Draft Summary Report on the

Transcription

1 WHO-EM/XXX/###/E Draft Summary Report on the INTERCOUNTRY MEETING ON MATERNAL AND NEONATAL TETANUS ELIMINATION SANA A, REPUBLIC OF YEMEN MARCH 2008 World Health Organization Regional Office for the Eastern Mediterranean

2 WHO-EM/XXX/###/E Summary Report on the INTERCOUNTRY MEETING ON MATERNAL AND NEONATAL TETANUS ELIMINATION SANA A, REPUBLIC OF YEMEN MARCH 2008 World Health Organization Regional Office for the Eastern Mediterranean Cairo 200X

3 World Health Organization 200X All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Publications of the World Health Organization can be obtained from Distribution and Sales, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: , fax: ; DSA@emro.who.int). Requests for permission to reproduce WHO EMRO publications, in part or in whole, or to translate them whether for sale or for noncommercial distribution should be addressed to the Regional Adviser, Health and Biomedical Information, at the above address (fax: ; HBI@emro.who.int). Document WHO-EM/XXX/###/E/YY.ZZ/PPP

4 CONTENTS 1. INTRODUCTION Global & Regional updates progress. 3- MNT elimination initiative: summary of recommended strategies. 4- Use of data to decide on strategies and or prioritize districts for routine strengthening and identifying high risk districts requiring TT-SIAs. 5- Ensuring high population immunity. 6- Operational issues. 7- MNT Surveillance. 8- Drafting country work plan. Annex 1: Annex 2: Agenda List of Participants Annexes

5 1. SESSION 1: INTRODUCTION The meeting was held in SANA A, Republic of Yemen from March 2008 The objectives of the Meetings were to: 1- Discuss progress and constraints towards MNT elimination in countries that have not yet reached the elimination goal (6 countries + South Sudan). 2- Update country plans to accelerate MNT elimination activities and The meeting was attended by EPI national managers (from Afghanistan, Pakistan, Somalia, Sudan, south Sudan, Iraq and Republic of Yemen), UNICEF (HQ, MENARO, SEARO and ROSA), CDC Atlanta, representatives from UNICEF & WHO country offices in above-mentioned countries, in addition to WHO/HQ and WHO secretariat. Dr Mohsni, Regional Adviser of VPI WHO/EMRO opened the meeting and delivered opening remarks, highlighting the progress made in the Region in terms towards MDG4 through implementing the WHO and UNICEF Global Immunization Vision and Strategies (GIVS). The Regional routine immunization coverage average has substantially increased, measles mortality has been reduced by 63% between 2000 and 2006 and several new vaccines (HepB and Hib) and technologies (AD syringes, etc) have been successfully introduced into national immunization programmes in the Region. Unfortunately, progress in terms of MNT elimination has not followed the same trend and has been very slow, despite the availability of a well-defined strategy that showed to be efficient wherever and whenever properly implemented. Without going in much details for the reasons behind that, Dr Mohsni invited participants to use the opportunity offered through this meeting to review each country situation, determine main constraints, identify possible solutions and draft an acceleration action plan with the support of WHO, UNICEF and CDC colleagues. In his talk to the meeting, Dr. Mahendra, UNICEF-MENARO welcomed attendants and colleagues from WHO and UNICEF/HQ, regional and country offices. He emphasized that global goal of MNT elimination has shifted from 1995 to 2000, yet up to 2008 still far from reaching the objective. He highlighted that less attention was paid to TT coverage compared to other vaccine preventable diseases of infancy. Dr. Mahendra pointed out that RED approach had a positive impact on immunization coverage in the region to reach at 80% coverage of al antigens except for tetanus in many countries. He emphasized the role of social mobilization as a key component to combat rumours jeopardizing the program. He added that most planned activities in Yemen, Afghanistan and Pakistan and other countries are funded. So, next step is to finalize plans in remaining countries to secure funding. Finaly Dr. Mahendra wished that during the days of the meeting participant have to work to identify ways to improve TT coverage and identify, as well, bottlenecks and course corrective actions to reach the goal.

