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Final Country Report

By Dr Abuzar Taizai

It gives me great pleasure and satisfaction to write down a few words to appreciate the serenity and fortitude of those who helped me in my STOP Mission.

I would like to say thanks first to Ms Virginia Swezy who was my Atlanta based supervisor, who through her simple, and encouraging e-mails kept my moral up and my mission on the move. Jason Roathbird, Andrea Masters Yinka Kerr, and Danielle Chekaraou, La Chandra Murphy and Felicia Betancourt were amongst the prominent coordinators who guided me in the initial phases of my mission and they deserve my sincere thanks, they gave me the chance and opportunity to exercise my skills and efforts in the noble and global cause of Polio Eradication. I will be in debt if I don’t say thanks to Dr M.Abdur Rab WR Sudan who was the first to say well come to me and arranged vehicle for me to take me from the air port to the Hotel in Sudan. The help and support provided by Dr Salah Haithamei my in country supervisor is of course much and unforgettable. I am also very much thankful to Ms Kelly Ronan and Ms Leila Kadri of WHO headquarter – Geneva, for their sincere and enormous administrative support and processing my UNLP which enabled me to get smoothly on the board and through my assignment in Sudan.

I am very grateful to the Government of the republic of Sudan and it’s Federal Ministry of Health for their hospitality and giving me the opportunity to work as part of the Polio Eradication team in this country, especially Dr El Tayyeb El Sayed National EPI manager Sudan, and his team. I am really thankful to Dr Mehboob Badini STC Khartoum state, Wisal, and Mai for administrative supports and useful information they gave me during orientation and briefing at Khartoum.Dr Hassan Khan STC of course deserves a lot of thanks for his regular calls from Darfur to help me in the understanding of the Sudan security situations and work related details.

I am also thankful to the Minister Health Sennar state Engineer Mr. Abu-Almaali, DG Health Sennar Dr Abdullah Yaqoob, Mr. Atta Ahmed Abdullah the state operational officer Mr. Ahmed Mansoor commissioner Dinder locality and Dr Saif Ali Azal Director Primary Care for their cooperation and hospitality in their state.

I am very much grateful to the provincial ministry of health NWFP Pakistan for granting me permission to be on the STOP Mission in Sudan.

Introduction:

Sudan gained independence from British-Egyptian rule on 01 January 1956. Sudan is the largest country in the African Continent both population wise as well as territory/land wise because its territory is covering about 2.5 million square kilometers and 40 million is its total population which is more than any other African country.

Bordering countries of Sudan:

Northern Border: The northern border of Sudan is touching with Egypt.

Eastern Border: There are two countries and one famous sea namely Eritrea, Ethiopia and the Red Sea.

Southern Border: Ugunda, Kenya and democratic republic of Congo lie on its southern border.

Western Border: Chad, Libya and Central African Republic touch its Western Side. Sudan has a total population of around 40 million. Most of the Sudanese are living in the rural setup (68%) the remaining 32 % are Urban Dwellers. About 7 % people here are the Nomads. In South there are some Christians and Animists but Islam is the predominant religion in Sudan.

About the Sudan Government:

Sudan since her inception enjoyed only ten years of Democracy the rest of the period remained under military regimes. The Sudan is a republic with a federal system of Government. There are multiple levels of administrations, with 25 states which are inturn subdivided into approximately 120 provinces.

Sudanese People:

The Sudanese are very friendly and hospitable people but their national identity is very complex to define but fairly they can be called Afro-Arabic. They speak more than 130 dialects but Arabic language is spoken in most of the Sudan regions. Now they have started taking interest in English language especially in the young student stratum of the Sudan.

Economy and World Ranking of Sudan:

In 2004 Sudan was the least developed country (LDC) and was ranking 139 according to UNDP’s Human Development Index but now it has gone further down two places in 2005 and its number is now 141.There is no adequate national road grid which connects the country. The largest parts of Sudan rely on agriculture and pastoral economy. Long fiber cotton sorghum and can sugar are its main crops. Commercial agriculture industrial development, limited exploitation of the natural resources specially following the discovery of oil in central and southern parts of Sudan have developed in the recent years.

Internal Conflicts of Sudan

The internal conflict erupted in 1983 between North and South Sudan. Its impact was significant on Sudan in many ways. It was the longest conflict in Africa, involving serious human rights abuses and humanitarian disasters. During the conflict more than 2 million persons died and 4.5 million people were forcibly displaced from their homes. However due to increase international pressure the conflict was resolved and on 31 December 2004 the two sides agreed on the outstanding issue of power sharing, wealth sharing and ceasefire.

