Orbis International Ethiopia
ArbaMinch Zuriya woreda 9th Round Zithromax Distribution Final Report
Prepared By Yalew Tarekegn
GGDKA Project FC
[December 15, 2016]

Executive Summary

Trachoma is one of the infectious causes of Blindness, caused by Chlamydia trachomatis. The active trachoma affects mostly children ages 1-9 years and the chronic Trachomatous Trichiasis (TT) affects mostly adults, especially mothers. Arbaminch Zuriya Woreda is one of the 15 woredas and two town administrations of Gamo Goffa Zone and found 505 KMs from Addis Ababa and 275 KMs from Hawassa.

WHO recommends Zithromax distribution where the prevalence of active trachoma greater than 5%. The prevalence of AT in AZW is 22.04% (IA done by independent consultant teams in April 2016). Based on the AT result MDA continued for 9th round. Due to government meetings the distribution in AZW postponed two days after the agreed distribution dates. The training began in November 24 and 25/2016 at A/M/H/S/College meeting hall. Participants

Training Participants were selected from 29 kebeles, 86 teams which contained (50 HEWs, 36 HPs, 86 HDAs and 86 Kebele Managers), 17 woreda supervisors and 3 woreda Cabine members.

The training began after the opening speech of AZW administrator Ato Yarsa Yame. In his speech he told participants about the impact assessment results of AZW, he was unhappy of the IA result. He concluded the results might be due to many factors; low awareness creation during MDA, false report and misunderstanding in some kebeles.

Then I started the training based on the new MDA training manual and time table. After explaining the overview of Orbis’s mission, vision and objectives, I continued training on Trachoma (causes, S/S, MOT, treatment and SAFE strategy). In between woreda Administrator Ato Yarsa had taken time for discussion and suggestion from participants. During discussion time he asked some kebeles to dig important points for discussion. In the second day the administrator given chance to continue the remaining parts of the training. I completed the training (Azithromycin s/effects, use, preparation, dosage and measurement) then the responsibilities of MDA distribution teams; the woreda administrator Ato Yarsa and Woreda health office head Ato Darge took the leading for general discussion, questions and answer. During this time questions raised from participants based on the previous distributions especially 8th round were:

·  Supervisors-poor support (missing some hidden/ sub villages) collecting reports only by phone, poor controlling system, leaving the place without submitting the reports, etc.

·  Distribution teams HEWs: late starting and early return from the sites, poor drug management, report collection and compilation (false reporting). (Only few HEWs properly managed the distribution and reported timely)

·  Kebele managers and PALs: low mobilization and awareness creation, this results in low service utilization.

·  The woreda administrator and WoHO head finalized after putting the following points:

§  The way of mobilization should be up to the lowest administrative units 1 to 5 development teams.

§  To reduce wastage of time especially during lunch time, the kebele PALs has to prepare locally available foods for distribution teams,

§  Drug should never be given at hand,

§  TT case detection should be integrated and the cases should be submitted with the reports.

§  Had it been the kebele PALs have other assignments they have to integrate the distribution.

Ø  At the end of the day administrative issues and logistics were distributed.

Ø  In day 4- the distribution started in all kebeles. The overall distribution completed from 8-10 days.

v  Results

§  Treatment

  • We planned to treat 95% of 190,599, but due to drug shortage we achieved 161, 764 (89%)(Total Male=79906 and Females=81858) out of 95% of the target population
  • Person treated with Zithromax tablets male=67233 and females=67506 total=134739
  • Children treated with azithromycin suspension male=11536 Female =11484 and Total23020
  • Tetracycline eye ointment distributed for <6 males=1137, <6 females=1179 and PW=1689 total=4005

§  Overall drugs utilized during the campaign, Zx. Tabs 463069 (926tins), Zx suspension 203815ml (6794bottles) and 8010 tubes of TEO were used.