6 Page 2 In her talk to the meeting, Dr. Jamila Raibei, Deputy Minster of Health in Yemen, welcomed and thanked all participants who are coming for exchanging experiences & information. She pointed out the positive effect of TT immunization on reproductive health of women, despite that TT coverage is still below the acceptable level. However, she emphasized that through EPI immunization strategies (fixed facilities, outreach and mobile teams) improvement of TT coverage among CBAWs should be targeted. She added that it is one of children s human rights to secure a sound healthy life for them. She wished successful meeting and a nice stay in Sana a city. Annex 1 shows the agenda of the meeting and Annex 2 contains the list of participants. 2. SESSION 2: USE OF DATA TO DECIDE ON STRATEGIES AND/OR TO PRIORITIZE DISTRICTS FOR ROUTINE STRENGTHENING AND IDENTIFYING HIGH RISK DISTRICTS REQUIRING TT-SIAS A pre-meeting quiz was conducted for EPI national managers. This was followed by 3 presentations about Global & Regional updates and rational & strategies for MNT elimination. These presentations included some basic facts about MNT, magnitude of the problem globally & regionally, elimination initiative highlighting the MDG4 which is about reducting under five mortality rate, that includes an important component relating to neo-natal mortality and in which MNT is one of the main addressable causes. In addition, all programme components including the different adopted strategies were summarized, in terms of, immunization (routine & SIAs), surveillance & ensuring clean delivery. Discussion: the following issues were raised during discussion Routine immunization remain the basic strategies for MNT elimination. Wherever routine immunization is not strong enough, TT SIAs should be implemented to improve CBAW immunity and reduce the risk of MNT. The most cost effective strategy in MNT elimination is immunization. Come next other strategies which may need mobilization of resources in many countries. Missed opportunities should always be used to immunize women in parallel with their children routine immunization contacts (DPT1, DPT2, DPT3 and measles). Timing of SIAs to be decided whenever feasible and suitable for each district. Corrective round to be considered if previous SIAs has not achieved coverage figures higher than 80%.

7 Page 3 Different indicators should be used as criteria for selecting high risk districts, that should be targeted with 3 TT SIAs rounds. Clean delivery as one of the indicators (>70% of deliveries) of MNT risk is usually lacking or difficult to obtain in many areas. History to check immunization status of CBAWs is still more reliable and can be used in case maternal immunization cards are not retained by women. 5 valid doses of TT remains the most valid way for protecting women through out her life. This means that considering doses received during childhood and school age is possible except if it cannot be confirmed by strong documentation (immunization cards). In that last case, we should restart from scratch and implement the 5 dose schedule. All efforts are needed to include females in vaccination teams especially in countries like Pakistan, Afghanistan and Yemen. In order to address cultural barriers and improve population adherence to TT immunization. Group work: about use of data to select all high risk districts for MNT and agree on priority strategies. A case study was used as an exercise for the four groups. The case study included fictitious data on district routine childhood EPI coverage figures, routine TT2+ coverage, SIAs, clean delivery, service indicators, etc. The objective of the exercise was to train participants on the need of basing their high risk identification process on a couple of important indicators and not only on MNT reported incidence rate or on TT2+ reported coverage rate. Participants moved than to a second working group session organized by country and where they had to do the same selection exercise but this time using their proper data. 3. SESSION 3: ENSURING HIGH TARGET POPULATION IMMUNITY AGIANST MNT Presentations delivered were related to TT immunization through routine & SIAs, and operational issues. In addition 5 country experiences were presented by EPI managers in relation to TT immunization strategies. Throughout the day, discussions elaborated the following points: Routine immunization remains the mainstay MNT elimination. In order to reduce missed opportunities, immunization status of all mothers should be checked during childhood immunization contacts, and defaulters should be caught up accordingly.