Endemic/Common Diseases in Sudan

The commonest amongst the Sudan endemic diseases is the Malaria especially the plasmodium Falciparum, TB, Bacterial Meningitis, Intestinal amoebiasis Giardiasis Dengue fever and Leishmaniasis are the common diseases in Sudan.

In addition to the above mentioned diseases Malnutrition is also very common especially amongst the children and women of Sudan.

The seasonal Catastrophes and Environmental Disasters

Sudan has the most common environmental Problem of (HABOOB) the dust Storm it has also a season of heavy rains starting from May up to September. The other important disasters are the periodic droughts.

The Climate and Terrain

The climate of Sudan is tropical in the Southern part, it is a desert in theNorth, and the rainy season has no specification for the states but is almost universal for the whole Sudan. The rainy season starts from May and lasts up to November. The Sudan has mainly a flat terrain without any specific features, except sparsely spread naturally grown trees the Sudan is dominated by the deserts. The mountains are mainly situated in Far South, Northeast and in the Western Sudan.

Main Activities of the STOP 24 Team

Meeting with the National EPI Manager, Sennar State Minister Health and DG Health to seek their permission to work in their State and taking their commitment.

1. Ensuring the weekly reports including the zero reports from all the reporting sites

2. Updating the Micro planning for NIDs and AFP surveillance in Sennar State

2. NIDs trainings for the supervisors and teams

3. NIDs campaign monitoring and post campaign evaluations

4. Detail case investigations (DICs) of AFP reported cases

5. Data analysis and 60 days follow-ups of AFP cases

6. AFP sensitization and health facilities records review

7. Orientations for Polio field supervisors and assistants

8. Strengthening the routine EPI activities

Sudan and Polio Virus the overall Perspectives

The epidemiological Study of the Sudan in the perspective of Polio Virus transmission is complex however the following factors can be easily separated and studied for the better understanding of the situation and it a will also help the Polio Eradicators by strengthening the positive factors and abolishing, minimizing or controlling the negative factors.

Negative factors for the Polio Eradication Programme

· Sudan is bordering a large number of countries (9) most of which or not Polio free and there is a continuous influx of refugees which is one of the most important factors in the Polio virus transmission. This was the only one factor which imported Polio virus to Sudan after it was Polio free for a few years.

· Low literacy rate and unawareness of the community about the importance of immunization.

· Poverty and hence malnutrition especially the protein energy malnutrition which makes the immune system to respond sub optimally to the vaccines.

· In most of the regions of Sudan the drinking water is from the rivers or canals which is unsafe and helps the virus to be transmitted to the other regions downstream.

· The high prevalence of diarrheas and other GIT diseases also make the vaccine to be absorbed lesser than would be otherwise.

· In Sudan 7 to 10 % of the total population is nomadic or IDP and no body knows there timetable of arrival and departure which makes their children vaccination very difficult and uncertain.

· The internal conflicts and wars make some of the areas inaccessible for the effective vaccination and hence is a big hindrance to the programme.

Factors which favors the Polio Eradication initiative

· Large surface with comparatively very little population, most of the people live in clearly separated and defined pockets which are far from each other so there is less likelihood for the virus to transmit easily.

· Sudan has already eradicated Polio for more than two years, but unluckily the wild virus was imported from Chad so it can eradicate Polio with the same strategies and now the rehearsals are almost complete for the eradication and the day is not far for Sudan to get the Polio free international certification.

· The climate of Sudan is very hot and the wild Poliovirus cannot survive longer here in vitro.

· The government is committed and is doing her best to eradicate this menace.

· The big international organizations like WHO, UNICEF, CDC and their sister international organizations and local NGOs have developed strong roots in Sudan and they have already committed to eradicate this disease from the whole world including Sudan.

The Federal EPI Structure of Sudan

Although Sudan is a poor and war bitten country but still it has achieved a great progress in the field of EPI and is considered one of the most advantageous and advanced country in the whole WHO- EMRO region. It celebrated its 30th anniversary in 2006 since its beginning in 1976.Sudan has good and well organized EPI systems, especially at the federal and states levels. The EPI at the Federal Ministry of Health has eight functional units which are managed by experienced, well trained and skilled staff. These units are: Social mobilization; Training; Cold chain; Operation, Information; Surveillance, Supplementary Immunization Activities and Advisory committee on adverse effect following immunization.

The Sennar State:

It has three localities namely Sennar Proper, Singa and Dinder. Each Locality is in turn subdivided into 7 administrative Units and hence Sennar State has 21 administrative units in total. The following table shows the administrative units attached to its locality.

