reported improvements in their ability to conduct daily tasks; and 97% reported improvements in their social interactions.
The second round of follow-up took place in July 2018 and targeted the 568 patients who had received project-supported surgery between July 2017 and January 2018 (496 in the Center North and 72 in Hauts-Bassins). A total of 214 cases were reached for interviews and clinical exams (158 in the Center North and 56 in Hauts-Bassins); this relatively lower rate of participation (38%) was largely due to weather conditions, the resulting difficulties in accessing certain areas, and a higher number of incomplete patient records. While the data are still pending final analysis, preliminary results showed a recurrence rate of 2.3% (5 of 214 patients). Analysis of data on patients’ perceptions of quality of life was still in process at the time of report writing.
Additional M&E activities during the reporting period included periodic supervision of district management teams and data validations sessions encompassing both LF and TT. Four data validation sessions were held: two in Center North (September 25-27, 2017 and September 18- 19, 2018) and two in Hauts-Bassins (October 2-3, 2017 and September 21-22, 2018). The first round of validation sessions focused on FY17 data and the second round focused on FY18 data.
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, 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.
INTEGRATION WITH OTHER DISEASES Case identification and referral within the health system took place for any hernia cases identified during the hydrocele case confirmation.
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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 General Directorate of Public Health 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 helped strengthen the MOH’s ability to manage trachoma and LF morbidity.
• Health Workforce: The project’s introduction of the FASTT and HEAD START training packages has led to increasing interest from the MOH in adopting these packages as preferred training methodologies. The MOH already recommends both training packages to other projects and has used them to train surgeons in non-MMDP supported areas. Furthermore, workshops to introduce the FASTT and HEAD START simulators to the country’s National School of Public Health (ENSP) and the Health Sciences Training and Research Unit (UFR SDS) responsible for training doctors and health assistants in ophthalmology and surgery are planned for FY19. These workshops will provide an opportunity for participants to learn more about the training packages, assess them and, possibly, adopt them as teaching tools in their training facilities.
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 that have 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 had to completed by the end of June 2018, the national program has had to put certain MMDP Project-supported activities (e.g., TT-only surveys) as second-tier priorities.
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• 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 project collaborated with the Trachoma TAB to develop a protocol for mixing lidocaine and adrenaline, which was reviewed by the national program and national pharmacy staff. The protocol was validated and used for hydrocele surgeries in FY18. Approval for its use for TT surgeries is still pending.
• 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 important programmatic implications. 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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In the Far North region of Cameroon, Soudi's wife, who was trained in lymphedema management, helps him wash his leg as part of self-care. (Photo: William Nsai/Studio 3)
CAMEROON
• The MMDP Project targeted two districts for trichiasis services in FY18 (one in the Far North region and one in the North region). Four TT campaigns were held, providing 241 people with surgery.
• A Trachoma Action Plan meeting was held in June 2018 with support from partners, including the MMDP Project, to document the progress made towards elimination of trachoma in Cameroon and to plan next steps.
• The MMDP Project supported hydrocele surgery for 59 cases in five districts and conducted 6-12 month post-operative follow-up for 80 patients who received surgery in FY17 and FY18.
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IN BRIEF
In FY18, the Morbidity Management and Disability Prevention (MMDP) Project supported Cameroon’s national program to further its progress towards trachomatous trichiasis (TT) elimination through the implementation of TT management activities, disease assessment activities, and the facilitation of a Trachoma Action Plan (TAP) meeting. The project28 supported four TT campaigns targeting two districts (Touboro in the North region and Meri in the Far North region). Each campaign was preceded by a series of advocacy and social mobilization activities at the district, regional, and national level to obtain the support of key stakeholders and to ensure the delivery and uptake of services in target communities. In addition to supporting TT campaigns, the project supported training of seven surgeons, 18 health area29 nurses, and 799 community outreach workers to provide high-quality screening of TT cases, manage campaigns, and provide surgeries. Through support of a TT-only survey in Mada district, the updating of TT burden data in the region of Adamaoua, and the national TAP meeting, the project also contributed to Cameroon’s assessment of the TT burden and critical gaps remaining for the completion of the elimination dossier.
For lymphatic filariasis (LF) morbidity management, the project continued to provide support for hydrocele surgeries and associated five-day and 6-12 month post-operative follow-up. A total of 59 hydrocele surgeries were conducted with project support in FY18. In addition, the project contributed to the country’s efforts to develop a long-term plan for LF morbidity management. A workshop was organized to document the lessons learned from the MMDP Project’s pilot of LF morbidity management activities in five districts (Kaele, Kar-hay, Guidiguis, Bibémi, and Ngong) in the North and Far North regions. Results from the workshop were then used to inform a draft LF strategic plan for Cameroon. Project staff also provided input for the development of an integrated strategic plan for the morbidity management of all Neglected Tropical Diseases (NTDs), a process led by a non-governmental organization (NGO) called Accelerating Integrated Management (AIM).
PROGRAM BACKGROUND
TRACHOMA
Cameroon has three regions that were suspected endemic and mapped for trachoma at baseline: the North, Far North, and Adamaoua. The TT data collected in the North and Far North during 2010-2012 baseline mapping was standardized by age and sex in 2016, resulting in a significant reduction of the country’s backlog as compared with initial baseline projections. Standardization of Adamaoua region baseline trichiasis data, which was only recently completed in July 2018, and
28 We have used the term “the project” to include the national NTD program, HKI, and all MMDP partners involved in implementation. 29 Health area refers to a district sub-division.
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implementation of impact and surveillance surveys slightly reduced the estimated national burden even further. Figure 6 below shows the change in the estimated Ultimate Intervention Goal (UIG) by health district since baseline.
Figure 6: UIG at Baseline Survey (2010 – 2012) and at Most Recent Survey
When the MMDP Project began providing TT surgeries in FY16, the national remainder against the UIG was estimated to be 3,421 TT cases nationally: 2,471 in the Far North,30 808 in the North, and 142 in Adamaoua. However, these UIGs were revised once new data were made available following 2017 Trachoma Impact Surveys (TIS) in 13 districts,31 two TT-only surveys (one in Touboro district in 2016 and one in Mada district in 2017), and WHO’s age and sex standardization of baseline data from the Adamaoua region. While the national program has not yet released official new estimates, the latest data made available to the project yield a new UIG (as of the most recent surveys) of approximately 6,080, distributed as follows: 3,502 in the Far North (across six districts32), 2,486 in the North (across three districts33), and 92 in Adamaoua
30 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. 31 Goulfey, Guere, Kousseri, Makari, Maroua, Meri, Moutourwa, Pete, Tokombéré, Yagoua, Poli, Rey-bouba, and Tchollire 32 Goulfey, Guidiguis, Kar-hay, Mada, Meri, and Tokombéré 33 Poli, Touboro, and Garoua I
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(concentrated in one district, Meiganga, which is proposed for a TT-only survey in FY19). The increased TT prevalence estimates in the North were unexpected and primarily due to the results of a TT-only survey in Touboro district, which produced a much larger estimated UIG than previously generated from the baseline survey (prevalence increased from 0.40% to 0.77% in adults > 15). Figure 7 below shows how these evolving estimates have led to changes in districts above and below the trichiasis elimination threshold over time.
Figure 7: Health Districts Above TT Elimination Threshold at Baseline Survey and at Most Recent Survey
In the North region, the project has consistently targeted Poli and Touboro districts since FY16. These were two of the three districts in the North with a TT prevalence above the elimination threshold at the start of the MMDP Project.34 Following the project’s provision of intensive TT management services, each district conducted a new epidemiological survey (a 2016 TT-only survey in Touboro and a 2017 TIS in Poli). However, the survey results showed both districts were still above the WHO elimination threshold. Since then, four project-supported campaigns across the two districts have collectively addressed approximately 7% of the North region’s UIG
34 The third district, Tchollire, had a low theoretical UIG of 24 people. The project determined the level of intervention needed would be re-assessed following Tchollire’s next trachoma survey in 2017. The 2017 survey ultimately yielded a TT prevalence below the WHO elimination threshold.
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of 2,486. The current remainder against the UIG is spread across three districts (Poli, Touboro, and Garoua I35). As described in the FY19 work plan, the project will continue to target Touboro district, where the majority of the burden in the North is concentrated; the other two districts will be re-assessed through either a TIS or TT-only survey in FY19.
In the Far North region, the MMDP Project began by supporting two TT outreach campaigns in the district of Mokolo in FY16.36 The campaigns resulted in 267 people operated or otherwise made known to the health system, thus reducing the regional UIG at the start of the project by 11%. In FY17, the project did not support any Far North campaigns due to security concerns in that region and given that 2017 TIS surveys were in process for multiple districts.
Following the release of these 2017 results, an updated analysis of the region identified a total of six districts (Goulfey, Guidiguis, Kar-hay, Mada, Meri, and Tokombéré) that have not yet achieved the TT elimination threshold per their most recent survey. One of these districts, Meri, was selected to receive project support in FY18 because it had the highest age- and sex-standardized TT prevalence among the districts surveyed through a 2017 TIS. Meri had two project-supported TT campaigns in FY18, through which approximately 22% of the district’s theoretical UIG (and, in turn, 5% of the latest regional UIG) was addressed. The two FY18 campaigns collectively covered 100% of the district’s health areas, making it prudent to wait for future trachoma survey results before continuing an intensive TT management approach. As described in the FY19 work plan, the project will be shifting its support from Meri to Tokombéré district in the coming year. For a summary table of MMDP Project-supported progress towards the UIG, see Appendix A (Tables A1 and A2).
Finally, the East region in Cameroon was not suspected as endemic during the time of baseline mapping. However, mapping in neighboring Central African Republic demonstrated a high TF prevalence in districts bordering Cameroon. WHO therefore recommended baseline mapping in five districts in the East region of Cameroon that are contiguous with endemic districts in Central African Republic. These baseline surveys are planned for FY19 with support from the ENVISION project.
LYMPHATIC FILARIASIS
The program to eliminate LF in Cameroon is quite advanced. Initial mapping for LF between 2010 and 2012 determined that nearly 90% of the country’s districts were endemic (see Figure 8 below). Since then, more than 80% of endemic districts have successfully stopped MDA. However, LF morbidity interventions in Cameroon are limited and inconsistent, highlighting the need for a national plan to identify and manage LF morbidity cases with high quality services. For
35 Following age and sex standardization the TT prevalence estimate in Garoua I shifted from below the TT elimination threshold to above it. 36 Mokolo was one of four districts in the region calculated to have a remaining UIG at the start of the project. Its estimated remainder against the UIG was the second-highest in the region. The district with the highest estimated remainder at the time (Makari district) was also targeted, but activities could not take place as planned due to the security situation.
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the MMDP component of LF elimination, the national program, with support from the MMDP Project, piloted the management of complications related to LF in five districts: two in the North (Bibémi and Ngong) and three in the Far North (Kaele, Kar-hay, and Guidiguis), as shown in Figure 8 below.
Figure 8: LF Endemicity in Cameroon (as of 2010-2012)
The North and Far North regions were selected for the LF MMDP pilot given the project’s existing focus on the North and Far North regions for trichiasis activities. Specific districts within the regions (Kaele, Kar-hay, Guidiguis, Bibémi, and Ngong) were selected based on the number of suspected hydrocele and lymphedema cases. These cases were identified during FY16 pre- Transmission Assessment Surveys (TAS), which the project used as a platform for LF burden data collection in close collaboration with the ENVISION Project. 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.
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Before beginning disease management activities in FY17, the project designed and implemented enhanced hydrocele and lymphedema case finding activities to refine burden estimates prior to delivery of services. Figure 9 below illustrates this contribution towards identifying cases in the pilot districts as well as additional BAs that have taken place.
Figure 9: Districts with LF Burden Assessments
The project’s case finding activities in the pilot districts resulted in identification and confirmation of 300 hydrocele cases and identification of 148 lymphedema cases. The project has provided hydrocele surgery to 106 of the 300 hydrocele cases identified through its enhanced case finding, with 59 of these surgeries conducted in FY18.37 A total of 112 of the lymphedema cases have been trained in self-care (all in FY17). As the scale of the pilot was not designed to address the full disease burden across all five targeted districts, the list of remaining cases is with the appropriate health system staff for follow-up outside of the project. For a summary table of LF disease management achievements to date, in relation to current burden estimates, see Appendix A (Tables A5-A6).
37 Number has increased from previous reports’ totals due to additional data being reported.
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In previous fiscal years, the project has also supported quality assessments of select health facilities providing hydrocele and/or lymphedema services (in the districts of Bibémi, Ngong, and Guidiguis, shown in Figure 10 below). The project is not aware of any other LF health facility assessments having taken place in Cameroon to date.
Figure 10: Health Facility Assessments for LF Services
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MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD
TRACHOMA
STRATEGIC PLANNING In FY18, MMDP Project staff participated in strategic planning meetings related to national and regional evaluation and planning for the integrated control of NTDs. This included a three-day national evaluation meeting in February 2018 funded by ENVISION. The meeting was attended by all key actors involved in the implementation of NTD control activities in Cameroon, including regional health delegates, NTD control program managers (onchocerciasis, LF, trachoma, schistosomiasis, and intestinal worms), WHO/Cameroon, and representatives from partner NGOs (HKI, AIM, Sightsavers, International Eye Foundation, PersPectives, Good Neighbors, and FAIRMED). The main objective of the meeting was to evaluate activities carried out in calendar year 2017 and develop an action plan for calendar year 2018. Presentations included an overview of NTD activities implemented in each region. A major outcome of the meeting was the introduction of AIM as the lead for the development of an integrated five-year strategic plan for the morbidity management of all NTDs.
In June 2018, AIM shared the first draft of the plan with relevant stakeholders including HKI. This was followed by a workshop to expand on the initial draft, organized by AIM and attended by representatives from the National Onchocerciasis Control Program (PNLO), the national Leprosy and Buruli Ulcer Control Program, HKI, FAIRMED, and WHO. After the workshop, the PNLO was tasked with leading a smaller working group to incorporate feedback from the workshop into a second draft of the plan. HKI’s contributions to this process included verifying the data in the draft plan, sharing lessons learned from the LF morbidity management pilot, and ensuring that morbidity management for trachoma and LF is taken into account in the plan. At the time of this report, the Ministry of Health (MOH) had not yet shared the second draft with partners.
Other strategic planning meetings supported by the MMDP Project were the mid-term evaluation meetings and the TAP workshop. After the first two TT campaigns, the project participated in mid-term evaluation meetings in the North (in Touboro in June 2018) and Far North (in Meri in May 2018). Participants included district managers, teams from the North and Far North regional delegations, HKI staff, and Sightsavers staff. During the meetings, data from the first two campaigns were presented and validated and participants agreed on the campaign schedule for the rest of the fiscal year. The mid-term evaluation meetings also provided an opportunity to discuss the difficulty of finding TT cases in the field during the first campaign in Touboro. It was noted that using the door-to-door strategy for the first campaign in Meri had provided higher numbers of people screened. As a result, it was recommended that the door-to-door strategy should be used for the last campaigns both in Meri and in Touboro.
The TAP workshop was held in Yaoundé June 22 – 25, 2018 with support from the MMDP Project and ENVISION. The primary objective of the meeting was to document the progress
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made towards the elimination of trachoma in Cameroon in order to identify remaining activities, develop a plan for the implementation of those activities, and define a timeline for the development of the trachoma elimination dossier. Discussions at the meeting focused on the history of trachoma elimination in Cameroon, a review of data available to date, lessons learned, and challenges faced. Some of the next steps identified at the meeting included but were not limited to: conducting a mapping survey in Kolofata district which has been inaccessible due to insecurity for several years; documenting the prevalence in districts in the East that border known endemic districts in Central African Republic; documenting a revised TT prevalence in Garoua I and Kar-hay districts; and continued TT outreach in the districts of Goulfey, Mada, Meri, Tokombéré, and Touboro. The workshop was attended by stakeholders from Sightsavers, ENVISION, HKI, WHO, North and Far North Regional Delegations of Public Health (DRSP), and the National Blindness Prevention Program (PNLCé). It was immediately followed by the MMDP FY19 work planning workshop during which the national program worked with HKI, WHO, and Sightsavers to determine priorities for FY19.
ADVOCACY Advocacy activities during the reporting period included district- and regional-level advocacy meetings. District-level meetings were held throughout the fiscal year in Touboro and Meri prior to each of the TT surgery campaigns. During the meetings, district authorities (administrative, religious, and traditional) were informed of campaign objectives, the schedule of the surgical teams, and how they could support field activities. As a result of these meetings, 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 and Far North regional delegates, regional governors, and regional-level religious, traditional, and civil authorities (who committed to sending letters supporting project activities to their district-level counterparts).
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE In FY18, information, education and communication (IEC) tools and materials that were developed and used in the FY17 campaigns were reproduced for the four campaigns that took place in the North and Far North. The project delivered these materials (posters, flyers, and fact sheets) to the regional delegate’s office, which in turn distributed them to health centers at the district level to disseminate them to the appropriate individuals in the community, including outreach workers. The latter ensure that the posters and flyers are displayed in public areas (mosques, churches, and markets) and use the fact sheets to provide members of the community with general information on trachoma, the screening process, and the availability of free services. The table below shows type and quantity of materials reproduced in FY18.
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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 Community 1,500 cases and awareness messages inviting community members members to be screened for free services. 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 Community 18,000 cases and awareness messages inviting community members members to be screened for free services. 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
Messages were also broadcast via local radio stations before and during campaigns in official and local languages. The messages were developed by the communication focal point in each region with support from the MMDP Project and provided general information on TT, the risk of blindness that it poses, the importance of screening, and the availability of free care. The messages were broadcast in line with USAID branding and marking requirements.
In addition, prior to each of the TT campaigns, community meetings were held in a total of 94 target villages in Meri (45 for the first campaign and 49 for the second campaign) and 99 villages in Touboro (52 for the first campaign and 47 for the second campaign). The meetings were organized by the village leader and led by the health area nurses. During the meetings, the health area nurses provided general information on trachoma and the free surgeries offered by the health system. Members of the community learned that opting for surgery can reduce the pain of TT, that the surgery only takes a few minutes, and that they can return to normal activities the day after the procedure. Furthermore, for the first campaign in Touboro38 the meetings provided an opportunity for active case finding since the health area nurses conducted a preliminary screening of suspected TT cases. All cases identified by the health area nurses were added to a list of suspected cases that was used to plan and organize the campaign’s surgery sites.
CAPACITY BUILDING A two-day refresher/debriefing session for three TT surgeons39 and a TT surgeon assistant in the North was held in March 2018. This session did not include HEAD START40 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
38 For both campaigns in Meri and the second campaign in Touboro, active case screening was done using the door-to- door strategy. 39 One of these surgeons functions as a technical supervisor. 40 Human Eyelid Analog Device for Surgical Training And Skills Reinforcement in Trachoma
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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 of nurses and health care workers during TT campaigns.
For the Far North, a six-day refresher training for TT surgeons was held in April 2018 with a HEAD START session. Since the MMDP Project did not support activities in the Far North in FY17, project staff could not monitor the technical quality of the six surgeons who had been trained and certified in FY16. As a result, a HEAD START session was included in the Far North surgeon training to ensure the technical competency of the surgeons before their participation in the TT campaigns in Meri. Two national technical supervisors led the training, with remote technical support from Dr. Amir Bedri Kello. The project had originally planned to train six surgeons, but due to the limited availability of trainers, only four surgeons were trained.41 The following topics were covered: a review of the anatomy of the eyelid, preferred practices for the management of TT cases, a review of standard surgical procedures, infection control, and waste management. Two days were dedicated to practice on the HEAD START simulator, followed by three days of surgery on actual TT cases in Meri. Out of the four surgeons trained, three were cleared to practice surgery during the TT campaigns in Meri.