8 Page 4 In countries with a strong routine TT immunization programme, TT2+ often underestimates the reality in terms of mothers protection against MNT. Protection at birth method constitutes in that case the most adequate indicator. This method is currently used in a couple of countries in the Region, and needs strong training of the staff as well as continuous supervision. However, for countries with limited human resources, TT2+ is still the most adequate performance indicator, provided that it is correctly calculated, taking in consideration previous TT doses received by the pregnant woman. In routine immunization, doses provided to non-pregnant CBAW should not be tallied with doses administered to pregnant women. Coverage surveys should look for all TT doses received by the surveyed women including routine immunization and SIAs. Information should be collected according to immunization cards as well as history. Screening of women regarding TT doses through history needs training of midwives or vaccinators. Analysis of SIAs coverage better to be conducted on sub-district level especially in highly populated areas. SIAs in districts/areas which were poorly done (having low coverage figures <80%), corrective rounds or immediate mop-up could be considered accordingly. Linking TT SIAs to other PHC interventions like measles SIAs, bednets distribution, VitA, deworming campaigns, etc, showed to be synergetic and contributed to achieving higher TT coverage figures during the SIAs. Delay in 2 nd dose in SIAs is immunologically sound, yet, programmatically it will delay protection. Exclusion of previously immunized women during SIAs depends upon availability of reliable data. SIAs is a good opportunity to deliver health education messages regarding MNT. Detailed checklist for all operational issues is to be used to avoid missing important activities. NT rate is one of good indicator for the impact of SIAs, but should not be used alone and should be considered together with other basic indicators like TT2+ and clean delivery rates for example. Training on standardized calculation of coverage for routine & SIAs is highly needed to avoid errors in data.

9 Page 5 Cultural barrier lead to low coverage figures. So, every effort to solve these barriers (e.g include females in vaccination teams especially in areas where women refuse male vaccinators. Positive effect of social mobilization is well known from previous experiences with polio eradication & measles elimination program. The specifity of TT immunization (routine and SIAs) is that it targets pregnant women (in addition to CBAW), which has resulted in several countries to false rumours. High quality microplanning of SIAs is a key element towards successful campaign. GROUP WORK A presentation on communication was delivered followed by group work on a case study (4 groups, including facilitators). A case study on communication was administered to the 4 groups. The case study highlights the necessity of a including in the SIAs plan a strong and comprehensive social mobilization component that consider the different high risk districts specificities, that should be determined based on district cultural and other social specificities. This was followed by group presentation in which discussion has elaborated the following agreements among the participants for communication at both national & district levels. 1- At national level: National level plans must consider all available resources and all social and cultural specificities relating to targeted population. Involvement of all relevant stakeholders as possible. A special plan for managing emerging rumours. Role of mass media in dealing with rumours is to be monitored (both the negative / positive impact). All weaknesses in previous rounds must be addressed before coming rounds. Special plan for management of AEFI to avoid rumours. 2- At district level : To include all local leaders, NGOs & private sector. Consider important community events during campaigns e.g season of harvesting.

10 Page 6 Sub-district level better to be looked for in communication planning. Suitable communication plans for special population e.g nomads, mobile population, tribes. Using all available information in planning for social mobilization. 4. SESSION 4: NT SURVEILLANCE A presentation was delivered about NT surveillance, including pre & post elimination phases and the major challenges. It was followed by discussion of the following issues: Importance of training of field staff (e.g health team & TBAs) on reporting, investigation and follow up. Adequate of guidelines is needed. The possibility to involve polio teams dealing with AFP surveillance in MNT surveillance activities should be considered only where there is no more better solution, mainly because of the different sources of information (TT deaths occur often at home and are rarely brought to health facilities) and where there will be no risks of overwhelming the AFP reporting system. This will depend as well on the commitment of AFP teams & accountability is needed Wherever is possible, community based surveillance should be encouraged/established and used not only to get information on neonatal deaths (that should be later on correctly investigated) but to improve community involvement and active participation in the whole MNT elimination district programme. MNT surveillance should be used for action rather than simply targeting collection of information. All resources and facilities should be utilized to integrate the MNT surveillance in the system and to decide about the most suitable type of surveillance (health facility or community based). All efforts are needed to identify all neonatal deaths, in line with MDG4. Trained TBAs are suitable category to implement community based surveillance in many areas of some countries. All indicators are to be used (district by district) as criteria to classify risky districts. Despite that surveillance is an effective part of elimination activity, the priority should be giving to implementing the high risk approach strategies (SIAs).