Name of the Locality	Administrative Units	Total < 5 years Children	Total < 15 years Children
Sennar Proper	1.ELGHARBI	96290	248542
	2.ELSHARQI
	3.WED-ALABBAS
	4.WED-TAKTOOK
	5.DOBA
	6.SENAR TOWN
	7.ELSUKKAR
Singa	1.SINGA TOWN	65556	163674
	2.RIFI SINGA
	3.RIFI UMBININ
	4.DALI
	5.MAZMOOM
	6.WED ELNIEL
	7.ABU HUGYAR
Dinder	1.DINDER TOWN	76959	193983
	2.GHARBELDINDER
	3.SUKI
	4.KARKOJ
	5.ELLAKANDY
	6.RIFI ELSUKI
	7.SHARQI DINDER
Total	Total 21 Admen Units	Coverage of Various Antigens in 2006 Sennar State January February March April May June July August September October November December TOTAL BCG 2201 3837 8773 1316 16832 29765 23681 26272 28635 3499 41018 44983 82.40% Zero 347 701 1348 2065 2632 3250 3810 4279 4651 5789 7034 7954 16.50% OPV-1 3432 7066 10719 14167 17453 21300 24202 26770 28915 34575 40159 44266 92ز3% OPV-2 3671 7442 11508 14663 17804 21391 24767 27006 28903 32187 38642 44185 91.50% OPV-3 3582 7492 11469 14754 17842 21246 24365 26590 28336 31215 35814 42915 88.90% DPT-1 3432 7066 10719 14167 17453 21300 24202 26770 28915 34575 40159 44266 92.30% DPT-2 3671 7442 11508 14663 17804 21391 24767 27006 28903 32187 38642 44185 91.50% DPT-3 3582 7492 11469 14754 17842 21246 24365 26590 28336 31215 35814 42915 88.90% HB-1 9607 15529 20243 24285 27864 31687 35140 37418 39557 45327 50828 55183 114.30% HB-2 4755 12238 18609 23101 27042 31091 24537 36899 38743 41992 48353 53906 111.60% HB-3 3797 8213 14102 18978 23330 27389 31013 33463 35328 38256 42647 49762 103% Measles 2483 5296 8252 11413 14297 17675 20921 22782 24681 28423 32554 35629 73.80% TT-1 948 2016 3156 4216 5533 7079 8391 9491 10417 11750 13894 15008 27.50% TT-2 1446 3293 5165 6739 8541 10639 12845 14520 15876 17662 19952 33380 40.80% TT doses given to the Women during the Period January – December 2005.Senar State Locality Pregnant CBA Pregnant Child Bearing Age TT1 TT2 TT3 TT4 TT5 TT2&+ % Ann TT1 TT2 TT3 TT4 TT5 TT2&+ % Ann Senar 21822 135633 6480 5196 3063 1712 1176 11147 51 51 6480 5196 3063 1712 1176 11147 8 8 Singa 14370 89319 3837 2708 1479 616 186 4989 35 35 4116 2814 1563 655 202 5234 6 6 Dinder 17031 105860 3860 2555 1151 604 377 4687 28 28 3923 2597 1187 616 380 4780 5 5 Total 53223 330811 14177 10459 5693 2932 1739 20823 39.1 39.1 14519 10607 5813 2983 1758 21161 6.4 6.4 TT doses given to the Women during the Period January – December 2006.Senar State Locality Pregnant CBA Pregnant Child Bearing Age TT1 TT2 TT3 TT4 TT5 TT2&+ % Ann TT1 TT2 TT3 TT4 TT5 TT2&+ % Ann Senar 22374 139064 6745 4742 3195 1636 1011 10584 47 47 6757 4743 3396 2636 1012 10587 8 8 Singa 14734 91579 3991 3008 1608 711 491 5314 40 40 4044 3118 1544 756 505 5923 6 6 Dinder 17462 108538 4272 3087 1503 772 480 5842 33 33 4285 3094 1508 773 480 5855 5 5 Total 54570 339181 15008 10837 6306 3152 1985 22280 41 41 15086 10855 6348 3165 1997 22365 7 7 PROPORTION OF UTILIZATION OF VARIOUS STRATEGIES FOR THE ROUTINE IMMUNIZATION IN YEAR 2006 Constrains of Routine EPI · Less number of skilled EPI staff · Lack of professional Knowledge and skill in the existing EPI workforce · Improper and infrequent skilled supervision · Lack of adequate and sustained financial incentives to the staff · Problems in the transportation like less number of vehicle are available than required specially for the mobile teams and the supervisors · Rough and bad roads and long distances also contribute to the low coverage of the routine antigens administration to the children · Lack of refresher courses and trainings · Vaccine safety and Cold chain problems · The community involvement and their awareness about the importance of immunization is very low in the Sennar state which is also a hurdle in the way of reaching the target. Recommendations for the improvement of the Routine EPI System 1. In the face of the heavy work load more EPI staff should be recruited to run the system effectively. 2. The EPI staff should be given regular trainings; there should be EPI workshops, Seminars and refresher courses in addition to their regular formal trainings to build up the capacity of the whole staff. 3. There must be regular, skilled and supportive supervision for all the three strategies of the Routine EPI Programme. 4. The government needs to increase financial support to the programme and during each fiscal year proper budget should be kept for this crucially important sector of preventive health. 5. More vehicles should be provided to the field staff and supervisors and also the existing cars should be repaired to prevent unnecessary wastage of time. 6. The non working refrigerators and cold chain equipments should be repaired to ensure the vaccine safety. 