In addition to the refresher/debriefing session for surgeons, the project organized trainings for health area nurses and community outreach workers. 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. In FY18, the project supported four refresher trainings for health area nurses based on key training manuals recommended by the International Coalition for Trachoma Control and using aide memoires developed by the MMDP Project as support materials.
Training sessions for the health area nurses focused on the supervision of social mobilization activities, organization of surgery sites, pre- and post-operative care, and post-operative monitoring. In addition, the project reviewed and analyzed the data collected through supportive supervision activities to date and tailored the sessions 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. Health area nurses were trained prior to each TT campaign, with a total of 8 nurses trained in Touboro and 10 nurses trained in Meri.
Trainings for the community outreach workers were held in the health areas that were targeted for surgery campaigns. Four trainings were organized to train a total of 799 community outreach workers (331 in Touboro and 468 in Meri). The main objective of the trainings 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
41 Based on preferred practices, a trainer should work with a maximum of two surgeons at a time during a session. At the time of the training in the Far North, only two trainers were available, so only four surgeons could be trained.
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TT, and the advantages and availability of TT surgeries. They were also trained in the mobilization, counseling, 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. Joint teams of staff from HKI and the Regional Delegations from the North and the Far North provided supervision of the activities.
ASSESSING DISEASE BURDEN In the first quarter of FY18, the MMDP Project supported a TT-only survey in Mada district in the Far North. Mada was selected because the district’s TT data had not been updated since its 2010 baseline survey, as its initial Trachomatous inflammation - Follicular prevalence was not high enough to trigger Mass Drug Administration activities. Updating the initial baseline TT prevalence was an important step in achieving elimination because it determined whether intensive TT management activities are still needed in the district. The project collaborated closely with the PNLCé and WHO’s Tropical Data to support the development of a protocol for the survey (in October 2017) and the training of eight graders and eight recorders (in November 2017). The survey team engaged in data collection throughout the month of November under MOH and MMDP Project supervision. Although the survey was originally included in the project’s FY17 work plan, these activities took place in the first quarter of FY18 because a Tropical Data-certified trainer was not confirmed until the very end of FY17. Following data collection, the project liaised extensively with the PNLCé and WHO to facilitate access to and dissemination of Tropical Data’s analysis of the Mada TT-only 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 also liaised extensively with the PNLCé and WHO to facilitate finalization and sharing of the following additional TT data sets:
• Tropical Data results from the TT-only survey in Touboro district (conducted in FY17 with project support), which were made available in January 2018 and indicated a TT prevalence among those 15 years and older of 0.77%;
• Tropical Data results from the 2017 TIS, which informed Cameroon’s planning for elimination during the June 2018 TAP and provided the evidence base for holding project- supported campaigns in Meri district in FY18;
• Results from 2014 and 2015 TIS, which were shared with Tropical Data to generate age- and sex-standardized results but have not yet been finalized; and
• Results from the Adamaoua region’s baseline survey, which were shared with Tropical Data to generate age-and sex-standardized data; after providing assistance in developing a data dictionary for Tropical Data in January 2018, the project received the final results from the PNLCé in July 2018.
The age- and sex-standardized baseline data for Adamaoua region made available in July 2018 showed only one district, Meiganga, to be above the TT elimination threshold. Meiganga was
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found to have a TT prevalence of 0.33% among adults 15 years of age and older, which yields an estimated UIG of 92. To verify the exact epidemiological situation of TT on the ground before initiating any TT case management activities, it was recommended at the June 2018 TAP to conduct a TT-only survey in the district. The project agreed to support implementation of this survey, per the FY18 work plan. In August 2018 the project supported the PNLCé in developing a Meiganga TT-only survey protocol for sharing with Tropical Data. As the protocol was still being finalized at the end of FY18, the survey is currently planned for the first quarter of FY19. The second TT-only survey in Adamaoua tentatively planned in the FY18 work plan did not take place since the age- and sex-standardized data showed the survey was not needed.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY The project supported implementation of four TT campaigns in FY18: two in Touboro district in the North region (April and September 2018) and two in Meri district in the Far North region (April and July 2018). A total of 110,521 people were screened during these four campaigns, of whom 288 were confirmed to have TT. Of these confirmed cases, 241 people received TT surgery, 47 refused surgery, and 35 were referred to a higher-level facility for surgery either because they were less than 15 years old or because they had post-operative TT. No individuals were referred due to lower eyelid TT. A total of eight people were provided epilation counseling, which includes receiving high-quality forceps and guidance on how to use them.
For the first campaign in Touboro in April 2018, health area nurses conducted preliminary screening of suspected TT cases at community meetings in each village included in the campaign. The nurses recorded the suspected cases in a list and also conducted home visits to potential cases (identified by community outreach workers) who were unable to attend the meetings. Using this approach, a list of individuals suspected to have trichiasis in each district was created. The list then served as a basis for planning and organizing the campaign’s surgery sites. The project organized travel and selected surgery sites (such as schools or health centers) based on the number of suspected cases and other operational factors. During each campaign, community outreach workers sought out the individuals on the list of suspected cases and directed them to surgery sites, where their suspected trichiasis could be confirmed. Each surgery site team included two surgeons, a technical supervisor, a health area nurse, and a surgical assistant responsible for sterilizing equipment and managing waste.
The second campaign in Touboro (in September 2018) and the two campaigns in Meri employed a modified approach to case finding. Given the districts’ continued TT prevalence above the elimination threshold despite previous campaigns, case finding teams organized door-to-door screening in selected villages. Each screening team consisted of a TT surgeon, a nurse from the health center whose area of coverage includes the village being screened, and at least one community outreach worker. The latter served as a guide through the village by orienting the rest of the team to the different households. The nurse coordinated all prior social mobilization and behavior change activities and the surgeon screened all persons found in the household. All identified TT cases were then recorded and referred to a surgery site. Surgery sites were selected
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based on the number of cases identified in a village and the distance that cases had to travel from their village to the site.
Across all campaigns, individuals with confirmed TT received pre-operative counseling. Counseling addressed the benefits of the surgery, explained the procedure, and obtained the person’s consent. After surgery, cases received post-operative counseling and were reminded of key post-operative medical appointments: Day 1 for the dressing and Day 7-14 and 3-6 months post-surgery for routine monitoring. These appointments also provide an opportunity to disseminate messages on the Facial Cleanliness and Environmental Improvement components of trachoma control. Operated cases received a tube of tetracycline, provided by the project, after the operation. Data on the individuals screened at the surgery site were collected using a registration form. Confirmed cases were noted in the surgery register and the post-operative monitoring register. Data was compiled daily using summary forms that include information on the number of individuals examined, the number of confirmed and operated TT cases, and consumables and drug management.
During the two campaigns in Touboro, the project integrated taking photographs of operated eyes immediately before and after TT surgery as part of a pilot to generate additional information regarding potential predictors of surgical outcomes in a programmatic setting. For details on the pilot, which was also conducted in Burkina Faso, see the Operational Research sub-section of the Global section of this report.
The screening teams’ experience seeking out cases during campaigns ultimately yielded far fewer trichiasis cases than estimated to exist in each district. The results of the campaigns are therefore below the initial target of 2,520 people receiving surgery in FY18. Although the number of cases confirmed during field implementation was below the number expected, the campaigns collectively covered all eight health areas in Meri and 10 of the 13 health areas in Touboro (with the remaining Touboro health areas already covered during a previous FY17 campaign).
The average number of people screened per FY18 campaign is higher than in FY17 because the project adjusted its data collection processes at the beginning of the year to better reflect the evolution of case finding strategies. Screening data from the first campaign in Touboro includes those who were screened for TT during participation in the community meetings (rather than only those individuals who were screened at the surgery site, as was the case in FY17). Screening data from the second campaign in Touboro and the two campaigns in Meri includes the much larger number of individuals who were visited by a screening team under the new door-to-door approach.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT Procurement in FY18 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 from any USAID-approved wholesaler; therefore, HKI procured
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the item with private funds. To ensure the quality of lidocaine with adrenaline procured locally in-country, the team purchased the items from the national pharmacy, which follows the national drug guidelines and management in Cameroon.
• HEAD START Surgical Simulator Parts: The MMDP Project Global team procured HEAD START consumables centrally. During the reporting period, eight orbits and 100 eyelids were shipped to Cameroon for use during the surgeon refresher training in the Far North.
• Consumables for FY19: Consumables for FY19 TT surgeries were purchased locally during the reporting period.
SUPPORTIVE SUPERVISION Joint teams from HKI and Regional Delegations supervised the TT surgeon trainings, health area nurse trainings, and the community outreach worker trainings. 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 was conducted as part of routine campaign activities to monitor the quality of the campaign. This ensured that surgery site preparation, including social mobilization and counseling, was organized based on preferred practices.
SHORT-TERM TECHNICAL ASSISTANCE During the reporting period, Dr. Bedri 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 worked remotely with the national trainers to develop a training plan for the 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 has shifted its approach to 3-6 month follow-up by incorporating outcome assessment and surgical audit as two distinct activities. In the low-burden context of Cameroon, however, recent campaigns have not always yielded a sufficient number of surgeries to enable auditing at least 20 individuals per surgeon, as is the current preferred practice for surgical audit. When this challenge arose, the project employed 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
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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 this “hybrid” model of outcome assessment including surgical audit principles in Poli district. A total of 34 people had received surgery the previous fiscal year 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 (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— remains necessary to ensure 100% of cases receive this critical follow-up examination. 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.
Of the FY18 campaigns, outcome assessment for the first campaign in Touboro district took place in September 2018. All 24 cases operated during the April 2018 campaign were found and examined. The results will inform the refresher session that will take place prior to the first campaign of FY19. During this outcome assessment the project also photographed the operated eyes 3-6 months after surgery as part of the pilot designed to generate additional information regarding potential predictors of surgical outcomes in a programmatic setting. For details on the pilot, see the Operational Research sub-section of the Global section of this report.
For the first campaign that took place in Meri district in April 2018, the national program and the project decided to conduct a surgical audit to assess the quality of surgery provided following the refresher training held for three surgeons prior to the campaign. For each of the three surgeons, the audit targeted 20 individuals who had received surgery during the campaign. Out of the 60 operated cases targeted during the audit, 50 cases (83%) were visited and examined. Fewer cases were reached than targeted because of difficulties accessing villages due to flooding that occurred in Meri at the time the audit was implemented. Analysis of the audit results was still underway at the time of reporting and, once finalized, will be used in the planning of FY19 surgeon refresher sessions. Follow-up activities for the final two FY18 campaigns will be conducted in FY19.
In addition to these quality assurance activities, the MMDP Project began supporting the PNLCé to organize TT data in advance of the June 2018 TAP workshop. As a result of this collaboration between the PNLCé and partners, the trachoma data available to date (which will be needed as part of dossier submission) was compiled using WHO’s Excel template. During the TAP,
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participants used the compiled data to assess progress achieved to date and to identify remaining gaps in achieving trachoma elimination (see the Strategic Planning section).
Finally, prior to the first TT surgery campaign of FY18, minor updates were made to data collection tools. These changes enabled improvements in tracking screening data, post-operative signs and symptoms by eye, and geographic coverage at the sub-district (health area) level.
LYMPHATIC FILARIASIS
STRATEGIC PLANNING In FY18, the MMDP Project supported the MOH’s efforts to develop a strategic plan to identify and manage LF morbidity cases. As part of this support, the project collaborated with the national program to organize a workshop to document lessons learned from the implementation of the LF morbidity management pilot conducted in 2017 and 2018 (in Ngong and Bibémi districts in the North and Kar-hay, Kaele, and Guidiguis districts in the Far North). The aim of this pilot phase was to generate data and document lessons learned from LF morbidity management activities, so they could be taken into account when scaling up LF morbidity management activities in the country.
The lessons-learned workshop was held August 27-28, 2018 and was attended by national hydrocele surgery trainers, hydrocele surgeons, national lymphedema management trainers, regional health delegates from the North and Far North regions, North and Far North regional focal points for NTDs and LF, health district chiefs, community health workers, HKI staff, and representatives from the PNLO. The methodology used consisted of presentations on the activities that were implemented during the pilot, followed by group work and plenary discussions. The information collected was structured into five categories, namely: the historical context for LF in Cameroon and activities to date, the results of the implementation, key success factors, lessons learned, and suggestions. Key successes from the pilot that were discussed at the meeting included:
• Training of two national trainers for hydrocele surgery
• Training of seven surgeons in hydrocele surgery
• Surgery for 106 hydrocele cases
• Training of five national trainers in lymphedema management
• Training of health area nurses and patients in home care techniques for lymphedema
Some of the recommendations from the workshop included:
• IEC materials posted in public places should be systematically explained to the public by a community mobilizer or trained health staff.
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• Real images of hydroceles and lymphedema cases should be used for advocacy tools.
• People need to be convinced of the feasibility and success of hydrocele surgery and lymphedema management. In community meetings, the testimony of patients already having received surgery or of those who have found relief by using the washing technique can mobilize more patients and encourage their support for interventions.
• Accurate identification of hydrocele cases is important for effective management. To facilitate sorting at the health center level, it would be useful to develop an algorithm for use by nurses and familiarize them with it during a training.
• The MOH should be encouraged to provide the drugs needed for case management to avoid delays related to the importation of drugs.
• National trainers and surgeons should be involved in developing and updating data collection tools. Recommendations from the workshop were then included in a report which was used by a small working group of HKI and PNLO staff to inform draft 0 of a five-year LF strategic plan. In FY19, the MMDP Project will help to finalize the draft by supporting the organization of workshops to complete and validate the document, providing technical input, and coordinating input from key technical experts including WHO/Expended Special Project for the Elimination of Neglected Tropical Disease.
ADVOCACY No activities were planned under this section for FY18.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE No activities were planned under this section for FY18.
CAPACITY BUILDING/TRAINING No activities were planned under this section for FY18.
ASSESSING DISEASE BURDEN No activities were planned under this section for FY18.
HYDROCELE SURGERY A total of 59 people received hydrocele surgery in the first quarter of FY18 across five districts in the North and Far North, for a total of 106 surgeries conducted over the life of the project.42 Surgeries were performed in Ngong and Bibémi 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
42 Number has increased from previous reports’ totals due to additional data being reported.
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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. Of the 300 cases, for logistical and planning purposes a total of 95 were referred by health area nurses to a district hospital where surgeons trained under the MMDP Project confirmed the hydrocele diagnosis. The results indicated a 100% accuracy rate for health area nurses, with all 95 cases confirmed by surgeons as being true hydrocele cases. 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 district hospital the evening before their surgery to check in and start the pre-operative case management process. (The remaining cases are awaiting confirmation of diagnosis by surgeons within the routine health system.)
LYMPHEDEMA MANAGEMENT No activities were planned under this section for FY18.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT No activities were planned under this section for FY18.
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 Filaricele Anatomical Surgical Task Trainer (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 No activities were planned under this section for FY18.
MONITORING AND EVALUATION In September 2017, prior to the start of the hydrocele surgeries, the project conducted an “Obstacles to Surgery” study using a survey tool. The survey was integrated into the case identification activity described in the Hydrocele Surgery section, in the districts of Bibémi (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.
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• 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, 10% of 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 plan.
Beginning in FY17, the project supported hydrocele surgeries in the five district hospitals of Ngong, Bibémi, 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. Following all surgeries, the project encouraged follow-up (to be conducted by the routine health system) at Day 1-2, Day 3, Day 5, Day 7, Day 14, Month 1-3, Month 6, and Month 12.
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 106 patients receiving project-supported surgery in FY17 and FY18, 100% received follow-up within five days following surgery. In total, 12 of the 106 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.
As an additional quality assurance measure, in June 2018 the project supported a distinct follow- up activity to interview and examine patients 6-12 months after surgery, as this is a critical time window in which clinical postoperative outcomes can be linked to the quality of surgery provided. This follow-up activity aimed to ensure all individuals receiving surgery under the project received a 6-12 examination. A protocol was developed to identify any case of recurrence as a measure of the quality of surgical procedures performed and to assess any perceived changes in the quality of life of patients.
A total of 80 patients (75% of the 106 operated cases) were followed-up and all agreed to participate in the activity. Trained surgeons conducted the clinical examination component, with additional staff from district health centers, the national program, and the MMDP Project providing support for the activity. While report finalization was still underway at the end of the reporting period, the preliminary analysis showed a recurrence rate of 10% (8 out of the 80 individuals examined). Of the 80 patients interviewed, 97% of respondents reported a perceived improvement in their economic situation. The final results and corresponding analysis will be used in FY19 to further strengthen surgical capacity in Cameroon and inform the global LF community.
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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 NTD activities for calendar year 2017, including those of the MMDP Project, and developed detailed implementation plans for 2018 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 related to infection control and health care waste management collected through supervision visits conducted during a previous TT campaign were analyzed. Specific issues and challenges observed (e.g., the sterilization process and the nonsystematic segregation of contaminated and non-contaminated waste in the operating room) were discussed and reviewed during the refresher trainings for TT surgeons and the trainings for nurses organized prior to the TT campaigns.
INTEGRATION WITH OTHER DISEASES Case identification and referral within the health system took place for any hernia cases identified during hydrocele case confirmation activities.
HEALTH SYSTEMS STRENGTHENING In FY18, the project contributed to strengthening the health system in the following ways:
• Leadership and Governance: 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 with the DRSP 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, helps 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. Bedri’s provision of remote technical assistance for the Touboro and Meri TT surgeon 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 means of 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 (trained in FY17) 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 for hydrocele is cost. This information will be taken into consideration in the background information used to prepare the country’s strategic plan of action.
• One major challenge for the MMDP Project has been the increasing difficulty of finding TT cases. As a result, the MMDP Project changed its case finding methodology to door- to-door screening for the last three campaigns in FY18. As countries like Cameroon get closer to elimination, national programs will have to consider new and possibly more resource-intensive methods to reach the UIG.
• For LF morbidity management, using real images of hydroceles and lymphedema as well as stories that show life before and after an intervention is an effective advocacy tool to encourage uptake of services in target communities. In community meetings, the testimony of patients already having received surgery or of those who have found relief by using the washing technique can mobilize more patients and encourage their support for interventions.
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Tsegay Hagos, ophthalmic nurse, provides health education at screening program at Adi Nebride Health Center, Lalay Adiabo woreda, Tigray region in Ethiopia. (Photo: HKI)
ETHIOPIA
• The MMDP Project supported provision of TT management services in 162 woredas, screening 401,592 individuals and providing TT surgery for 20,034 people. • The project supported the roll-out of new Federal Ministry of Health (FMOH) guidelines for TT quality assurance through a national-level training of trainers and regional trainings in the regions of Oromia and Tigray. • Across four regions, a total of 330 hydrocele surgeries were conducted and 796 lymphedema cases were trained in self-care.
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IN BRIEF
In FY18, there were several notable successes under the Morbidity Management and Disability Prevention (MMDP) Project, both at a policy and project-level: first, good progress was made towards annual targets: 20,034 persons with trachomatous trichiasis (TT) were operated out of 24,541 targeted (82%); for hydrocele surgery, while only 55% of the target was reached (330/600), the project supported an entirely new region, Gambella, to implement services. Second, the regional health bureau (RHB) of Oromia declared all lymphedema and hydrocele services to be free of charge to patients. While there have been challenges in realizing this aspiration, the support of the RHB is a very positive step. On a related note, the human resources’ division of the Federal Ministry of Health (FMOH) integrated a lymphedema management section into the pre-nursing curriculum. All graduating nurses will know how to care for lymphedema patients which is a promising step to ensuring sustainability of services. Next, the FMOH developed and rolled-out quality assurance guidelines for TT surgery. The document borrows heavily from MMDP Project-developed documents, and additionally, the MMDP Project supported the roll- out the guidelines, financially and technically, through a national-level training of trainers (TOT) and regional trainings in Oromia and Tigray.