§  Budget utilization

  • For training 150,432.00 ETB
  • For distribution 395,070.00 ETB
  • For Drugs Zx. Tabs/Tin 926*11598=10,739,748, Zx POs/bottle 7000*125.00=875,000.00 and TEO per tube 8010*3.00 ETB
  • For vehicles 16days *3000.00 ETB=48000.00 ETB
  • Total budget utilized per individual including running cost and for vehicles is 75.61 ETB
  • Strengths: the whole distribution was controlled by the woreda command post established for the distribution and at health office level.
  • All woreda vehicles were involved for the distribution. This answers the sustainability issues questions.

v  Challenges

  • Shortage of drugs (Zithromax tabs and Zithromax suspension)
  • Low commitment of some supervisors
  • Solutions
  • Shifting Zithromax suspension and tablets from other districts
  • Using suspension instead of tablets (6ml for 1 tab, 12ml for 2 tabs)
  • Recommendations
  • To alleviate the shortage of drugs Zithromax tablets should be calculated as Total population * 85% * 3.5 tabs.
  • Budget request has to be based on the population number rather than number of kebeles.

1.  Acknowledgments

I would like to thank the woreda higher officials (specially the woreda administrator Ato Yarsa Yame, woreda health office heads (Ato Darge and Ato Tilahun Asane)), all distribution teams and supervisors for their invaluable contribution in the 9th round Zithromax distribution in Arbaminch Zuriya Woreda at large. Finally, I would like to thank Orbis international Ethiopia GGDKA Project office for their financial, Logistics, Vehicles, technical support & for overall 9th round Zithromax distribution campaign.

2.  Introduction

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

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

  The prevalence of active trachoma (AT) in children age 1-9 is 40% for the whole country ranging from 0.5% to 62.6% in different regions of the country. It is fourfold higher in rural children than urban due to poor sanitation (latrine coverage rural=66% and urban=94%) and water supply (rural=49% and Urban=93%). Over 9 millions children aged 1-9 years have active infection in Ethiopia.

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

According to the Global Trachoma Mapping Project (GTMP), the prevalence of active trachoma and TT in SNNPR are 25.6% and 1.5% respectively. The prevalence of active trachoma in AZW Woreda among children aged between 1-9 years according to GTMP on blindness and low vision reported to be 18.97% whereas the trachomatous trichiasis rate among people aged above 15 years appears to be 0.85%. However, the impact assessment done in 2016 conducted by consultants the prevalence of AT and TT 22.04% and 1.8% respectively.

Orbis International Ethiopia has been implementing the WHO recommended SAFE strategy in Gamo Gofa ;Konso Derash & Alle project to control and eliminate trachoma over the last ten years . Trachoma is still a major public health concern and need an immediate trachoma intervention program. Following these findings and as per the recommendation of WHO, Zithromax distribution program was planned in these Woreda including AMZ Woreda.

Table 1 Summary of trachoma Impact Assessment findings in AZW Woreda

S.No. / Woreda / Prevalence of Active
Trachoma in 1-9 yrs / Prevalence of TT
in >15 yrs
1 / Arbaminch Zuriya / 22.04% / 1.8%

3.  Back ground of Arba Minch Zuria Woreda

Arba Minch Zuriaworeda is one of the fifteen woredas and two town administrative partners of Gamogofa zone. It is one of the 18 woredas and two towns where Orbis delivers eye care services. The woreda sectors are found at a distance 505 kms from Addis Ababa, 275 Kms far from the regional town Hawassa and located in Arba Minch town (GG zone capital town). It Shares boundaries with six neighbor woredas like Dita & Chencha in North, Derashe in South, M/Abaya woreda and Amaro in the East and Bonke woreda in West & South West. The woreda is also bounded by Lake chamo and Lake Abaya in East and south directions. Tour centers like 40 springs, Nech Sar Park, Crocodiles market and crocodiles ranch found in the woreda. It has been divided in 29 administrative Kebeles (27 rural and 2 towns (Shele and Lante)). About 9 kebeles were found in “Kolla” weather condition while the rest are found in “Dega”. It is believed that, 190,610 people live in the woreda as to the population projection of 2016 based on Orbis census data of 2008. Gomonga, Gofigna, and Zeyisegna are the local language of the community. Almost all dwellers of the woreda depend on agriculture. The farmers highly cultivate Teff, Maize, peas, bean, barely, wheat, and “Enset” as food crops. Coffee and Banana are the main cash crops of the woreda while fishery is also another source of income. As to infrastructures, the woreda has health, education (KG up to high Schools), transportation, and Bank and telecommunication facilities. About 12 kebeles has got 24 hours pipeline water and hydroelectric power supply. Concerning health units, there are seven HC/DHCs, and 39 health posts. There are five currently functional IECWs trained and equipped with medical supplies to work on TT and other PEC services at five different clusters.