7. Behavior Change Communication BCC for the Community: There should be a plan for the social mobilization, public sensitization and behavior change communication regarding the importance of immunization. The implementation should be regularly monitored to improve the community involvement. The community should be made to understand that if we are coming from far flung health centers to your doorsteps at least you should bother to come to your own door step to vaccinate your child and prevent him/her from the diseases which is for your own benefit. THE AFP SURVEILLANCE SYSTEM IN SENNAR The Sennar has a very good and organized surveillance system; there are 13 sentinel sites 5 of which of are of High Priority, 4 each of medium and low priority sites. The priority is based on the daily turnover of the target age children at the site or the presence or otherwise of pediatrician/children specialist in the health centre or clinic. The Sennar has one central point of AFP Surveillance operational control which is managed by the state operational officer. There are three locality operational AFP Surveillance head quarters each of which is supervised by the respective locality operational officer, each locality is again divided into 7 administrative units and all these units has a Surveillance focal person. There is a smooth flow of the AFP Surveillance information/reporting from the grass root level/community to the administrative focal point, then to the locality headquarters, the state operational centre and finally to the Federal level. At all levels the information is share upstream and downstream. Table of Reporting Sites network in Sennar The total Target < 15 years children is 606199 hence 12 non Polio-AFP cases should be reported annually to meet the international standards for certification. The non-Polio AFP Rate has decreased since 2003 and in 2006 it has gone critically down i.e. below 2 cases per 100 thousands target children. Remedial Action to improve the non-polio AFP Reporting To identify the reason for the decreased reporting of the non Polio AFP I performed active visits in every locality and analyzed all the data. The problem was found in the Sennar Locality alone the other two localities namely Singa and Dinder were ok regarding their non-polio AFP reporting rate. In two of the high priority sites in Sennar the responsible doctor was not properly oriented and was showing least interest in the AFP Surveillance System he was not writing the diagnosis in the respective columns although the patients were been examined and admitted in the wards and treatment had already started but in the OPD register the preliminary diagnosis column remained blank, and it became problematic for the AFP focal person to decide whether AFP cases are present or not as there was no diagnosis for a large number of the examined cases in the out door patient register. I inquired about the issue and I through Dr Salah Haithamei MO/WHO. And Dr Tayyeb the National EPI Manager called the doctor and counseled him. Both of the dormant sites were related to this pediatrician. One of the sites is his private clinic and the other is Sennar Hospital Children OPD and ward, the doctor who is the leading pediatrician of the Sennar State was trained and now he agreed to cooperate in the AFP Surveillance and now he has started taking keen interest in the AFP cases reporting. All the other sites were also supervised and the focal persons and the operational officer were sensitized and trained. During my Supervision in Sennar State we received two cases in March and one in April and now total Non-Polio AFP cases are 5 till April 2007 and the annualized Rate for this year is more than 2 per 100000 which is very much encouraging. Data Analysis of the Reported AFP Cases Locality Wise 2005 -2006 Locality Population under 15 years Discarded Confirmed Compatible Non-Polio AFP Rate Year 2005 2006 2005 2006 2005 2006 2005 2006 2005 2006 Senar 236427 242409 6 2 0 0 0 0 3 1 Singa 18700 165432 4 3 2 0 0 0 3 2 Dinder 173000 181265 3 3 0 0 0 0 1 2 Final Diagnosis Diagnosis 2003 2004 2005 2006 Polio 0 3 2 0 GBS 11 4 6 5 Transverse Myelitis 0 0 0 0 Traumatic 1 0 1 0 Neuritis 0 1 0 0 Others 10 7 6 5 Total 22 15 15 10 Completeness and Timeliness of Zero Report and Active Visits to the Sentinel Sites Year Zero Report Active Visit Completeness Timeliness Completeness Timeliness 2003 100 % 100 % 100 % 100 % 2004 100 % 100 % 100 % 100 % 2005 100 % 100 % 100 % 100 % 2006 100 % 100 % 100 % 100 % Below given is the Graph Showing the Immunization Status of the Reported AFP Cases. Three AFP Cases were also