While some of the same challenges from previous years, such as insecurity, also hampered activities in FY18, new challenges also arose. In Tigray, human resources were an issue, as some TT surgeons were no longer active and others began an ophthalmic officer training at Mekelle University. This was partially mitigated by utilizing a house-to-house case finding approach and an agreement with the University to allow the TT surgeons to participate in some outreach campaigns.
In both regions, TT surgeons began to see fewer cases: in FY16, 127,618 persons were screened and 13,950 TT cases confirmed (11%); in FY18, 401,592 persons were examined, but only 22,161 had TT (5.5%). While this is positive news, sub partners Light for the World and Fred Hollows Foundation (FHF) both reported that TT surgeons were becoming disheartened when conducting outreach, as they were not able to do as many surgeries. Given this new paradigm, messaging to surgeons needs to change—screening to confirm that someone does not have TT is as important as confirming that someone does have TT and providing surgery. Finally, on the LF side, local non-governmental organization (NGO) the National Podoconiosis Action Network (NaPAN) aimed to conduct a “feasibility study” comparing two approaches for lymphedema management that was replaced by a brief rapid assessment.
All these challenges and successes from FY15-18, as well as the financial and technical support of the project, the hard work and innovation of partners, and a favorable policy environment at the national and regional levels have contributed greatly towards elimination goals in project areas.
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PROGRAM BACKGROUND
TRACHOMA
In 2016, the World Health Organization (WHO) estimated the backlog of TT cases in Ethiopia to be 693,037 persons, a target that the FMOH committed to reaching through the Honorable Minister’s Initiative to Clear the TT Backlog. The RHBs of Amhara, Oromia, Tigray, and Southern Nations, Nationalities and Peoples’ (SNNPR) regions have worked with the FMOH and NGO partners to alleviate the burden of TT through surgery. The USAID-funded MMDP Project targets parts of the Oromia and Tigray regions, with a project goal of addressing 11% of the overall ultimate intervention goal (UIG) in the country.43
In Oromia, the MMDP Project supports 131 woredas comprising 10 zones, through sub-partner FHF. Baseline mapping estimated more than 200,000 TT cases in the region, and the MMDP Project-supported woredas had a combined estimated UIG of 54,782 at the beginning of the project, revised to 54,417 after a trachoma impact survey (TIS) in 2018. The MMDP Project reached 8,342 persons with TT surgery in the first half of FY18 and 7,577 in the second reporting period, for a total of 15,919 persons operated. The cumulative total from FY16-18 is 42,263 persons operated, 78% of the estimated UIG in project areas in Oromia.44
In Tigray, the MMDP Project supports 31 woredas comprising five zones, through sub-partner Light for the World. At the start of the project, the estimated UIG was 22,272 in the region. In the first reporting period of FY18, 2,267 individuals had been operated, and an additional 1,848 persons were operated in the second half of the year, totaling 4,115 persons operated. Since the beginning of the project, 19,042 individuals have received surgery in Tigray, 85% of the UIG in project areas.45
LYMPHATIC FILARIASIS
Country-wide mapping to measure LF prevalence was initially conducted in 2013, and then was updated in 2015 with selective re-mapping. Since mapping did not establish the LF morbidity burden in these woredas, the FMOH established a goal of conducting Burden Assessments (BAs) in all 71 LF-endemic woredas by 2020. The MMDP Project has supported BAs in 41 woredas (35 endemic, 6 non-endemic), spanning four regions of Ethiopia.
Prior to MMDP Project activities, LF morbidity management activities had been conducted in only a small percentage of the country’s LF-endemic woredas. Since FY17, the MMDP Project has implemented hydrocele surgery in just under half of the country’s endemic woredas. In FY18, 28
43 UIG data specified in the 2014 National Trachoma Action Plan for Ethiopia. 44 Ethiopia calculates progress against the UIG using only persons operated; however, 44,687 individuals have been operated or otherwise made known to the health system in Oromia (managed through epilation, referred, or refused) over the course of the project, which is 82% of the UIG. 45 As noted above, Ethiopia calculates progress against the UIG using only persons operated. In Tigray, 21,380 individuals have been operated or otherwise made known to the health system over the course of the project, 96% of the UIG.
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woredas in Beneshangul-Gumuz (BG), Oromia, and Gambella regions were targeted for hydrocele surgery camps.46 A total of 330 cases were operated in FY18, which, combined with the 417 cases operated in FY17, addresses 50% (747/1,475) of the total hydrocele surgery needs in the four regions of BG, Oromia, Gambella and Tigray, as estimated by the BAs. The MMDP Project trained 102 clinical workers and five Neglected Tropical Disease (NTD) focal points in lymphedema management and post-hydrocele surgery care in FY18 and trained 1,395 individuals with lymphedema in self-care between FY17-18. Additionally, project advocacy has led to a policy of free service provision for lymphatic filariasis morbidity management and disability prevention (LF MMDP) services in the Oromia region.
MAJOR ACCOMPLISHMENTS FOR THE REPORTING PERIOD
TRACHOMA (Oromia)
STRATEGIC PLANNING Zonal IECW TT Surgery Performance Review and Planning Meeting
Performance review and planning meetings for integrated eye care workers’ (IECW) at the zonal level bring together IECWs and other key government staff together to jointly 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. Additionally, the meetings provide an opportunity for IECWs from select woredas to present on their performance and for high performing IECWs to share the experiences and accomplishments.
FHF institutional funding supported these planning meetings in all 10 MMDP Project-supported zones, with a total of 626 participants. Participants included RHB NTD teams, zonal health department (ZHD) heads and NTD focal persons, IECWs, primary health care unit (PHCU) directors, woreda health office (WoHO) head/deputy heads, woreda NTD focal persons and FHF staff.
During the reporting period for the first semiannual report (SAR I), Merti and Aseko woredas of Arsi zone, Boke and Guba Koricha of West Harerghe, Dugda Dawa of Borena and Wondo of West Arsi were among the woredas that shared lessons on factors enabling high TT surgery performance. Success factors include: dedication of the dedicated mobile teams (DMTs); commitment of IECWs; a high level of engagement of WoHOs; and a high level of coordination among IECWs, NTD team, health extension workers (HEWs), kebele structures and community leaders.
During the second SAR period, IECW review and planning meetings were organized in Arsi and Illubabora (IAB) zones in collaboration with Oromia Regional Health Bureau (ORHB) and respective ZHDs. In these meetings, key factors, such as poor social mobilization, lack of
46 All known hydrocele cases in the project’s fourth region, Tigray, received project-supported surgery in FY17.
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commitment by IECWs, and poor coordination, were discussed and addressed in action plans some of which were implemented in mini-camps immediately after the meetings.
There were also some significant challenges during FY18 that contributed to low TT surgery performance:
Social unrest: Unrest in Oromia was a pressing issue in the SAR 1 reporting period but had a minimal effect during the SAR II reporting period.
Case scarcity: One of the challenges increasingly observed by TT surgeons is a failure to find actual TT cases despite the large numbers of individuals screened for TT. The issue is more pronounced in some woredas estimated to have many cases such as Munesa, Lemu Bilbilo and Digelu Tijo of Arsi, Chiro of West Harerghe and Kofele of West Arsi zones. As a solution, FHF plans to work with the ORHB and respective ZHDs to organize house-to-house case finding in some woredas in FY19.
Inaccessibility: Poor road infrastructure and inaccessibility in some kebeles in very remote areas contributed to some of the performance issues. This challenge will be ongoing, as the remaining TT cases will increasingly be found in the hardest to reach areas. Adapting the outreach strategy to allow IECWs to stay for longer periods in the field and recruiting town criers to help mobilize populations one day prior to and on outreach days are the main strategies used to improve outreach. Prior to FY18, FHF employed three DMTs in hard-to-reach areas; a fourth DMT was added in FY18 to address this challenge in the nomadic areas of Bale (see the DMT section of the Trichiasis Management, Including Surgery section). However, it should be noted that as much as the DMTs can support specific areas, the large geography of the project area makes it difficult to reach all remote communities.
Social mobilization: IECWs also expressed concern regarding low TT case turnout where there has been an increased focus on social mobilization and case finding. FHF and the ZHDs continued to stress the need for active case finding and for coordinating activities closely with kebele leaders.
Commitment and coordination: In some woredas, the program witnessed low commitment from the IECWs, as well as poor coordination between IECWs and NTD focal persons. Low participation of HEWs and PHCU directors in community mobilization and case identification and poor integration with other health programs compound this challenge. FHF, the ORHB and ZHDs will continue to advocate for support for the TT program in these woredas.
Despite these challenges, each woreda developed a woreda-specific action plan incorporating lessons learned from other woredas. Plans detailed the roles and responsibilities of WoHOs, NTD focal persons, PHCU directors and IECWs. In doing so, an agreement was reached that IECWs would be free from other health activities to focus solely on case finding until TT cases are “cleared” from their respective woredas. ZHDs committed to providing support and close follow-up in woredas with high remaining backlogs by reviewing and providing timely feedback and support on weekly TT surgical reports. The action plans additionally request that PHCU directors need to provide close support for the TT surgery program by monitoring the case
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identification and referral system and supporting outreach. It was also determined that the number of outreach sessions needs to be increased, as well as the duration of outreach in hard- to-reach areas. Most action plans called to reactivate the woreda command posts (whose function is to closely monitor TT surgery activities and ensure a flow of information between key stakeholders) and to strengthen social mobilization using kebele and community structures, town criers, and TT case finding by HEWs. Daily progress is monitored at all levels and any issues are dealt with immediately.
Most importantly, the action points from the recent meetings in the SAR II period focused on changing the routine outreach and the massive intensified approaches to multiple contextual minicamps and enhanced an outreach strategy that requires active participation of local leaders, as well as deploying community mobilizers on outreach days.
ADVOCACY Zonal-level Advocacy Meetings
The objective of advocacy meetings is to foster greater ownership and leadership by local administration and political leaders to reach elimination goals. FHF planned to conduct 10 of these meetings in FY18 with an average of 54 participants per zone, 540 participants total. FHF supported nine of these meetings (five of these meetings during the SAR 1 reporting period and four during the SAR II period) through FHF institutional funding. The planned meeting in West Guji zone remains outstanding due to other government priorities and Mass Drug Administration (MDA) activities. FHF will support this meeting in October 2018 (FY19) and will align the activity with TT surgery minicamps and enhanced outreach strategies.
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. The advocacy meetings were jointly led by political and health sector leaders to create the sense of leadership and accountability to the health sector staff.
During the meetings, key agenda items included the Surgery, Antibiotics, Facial cleanliness, and Environmental improvement (SAFE) strategy; a review of current performance in TT surgery; challenges, strengths and lessons learned during implementation; the roles and responsibilities of different stakeholders; and, the required coordination and leadership among these stakeholders. One of the highlighted lessons was regarding integration of TT surgery with other program activities (MDA and cataract surgery) and mobilizing communities using available opportunities to enhance TT surgical output in some woredas. As a result, stakeholders agreed to apply this strategy to more woredas. Additionally, woredas have agreed to plan for enhanced outreach after results have shown that reaching hard-to-reach areas through enhanced outreach (extended days of outreach with enhanced case finding) has improved TT surgical output.
In addition, at a meeting during the SAR II reporting period, the zones of Guji, Borena, West Arsi and Bale discussed mobilizing IECWs from neighboring woredas to work together on improving
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the social mobilization approach during minicamps. This enhanced outreach is expected to improve uptake by the community and motivation among the TT surgeons. West Arsi meeting participants agreed that the “we have no more TT cases” attitude (i.e. claims that there is no more TT, although no impact assessments have been conducted to determine whether the elimination threshold has been met) from some woredas should not be accepted so long as the woredas have not reached their elimination thresholds through trachoma impact surveys. All woredas committed to continuing to mobilize cases for surgical intervention until elimination thresholds have been met. Additionally, in woredas that have attained their UIG, the local government has committed to continue providing surgical services as long as suspected cases are confirmed to have TT.
Woreda-level Advocacy Meetings
The woreda-level TT surgery advocacy meetings have the same general objectives as the zonal level advocacy meetings but are prioritized to woredas with high estimated number of cases and held immediately before the start of intensified camp activities. At the end of each meeting, participants developed a micro-plan for each kebele clearly laying out roles and responsibilities for the planned TT surgery intensified camps and routine TT surgery outreach services. HEWs and kebele leaders also agreed on their role in social mobilization and case finding and committed their support for the intensified camps and routine surgical outreach.
These meetings had been planned in 10 woredas through FHF institutional funding. Participants included HEWs, kebele leaders, IECWs, PHCU directors, WoHO leaders and NTD focal persons. Six of 10 planned meetings were conducted, all during the SAR I reporting period. Significant challenges in the second half of the year, such as heavy rains causing road closures, prioritization of other issues at all levels of the government, and budget constraints, affected the implementation of the remaining four woreda-level advocacy meetings. Additionally, FHF determined that house-to-house case finding is a better approach and will conduct case finding in FY19 in the woredas where these meetings did not take place in FY18.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE Radio Messages
In FY18, to inform community members about TT surgery services, FHF planned to disseminate TT messages by radio in collaboration with the Oromia broadcasting network to reach 17 million people residing in the zones supported by the MMDP Project. The spots, broadcast in Afan Oromo, encourage individuals with TT to seek surgical services and communities to refer cases to IECWs for surgical services, which are free of charge. The three role-plays include the following scenarios:
• During a coffee ceremony, a woman encourages a neighbor suffering from trichiasis to visit IECWs and benefit from surgical management.
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• A discussion among community members includes encouragement to visit IECWs for eyelid correction.
• A key message delivered by HEWs to a “gare” (community group) to find TT cases and refer them to health facilities where IECWs are working.
Given that more than 70% of TT cases in Ethiopia are women, the messages are prepared by female actresses and focus on encouraging women to seek the services. The messages also ask that those women who have been operated on for TT encourage women with unoperated TT to present for surgery. The radio broadcasts paid for with FY18 funds started in early August 201847 and will be aired twice a week for 40 weeks into FY19, supported by FHF institutional funding. No information, education and communication (IEC) or social mobilization materials were produced in FY18 with USAID funding.
CAPACITY BUILDING FHF planned to conduct three categories of trainings in FY18 in MMDP Project areas: a training for 40 new IECWs, a refresher training for 22 IECWs, and TT case screening and counseling training for 260 HEWs. Details are found below.
Training of TT Surgeons, Evaluation and Certification
In February 2018, FHF assessed IECW posts to determine whether IECWs are still posted to MMDP Project area woredas and, if so, whether the posted IECW is still conducting TT surgery activities. The assessment demonstrated that 21/125 (17%) IECWs had left their posts or stopped working on TT surgery. A 30-day IECW training, organized in collaboration with the hospital and the ZHD at Yabalo hospital (Borena zone), began at the end of March 2018. Qualified eye health professionals (two ophthalmologists, two cataract surgeons, and two ophthalmic nurses) delivered the training. Twenty health professionals were enrolled in the training and 19 were certified as IECWs. The one trainee not certified had discontinued the training for personal reasons.
The training was divided into three major sections: a one-week classroom-based theoretical training; a one-week practical training utilizing the HEAD START surgical simulator; and two weeks training on live surgery in the field. All IECWs performed a minimum of 30 eyelid surgeries within the scheduled period and were determined to merit certification. All certified IECWs were provided with the necessary TT surgery commodities and have started the actual lid surgery, with close monitoring by DMTs and FHF TT surgery supervisors. The activity was split between MMDP Project funds and FHF funds. No further training was required in FY18, as this training resulted in IECWs certified to occupy almost all vacant posts.
47 FHF has “forward paid” the messages for each fiscal year, because in the first year of the project, the radio spots started so late that what was paid for covered the next fiscal year, and this has carried through the project. Therefore, radio messages that occurred earlier in FY18 to mobilize cases this year were actually paid for in FY17, and FY18 funds were used to pay for radio broadcasts starting in August 2018 (which are paid for with FHF institutional funding).
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IECW Refresher Training
IECW refresher trainings aim to address surgical skill gaps identified during supportive supervision and TT surgical quality audits. Over the course of FY18, three IECWs were identified to need refresher training, through surgical audit and recommendations from supportive supervision. A refresher training was conducted for two IECWs, one in IAB and one in Buno Bedele zone (BB); however, the remaining one IECW did not complete refresher training due to insecurity and other priorities of the IECW and trainers. The refresher training for this IECW has been scheduled for October 2018 (FY19).
HEWs Case Screening and Counselling Training
In FY18, FHF planned to train 260 HEWs on TT case screening and counseling in woredas which did not receive this training in FY17, using funds carried over from FY17 into FY18. The aim of the training is to build the skill of HEWs to identify TT cases, provide counseling, and refer cases to the surgical sites.
The training was delivered in June 2018 to HEWs working at Kofele, Ginir, Goro and Uraga woredas of Shashemene cluster. A total of 244 (94% of the planned target) HEWs in these four woredas participated in a one-day training. Sixteen HEWs could not attend the training because of annual leave, maternity and transfer. Additionally, HEWs’ supervisors participated, for a total of 276 participants.
During the training, 16 WoHO NTD focal persons provided orientation on community mobilization and referral; five IECWs provided training on TT case screening and counseling; and 22 PHCU directors provided guidance and supervision.
The training began with an overview of the basics of trachoma (modes of transmission, the SAFE strategy) and disease burden and distribution in Oromia. The stages of trachoma with signs and symptoms of TT were discussed to introduce the TT screening technique. Then, IECWs led a demonstration and practical session on TT case screening and counselling. This focused on technical skills to enable HEWs to identify TT and soft skills to establish a rapport with community members to ensure effective counseling on the need for lid surgery. Other topics discussed included social mobilization, registration, and reporting of TT case screening.
ASSESSING DISEASE BURDEN In FY18, a TIS was conducted in the woreda of Metu, in IAB zone, with support from the ENVISION project. The age-adjusted trachomatous inflammation follicular (TF) prevalence in children 1-9 years is 0.16% and the TT prevalence in adults 15 years and above is 0.03%. The original backlog and UIG of this district were 440 and 365 respectively; however, the estimation from the recent TIS survey shows that the total estimated number of TT cases is only 13 with zero UIG. 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 as part of the FY19 work plan.
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TRICHIASIS MANAGEMENT, INCLUDING SURGERY FHF planned and implemented three TT surgery delivery approaches to reach its FY18 MMDP Project target of operating 18,560 cases. The service delivery strategies include static and outreach services by IECWs, DMTs, and TT surgical camps. TT surgeons used the Trabut surgical method throughout the MMDP Project-supported area. During FY18, a total of 15,919 cases were operated, 86% (15,919/18,560) of the annual target. Tables 6 and 7 below further show the breakdown of progress against quarterly targets and strategy-specific targets.
Since the start of the MMDP Project, FHF has supported 42,623 TT surgeries, 78% (42,623/54,417)48 of the estimated cases in the project area. Through this work, 54/131 (41%) woredas in the MMDP Project areas in Oromia have zero estimated cases following the provision of TT management services. While working to enhance TT surgical output, FHF has also tried to reach most kebeles. Accordingly, geographic coverage data revealed that FHF has reached 2,202 kebeles out of 2,752 (80%) of the total kebeles found in all MMDP Project-supported woredas in FY18.