11 Page 7 Quality of reporting is to be considered especially if case definition is not clear. Advocacy about MNT, as a silent killer, with high political levels, is needed to be included as a priority health problem. Nevertheless, surveillance figures are highly needed to convince decision makers. After discussion, post test was conducted for all participants. It was followed by a group work. 5. SESSION 5: DRFATING COUNTRY WORKPLANS Group work: 7 groups were classified, country wise, to draft their own plan. After that, country draft plans were discussed one by one with WHO, UNICEF and CDC HQ and Regional staff attending the meeting. Priority activities were identified and scheduled and required partners support was agreed upon: Afghanistan o Past performance: screening was done in R3, resulting in many TT1, which in reality are TT3. o MNT Plan: No TT SIAs in Part of cmyp ( ). o Situation review needed. Need to improve TT2+ through TT SIA. Need a data review. o TT SIA in 2 phases: Feb, Apr, Nov2009; (second phase also in 2009, but start in May). Combined measles-tt campaign in R1. o Can request special funds from UNICEF for uniject. This is the right time to request. UNICEF/Afghanistan to request now (Jun and Oct). o Validation: late o Strengthen routine immunization. o Support required o Support needed for desk review (late May 2008-early 2009). (back to back with Pakistan?). Will decide on districts and timing. o SIA review in Jun 2009 after 2R o Support needed during implementation. Iraq o TT2+: very small progress. MNT not on the agenda. Almost all districts <50% TT2+ o DTP3 declining. o 2007: 7 NT reported. o MOH buys all vaccine and AD's for routine and for ADC. o Last year measles campaign (9-59mo), with high coverage. o No MNT acceleration plan. cmyp (=7 pages) contains MNT, but very basic. o Support needed:

12 Page 8 o Develop protocol for EPI program review (UNICEF/WHO) to prepare review in May. (should include old data). Iraq to send TOR and dates. o Need a comprehensive EPI program review, leading to updated cmyp. This can be done in Amman or add few days to inter-country meeting on HiB-introduction in May08. Pakistan o See briefing paper and detailed plan o Need a data review for past performance and HRD identification o Need to schedule TT SIAs. Maybe next phase: Aug08, Sept08, Mar09 but depends on data review. o Support needed: o Country visit for data review, planning and advocacy. Date: first or second week of May. Irtaza will coordinate. Plan will be updated after review. Somalia o CMYP not finalized. Includes MNT and Child Survival. o The specific MNT plan was shared with UNICEF. Feedback was provided. Funds for phase 1 (3 rounds) have been sent to UNICEF/CO. Supplies for R1 and R2 have been ordered. Updated plan means TT SIAs will be in CHDs, and TT SIAs will be nationwide (1 phase only). o Country has 113 districts, all at risk. Total target 1,591,613 WCBA. o Phasing depends on CHDs and on security. All rounds will be done with CHDs. Package: for 9mo-5yo: measles follow-up, deworming, Vit A. Also distribution of ORS (maybe after nutritional screening) and TT (15-49 WCBA). ITN will be given depending on availability only in the malaria-prone areas (South). o All areas already targeted in the past TT SIAs will be re-targeted now (because low coverage in those rounds). o CHD: May-June and Nov-Dec. Hence TT will be given every 6 months. Last TT round will be May-June 2009 (security allowing). Validation can be mid-2010 at the earliest. Implementors will be polio-staff. Focal point to be hired in every zone. Documentation of CHD implementation and planning will be done (by WHO-UNICEF in-country). o Country team will send by all results of past Rounds (TT3/R3 data missing for SIAS that started in 2004 and in 2005) o Support needed: o Communication support. Plan exists. Applied to CIDA and Japan for funding. Country to contact Rosemary Wellington.

13 Page 9 Sudan South Sudan o MNT Plan for TT SIAs to be completed in Part of cmyp ( ). o In past: some sub-districts and some full districts. o Country team will send results of R3 of latest phase (done in 2008) o 45 HRD. 6 done. Remains: 39 districts : o 2008: 13 districts: 1,000,000 WCBA - dates to be decided when funds available. Maybe R1 in first week of May 2008 as part of ACSI. Budget: 3m USD (operational cost only) for 3R. Mainly because it is House to House (measles is fixed site). So far 900,000 USD allocated. 3.22m TT requested for July08. Will borrow supplies from routine EPI for TT SIAs. Country to decide by end March 2008 whether R1 will be done in May08 with ACSI or not, and inform WHO and UNICEF accordingly. Package includes other interventions, but different package for different areas. o 2009: 13 districts: 1,000,000 WCBA o 2010: 13 districts: 1,000,000 WCBA o Validation by o Action points: o Need to review strategy to see if ACSI in May is realistic for TT, and whether the package makes sense. o Country team to revise the costing for TT o Joint WHO-UNICEF Regional Office visit needed. o MNT Plan: TT SIAs. Part of cmyp ( ). o Many returnees after measles campaign. Plan to implement measles campaign with TT SIAs. o 2008: 6 counties in 2 phases: start in May and in Nov/Dec. Preparations for May ready. In May: TT plus follow-up measles SIA. Total about 500,000 WCBA. o Later: all other counties will be targeted again. o ACSD supports also ITN and VitA, and possibly de-worming. Maybe this package will be implemented. o Budget needed: approx 1.3 m USD (including vaccine and op costs), but only 220,000 USD received. No vaccines and AD's ordered yet. Vaccine forecast to be left as it is. o Whole Southern Sudan needs to be re-targeted (approx 2.5 m WCBA). o Operational cost: approx 2.8 USD per round per targeted individual (even if combined). (measles vacc campaign cost about 6 USD per head). o Support needed: o None