4.  Goal of the 5th round zithromax distribution campaign

v  To achieve the highest Zithromax distribution coverage of the woreda target population as much as possible and to reduce the community reservoir of infection and therefore stop transmission.

5.  Objectives of MDA

  • To implement ‘A’ components of SAFE strategy to suppress the recurrences of AT by treating source of infection.
  • To reduce AT from 22.04% to below 5% after consecutive mass drug administration for the eligible population of the woreda.
  • To reduce TT from 1.8% to less than 0.1% by draining AT.
  • To create awareness within the community on trachoma and SAFE strategy.
  • To reach at least 95% of the residents through MDA within 12 days.

6.  Eligible/target

§  Zithromax is safe and recommended by ITI for all individuals except for children less than 6 months and those hypersensitive for Zx (macrolides). However, the FMOH does not recommend for mothers in their first three months of pregnancy. TEO will replace Zx for those who are not feasible for Zithromax.

§  So, our eligible population for Zithromax and TEO eye ointments is all permanent residents in the woreda (190,599 people).

7.  Strategies of distribution:

Distribution time was fixed by repeated discussing with woreda officials, so that there will be no activity overlap. The woreda health office was made to call distribution team for training. Thus, distribution team members were called for two days orientation and training by call letters dispatched to each kebeles via woreda health office and woreda administrator office. The campaign was planned to be completed within ten days duration excluding travel days, training days and reporting days. A team composed of three members; i.e. one kebele leader, one community health agent and one health extension worker/health worker. Two to five teams with their own specific role and team work role were assigned at each kebeles based on their population size and geographical situation. Since the woreda topography is not easily unmanageable, one supervisor assigned for two kebeles. Three woreda cabines were also assigned to support all kebeles and two command post teams organized in two places at health office level and at woreda administrative level two overall coordinators were also arranged. Supervisors and overall coordinators followed the team to provide support. They communicate with teams or team supervisors through physical visit or phone as well as community volunteer messengers. Teams, drugs and logistics means of transportation to kebeles was secured using vehicles, human labor. Transportation will be completed one day ahead of distribution date (which is the travel day of the campaign) except for two clusters where drugs mobilization held during the start of the training. Transportation of drugs to remote kebeles was given priority.

The kebeles’ villages centered sites, which increase accessibility of the villagers and minimize long travel to clients from their houses, were selected by teams for distribution strategy. CHAs and HEWs/HWs sit at selected areas while PA leaders mobilize the community to campaign site. PA leaders also fetch those clients who missed in the HHs by taking their lists from the registration books. The teams also make house to house visits to provide drug for those who were not able to book the team for different problems (e.g. illness, postnatal, aging etc.) and also when clients flow decrease. House to house visit after 3 to 4 days of the campaign period was compulsive to fasten the coverage. These will be monitored by supervisors and team leaders based on their daily coverage which must be more than 10%/day. Height measurement will be done to determine the POS and tablets dose for children >=6 months - <5yrs. Adults and children above 5 years were treated according to the treatment guide with tabs stat. Two tubes of tetracycline eye ointment will be provided for mothers whose pregnancy period is three or less months (1st trimester) and children <6 months after counseling on how to use it for home application. Unlike that of TEO; Zithromax (both tabs & POS) will be administered by directly Observed Therapy (DOT) of HEWs/HWs to avoid drug compliance and abuse.