Table 6. Progress Against Quarterly and Annual Targets in Oromia in FY18 % Annual Quarterly # of Surgeries % Quarterly Quarter (Q) target target conducted target reached reached Q1 (Oct – Dec ‘17) 3,898 4,783 123 26 Q2 (Jan – March ‘18) 4,826 3,559 74 19 Q3 (April – June ‘18) 6,682 4,211 63 23 Q4 (July - Sept ‘18) 3,154 3,366 107 18 Total 18,560 15,919 86 86
Table 7. Surgery Output by Strategy in Oromia in FY18 # of Surgeries % Target % of Total Strategy Annual target conducted achieved annual output IECW (static and 7,520 5,406 72 34 outreach)
DMT 5,040 2,096 42 13
Intensified camp 6,000 8,417 140 53
Total 18,560 15,919 86 100
48 UIG at the beginning of the MMDP Project was 54,782; following a TIS in FY18, it was reduced to 54,417. This progress towards the UIG is calculated at the regional level.
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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 outreach sessions per month for three days including travel, surgery and post-operative follow-up activities. However, FHF has been flexible in the implementation of schedule and duration of the outreach based on local context: since most outreaches are organized in distant and remote areas (because that is where cases are found), three days is often not enough time. In some woredas, IECWs have stayed for weeks to conduct TT surgeries before returning home. Most outreach activities are organized in health posts, schools or farmer training centers to reach the most remote communities.
FHF planned for the IECWs to conduct 7,520 TT surgeries by static and outreach services; a total of 5,406 surgeries (72% of the target) were conducted in FY18 using this strategy. Only 4.3% of surgeries were conducted via the static site strategy.
In the SAR 1 reporting period, 61% (76/125) of IECWs were surgically active in any one month; this decreased to 42% (52/125) in the SAR II period. Per anecdotal discussions with IECWs and government leaders, the main reason behind this decline is the effort required to find TT cases in hard-to-reach areas. Moreover, because of government officials’ turnover as a part of regional political reform, the TT surgery program did not receive adequate support in some zones and woredas, as there was no one supporting the IECWs’ or case finding efforts. This is partly due to lack of awareness of the trachoma elimination program by new appointees and priorities given to system strengthening. FHF has used all available opportunities to advocate to the new appointees and has worked continuously with new leadership at all levels to leverage support for trachoma elimination. Despite these staff changes, as well as heavy rains, and public protest in some MMDP Project-supported areas in Oromia, FHF cluster offices and zonal TAs have been carefully monitoring the situation and continue to support IECWs to provide TT surgical services.
DMTs
DMTs consist of two TT surgeons and one coordinator who 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 of operated cases and refusals, and provide on-the-job mentoring to IECWs during intensified camp activities. During FY18, 42% (2,096/5,040) of the planned DMT surgeries for the year were conducted. DMT targets do not take into account their anticipated contributions towards intensified camp outputs, and the 2,096 surgeries reported as conducted by the DMTs does not include these contributions, as the intensified camp data are aggregated by camp and not segregated by surgeon type. Outputs also appear low as heavy rains in the implementation zones resulted in lower than planned surgical activities, and insecurity in the SAR I period further impacted ability to provide services. This is despite the fact that more surgical camps were implemented than originally identified in the work plan (two rounds of camps, each lasting for three weeks, were planned in the approved work plan).
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Like the IECWs, DMTs had difficulty reaching and managing TT cases located in inaccessible areas. In many instances, the team had to travel long distances in areas with no roads and were often stationed in difficult situations for days to manage TT cases found in remote communities. In some instances, because of security issues, FHF relocated the DMTs to woredas in the MMDP Project area with better security. For example, the Shashemene DMT was mobilized to Gechi woreda of BB which currently has no active IECW. Additionally, the DMT in West Harerghe was relocated to Arsi zone to support TT surgical activities.
In FY18, a fourth DMT was added to the existing three DMTs to support nomadic populations. The newly established DMT is stationed in Bale Robe hospital in Bale zone to provide TT surgery in the remote and nomadic pastoralist parts of this zone. A high number of estimated TT cases are expected to be found in these woredas. DMTs commenced TT surgery in February 2018 after receiving a two-day orientation and training by FHF staff and RTI’s Quality Assurance (QA) Officer. After the orientation, the DMT engaged in TT surgery with support and supervision by the Bale ZHD, Robe hospital and WoHOs where they were assigned to work. Since the team began, they have contributed a significant number of TT surgeries in Bale zone. The assumption for DMT output is to operate on five TT cases per day for four days per week, with a goal of operating 160 cases per month. Overall, 1,274 TT cases were operated by the team, nearly 100% (1,274/1,280) of the planned target for eight months. This output is 51% (1,274/2,500) of the total surgery output in the zone.
As outlined in the SAR I, to improve the performance of DMTs, FHF organized a day-long DMT performance review meeting in January 2018 in Addis Ababa in which all DMTs, the cluster coordinators, zonal NTD TAs, and program managers came together for an in-depth review of the DMT system and prepared an action plan for the remaining period. The biggest challenges identified were the limited participation of 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. Following the meeting, ORHB and FHF have been collaborating to enable the local community leaders to deliver all the necessary support in community mobilization and case finding for the duration of FY18 and into FY19.
Intensified TT Surgical Camps
The aim of TT surgery camps is to intensify case finding and manage many TT cases within a short time frame. FHF planned to perform 6,000 TT surgeries through the TT surgical camp strategy in the five zones with the largest estimated number of TT cases (Bale, Borena, Arsi, West Arsi, and West Harerghe). In FY18, a total of 8,417 TT cases were operated through the intensified camp and minicamp strategies (140% of target, 8,417/6,000).
However, emerging problems such as insecurity in the region forced FHF to become innovative, leading to smaller “minicamps” since security measures from the government did not allow the convening of large-scale campaigns except in BB, IAB and Guji. Of the 10 planned intensified camps in FY18, FHF was able to accomplish four full-scale intensified camps and eight minicamps.
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Among the four intensified camps, two took place in BB zone, one in IAB, and one in Guji. The breakdown of the minicamps is as follows: one in East Shewa, three in Arsi, two in Bale, one in West Arsi, and one in West Harerghe. Some of these camps used integrated approaches, such as integrating TT with cataract surgeries and MDA implementation (see TT plus below).
TT Plus
TT plus is a newly introduced approach aimed to provide TT surgery alongside other health services, such as cataract and MDA. FHF, in collaboration with Goba Referral Hospital and Bale ZHD, implemented TT plus activities in two rounds of minicamps. FHF supported all cataract surgical services with its own funding, while TT surgery was supported by the MMDP Project. In April 2018, 291 TT cases were operated in five woredas (Ginir, Seweyna, Berbere, Goro and Guradamole) of Bale zone using the new approach. In this approach, IECWs are assigned at health facilities to screen suspected cases of both cataract and TT and subsequently perform TT surgery on persons with confirmed TT. During this period, a total of 2,790 suspected TT cases were screened. In total, 291 TT cases and 126 cataract cases received surgery. The TT surgery data from this approach is included in the TT surgery minicamp data. One key lesson resulting from this intervention is that when there is strong engagement with key stakeholders (hospital eye professionals, ZHD and supporting partners), high output can result from this approach.
While the TT plus model was successful in mobilizing cases for TT surgery with cataract camps, anecdotal reports from the field indicate that TT case finding during MDA activities was not as successful because of the inability of the health workers to conduct MDA and screen for TT at the same time.
Patient Counseling
Counseling for TT cases is primarily provided by HEWs and TT surgeons (IECW or DMT) to provide the person with the necessary information to decide whether to undergo TT surgery. The HEWs screen and counsel the person at home, at a health post, or at community gathering areas to encourage them to receive surgical services. The surgeon is responsible for counseling the case on the importance of surgery, the procedure, the risk if not operated on, and other relevant information before surgery. Post-surgery, the TT surgeon counsels the case to return the next day and then seven to 14 days and 3-6 months following the surgery. Cases are given appointment reminder cards for these follow-up visits. The surgeon also counsels the person on how to take care of the surgical wound.
If an individual refuses surgery, the TT surgeon will counsel the person on the risk of not receiving surgery. Moreover, the individual’s contact information is shared with HEWs to visit them one to two times to provide further counseling on the surgery, though no data are available on how many of the refusals have been followed up by HEWs, or the frequency of their visits.
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Patient Referrals Management
Patient referral is an activity by which patents with complicated TT are referred to secondary or tertiary eye care units (ECUs) for TT cases who cannot be managed by IECWs and DMTs. In FY18, a total of 705 cases were referred, with 99 reported to have later received surgery. FHF covers the cost to operate these referral cases. Referrals include cases with high blood pressure and other medical complications, post-operative TT, lower eyelid TT, and pediatric TT. The remaining individuals chose not to attend surgery, and FHF does not have information on why they chose not to attend.
Refusals Management
Refusal management aims to provide effective counseling to persons who have refused TT surgery. Approximately 5% (930/17,718) of the confirmed TT patients refused surgical services in FY18. Individuals who refuse surgery are first counseled by an IECW, then by HEWs trained in counseling by the MMDP Project and by kebele leaders. The HEWs, in collaboration with kebele leaders, are counseled 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 shows 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. No data are available on whether those who initially refused services later receive the surgery.
Epilation
In FY18, FHF commenced epilation services only in cases where individuals with fewer than five lateral lashes were refusing surgery. Although the WHO recommends epilation for all refusals, following FMOH guidance, FHF has limited the support for epilation to individuals with TT who have less than five inverted lateral eyelashes who have refused surgery after counseling.
Only DMTs (not IECWs) offer epilation and do not provide forceps to the cases. In FY18, nine TT cases were provided epilation in lieu of surgery by the DMTs. It is important to note that these individuals were not provided with epilation outside of the surgical setting due to the mandate from the FMOH not to encourage the practice of epilation to TT cases and the FMOH does not support the distribution of forceps to individuals. Cases provided epilation are informed that the epilated eyelashes can regrow and could cause damage to their eyes, so they are highly encouraged to visit TT surgeons every four to six months for further management.
TT case registers and reporting forms capture reasons for referral, refusals and epilation. 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 cases later opted for surgery.
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COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT In FY18, FHF planned to procure 25 types of commodities for the MMDP Project-supported zones, and a combination of FHF and MMDP funds were utilized to procure supplies. FHF supports the purchase of items that are considered restricted commodities per U.S. government regulations, and therefore, all pharmaceutical purchased in FY18 were purchased with FHF institutional funds. FHF procured the various commodities required for 4,000 surgeries in FY19 using FY18 MMDP Project underspending.
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 respective areas. In FY17, FHF trained 24 individuals on supportive supervision: 12 ophthalmologists, ophthalmic nurses, and cataract surgeons from six hospitals were trained on direct surgical supervision, and 12 zonal NTD focal persons and zonal NTD technical experts were trained on the operational side of TT case management. Out of these, 10 are still actively engaged in MMDP Project areas. 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.
In FY18, FHF planned to visit 70 IECWs at least once. Supervisory visits were conducted for 17 IECWs in the SAR 149 reporting period and for 42 IECWs in the second half of the year, 84% (59/70) of the FY18 supervisory target. The IECWs not reached in 2018 will be prioritized to be supervised in FY19.
The MMDP Project supportive supervision checklist was used during the SAR I reporting period but the program switched to the tools developed by the FMOH in the SAR II reporting period. The new FMOH tools do not support the use of database for supportive supervision findings. The FMOH tools allowed the collection of information pertaining to TT surgery: patient counseling, data management, operative procedures (pre, intra and post), infection prevention and instrument processing. Supervisory visits include: 1) discussions with IECWs, PHCU directors, NTD focal persons and cases, 2) observation of surgical procedures, infection prevention precautions, and 3) review of case registration books.
The strengths noted from supervisory visits include standardized levels in patient counseling, quality recording and reporting, optimum surgical technique and a well-managed infection prevention system. These positive findings are observed in most zones but all IECWs visited in Arsi were especially strong. It was also found that some woredas initiated the integration of house-to-house case finding with other community-level health service activities. For instance, in one woreda, IECWs reached more than 80% of kebeles through the outreach strategy with full support from respective HEWs and the WoHO. The majority of IECWs’ documentation has improved; the cases’ registration forms and consent forms were correctly filled and documented,
49 21 reported in SAR 1; however, only 17 were actually supervised during that reporting period. For the remaining four, the supervision began at the very end of the SAR 1 reporting period.
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and all cases were registered systematically with correct information. Zithromax was generally available in health centers as of February 2018, final waste disposal ensured, and incineration of waste materials was carried out efficiently.
Supervision teams also identified the following gaps: general lack of coordination among WoHOs, PHCUs and the IECWs in outreach organization and TT case finding, low TT surgery performance due to the difficulty in organizing outreach activities particularly in remote villages, and 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 to other health service activities. Other persistent challenges are the competing priorities that take up some of IECWs’ time and poor engagement of HEWs in case finding and screening. In some woredas, there were no woreda-specific plans or performance targets, outreach schedules were not scheduled, there was an absence of woreda initiated TT surgery specific/integrated supervision, and weak involvement of HEWs in TT case identification.
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. Additionally, all supervisory teams in the SAR II period have delivered supervision findings feedback to the respective zonal health departments. The supervisory teams also provide feedback to PHCU directors and WoHOs; 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 advocacy meetings and IECW performance reviews.
In addition, zonal-level supportive supervision was also carried out in the reporting period. This supervision focused on how the zonal NTD TA and zonal NTD team can provide enhanced coordinated support to the WoHOs and PHCUs, and the capacity of the zonal team to monitor activities and provide practical support for TT surgery activities. A good example is a one-day activity assessment and subsequent meeting made with the Arsi ZHD head and the NTD team. Because of this, 55 cases were operated in September 2018 using the enhanced outreach and minicamp approaches, compared to only 142 operated in the prior three months combined in this zone.
SHORT-TERM TECHNICAL ASSISTANCE No activities were planned under this section for FY18.
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MONITORING AND EVALUATION Surgical Audits
Surgical quality audits are used to assess the surgical quality and performance of individual TT surgeons. The auditors select persons operated by a specific IECW 3-6 months prior to the auditing activity. The supervisors examine the eyelids for presence of any abnormalities and report findings. According to the FMOH’s guidelines, the IECWs are categorized as having high rates of post-operative TT or low rates of post-operative TT based on the number of post- operative TT cases detected. The new guidelines use the lot quality assurance sampling (LQAS) system of examining up to 40 eyelids to determine surgical quality. In most cases, the audit teams were unable to reach 40 eyelids per surgeon, either due to fewer than 40 eyelids having been operated in the 3-6 months prior, or because of the scattered locations of cases which made it impractical to reach 40.
Actions following the surgical audit are dependent on the surgical quality. If surgeons have poor outcomes, they are recommended to either stop surgery or receive additional training based on the findings and the judgment of the supervisor. In most cases, if the IECW is identified as having high post-operative TT a skills refresher training will be delivered, tailored to the individual surgeon, to improve their surgical skills, when recommended by the supervisor.
Current Surgical Audit Framework
The current methodology used for surgical audits follows the FMOH guidelines, which includes the following major points:
• IECWs are prioritized and selected for audit using the following criteria: high number of surgeries, identified as needing extra supervision during the training or during supervisory visits, those who report many refusals and with low surgical output;
• Cases within the 3-6 month post-operative window are randomly selected using data from the surgeon’s logbook to audit 40 eyes;
• 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;
• Cases are examined by the TT supervisor for post-operative TT, eyelid margin abnormality, granuloma, and patient satisfaction (the tool was adapted from the annex in the surgical quality audit guidelines for MMDP). If a person is not available this is noted on the data collection form and another person is visited;
• If the cases included in the audit of the IECW are found to have poor outcomes, 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;
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• 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.
During the SAR II reporting period, 37 IECWs were audited, which resulted in the examination of 915 operated individuals by two approaches: first, the dedicated quality team (DQT), further described below, and “second approach,” consisting of a team of the TT surgery supervisors with coordination support by FHF staff. Including the SAR I data, the total number of TT cases assessed and IECWs audited make the annual performance 966 and 44, respectively. In summary, 44 IECWs were audited, 39 were recommended to continue surgery, two were identified as needing close supervision, and three were identified as requiring refresher training.
In the FY18 MMDP Project work plan, FHF had planned to include examination of 1,248 cases during the audits; 77% have been reached (966/1,248). The main reasons for the low output against planned targets are the delayed establishment of the DQT and the insecurity in the region, which has limited the ability to move around the woredas and zones. Among the three IECWs identified as having poor surgical quality based on the LQAS method, FHF provided a five-day refresher training in September 2018 for two IECWs in BB and IAB and has plans to provide the refresher training for the third in October 2018.
Dedicated Quality Team
In Q2 of FY18, FHF came to an agreement with Shashemene Referral Hospital to hire a full-time DQT (as per the approved FY18 work plan), which includes a qualified TT surgery supervisor and a coordinator to increase the coverage of the TT surgery quality audits. 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 a health officer responsible for organizing the surgical audit activities and communicating with ZHDs, WoHOs, IECWs, HEWs and community leaders before and during the activity. She was formerly an IECW in West Arsi zone and is a public health officer by training. FHF institutional funding covers the administrative fees to the hospital to host the team. Shashamane was selected because the hospital is a Secondary Eye Care Unit (SECU) located centrally within the MMDP Project zones. FHF, in collaboration with the RTI QA Officer, provided a training for the DQT, which took place both in the classroom and through field visits, where an audit was conducted. The DQT started field work in February 2018. With this DQT in place, the pace to conduct the audits increased from eight IECWs in the SAR 1 reporting period to 44 by the end of FY18.
3-6 Month Outcome Assessments
The objective of patient follow-up is for TT surgeons to examine the eyelids they operated and determine whether the person has successful or unsuccessful post-surgical outcomes or whether the person requires any further management or referrals. Successful surgical outcomes are defined as no eyelashes touching the eyeball and no other complications. FHF plans for IECWs to conduct these outcome assessments for all operated cases. During post-surgical counseling and during the one-day and seven to 14 days’ follow-ups, surgeons advise the cases to return
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3-6 months after surgery. In FY18, 15 surgeons followed-up with 365 cases passively and no complications were reported. It should be noted, however, that because these surgeons followed-up their own cases and because these data are self-reported by the surgeons, FHF relies more heavily on more objective measures, such as supervision and surgical audit findings, to determine surgeon skill level.
Some reasons why cases do not attend these follow-up visits have been anecdotally captured by IECWs: the cases did not recall the appointment period and must travel far distances to the health facility or appointment sites. During IECW review and planning meetings, these follow-up visits were discussed, and it seemed that IECWs who have good counseling skills and were well- known by their cases were more likely to have cases attend the 3-6 month follow-up visit. This topic will continue to be discussed during all opportunities with IECWs, such as the review and planning meeting and during supportive supervision.
TRACHOMA (Tigray)
STRATEGIC PLANNING Regional-level Strategic Planning Meeting
In December 2017, Light for the World and the Tigray Regional Health Bureau (TRHB) conducted a one-day strategic planning meeting in Mekelle. The 72 participants focused their discussion on the FY16 and FY17 TT surgery performances and challenges; TT surgery targets for the FY18 work plan; the number and distribution of available certified TT surgeons in the MMDP Project-supported woredas; approaches for case identification; and findings from the pilot house-to-house case identification strategy in UK Department for International Development (DFID)-supported project areas. Two key outcomes from this meeting were action items focused on strengthening political commitment and revising the current case-finding strategy of mass mobilization. Participants proposed redefining the strategy to scale up the systematic house-to- house case finding strategy in MMDP Project areas that are hard-to-reach and those with high estimated numbers of cases.