14 Page 10 Yemen o MNT plan available, integrated within the cmyp, and is in the process of being updated. o The partial supply of vaccines and injection safety equipment for the planned SIAs in 2008 has been already being secured. o Joint WHO EMRO and UNICEF HQ team will extend their stay in Yemen for four days to assist national EPI in reviewing the selection of high risk districts and the SIAs plans. o Support needed: Will be decided upon above-mentioned joint mission. 6. GENERAL RECOMMENDATIONS Infant and in particular neonatal mortality (in which tetanus constitutes one of the major avoidable causes) constitutes an important proportion of under-five mortality and should therefore be taken in consideration in country action plans aiming at reaching MDG4. Millennium development goal number 4, relating to reducing under-five mortality rate, should be widely used to raise national decision makers awareness and get the required political and financial support to implement MNT elimination activities. WHO, UNICEF and other partners should play a more active role in raising national decision makers as well as partners and donors (national and global) awareness about MNT, in mobilizing the required resources and in providing national programmes with required technical support. MNT Elimination is an integrated program, based on community involvement and political support, as well as active participation from all partners working in Child and Maternal programs. MNT Elimination is based on maternal immunity against tetanus, particularly where clean delivery rates are lower than 70%. Immunity can be achieved through routine immunization and, in high risk areas where fewer than 80% of women are immunized through routine services, through TT SIAs. As available data might not be sufficiently accurate, the identification of high risk areas should be based on a review of several district-level indicators, including NT rates, DTP1, DTP3, TT2+, ANC, access to primary health care, clean delivery rates, etc Efforts should be made to increase immunity through routine immunization services. In particular: RED strategies target children and women. All RED activities - including outreach activities - therefore must also include TT immunization of adult women.

15 Page 11 Protection of pregnant women against tetanus should be systematically monitored as part of RED implementation. Every ANC contact must be used to screen and immunize women with TT. TT coverage should not be less than the ANC coverage rate Countries should use the DTP1, DTP2, and measles immunization contacts to screen and immunize eligible pregnant and non-pregnant women. All selected high risk districts should be targeted with 3 properly-spaced rounds of TT SIAs, targeting all women of child bearing age. Minimum intervals between the first 2 rounds is 1 month and between the second and third round 6 months. There is no maximum interval, but efforts should be made to complete the 3 rounds over a 1-year period. All TT SIAs should be completed over a period of months maximum. At least 80% of women targeted in TT SIAs must be vaccinated with at least 2 TT doses after 3 rounds. Accordingly, planning and implementation should ensure achieving this target. Planning should start well in advance of the TT SIAs The composition of vaccination teams should take into account cultural barriers (e.g. need for female vaccinators) Social mobilisation and communication must involve communities and address their concerns Monitoring of TT SIAs should be by dose (TT1, TT2, TT3) and by round. Assessment of the quality and coverage of the TT SIAs should be done after every round, and used to plan corrective measures as needed. National TT SIA plans should include a strong communication component, that considers as well district-specific issues. Communication strategies should be driven by a data analysis to ensure optimal receptivity and create demand. Communication should include strategies to pre-empt and react to false rumours and tackle possible AEFI.

16 Page 12 Monitoring of the implementation of communication activities should be regularly conducted. Weaknesses should be corrected after each round. NT Surveillance is an essential part of MNT Elimination NT Surveillance should be optimized, using and building on existing systems. Community involvement should be sought to the extend possible to improve information-gathering on vital events (births and neonatal deaths). To guide the MNT program, NT data should be interpreted in connection with other service and performance indicators. All NT cases detected should be used to improve community awareness and participation in the MNT elimination strategies, and to implement corrective measures as needed.