Strategic Planning Meetings at Zonal Level
In December 2017, Light for the World and the TRHB conducted three one-day strategic planning meetings in three zones (Central, North Western, Eastern) that included all MMDP Project woredas (Mekelle was merged with the Eastern meeting and Western was combined with North Western). The 240 total participants discussed 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 the “TT worksheet” adapted from the International Coalition for Trachoma Control (ICTC) trachoma action planning template, that was used for district-level microplanning by each woreda-level team. Discussions on how to fill the human resources gap when five of 24 certified surgeons in the MMDP Project zones enrolled in the ophthalmic officer training at Mekelle University were held to make an agreement with the university to enable those trainees to
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continue offering their services. As a result, the trainees have been able to continue providing some services in outreaches organized around Mekelle, as well as outreaches organized on weekends and during breaks.
Zonal-level Quarterly Monitoring Review Meetings
In FY18, Light for the World conducted four sessions of one-day zonal-level monitoring meetings in each zone in collaboration with the TRHB as per the FY18 work plan. In each session, the meetings were held in Central, North Western, and Eastern zone capitals. Participants from Western and Mekelle zones were merged with North West and East zones, respectively. Participants, who totaled 583, included representatives from the TRHB, zone administrations, ECUs (including TT surgeons), and WoHOs. The objective of these meetings was to monitor performance of each district, identify any best practices that could be replicated, and identify challenges and possible solutions. The fourth quarter performance review meeting was scheduled to take place the last week of September 2018; however due to busy schedules in all zones, it was postponed and conducted during the first week of October 2018.
Over the course of the meetings, two challenges were frequently discussed, including the shortage of TT surgeons due to surgeons attending the Mekelle University course and low yields of TT cases during outreaches. Solutions included: a discussion with Mekelle University to enable the TT surgeons attending the training to participate in outreaches organized around Mekelle zone, as well as during weekends and semester and annual breaks. The proposed solution for the low yield of TT cases during outreaches was scaling up the systematic house-to-house case finding strategy to cover more kebeles. Hard-to-reach kebeles and those with high estimated numbers of cases would be prioritized.
Findings of the systematic house-to-house case finding in five kebeles of Werilekhe woreda in March 2018 were shared as a model of how the case finding should be conducted. In those five kebeles, the population size of age ≥15 is estimated to be 17,316; out of these, 16,531 (95%) were screened, and 150 TT confirmed cases were identified and all managed. During the whole process, starting from case identifiers selection to the end of the outreach, WoHO experts, HEW supervisors and kebele leaders were actively engaged and contributed to ensure success.
ADVOCACY Advocacy Meetings for Political Leaders at the Zonal Level
In FY18, Light for the World had planned to conduct three one-day zonal level advocacy meetings with participants from all five MMDP Project zones. The objective of these meetings was to secure commitment from political leaders to enable the TRHB to reach the remaining TT cases.
The three meetings were conducted between April 23 – 30, 2018 in the Central, North Western and Eastern zones of Tigray. A total of 225 participants from zonal and woreda administrations attended the meetings. Program/project coordinators gave presentations on the disease burden, elimination strategies, progress towards elimination, opportunities and challenges. Opportunities
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included the TRHB’s commitment to clear the TT backlog and eliminate trachoma as a public health problem, the strong primary health care network in the region, and financial and technical support from partners. However, despite the well-equipped surgical teams conducting outreach in health centers and health posts, uptake is lower than expected due to poor community mobilization and less attention of community leaders at the kebele level. By the end of the meetings, the political leaders stated that they clearly understand the situation, and their role in increasing surgical uptake by participating in community mobilization and awareness creation and channeling information on government priorities to the local kebele leaders, HEWs and health development armies (HDAs); they agreed to support the TRHB to meet the target.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE HEW and HDA Network
As one method of mobilizing cases, Light for the World uses the existing TRHB health service provision network to create awareness of TT surgery availability. This network is structured in the following manner: one HDA member is responsible for communicating with five households; one HDA leader is responsible for 6 HDAs; and, one HEW is responsible for 30 HDA leaders. This network includes more than 3,000 HEWs and HDAs who were trained on trachoma elimination strategies and case identification counseling and referral by the MMDP Project in FY16 and refresher-trained in FY17 through a training integrated with the trachoma MDA drug distributers’ training. Light for the World encourages HEWs and HDAs to integrate trachoma prevention and TT surgery messages into their regular health related meetings with community members (which include discussions on nutrition, maternal and child health, immunization, hygiene and sanitation, etc.), during community gatherings, and during household visits. These TT messages include the information 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. In this regard, Light for the World and the TRHB have agreed to integrate MMDP Project activities with the existing regional- level comprehensive eye health services directly financed by Light for the World. When TT surgery outreach is organized for MMDP Project activities, during the screening of cases, other eye diseases, such as cataract and glaucoma, are also identified and referred to the nearest SECU by the outreach teams. Other minor cases, such as eye infections, that can be treated locally are provided with a prescription by the outreach team. In FY18, more than 3,000 cataract cases were identified using this mechanism and subsequently referred/appointed to the nearest SECU or next cataract campaign. During cataract campaigns, which are organized at hospitals, the teams always plan for both cataract and TT surgery. As a result, from December 2017 to September 2018 five cataract campaigns were organized and 292 TT cases were operated (data are captured in surgical output detailed in this report).
In FY18, trachoma MDA was conducted in all trachoma-endemic woredas (25 woredas and six subdistricts in the MMDP-supported zones) in May 2018 and all 14 TT surgery outreach teams
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were deployed to drug distribution sites for screening and performing TT surgeries. As a result, a total of 456 TT cases were identified, and 424 TT cases were operated (data are captured in surgical output detailed in this report). Light for the World would recommend this strategy in the future in areas where trained surgeons are available and have a proper place where they can conduct surgeries. This approach may be particularly applicable to settings where support is not available for outreach.
Radio Spots
Radio activities were planned in FY18 to mobilize the community for TT surgery services and create awareness around trachoma. The original plan was to transmit 24 radio spots (3 spots per week for 2 weeks per quarter for 4 quarters). The revised plan (revised because the Fixed Obligation Grant could only be signed after USAID work plan approval in December 2017) was to air six radio spots per month from March to June 2018. Radio spots began airing in March 2018 following the signature of the contracts with the local radio station “Dimtsi Woyanie” which has the potential to reach every kebele in the entire region of Tigray. Although this contract was signed in March 2018 with MMDP Project funding, it should be noted that a four-month contract had been signed with the same radio station via DFID funding in November 2017, so communities did receive information about TT and the availability of free services nearby via the DFID-funded radio drama.
With the support of the MMDP Project, starting from the fourth week of March 2018, radio spots were broadcast once per day, three days per week, for 13 consecutive weeks until mid- July 2018 (a delay in the TRHB submitting the spot to the radio station is the reason for the change from the revised plan). The 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 come back 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 they are held near their communities.
CAPACITY BUILDING Training of House-to-House Case Finders
In FY18, Light for the World requested to use underspending from the birr devaluation to conduct house-to-house case finding, due to the scarcity of TT surgeons and the difficulty finding cases. Light for the World and the TRHB had originally requested support to cover 350 kebeles with systematic house-to-house case finding; however, this target was amended to 150 kebeles based on the time it takes the case finders to sweep their areas and the need to have more case finders in a single kebele than originally estimated. When the refresher training for TT surgeons was cancelled, Light for the World and TRHB requested to use those funds to target an additional seven kebeles, for a total of 157 kebeles with systematic house-to-house case finding (though this took place in only 156 before the end of FY18). The one-day trainings covered: examination of community members for TT, counseling (addressing the main issues that might prevent cases
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from attending surgery such as ensuring the case understands that the service is provided nearby to the community, the service is free, the team may not come back again, as well as informing the person that blindness due to TT is irreversible), and registration of households and suspected cases.
In each kebele selected, seven case finders were trained two weeks before the scheduled outreach date. In total, 1,092 case finders from 156 kebeles were trained and deployed the day after the training to their respective kebeles and they conducted house-to-house TT screening for four to six days. Case finders recorded the screening information using a TT screening form and informed and counseled suspected cases to present at the outreach site on the scheduled date.
Refresher Training for TT Surgeons
In FY18, Light for the World had planned to conduct a refresher training for all 17 TT surgeons who were trained and certified in FY16 and were still actively providing TT surgery. Since their training took place two years prior, this refresher training was planned to ensure that their skills and practices are of the quality recommended by WHO and national standards.
This training was postponed many times over the course of FY18 due to program overlap as well as unavailability of trainees (due to their enrollment in Mekelle University). The refresher training was finally canceled, and the budget re-allocated to house-to-house case finding. Because this refresher training was not conducted, Light for the World monitored service quality through supportive supervision and with “on-the-job” feedback.
New TT Surgeon Training
When developing the FY18 work plan, Light for the World took into consideration the overall 13% attrition rate of TT surgeons over the past two years in both MMDP Project and DFID- supported areas. Of the 38 total TT surgeons trained in those two areas, five had already left their posts by the FY18 work planning period for the MMDP Project. In addition, Light for the World knew that Mekelle University had plans to introduce an ophthalmic officer training course, which was expected to attract additional TT surgeons for career advancement. There was also an assumption that the FMOH would deploy newly graduated optometrists to Tigray to fill current staffing gaps. With this in mind, Light for the World had planned to train five new TT surgeons in FY18 in MMDP Project-supported zones through project support. However, as of June 2018, only two new optometrists have been deployed to MMDP Project zones, and it is not cost- or time-efficient to organize a training for such a small number of trainees. In addition, due to the agreement with Mekelle University, the five surgeons participating in the training course were available to participate in surgical outreach in Mekelle zone on weekends and during breaks. Thus, the training was cancelled, and the budget reallocated to house-to-house case finding activities to help make surgical outreach more efficient.
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ASSESSING DISEASE BURDEN The TIS scheduled in 22 woredas in MMDP Project-supported woredas in Tigray did not take place as planned in FY18; instead, they will take place in December 2018 through ENVISION project support.
TRICHIASIS MANAGEMENT, INCLUDING SURGERY In FY18, Light for the World aimed to support the TRHB and FMOH to reach the 5,981 remaining estimated cases in the MMDP Project-supported areas of Tigray. Surgery was conducted by ophthalmic professionals (not IECWs) based in SECUs and Primary Eye Care Units (PECUs). All TT surgeons in the region are trained on the Trabut technique.
TT surgery services are conducted through both static and outreach services. Static services are provided at two SECUs and five PECUs in the MMDP Project-supported zones, each of which has at least one trained and certified ophthalmic nurse. The FY18 target for static services was 221 surgeries, based on the previous years’ data showing small numbers of cases presenting through this mechanism. For outreach, TT surgeons travel from the ECUs to health centers and health posts in the communities, per a pre-determined schedule that was developed during the planning meeting conducted in December 2017. Through outreach, 5,760 cases were targeted for services in FY18. Though the number and length of outreach visits vary, on average, each surgeon conducted six days of outreach per month, although the plan had been for each surgeon to conduct an average of two days of outreach per month. The reason for the increase was due to the decrease in surgeons (from 24 to 14 active TT surgeons available). In FY18, a total of 4,115 cases were operated, 69% of the planned target. Static site surgeries accounted for 3% (124) of the total; the remaining cases (3,991) were operated through outreach services. The main reasons for the underachievement were the decreased number of surgeons and a decreased yield of TT cases during outreaches.
Table 8. Progress Against Quarterly and Annual Targets in Tigray in FY18 Quarterly # of People % Quarterly % Annual FY18 Quarterly plan target operated target reached target reached
Q1 (Oct – Dec ‘17) 897 649 72% 11%
Q2 (Jan – March ‘18) 2,094 1,618 77% 27%
Q3 (April – June ‘18) 2,093 1,068 51% 18%
Q4 (July - Sept ‘18) 897 780 87% 13%
Total 5,981 4,115 69% 69%
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Table 9. Surgery Output by Strategy in Oromia in FY18 # of People % Target % of Annual Strategy Annual target operated reached output Outreach 5,760 3,991 69% 97% Static 221 124 56% 3% Total 5,981 4,115 69% 100%
Pre-surgery Screening and Counseling
TT surgeons conduct health education with cases before screening on trachoma and its complications. The surgeons explain to the person what the TT surgeon is looking for during the screening; they explain that the surgeon may recommend different management options (surgery or epilation) and they encourage the person to accept the relevant management mechanism for any eye condition found.
After the group health education session, TT surgeons screen the suspected cases. Out of the 51,448 people screened, 4,443 TT cases were confirmed. It should be noted that cases with various eye conditions besides TT (e.g. conjunctivitis and cataract) are mobilized to seek care and are screened. Cases with conditions that can be treated on site are treated; others are referred for care at the ECUs. Cases with confirmed TT and with only one or two eyelashes turned in but not touching the cornea are counseled for management by epilation instead of by surgery. For cases with confirmed TT needing surgery, patient counseling is then provided to individuals using the standard MMDP Project patient counseling format, adopted from the ICTC outreach manual. Messages include:
• The person has eyelashes which are turned in and scratching the cornea due to trachoma infections; the person will permanently lose his or her vision if the position of the eyelashes is not corrected and the eyelashes continue to scratch the cornea;
• This condition, known as TT, can be corrected with minor operation on the eyelid only;
• The operation takes approximately 20 minutes; the person can return home within one or two hours after the surgery and can return to work after the patch is removed the next day;
• If the person provides informed consent to undergo surgery, a patient identification form will be completed and relevant information (patient contact information, clinical status) will be entered in the patient registration book for proper documentation.
After undergoing surgery, cases are asked to come back the next day for patch removal by the surgeon. During this follow-up, cases are encouraged to come back to the outreach site seven days post-surgery for removal of the sutures (silk sutures are utilized in Tigray), which will be removed by either the TT surgeon or by the trained outreach coordinator. All cases who
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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 cases 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
When individuals refuse to have surgery, the next option presented to them is epilation. For those who agree to receive epilation, the TT surgeon epilates the individual’s in-turned lashes, as it is against FMOH policy to provide epilation forceps to a TT case. After epilation, individuals are counseled to reconsider their options and observe other individuals who have had surgery. As part of the counseling, epilated individuals are informed that the eyelash will regrow in a few weeks, and the permanent solution is a minor surgery. Individuals are encouraged to contact the ECU for the next outreach or static site opportunity to have surgery.
During this fiscal year, out of the total 4,443 identified TT cases, 4,412 cases were eligible for surgery (defined as a case with one or more in-turned eyelashes touching the cornea/center of the eyeball) and offered surgery. The 31 non-eligible cases were counseled for epilation; all accepted and were epilated by the surgeon.
Out of the 4,412 cases eligible and counseled to receive surgery, 4,115 accepted and were operated. The remaining 297 cases refused surgery, and all were counseled for epilation; 169 cases accepted and were epilated. The remaining 128 cases refused all services. The most common reason for refusing epilation was that individuals wanted to come back for surgery. The main reasons for refusing surgery were a fear of surgery, an unwillingness by some farmers to be operated during farming/harvesting, imminent social commitments such as weddings, and a lack of a relative to bring the individual back home after surgery. The refusal rate among those eligible for surgery in FY18 was 6.7% compared to 5.6% in FY17; it is likely that the last cases will be harder to reach both in terms of geography and willingness to accept services, though we are not certain this difference is significant.
Tracking Refusal and Epilation Cases
Lists of TT cases who were epilated and those who refused both surgery and epilation are given to the outreach coordinators for continuous follow-up and counseling. The outreach coordinators then provided their lists to the geographically relevant case finders for further follow-up. Per previous questions from HKI, Light for the World has attempted to trace the number of refusals and epilated individuals who have returned and received surgery but has been unsuccessful because the registration book does not ask the TT surgeon to indicate whether the case previously refused surgery or had been epilated by a surgeon.
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COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT For FY18, the necessary consumables were procured in advance by RTI and Light for the World by using the underspending in FY17, except for restricted commodities. These restricted commodities were purchased during the reporting period with Light for the World institutional funding. Consumables (not including restricted items) required for FY19 were purchased for Light for the World by RTI with FY18 underspending.
SUPPORTIVE SUPERVISION There are currently nine supportive supervisors who are trained cataract surgeons, ophthalmic officers, and senior ophthalmic nurses. Seven of the nine supervisors are senior government employees from the three SECUs. Two are Light for the World -seconded staff.
The supportive supervisors were trained by the MMDP Project in FY16 and received refresher training in FY17. In September 2018, all nine received a refresher training on supportive supervision and conducting surgical audits as per the national guidelines. Like previous trainings, the objective of this training was to ensure cases receive quality service; in addition, this training also introduced surgical audit methods. This training was supported by the MMDP Project and organized by RTI (see RTI section below). Supportive supervisors are assigned to specific geographic areas within the MMDP Project-supported area, creating a sense of responsibility.
The supervisors use the MMDP Project supportive supervision checklist to assess the quality of services provided to the cases and the effectiveness of the static and outreach sites. The supervisors also check whether services are being provided as per WHO and FMOH standards and regulations.
During FY18, 83 outreach and static sites were visited by the supportive supervisors, for a total of 170 days spent conducting supervision in the field at outreach sites. In general, surgical practices are 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. Supportive supervisors provide feedback to responsible parties at all levels, including woreda and zonal administrations.
SHORT-TERM TECHNICAL ASSISTANCE No activities were planned under this section for FY18.
MONITORING AND EVALUATION Surgical Audits
In FY18, Light for the World planned to audit 14 surgeons. The plan was to start auditing surgeons at the beginning of the fiscal year to use the findings as additional input for the refresher training of TT surgeons. However, the final version of the national quality assurance guidelines was released in December 2017 and, because Light for the World wanted to follow the FMOH
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guidelines for audits, could only start once the guidelines were available. The method in Tigray is a change from previous years: the sampling is based on cases operated by a specific surgeon, rather than cases operated in a geographical area, providing more reliable information about specific TT surgeons’ performance.
In January 2018, supervisors, trained by the Light for the World NTD/Eye Health Director in FY16 (and refreshed by the Director in FY17), began conducting the surgical audits using the methodology from the FMOH guidelines. In FY18, with MMDP Project support, 12 surgeons were audited. The results of the audit show that post-operative TT is <5% in all audited surgeons and they 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 3-6 months, which may require sampling cases from many woredas. This requires a significant investment in time and human resources, and it takes approximately 10 days to audit each surgeon. This is why there was not enough time to audit all 14 surgeons as planned.
3-6 Month Post-Surgery Centralized Follow-up
In FY18, in addition to counseling operated cases to return after 3-6 months for follow-up, Light for the World began to provide cases with appointment cards, produced through MMDP Project funding, to remind cases. In addition, WoHO trachoma focal persons, outreach coordinators and case identifiers were asked to mobilize cases who were operated 3-6 months previously, by using the patient information registered in the TT surgery registration book during operations. Cases are asked to return to the outreach sites so that the surgeon or the supervisor can assess the outcome of the surgery. When possible, Light for the World organizes outreach with surgeons from the closest ECU. Thus, the 3-6 month post-operative follow-up may or may not be done by the surgeon who performed the surgery. In FY18, in the MMDP Project-supported zones, out of the 4,156 cases operated in the last quarter of FY17 and first three quarters of FY18, 378 (9%) cases returned to the outreach sites for follow-up and were examined by the TT surgeons. Only positive outcomes (no post-operative TT, eyelid margin abnormality, or granuloma) have been reported.
Zonal and Regional Program Coordinators’ Monitoring Visit
In FY18, Light for the World planned a total of 256 monitoring visits to districts and ECUs by the four Light for the World regional and zonal coordinators and provide technical and operational support to woredas and ECUs. Light for the World program and zonal coordinators conducted a total of 264 visits to the ECUs and WoHOs to provide feedback to officials on the identified gaps and strengths of TT surgery outreaches and the overall progress in achieving the set target for the month or quarter.
In addition to WoHOs and ECUs, the coordinators visit the political administrations of the woreda and zone for further conversations about the status of action items that were developed at strategic planning meetings. All eight planned visits were conducted.
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Light for the World Director of Eye Health/NTDs Technical Assistance and Monitoring Visits
Light for the World’s Director of Eye Health/NTDs planned two technical assistance and monitoring visits for FY18. The first was originally scheduled for November 2017; however, due to conflicts in his schedule, the first visit was conducted 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. He also attended the one-day post-operative follow-up at the outreach sites.
The Director had also planned to conduct a TT refresher training and second monitoring visit, which did not take place. The second monitoring visit was planned as a follow-up to the TT surgeons’ refresher training to ensure that the learnings from the training are implemented. Once the refresher training was cancelled, the Director was unable to schedule a different time due to his busy schedule.
TRACHOMA (RTI)
STRATEGIC PLANNING Participation in National Trachoma Taskforce
RTI participated in the four National Trachoma Task Force (NTTF) meetings held over the course of the fiscal year. In October 2017, as previously described in the SAR 1, the NTTF discussed progress on the draft national guidelines for TT surgery service supervision, outcome assessments and surgical audits. Following the finalization of the guidelines, a national consultative workshop was conducted in Adama from December 7-9, 2017. These guidelines have subsequently been rolled out and adopted by MMDP Project partners.
On January 4, 2018, the NTTF, including RTI participation, discussed the development of training manuals to guide implementation of TT surgical audits and manage post-operative TT.
RTI also attended the NTTF meeting held on May 18, 2018. RTI reported the FMOH’s request to HKI to fund the national-level TOT and regional trainings for Oromia and Tigray regions to roll out the FMOH’s TT surgery quality assurance guidelines. The FMOH reported that it planned to establish a ‘Trachoma Expert Committee’ whose task will be to analyze impact assessment data and advise the Ministry and NTTF on actions required as the country moves towards trachoma elimination. The FMOH will draft terms of reference to share with the NTTF. The NTTF also discussed the need for a roadmap to help the FMOH and partners in the transition towards elimination, focusing on utilizing other platforms, such as cataract, and management through the routine health system.
Another NTTF meeting was held on August 24, 2018. During this meeting, the NTD Focal Point gave an update on the TT Fast Track Initiative, particularly the TOT on surgical quality assurance
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supported by the MMDP Project and facilitated by Dr. Wondu Alemayehu of FHF. Partners then provided updates; of relevance is that as of January 2019, FHF plans to transition to comprehensive eye care approach in all its work in Ethiopia (with an emphasis on cataract and refractive error) and provision of TT surgeries through that mechanism, as they have seen an increase of cases accepting surgeries when offered in this holistic manner. The FMOH presented on a TT consultation meeting planned by the FMOH to review global and Ethiopia-specific recommendations, research and practices for the provision of TT services with the objective of determining how to improve services in Ethiopia. A date has not yet been set. Finally, the FMOH presented its annual trachoma plan. Targets related to TT surgical services include a total of 185,119 TT surgeries (with approximately 51,000 planned in Oromia and 4,000 in Tigray); ensuring that TT services will begin in all regions; 1,117 IECWs functional by the end of the year (approximately 800 are currently in place); and procurement of 300 TT kits.
CAPACITY BUILDING TOT and Regional Trainings on TT Supportive Supervision and Surgical Audit
In conjunction with the roll-out of the FMOH guidelines on TT quality assurance, the FMOH requested RTI to support a national level TOT on supportive supervision, outcome assessments, and surgical audits to assure national and regional capabilities within the public healthcare delivery system for the rollout of the FMOH’s national quality assurance guidelines adopted in December 2017. The FMOH further requested RTI and other partners to support regional-level trainings in the respective RHBs they are working with to put into practice the TT surgical quality assurance mechanism. RTI subsequently identified savings within its budget and requested supplementary approval from HKI to conduct these trainings.
In FY18, three four-day trainings were conducted as follows:
• National TOT- August 13 –16, 2018 at Hawassa: 19 trainees selected from government and eye health development organizations working in Amhara (5), Oromia (6), Tigray (3) and SNNP (5) regions to be trainers for surgical audit, supportive supervision, outcome assessment, and infection prevention;
• Tigray - September 5-8, 2018 at Mekelle: 7 trainees selected by the RHB from the SECUs and partners to work as TT surgical auditors and supervisors;
• Oromia - September 19-22, 2018 at Adama: 18 trainees selected by the RHB from the SECUs and partners to work as trichiasis program surgical auditors and supervisors.
Following a pre-test, details of the national guidelines, preferred TT surgical practices, supportive supervision, and audit processes were presented and thoroughly discussed. Following the classroom sessions, a half-day field practice on surgical audit and supportive supervision was carried out under supervision by the facilitators/trainers at each training site. Presentations of findings by trainees were made and feedback provided by facilitators and fellow trainees. A questionnaire was administered to assess the capacity of trainees to apply the newly learned skills
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and evaluation of the training program. In addition, a post-test was conducted; it demonstrated a marked improvement in the knowledge and understanding of most trainees.
Recommendations from the training include the following:
• Training schedule should be modified and refined based on the experience of the specific category of trainees.
• Involvement of academic, tertiary and secondary institutions in this activity ensures continuity and further provides research opportunities for continuous improvement of the trichiasis programs.
• TOTs should be used in Tigray where non-ophthalmic personnel are not used, as TT surgeons can involve trained TOTs from above-mentioned institutions, as needed.
• The assessment of trainees has indicated that many have limited access and capacity in computer and internet use, which has implications for report writing, literature reviews and continuous professional development. Therefore, ways and means to alleviate this critical issue by supporting the trainees individually and programmatically to ensure the implementation of computer skills is essential.
• Certification of trainees for a successful completion of training course to encourage continuing professional development is advisable.
• Upgrading the utilization of the guidelines by sharing the electronic version would ensure efficiency and effectiveness.
• Follow-up and support by the RHBs to ensure the implementation of surgical audits and supportive supervision by trained supervisors is important for the application of skills obtained through the trainings.
• Use of the post-test as one of the assessment tools for the selection of the high scoring trainees (>80%) as leaders of future trainers appears reasonable.
LYMPHATIC FILARIASIS
STRATEGIC PLANNING Hydrocele Surgery Planning and Performance Review Meeting
RTI originally planned to support the FMOH to hold a national level hydrocele surgery performance and planning meeting in FY18. However, as explained in the SAR 1 report, the FMOH determined it would not hold this meeting, and instead, RTI supported the ORHB to organize a regional hydrocele planning workshop, given its low output in FY17. The workshop was held in Adama on February 6, 2018. The major outcome of this meeting was a letter from the ORHB stating that all LF morbidity-related services should be offered free of charge to
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patients (transportation, consultation, lymphedema management, hydrocele surgery, medications, laboratory costs, and hospital admissions).
Another action item resulting from this meeting was to hold a follow-up meeting to discuss progress. RTI, in collaboration with the ORHB, organized this follow-up meeting with support from the MMDP Project on May 30, 2018 in Nekemt Town. Participants included five zonal NTD focal points, 10 woreda-level NTD focal points, two hospital Chief Executive Officers, three integrated emergency surgical officers (IESOs), one medical director and one RTI staff person.
Main discussion points at the meeting included:
• Best practices to mobilize patients for hydrocele surgery;
• Best practices to provide hydrocele surgery for patients;
• Strengthening lymphedema morbidity management (LMM) services through joint periodic technical supportive supervisions;
• Roles and responsibilities of all concerned bodies to support key health system strengthening activities;
• Clarification on woreda-specific hydrocele surgery action plans developed during the meeting (hydrocele surgery and LMM services).
Action items included:
• Strengthening planning among RTI, the ORHB and respective ZHD and WoHOs to reach the remaining cases in the western part of Oromia due to the much higher burden of LF- related morbidity in that part of the region;
• Ensuring the free provision of LF-related services by the ORHB to patients in all health facilities across the region by:
o Conducting follow-up by the RHB with the different hospitals and ZHDs to verify whether the letter regarding free services was received by these different bodies;
o Assessing of implementation of free services during supervision opportunities; and
o Sensitizing Hospital and ZHD representatives will sensitize their staff regarding the free services.
Consultative Workshop on Inclusion of FASTT Hydrocele Surgery Training in Medical School Pre-Service Training
As part of the FY18 work plan, RTI aimed to hold a consultative workshop to introduce the Filaricele Anatomical Surgical Task Trainer (FASTT) training package to representatives of several universities (Addis Ababa, Gondar, Jimma, Debretabor, Mekelle, Hawassa and St. Paul Millennium Medical College) and discuss mechanisms for integrating this surgical training package and surgical
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simulation device into skills laboratories and the curriculum of these universities’ medical colleges. The long-term objective is to provide students with a standardized approach to learning hydrocele surgery during their training, based on the latest WHO hydrocele surgery guidelines and enabling them to safely practice the steps of the surgery on the FASTT simulator prior to operating on live patients to ensure all patients in Ethiopia with hydrocele receive quality surgery.
This meeting was held on February 5, 2018 in Addis Ababa and was attended by representatives from the universities listed above, HKI, the Centre for Neglected Tropical Diseases (CNTD) at Liverpool School of Tropical Medicine, NaPAN, the Surgical Society of Ethiopia (SSE), and RTI.
A related meeting was held on February 7, 2018 with the Ministry of Innovation and Technology (MoST)50 to discuss the possibility of development and manufacture of all components of the FASTT simulator in Ethiopia, which is necessary to ensure a sustainable supply. Discussions are ongoing among RTI, HKI and MoST; no further actions can be taken at this time as HKI is in discussions with the FASTT developer regarding the modalities of the technology transfer.
During the SAR 1 period, RTI had engaged a consultant to document the FASTT integration process to provide a comprehensive report to assist other LF-endemic countries to integrate the FASTT surgical simulation package into their medical schools. To date, the consultant has documented the process and outcome of the consultative workshop described above, collated hydrocele surgery training reports and pre- and post-test results, hydrocele surgical campaigns, number of surgeries performed and patient outcome data for analysis and writing. The consultant received the hydrocele surgery training curriculum drafted by Dr. Andualem, which is still under review and revision with support from HKI and Dr. Catherine DeVries.
Consultative Workshops on Inclusion of Lymphedema Management in the Comprehensive Pre-Service Training of Nursing Curriculum
In the FY18 work plan, RTI had planned to support the Human Resources Development (HRD) Directorate at the FMOH to conduct a series of two workshops to integrate LMM into the pre- service nursing curriculum. RTI met with the HRD on October 10, 2017 to begin discussions to hold these workshops. However, Jhpiego had an ongoing project to support the FMOH’s HRD and a review of the nursing curriculum was included as part of this project. Therefore, MMDP Project funds were not required to support this activity.
RTI was invited to take part in certain meetings as part of this process, and Dr. Fikreab Kebede participated in a consultative meeting on January 25, 2018 with Nebiyu Negussu, NTD team leader and Tirsit Mehari, Nursing Initiative Coordinator who represented the HRD, to discuss inclusion of LMM and other case management NTDs into the curriculum. RTI was further asked, and positively responded, to provide input into the draft curriculum on lymphedema management for this Ministry document.
50 Formerly named the Ministry of Science and Technology
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The nursing training team has since adopted the lymphedema management curriculum into its official curriculum and requested RTI to provide training for college instructors to enable the instructors to provide a standard and accurate training to their students. The request is included in the FY19 work plan. Although the HRD process did not allow enough time for RTI to request input from HKI for inclusion in the curriculum, RTI will ask HKI to provide input into the instructor training activity in FY19.
Participation in LF/Podoconiosis Technical Working Group (TWG)
RTI also participated in the LF/Podoconiosis TWG meeting on November 27, 2017 in Addis Ababa. Representing RTI was Addisu Deressa, RTI/Ethiopia’s monitoring and evaluation (M&E) manager. During the meeting, no points related to LF MMDP were discussed. No other TWG meetings were held in FY18.
ADVOCACY No activities were planned under this section for FY18.
SOCIAL MOBILIZATION AND BEHAVIOR CHANGE LF Tool Printing
Printing of materials took place during the SAR 1 reporting period and further details can be found in that report. Table 10 below shows the breakdown of materials created and/or printed over the course of FY18.
Table 10. IEC Materials Produced in FY18 Type of material Brief description of material Quantity New Hope manual Amharic 1,085 Tigrigna 150 Oromiffa 13,496 Post-hydrocele surgery flash Amharic 269 cards Oromiffa 712 Radio spots Previously created radio spots for BG translated 1 into local language (Agnuwa) for Gambella region
Mobilization of Patients for Hydrocele Surgery
In FY18, through the MMDP Project, RTI planned to use both community-based mobilization (through the HEW and HDA network) to mobilize patients for hydrocele surgery and radio spots. A total of 30 radio spots were budgeted versus the planned 48, shown in Table 11. Messages were broadcast in different languages, depending on the region.
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Table 11. Radio Spot Broadcasting in FY18 # # Hospitals # of Spots Broadcasting Language Broadcasts/day days Gambella 7 7 once /day Agnuwa Dambi Dolo and Shambu 7 7 once/day Oromiffa Assosa and Gimbi 8 4 twice/day Amharic Bule Hora and Ginir 8 4 twice/day Oromiffa
Total 30 22 N/A N/A
Prior to some campaigns in Oromia, montarbo (audio-mounted vehicles) were also used to mobilize patients. During the hydrocele surgery planning and performance review meeting in Oromia (described above in Strategic Planning), the low uptake of surgical services in FY17 and early FY18 was discussed, and a request was made by the ORHB for increased support to the region, including intensified social mobilization.
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 BG in campaigns planned over the next six months.
Assessing the Effectiveness of Radio Spots
In FY18, RTI had 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 into surgical camps. This activity took place during hydrocele surgery camps in April and May 2018 in Oromia and BG regions.
Patients included in the survey were selected from the hydrocele surgical registers through systematic random sampling. Data collection took place in two rounds (one in Oromia and one in BG), but we have aggregated the principal findings below. Out of the 120 persons operated in the two regions in the study timeframe, 71 were randomly selected and all interviewed.
Principal results include:
• 19/71 (27%) received information about the surgery from radio only.
• 7/71 (10%) received information about the surgery both from radio and HEWs.
• 40/71 (56%) received the information about surgery from HEWs only.
• 5/71 (7%) received the information about surgery from other source (e.g. family member).
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In conclusion, while HEWs were a greater source of information to patients for these hydrocele surgery camps, over one-quarter only received this information via the radio. Therefore, we recommend that mass media continue to be utilized to ensure a greater proportion of cases are aware of the opportunities to receive treatment; however, the effectiveness should continue to be monitored.
CAPACITY BUILDING Training of Hydrocele Surgeons
In FY18, RTI, through MMDP Project support, planned to support trainings for six hydrocele surgeons or IESOs from three hospitals to serve the Gambella region. In total, three surgeons and three IESOs were trained as planned. The trainings took place at Gambella hospital (Gambella region) and Mizan Aman and Tepi hospitals in SNNPR (as these are the closest hospitals to the southern LF-endemic woredas in Gambella region). All these trainings, led by MMDP Project- trained National Trainers, took place during the SAR 1 reporting period and further details can be found in that report.
Refresher Training of Clinical Workers on Post-Hydrocele Surgery Survey
In FY18, RTI, through the MMDP Project, planned to conduct a follow-up survey of patients who were surveyed on the fifth day following their surgery in FY17 in the regions of Oromia, BG, and Tigray. The time period for the follow-up survey was nine to 12 months after their surgery. The objective of these surveys was to assess surgical outcomes and to better understand the long- term impact of the surgery on the patient’s quality of life. Although surveyors received training for the five days’ follow-up survey in FY17, a refresher training was needed given the length of time between surveys and the slightly differing scope and survey tool.
The topics covered in the training included:
• LF morbidity;
• Hydrocele surgery, surgical complications, and quality assurance for hydrocele surgery;
• The survey: objectives, methodology, data collection, review and role-play of the questionnaire, and field practice.
The refresher training in BG region took place on February 18, 2018 in Assosa town and was previously reported in the FY18 SAR 1. The training in Tigray took place on May 21-22, 2018 in Wukro. A total of three people (one general practitioner, one clinical worker, one woreda NTD focal person) were trained. The training in Oromia took place from August 8-9, 2018 in Ambo; four persons (one general practitioner, one IESO, one zonal and one woreda NTD focal persons) were trained during this training session. The surveys then followed the trainings and are reported in the Monitoring and Evaluation section below.
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Training of Clinical Workers in Lymphedema and Post-Hydrocele Surgery Management
Post-Hydrocele Surgery Management
RTI had planned to train 42 clinical workers in BG, Oromia, and Gambella in FY18 to provide both lymphedema management and post-hydrocele surgery management. Plans shifted for two reasons: 1) USAID gave a caveat in its work plan approval that lymphedema management training for FY18 should happen after the conclusion of the feasibility study to incorporate lessons learned; and 2) the training of hydrocele surgeons in Gambella necessitated training for clinical healthcare workers to care for hydrocele patients operated in Gambella at the proper intervals post-surgery (five, seven, 14 and 30 days; six and 12 months). Due to the prolonged review and ultimate decision to cancel the feasibility study, clinical workers needed to be trained in conjunction with some the surgical camps to ensure post-operative follow-up.
Lymphedema Management
The training for clinical workers on lymphedema management was held from September 19-20, 2018 in Assosa, BG. The training was facilitated by Dr. Wondimagegnehu Embiale, a dermatologist from Bahir Dar University and Mr. Abaye Wale from a local NGO, (Action on Social Development and Environmental Protection Organization), as well as RTI.
Although 42 clinical workers were invited to participate, 40 were trained. Twenty-five were from Oromia (representing 25 health centers) and 15 from BG (15 health centers). This training included clinical workers from both regions, due to insecurity in Oromia at the time the training was to occur there. Because this was the only timeframe in which the training could occur, given the facilitators’ availability and near-end of FY18, RTI opted to combine the trainings. The trainings in Gambella did not take place as CNTD had already supported similar trainings in that region.
Topics covered during this training included:
• Overview of NTDs, disease mapping and importance of MMDP, including BA results;
• Milestones and progress towards LF elimination in Ethiopia;
• LF transmission, disease manifestations, disease staging, and differential diagnosis;
• LF MMDP prevention techniques;
• Acute dermatolymphangioadenitis (ADLA) or acute attacks - definition, clinical description, etiological factors, treatment, and prevention;
• Practical demonstration on LF MMDP;
• Method of program monitoring and evaluation;
• Introduction on LF MMDP planning;
• Group work and presentations on target setting and planning.
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This training incorporated lessons from the recently completed rapid assessment (see M&E section). For example, clinical workers interviewed during the rapid assessment had stated that they did not know how to grade lymphedema and had difficulties with the reporting. These were therefore covered in more detail during this training. RTI will continue to work to improve clinical workers’ skills and knowledge in FY19 during supportive supervision visits.
ASSESSING DISEASE BURDEN No activities were planned under this section for FY18.
HYDROCELE SURGERY Hospital Readiness Assessments
In FY18, a total of six hospital readiness assessments (RAs) were completed. The objectives were to assess and address any gaps that may affect hydrocele camps. The hospitals where RAs were conducted included Shambu, Gida Ayana and Bule Hora in Oromia and Gambella and Mizan Aman and Tepi in Gambella/SNNP. The selection of hospitals was based on the annual surgical target, and where cases are concentrated to be able to reach targets. Where the plan requires a new hospital to reach cases, an RA is conducted prior to organizing a camp. The SSE and RTI staff conduct the RAs using the standard checklist from the WHO (as used in FY17). Areas that are assessed include:
• Hospital staffing available to support camps;
• Availability and suitability of the operation theater, recovery units, inpatient beds;
• Availability of equipment and instruments that are required for hydrocele surgery;
• Costs of different services (e.g. laboratory, procedures, consumables);
• Environmental compliance (e.g. availability of an incinerator).
All hospitals except Tepi were equipped with the necessary operating theater, staff, and medical supplies that would enable hydrocele surgery camps to be held; therefore, no camps were organized in this hospital. This hospital was included in the capacity building activities to ensure that care could be provided through routine services.
Hydrocele Surgery
In FY18, RTI aimed to support 600 patients for hydrocele surgery. A total of 330 patients were operated (55%) (Table 12). There were several factors that led to not meeting the target:
• The majority of the first six months of FY18 were devoted to working with the Gambella RHB and Mizan Aman and Tepi hospitals of SNNPR to train surgeons and subsequently provide services. This included signing memoranda of understanding (MOU), selection of hospitals, and conducting RAs prior to even being able to train any surgeons and IESOs.
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Once services were available, the number of patients in Gambella was low (only 69 estimated by the BAs conducted in FY17).
• In Oromia and BG, insecurity hampered some efforts to organize surgical camps; the first surgical camps in Oromia could only take place in April due to security issues, and most government sectors, including health, have been engaged in efforts to stabilize the unrest in these regions and had limited availability for other activities. The camps in BG were conducted in May (Assosa and Gimbi) and July (Pawe) 2018.
• A relatively large proportion of suspected cases were found to be non-hydrocele when screened by surgeons during certain camps. As examples, in Gida Ayana, out of the 122 suspected cases screened, only 33 (27%) were found to be hydrocele; in Ginir, only 20/92 (22%) suspected cases were hydrocele.
Table 12. Progress Against Hydrocele Surgery Targets in FY18 Region Woredas Estimated Cases Cases Cases Cases % FY18 targeted case operated targeted operated remaining annual with burden in FY17 for in FY18 (against target hydrocele from surgery total reached surgery BAs52 FY18 estimated in FY1851 burden) BG 7 563 308 173 113 142 65% Oromia 15 835 101 356 140 594 39%
Gambella53 6 69 0 71 73 1 99% Tigray 0 8 8 0 0 0 n/a SNNP n/a n/a n/a n/a 4 n/a n/a Total 28 1,475 417 600 330 737 55%
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. Of the 330 surgeries, 60 patients were operated through routine services and the rest through camps. The method of hydrocele surgery recommended
51 Although there are more LF-endemic woredas, this is the number targeted in the FY18 work plan. We may provide services in other woredas as we continue discussions with the RHBs and hospitals. 52 Includes data from WHO-supported BAs in East Wellega zone (88 cases). 53 At work planning, preliminary data from the BAs indicated 71 cases in 7 woredas; final data indicate that there were only 69 cases. still in 7 woredas. However, through surgical campaigns 73 total patients were operated in Gambella. Of these, 68 of the 69 identified in the BAs have been operated. There is no plan to hold another campaign for the remaining single case in the seventh woreda. However, we will support costs for that patient during routine services. Please note that we did not change the FY18 targets based on the new data, as we wanted to be able to report against one constant.
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by the MMDP Project is resection, and most patients received surgery through this method (323/330). The remaining patients were operated through the eversion technique, which is recognized by WHO as an appropriate method; all of these were minor hydrocele cases and the surgeons judged that this technique was appropriate for those cases.
In FY18, a couple of lessons were learned: first, it is important to use multiple methods to mobilize patients, including the existing government structure (HEWs and HDA) and mass communications (radio messages). Another lesson to ensure data availability is by delegating the NTD focal points to collect post-operative follow-up data from the clinical workers and constantly follow up with them via phone calls to ensure they are collating these data.
Pre-Camp Screening
Only three pre-camp screening exercises (like those in FY17) took place in FY18 in Gida Ayana, Ginir and Bule Hora camps. During pre-camp screening, clinical workers, supported by HEWs and local kebele leaders screen suspected hydrocele cases who had been registered during the BAs prior to the hydrocele surgery campaigns and gave confirmed hydrocele patients an appointment date for surgery. Patients that were screened for hydrocele but those diagnosed with hernia, testicular tumor, or another condition were referred to hospitals for treatment after the hydrocele campaign. In other camps, the BA 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 screen patients using the pre-operative assessment form prepared by the MMDP Project in consultation with the FMOH and SSE. Patients are offered voluntary HIV testing alongside other basic laboratory tests (urinalysis, haemoglobin, and blood group). All patients are observed swallowing pre-operative antibiotics (Amoxicillin and Metronidazole). Prior to surgery and following counseling on the surgical procedure and possible complications and risks, patients sign a written consent form to undergo surgery.
Patient Follow-Up
Per FMOH guidelines, patients should be hospitalized until the third day following the surgery to ensure one aseptic change of dressing prior to patient discharge and determine any immediate post-operative complications. 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 five, seven, 14, 30 and 60, as well as at six and 12 months. Of 330 patients followed up, seven had Hematoma and five had an infection within the first five days of surgery.
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Lessons Learned in FY18 and Success Factors for Hydrocele Surgery
Principal factors for success include:
• RHBs are committed to provide patients food and accommodation for post-surgery visits. These efforts have helped the patients to stay within or near the health facilities until the seventh day to receive post-surgery follow-up on the fifth and seventh days. Patients then return for the fourteenth day and one-month follow-up visits. The WoHOs/NTD focal persons take responsibility to arrange these logistical details.
• The commitment and engagement of health center management and trained clinical workers have helped to provide post-operative care during the proposed follow-up dates (days five, seven, 14 and 30).
• Notifying trained clinical workers regarding the number of patients operated from their catchment areas and explaining the specific follow-up activities they will be doing during the subsequent follow-up visits have helped them to provide all the required post- operative care.
• It is important to notify the health facilities where post-operative care is to take place to ensure linkage with the trained clinical worker.
• Forms provided to patients on release from the hospital on the third day and then provided to the health center nearest to their homes have facilitated the clinical workers to record/report post-operative findings.
• Implementation of continuous telephone follow-up by RTI staff with NTD focal points at both woreda and zonal levels has helped RTI collect post-operative findings of the operated patients for project reporting.
LYMPHEDEMA MANAGEMENT Feasibility Study/Rapid Assessment
As part of the FY17 work plan, a study to examine the feasibility of providing community-based lymphedema management services was approved, and a local NGO, NaPAN, was selected to assist with this work. The general objective of this study was to compare two community-based lymphedema management interventions (a basic package of care, or “non-intensified” and an “intensified” model)54 to provide evidence for decision-making for scaling up of the LF MMDP services throughout endemic woredas in Ethiopia. Due to several factors, including not receiving quality deliverables from NaPAN, dissatisfaction from the FMOH with the long process for
54 The non-intensified intervention consisted only of training for clinical workers on how to teach patients self-care for their lymphedema. In the intensified woredas, clinical workers received this training; washing kits were provided to patients; and clinical workers also received supportive supervision visits (monthly for three months and quarterly for two months).
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approvals and implementation of the feasibility study, 55 and RTI’s determination that the evaluation of the lymphedema management work should be through an external party, RTI, in consultation with HKI, cancelled the feasibility study.
Instead, RTI proposed conducting a rapid assessment of the lymphedema management work, along with review meetings with the respective RHBs where NaPAN had conducted trainings and supportive supervision, to best determine how to improve service delivery. The assessment was conducted by Dr. Abebayehu Tora, a sociologist who focuses on lymphedema. The rapid assessment was conducted in all six woredas of the three regions (two in Oromia, three in BG, and one in Tigray) where intensified interventions took place and five woredas in Oromia (2) and BG (3) where the non-intensified model of intervention was implemented.56 Two health centers in each woreda (intensified and non-intensified) were purposively selected.
Dr. Abebayehu and RTI staff provided a half-day training for the data collectors before their deployment to the field. The training included an overview of the lymphedema management interventions; the objectives, methods of data collection and interview techniques; a review of the data collection tools including practice interviews; and a review of the data collectors’ roles and responsibilities.
Twenty-one key informant interviews of trained clinical health workers trained by NaPAN were conducted (nine in non-intensified woredas and 12 in the intensified). Additionally, nine focus group discussions with lymphedema patients who were enrolled for services and visited a health center at least once were conducted. Finally, surveyors conducted a review of the lymphedema case follow-up registers, individual patient records and washing kit distribution. Ethical clearance was obtained from the respective RHBs and verbal consent was asked and obtained from each participating individual.
A draft report has been submitted by the consultant and is currently under review by RTI. Once the comments are addressed by the consultant, the report will be shared with HKI for further review and feedback. Briefly, we describe the main objectives and findings below:
Objectives:
• Determine and compare clinical workers’ knowledge of LMM procedures, and their perceptions of the training and supportive supervision by intervention group (intensified vs. non-intensified).
55 RTI’s FY18 work plan was approved with a contingency that the feasibility study be completed prior to training more clinical workers on lymphedema management, to ensure that the training and intervention were based on evidence. However, the FMOH saw this as a block to RTI carrying out its commitment, and when it was apparent that the feasibility study proposed by NaPAN would not be viable within a reasonable timeframe for the FMOH, RTI determined it needed to change course. 56 There is only one LF-endemic woreda in Tigray, so there was not a “non-intensified” woreda in that region to select as a regional match.
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• Determine and compare patients’ understanding of self-care and perceptions of the treatment by intervention group (intensified vs. non-intensified).
• Determine and compare the number of clinical workers trained/retained, number of patients expected, enrolled and managed (completed three monthly visits); and the number of episodes of ADLA reported by intervention group (intensified vs. non- intensified).
• Determine and compare the number of foot washing kit components received by each health center and patients with number of patients enrolled and managed.
Principal Findings:
Knowledge of Lymphedema Management
• Most clinical workers in both arms retained information on the causes, complications, and consequences of lymphedema, though, as a note, those in the intensified arm had a better understanding. The majority were also able to describe the care needed for lymphedema and acute attacks.
• Clinical workers felt they needed additional information on differential diagnosis for different causes of lymphedema and determining the stage of the lymphedema.
• Clinical workers in the non-intensified woredas also specifically stated the lack of supervision or refresher training provided to them over the course of the project period as a challenge to skill/knowledge retention and care of patients.
Patients’ Understanding of Self-Care and Treatment
• Patient understanding of self-care was higher among focus group participants in the intensified woredas. Most were able to describe self-care procedures. In general, understanding about self-care in the non-intensified woredas was poor: some patients did not realize their condition was manageable; others had sought traditional treatment.
• While understanding appeared higher in the intensified woredas, patients expressed challenges to maintaining self-care routines. This was due to the time washing takes; patients’ inability to buy shoes that fit their feet; not receiving continuous medical supplies (this project only provided limited supplies to the patients in intensified woredas through the health centers with LMM-trained clinical workers); and a misunderstanding about “graduation” from the project (the project encouraged patients to come to the health center for three monthly visits; some patients had understood this to mean that self-care could be stopped after the third visit).
Patients Expected vs. Managed
• In the intensified woredas, a total of 8,714 lymphedema patients had been detected during the BAs, but only 784 (9%) enrolled for services at the health centers that were included
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in the rapid assessments.57 However, the gap was much wider in the non-intensified woredas selected for the rapid assessment: out of the 3,497 patients detected by the BAs, only 69 (2%) patients enrolled for services in assessed health centers. While the rapid assessment only took place in a proportion of health centers, given the size of the gap, we feel that we would have seen a similar trend had all health centers been visited.
• There was also a difference in the number of visits that patients made to the health centers. In the intensified woredas, 43% of the patients enrolled for services made at least three visits to the health center, while in the non-intensified woredas included as part of this assessment, no patient made more than one visit to the health center for treatment.
• Some patients believed that they would be cured within the month of their first visit to the health center; when this did not happen, some abandoned treatment.
• Some of the patients did not want to visit the health center for treatment as they would be “exposed” as lymphedema patients, due to the stigma surrounding this condition.
• Other reasons for not continuing to present for treatment included illness, inability to pay for transportation, distance from health center, and interruption of washing kit availability.
Episodes of Acute Attacks
In both the intensified and non-intensified woredas, clinical workers did not consistently fill out the patient record form with information regarding acute attacks; therefore, no data on frequency of acute attacks can be reported. However, for 75% of patients in the intensified arm, some data were recorded on patient experience of having had an acute attack; whereas in the non-intensified woredas, data was recorded for only 26% of the patients as having experienced an acute attack. However, given the inconsistency in the reports and due to the non-randomized sampling frame, we cannot draw a conclusion on whether one group experienced acute attacks more than the other.
In the sampled health centers of the intensified woredas, most supplies were distributed to patients. Again, because of the non-randomized sampling frame, we cannot conclude that this is uniform throughout the intensified woredas; however, in these woredas, most supplies were given to patients and what was not distributed is still safeguarded at the health centers. This is in line with the MMDP Project Manager’s supervision findings reported to HKI in May 2018. We can also conclude that supplies were generally given out as instructed, as each patient was supposed to receive one basin, and then one soap, towel and Vaseline on each visit (only 43% of patients made >1 visit).
57 Only two health centers were selected from each woreda (intensified and non-intensified) included in the rapid assessment; there is an average of five health centers per woreda. The 784 is reflective only of the patients who enrolled in services in the sampled health centers, not the total number provided with services in all health centers.
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Regional Review Meetings
The regional review meetings were not part of the original work plan for FY18 but were later approved, alongside the rapid assessment, to enable the dissemination of preliminary data to be shared with the RHBs. Due to scheduling conflicts with regions, three separate meetings needed to be held; of these, only two were able to take place by the end of FY18. The third is in the FY19 work plan.
A one-day meeting was held at Nekemt, Oromia region on September 14, 2018 and the second at Assosa, BG on September 18, 2018. Nineteen participants attended both meetings. Participants included trained clinical workers, ZHD and WoHO representatives, RHB NTD focal persons, RTI staff and LMM training consultants.
Dr. Abebeyahu presented the preliminary findings of the rapid assessment, which was followed by discussion. Issues raised in Oromia included that the free treatment directive sent by the RHB did not reach all health facilities and health offices; some health facilities did not accept providing the free services because of the impact on their budgets, the need to institute the health care financing scheme where the poorest of the poor can receive free treatment, and the fact that clinical workers consider LF MMDP as an extra duty. Similar issues were raised in BG. In addition, participants learned that the BGRHB is considering applying the Oromia model in which LF MMDP-related services will be offered free of charge. Finally, participants in BG discussed sustainability, including locally available supplies and expansion of services.
It was agreed by both RHBs to provide sensitization workshops so that all health care providers will be aware of LF MMDP and provide their services as part and parcel of the routine health service. It was suggested that experts from the RHBs as well as the finance and economy bureaus link free service provisions with healthcare financing.
COMMODITY SUPPLY MANAGEMENT AND PROCUREMENT In FY18, RTI, FHF and Light for the World continuously worked to manage stocks of surgical consumables and procure additional materials, as needed.
Notably, RTI procured 17,750 tubes of tetracycline eye ointment (TEO) through the USAID- approved wholesaler, IDA, for FY19 activities. RTI procures TEO for MMDP in conjunction with TEO for the ENVISION project; the drug is ordered well in advance due to the long production period for the large order and the lengthy country import approval process. As a restricted commodity, the TEO procurement was approved in advance by USAID.
The pharmaceuticals required for hydrocele surgeries were provided by CNTD, which provided payment directly to hospitals on surgeries were performed, on an ongoing basis. This arrangement worked well, as there were not shortages of pharmaceuticals reported for hydrocele surgeries.
RTI received HEAD START supplies from HKI and has since distributed most of the items to Light for the World and FHF.
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Finally, RTI worked with HKI to quantify the number of TT kits and FASTT materials to purchase for FY19. RTI received pre-import approval for the TT kits, which are expected to ship in early FY19. The FASTT materials will be delivered in FY19.
The main difficulty in FY18 was the unavailability of certain items for partners, such as surgical blades. To locate these items, RTI had to repeatedly check back with the PFSA, and enough were located for activities.
SUPPORTIVE SUPERVISION TT Surgery Supportive Supervision – RTI
RTI’s QA Officer conducted regular TT surgery supportive supervision to MMDP Project sub- partners FHF and Light for the World. The objectives of the supportive supervision were to ensure quality TT surgical services during peri-operative care and to maintain standards of infection prevention and waste management in both static and outreach levels. The QA officer further provided supportive supervision to post-operative follow-up and TT surgery audits. When conducting supportive supervision, the QA officer utilized the MMDP Project checklist. Although the FMOH developed guidelines in FY18, because they were not “officially” rolled out until the TOT and regional trainings supported by the MMDP Project in September 2018 were conducted; the FMOH guidelines will be adopted in FY19. When applicable, the QA officer provided recommendations to the implementing partners (FHF and Light for the World), to the TT surgeons and to the applicable government bodies.
Supportive Supervision in Oromia
The QA officer made a total of 12 visits to Oromia in FY18 and visited five of the 10 MMDP Project-supported zones (West Arsi, East Shewa, Arsi, Bale and West Guji). Insecurity was the main reason he was unable to visit all the zones.
The main strengths observed during surgical outreaches include:
• Active participation of the WoHOs in organizing outreaches, conducting social mobilization, managing patient flow;
• Strong patient counselling and ensuring that consent is provided;
• Provision of magnifying loupes to all TT surgeons;
• Provision of a single dose of Zithromax in most the health centers;
• Proper waste disposal and incineration;
• Recording and documentation of TT surgery forms and registers.
The observed gaps include:
• Most TT surgeons tend not to use the magnifying loupe supplied to them by the project;
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• Lack of IEC materials (banners, posters, leaflets) for social mobilization;
• Inconsistency in labeling (marking) of the eyelid to be operated;
• Inadequate surgical handwashing due to non-functional water systems in most health centers;
• Inadequate intra-operative patient communication in some of the health centers seen.
Supportive Supervision in Tigray
Supportive supervision was conducted by RTI’s QA officer in all five of the MMDP zones in Tigray during a total of six visits in FY18. The supervision was conducted in collaboration with the TT surgery coordinators based on the checklist. The following main issues were observed during the supportive supervision visits.
Strengths observed include:
• Well-organized outreach services, including social mobilization with a strong support from Adwa hospital, Adwa area woreda health office and the health posts;
• The house-to-house TT screening identified an increased number of people with TT;
• All forms and registers were correctly filled and documented;
• All patients were systematically registered and TT diagnosis was confirmed by the TT surgeons;
• All patients received adequate counseling on TT;
• The TT surgeons properly explained the procedure to patients, including referral information where applicable;
• The eyelids were correctly labeled pre-operatively;
• All surgical equipment and supplies including topical anesthesia (tetracaine eye drops) were all available and ready to use;
• Surgery was conducted with a good aseptic technique and sterility was maintained;
• All operated patients received a single dose of Zithromax tablets post-operatively.
Observed gaps were:
• Lack of IEC materials for social mobilization (e.g., banners, posters, leaflets);
• TT surgeons used the older magnifying loupes;
• Inadequate surgical handwashing due to lack of water in most of the outreach sites;
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• Incinerators were not fenced properly; some waste materials outside the incinerator;
• Work overload of the TT surgeons. All activities including TT screening, registration and surgery were done by the surgeons; surgeries conducted without an assistant.
• Hand sanitizers were not routinely available to TT surgeons to use during screening.
LF MMDP Supportive Supervision – NaPAN and RTI
NaPAN conducted LMM supportive supervision of clinical workers in the six “intensified” woredas (see Lymphedema Management section). Experts from NaPAN and NTD focal points working at regional, zonal and woreda levels were part of the technical supportive supervision visits. The technical supportive supervisions were made on a monthly basis (for three months) followed by two quarterly visits. The timeframe for supportive supervision extended from June 2017 to May 2018. Supervision teams utilized a pre-structured checklist, which included questions on the availability of trained staff, awareness of staff on LF MMDP services, whether HEWs and HDA have received orientation on LF MMDP, the availability of M&E tools, the availability and distribution of washing kits, enrollment and management status, and integration of services in the routine health services.
Key positive findings from the visits included:
• LF MMDP services were initiated in all intensified woredas;
• Trained clinical workers were available in most health centers throughout the follow-up period;
• Clinical workers cascaded orientation of LF MMDP to peer clinical workers and some HEWs;
• M&E tools were available;
• Washing kits and the New Hope manuals were being distributed to patients.
Areas for improvement included:
• Clinical workers should extend the LF MMDP orientation to new staff and HEWs not previously reached;
• Other clinical workers who had received cascade orientation were not providing any LF MMDP services; the burden was falling on those trained as part of the MMDP Project;
• LF MMDP was generally not included in regular health education activities at health facilities;
• Case management for individual patients by clinical workers needed strengthening.
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In addition to NaPAN’s supportive supervision, a team composed of RTI and zonal and woreda NTD focal points conducted LF MMDP supportive supervision to four health centers in Dano woreda, Oromia region from in July 2018. The team aimed to determine whether health centers and clinical workers continue the provision of LMM services and that patients were receiving follow-up visits. The main observations were that two trained clinical workers from two health centers had left their posts and a shortage of LMM supplies was common to all four health centers. Recommendations included: 1) training new clinical workers for the two health centers without a trained clinical worker (which was accomplished during the LMM training in September 2018 in Assosa), and 2) close follow-up by the ORHB regarding provision of free LF-related services in all health facilities.
Supportive Supervision of Hydrocele Surgeons by SSE Consultants
The SSE conducted two visits to hospitals in FY18, both in the SAR 1 reporting period: one to Assosa hospital in preparation for and during the October 2017 USAID-HKI field visit to Assosa hospital. The second visit took place in March 2017 to Pawe hospital in BG in March 2018. The main strengths include: the surgeons followed infection prevention protocols; patients were provided with correct pre-operative care; and reporting was complete. The main area of improvement was that many patients were discharged on the day of surgery, rather than being hospitalized for three days post-surgery per FMOH guidelines. RTI has discussed this with the hospital, and the hospital agreed to the three-day hospitalization, and an MOU is being signed to this effect.
RTI attempted to deploy surgeons from the SSE to conduct supportive supervisions to Gambella, Mizan Aman, and Assosa hospitals during the second half of FY18; however, this was not possible, for several reasons: unrest in Oromia made travel to Mizan Aman difficult (as one would have to travel to parts of Oromia); in Gambella and Assosa, no patients could be mobilized at the time the SSE was available; other competing activities did not allow for their schedule to align with project activities.
RTI and ORHB Joint Supervision of Hospitals Providing Hydrocele Surgery
RTI and representatives from the ORHB made three rounds of joint supportive supervision visits:
• May 31 – June 2, 2018 to: Gida Ayana, Nekemt, Shambu, Gedo and Ambo hospitals
• August 13-17, 2018 to Bale Robe, Ginir, Assella and Adama hospitals
• August 26 – September 1, 2018 to Dambi Dolo, Gimbi, Nekemt, Shambu, Gedo, Ambo University and Ambo hospitals
The major findings/observations include:
• Poor post-operative follow-up and referral linkage in Nekemt hospital;
• Limited community mobilization for hydrocele surgery at the woreda level (all districts);
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• Free service provision not provided at Nekemt hospital;
• Shortage of registers and other reporting tools (Bale Robe and Assella hospitals);
• Problem of autoclave (Gida Ayana hospital);
• Most hospitals were not providing medical certificates to patients when operated through routine services.
These findings were discussed with the surgeons and other relevant government stakeholders. Additionally, the following action points were discussed:
• The importance of follow-up visits once a patient is released from the hospital; NTD focal points agreed to strengthen the linkage with both the hospital and health facilities where the patient is expected to receive post-operative care;
• NTD focal points agreed to strengthen awareness creation and patient mobilization through existing government structure (HEWs and HDAs);
• Registers and reporting forms were provided after supervision by the RTI team;
• The surgical units agreed to provide medical certificates for all operated hydrocele patients. The supervisory team provided some medical certificates during their visits to avoid an immediate shortage;
• Routine meetings with hospital management and the ORHB NTD team are recommended. RTI and the SSE will follow up on this in FY19.
SHORT-TERM TECHNICAL ASSISTANCE No activities were planned under this section for FY18.
MONITORING AND EVALUATION Tracking LF MMDP Interventions: Hydrocele Surgery
RTI, through the MMDP Project, utilizes a standard set of reporting tools for hydrocele surgery, including:
• a medical history form, which is filled out by the examining surgeon;
• a hydrocele surgery register which is filled out by the surgeon in the operating room;
• a 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,
• a hydrocele surgery performance reporting form to be compiled by each hospital and sent to the RHB and then from the RHB to FMOH.
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For hydrocele, 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 the information to harmonize with the national integrated NTD database. These data are not yet reported through the Health Management Information System (HMIS) as planned, though there are indicators in HMIS (“patients operated for hydrocele” and “lymphedema patients managed”). While we anticipate that the FMOH will require data be reported through the HMIS at some point in FY19, the exact timeframe has not been clarified.
Post-Operative Hydrocele Follow-up
RTI conducted the three, five, seven, 14-, and 30-day hydrocele surgery follow-up in Oromia and BG regions as part of ongoing activities. All operated patients were followed up with at their respective health centers.
Post-Operative Hydrocele Surgery Survey
In FY17, through MMDP Project support, RTI had conducted surveys of patients five days post- hydrocele surgery. The survey targeted 68 patients in BG, 8 in Tigray, and 19 in Oromia. In FY19, RTI aimed to follow-up the same patients at the 9-12-month post-surgery benchmark to determine the presence of any recurrence and whether the patients perceived any changes in their quality of life or economic situation. The questionnaire used at five days post-surgery was modified between the two data collection time points to include quality of life questions at 9-12 months. In BG and Tigray, the survey questionnaire was translated into Amharic; in Oromia the English version was utilized, as surveyors were more comfortable with that language.
The follow-up surveys took place in BG from February 19-28, 2018 where 63/68 operated patients were surveyed. The Tigray survey took place from May 22-25, 2018 and followed up with 7/8 patients. Finally, the Oromia survey took place from August 9-12, 2018 and 18/19 operated patients were surveyed.
Prior to the survey, data collectors received training on the interview process and questionnaire. (described above in the Capacity Building section). The training was given by RTI staff.
Of note, only one infection, one hematoma and one hemorrhage were reported during the follow-up survey at five days; and a total of two recurrent cases were reported at the 9-12 month mark. All patients reported satisfaction with surgical outcomes; and all patients reported improved health status during the second survey.
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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.
ENVIRONMENTAL MITIGATION AND MONITORING PLAN Infection control remained at the forefront of all health center protocols in Ethiopia, and the MMDP Project routinely monitored the Environmental Mitigation and Monitoring Plan (EMMP) during supervision visits in FY18. In all health centers, there is an infection control and person safety team, responsible for any infection control activities, injection safety and disposal of healthcare waste. All partners worked with all levels of the health system to ensure the appropriate implementation of the EMMP and to assess any governmental policies related to environmental impact and address them accordingly. Infection Control and Health Care Waste Management (IC/HCWM) observation variables are included in the MMDP Project TT surgery supervision checklist, used by FHF, Light for the World, and RTI for most of FY18. IC/HCWM protocols were included in every applicable training conducted through MMDP Project support in FY18. Additionally, the FMOH recognized the importance of IC/HCWM and included these variables in its supportive supervision checklist for TT surgery, which was recently rolled out. For LF, one aspect of the hospital RAs for hydrocele surgery is to determine the availability of proper IC/HCWM systems within facilities, requiring the teams to determine whether autoclaves and incinerators are present and how non-hazardous waste is disposed. Of the six hospitals assessed, only five were equipped with the necessary operating theatre, staff, and medical supplies necessary to provide hydrocele surgery, based on project standards.
INTEGRATION WITH OTHER DISEASES FHF has integrated TT surgery with other activities. For example, in East Harerghe (a DFID project zone) TT surgery was integrated with a cataract surgery campaign supported by Himalayan Cataract Project in FY18. Also, in FY18, FHF worked with Arsi ZHD to integrate TT surgery with the MDA campaign.
Light for the World and the TRHB agreed to integrate MMDP Project activities with the existing regional level comprehensive eye health services that are directly financed by Light for the World. During cataract campaigns, teams are prepared to conduct TT surgeries in addition to cataract surgeries. As an example, in FY18, 130 TT cases were operated during the cataract campaigns in Axum and Adigrat hospitals. Light for the World and TRHB have also integrated refractive error services with the MMDP Project activities, where possible. Community screening have proved more successful for this integration than school-based based screenings.
RTI has been able to integrate patients with lymphedema due to podoconiosis into all activities targeting LMM in LF-endemic areas, since the FMOH does not distinguish between the underlying
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causes in terms of care. Ongoing lymphedema management as part of the activities reaches both types of lymphedema patients, providing important support for managing their conditions.
HEALTH SYSTEMS STRENGTHENING In FY18, the project contributed to strengthening the health system in the following ways:
• Leadership and Governance: The project’s support for leadership and governance took the form of participation in and support of key meetings and the provision of financial resources to the TRHP. Participation in strategic planning, performance review and advocacy meetings remains an important aspect of the MMDP Project, as these activities are critical to developing leadership within Ethiopia’s health systems, at regional, zonal, and district levels. Furthermore, by participating in Ethiopia’s NTTF and TWG meetings, the project continued to support country-led technical platforms that guide the national program to use WHO and national guidelines and support the development of guidance where lacking, and ensure partners are supporting national efforts. Light for the World’s use of FOGs promotes ownership and leadership of project activities by the TRHB leadership by enabling them to lead on key decisions related to the project implementation. The rigorous governance measures attached to the FOG ensure transparency and allow flexibility in decision-making.
• Service Delivery: In FY18, the project ensured the delivery and uptake of high quality trichiasis management services and hydrocele surgery through the following activities:
o Training of surgeons and clinical health workers;
o Hospital RAs to ensure that hospitals where camps are planned under the MMDP Project have the necessary resources and infrastructure needed for high quality hydrocele surgical care;
o Activities such as radio spots and social mobilization to raise awareness on the availability of project-supported morbidity services;
o Use of static and outreach settings to ensure access to services;
o Rapid assessments to assess the provision of community-based LMM services.
Systems were established to help strengthen the provision of care beyond the life of the project. To strengthen the links between the PHCUs and higher-level care and increase the number of major eye diseases managed, trachoma screenings and outreach campaigns were used to identify and refer major eye diseases to nearby SECUs. In addition, all partners worked with RHBs, hospitals and health centers to strengthen the integration of MMDP Project activities into the existing service delivery systems.
• Health Workforce: In FY18, the MMDP Project conducted clinical trainings resulting in a robust cadre of skilled health care professionals, to provide high quality care in health
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centers across Ethiopia. In addition, regular supportive supervision for surgeries and surgical audits conducted under the MMDP Project helped to improve the quality of care that surgeons provide. Supportive supervision ensured that all operations met WHO and FMOH guidelines and preferred practices and the surgical audits were an integral part of maintaining quality standards across the MMDP Project and within health centers.
In terms of longer term impact, the MMDP Project further developed with the national program and partners, the plan to integrate FASTT into the medical school curricula of higher education in Ethiopia. In this reporting period, RTI focused on establishing the plan as a priority activity for NTD and academic leaders and laid the groundwork for achievement of this health force strengthening in FY19.
• Health Information: The MMDP Project tracks and reports its contact with patients and surgical outcomes using reporting structures that are aligned with the HMIS pathway in Ethiopia, and advocates teams to report data through the HMIS system.
• Communications and Media Relations: In Tigray, all media including TV are actively engaged to support the TRHB to achieve the trachoma elimination goals. In April 2018, a press conference was held on trachoma elimination strategies and the role of media. The regional program coordinator also had a one-hour live session on local radio (no MMDP Project funds were used).
For document and publications, in FY18, RTI hired a short-term consultant to document the FASTT integration process and share Ethiopia’s experience in integrating FASTT into the medical schools’ pre-service curriculum (the report will be ready in FY19). RTI also developed two manuscripts on MMDP Project-supported activities for publication: one describing hydrocele surgery camps in Assosa in FY17 and a second comparing BAs experiences in FY16-FY17. These publications are planned to be submitted for HKI/USAID review in 2019 and subsequently to peer-review.
CHALLENGES AND LESSONS LEARNED Social Unrest: In Oromia, recurrent social unrest in almost all parts of the region was the greatest challenge in FY18 for FHF, particularly during the first six months of implementation. The unrest hindered movement within the region, which, in turn, affected FHFs performance of surgery, supportive supervision and surgical audits in most of the zones.
Human Resources: A significant challenge in Tigray was the reduced number of TT surgeons available due to the ophthalmic officer training in Tigray. In FY18, out of the 24 certified TT surgeons in the project supported zones, five have left the project area and additional five enrolled in ophthalmic officer training at Mekelle University. The solution was to hold discussions with the university on how to continue to utilize these trainees during outreaches without affecting the
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training process. As a result of these discussions, trainees did provide services, especially in outreaches organized around Mekelle zone, during weekends as well as during semester breaks.
Case-finding: Another challenge that presented in Tigray was difficulty in finding TT cases. Light for the World tackled this issue by developing and refining a strategy of house-to-house case finding immediately followed by a camp. Light for the World implements this strategy in areas where the need is identified (e.g. hard-to-reach areas where teams may only be able to access once and areas with high numbers of estimated cases to operate). This also helped to mitigate the reduced human resources, as surgeons could make better usage of their time during outreach.
Quality Assurance: Additionally, another challenge was the passive three-to-six month follow- up strategy and aligning with the FMOH QA guidelines. QA challenges included low turnout for follow-up: although HDAs and HEWs actively encouraged operated cases to come to a central point when an outreach planned for follow-up, low numbers of cases presented. To address this, Light for the World modified the radio messages to include the follow-up and added additional days to TT surgeons’ outreach plans to examine operated cases.
Surgical Audits: The key challenge to this activity has been the time it takes to carry out one surgical audit using the FMOH guidelines (approximately 10 days). At the same time, the criteria for grading audited surgeons only uses the number of post-operative TT cases; according to the guideline, the number of cases with lid margin abnormalities and granuloma have no value for grading the surgeons audited, which does not give the full picture of a surgeon’s quality. This will be reviewed by the national quality assurance team.
Lack of Follow-up: In the MMDP Project’s LF work, some follow-up visits to hydrocele surgery patients were not conducted as planned, so RTI mapped clinical workers to hydrocele surgery patients to ensure each worker’s understanding of which patients he or she is responsible to follow up with. During the SAR1 reporting period, 18 patients received hydrocele surgery in BG and were released on the same day of the operation. RTI increased discussions with the hospitals regarding the importance of hospitalizing patients until Day 3 and determine the support required by the hospitals, if any, to adhere to this protocol.
Impact of Integrated MDA Discussions: All partners noted that the FMOH’s push to move MDA towards an integrated approach took up most of the time for FMOH, RHB, and implementers in FY18, leaving less time for other projects, such as the MMDP Project. Some decisions were finally made: for example, BG and Gambella plan to move forward with integration while Oromia will not. RTI envisions that this issue will impact fewer activities in FY19.
Feasibility Study Protocol: The lengthy protocol preparation and review process delayed RTI’s ability to plan alternative options to assess the LMM activities to determine how to improve the FY18 LMM training. This resulted in the LMM trainings taking place at the very end of the fiscal year. RTI, for future similar undertakings, recommends that a technical advisory board member be assigned to support an activity from the beginning at the time of the work plan approval, so that the scope and timeframe for their involvement is clear at the time the activity is approved.
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HKI staff and trichiasis screeners conducting case finding during a trichiasis campaign in Burkina Faso. (Photo: HKI)
GLOBAL PROJECT - OPERATIONAL
OPERATIONAL ACTIVITIES
HUMAN RESOURCES During the reporting period, 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. On August 1, 2018, Kathy Tilford took over the role of Project Director formerly held by Stefania Slabyj, who departed in July 2018. Kathy Tilford brings extensive experience in international public health; she has worked primarily in Africa managing teams and leading program implementation, evaluation, and close-out.
With organizational restructuring, Whitney Goldman became the Associate Director of Neglected Tropical Diseases (NTDs) for HKI in September 2018; she continues in her role as Senior Program Manager for the Morbidity Management and Disability Prevention (MMDP) Project.
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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.
CENTRAL-LEVEL PROCUREMENT Central-level procurement of supplies for FY18 TT management and LF MMDP activities took place throughout the reporting period. Details are provided in Table 14 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 drug with HKI organizational funds. As Burkina Faso did not have a supplier with lidocaine with adrenaline (pre-mixed), during the reporting period surgeries were conducted only with lidocaine (without adrenaline) as recommended by the Burkina Faso national program. 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 initial campaigns in Burkina Faso, so as not to delay TT campaigns.
Table 14. 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 790 eyelids; 60 orbits - - Ethiopia58 120 eyelids; 10 orbits - - DC Office - 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 FY18 Semi-Annual Report, covering October 1, 2016 – May 31, 2018, was submitted in May 2018. Additionally, informal summary monthly updates on project activities were shared with USAID/Washington and the USAID Missions in Burkina Faso, Cameroon, and Ethiopia throughout the fiscal year.
FY19 WORK PLANS The FY19 work plan and budget for the three MMDP Project countries and the Global activities were submitted to USAID on August 15, 2018. The revised work plan and budget based on USAID feedback and comments was submitted to USAID on October 11, 2018.
58 HEAD START supplies provided to Dr. Gower for her work on POT in Ethiopia
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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 ANNUAL PROGRESS REPORT IMPLEMENTATION TIMELINES (separate attachment)
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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 support for trichiasis (TT) management services, the following table summarizes how achievements relate to the area’s UIG. • The project’s TT 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 TT 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 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 supported 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 support 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, the total number of targeted woredas increased to a total of 127. 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 TT 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 date.59 • 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.
59 In Ethiopia, the cost of the FY17 training of 2,050 TT case finders (HEWs/HDAs trained by Light for the World) 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 Annual Progress Report (October 1, 2017 – September 30, 2018) 142
Lymphatic Filariasis
Table A5. LF Disease Management Services: Targets vs. Actuals by Project Area
The table below summarizes 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 support for 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 supporting LF disease management services until FY17.
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Table A7. MMDP Project Achievements: LF Training (USAID-supported)
The following table provides a breakdown of LF training activities conducted with MMDP Project support 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)
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