reported in this period one each from Singa and Sennar Locality. The Details of Singa AFP Case are as follows Investigation of the AFP Case in Umshoka Village Investigator: Dr Abu Zar Taizai STOP Team Consultant/WHO With Mr. Atta Ahmed Abdullah State Operation Officer for Sennar Name of the patient: Hassan Yahya Father Name: Mohammad Adam Father occupation He is a farmer Mother Name: Amuna Abu Bakar Address: Locality Singa Administrative unit Umshoka Contact Person: Omar Jeeka (Chief) Raees of the Village. Telephone number: not available Date of onset of paralysis: 07/03/2007 Limb Affected: Right Leg Lt Leg Normal Rt Arm Normal Lt Arm Normal. Date of the case entering into the Rural Hospital 12/03/2007 Date of Notification of the Case: 12/03/2007 Date of investigation of the Case: 12/03/2007 Date of stool collection first sample 13/03/2007 at 10:00 am Date of stool collection second sample 14/03/2007 at 11:00 am Date of sending two stool samples to Khartoum 15/03/2007 Epidemiological study of the Case Socioeconomic History of the case The father of Hassan Yahya is a farmer and is economically very poor. Source of Drinking Water: The main source of drinking water is from the well to this house and also to the rest of the neighboring villagers. Presence of Rivers or Canal in the area (possibility of getting the disease from the upstream or transferring the disease downstream) There are no rivers or canals in the immediate vicinity of the case. Health of other brothers and sisters; The patient Hassan Yahya is a non-identical (Heterozygous) twin with his sister Husna who died when she was only 12 days old but the cause of death is not known. He has 13 brothers and sisters and he is the youngest. His father has 5 wives. There is no history of congenital diseases in the family. Accommodation of the household: There are only two living rooms in the house but they are well ventilated. Sanitary Condition of the house The house is overcrowded with the children. The sanitation is very poor having only one open toilet for urination and defecation for 20 members of the household. Nutritional History The case belongs to a very poor family their nutrition is unsatisfactory but there is no signs of chronic malnutrition in the child like retarded growth or stunted growth. Immunization History; The parents have a completed routine immunization card for this child The child has received last dose of trivalent OPV on in December 2006.The parents are aware about the importance of the immunization. History of Traveling; Neither the child nor his any family member has visited other country in the last six months. There is also no history of visitors who came in their house in the last six months. The Umshoka village in which the case is dwelling is a big thickly populated village having 1300-1500 houses. The overall condition of sanitation of this village is not good because there is no proper water drainage system and also there is no proper disposals of the excreta especially for the toddler and children majority of them defecate in the open air. Nomadic or camps in the area of the case There are no nomadic/camps in or near the village and also no other high mobility groups in or near the village. Prevalence of other diseases in the area There is no significant prevalence of infectious or other diseases in the area except the common endemic diseases like Malaria, Bacterial Meningitis, Hepatitis A, TB and malnutrition as in the other parts of Sudan. Clinical History of the case, The child is 21 months old and he started vomiting and high degree fever two days before the paralysis he was brought to the local paramedical personnel for treatment. His primary diagnosis was malaria. The care provider gave him injection on the right hip. After two days the child failed to stand or move his leg. Clinical Examination of the case; Sensory Nervous system: The right leg is painful (tender) on touch there is no sensory deficit in the right Leg Motor Nervous system: The knee and ankle jerks are diminished the muscle bulk is normal there is no sign of muscle wasting. The affected leg has reduced tone but is not floppy. The power in the right leg has reduced 2/5 as he cannot stand without support but he can move the leg. Prognosis History; According to the patient’s parents the paralysis of the leg has improved from the last two days, initially he could not move his leg and was unable to stand even with support but now he can move his leg and scan stand if supported. The vomiting and fever has subsided now. Provisional Diagnosis: Malaria with injection induced traumatic neuritis. Final Diagnosis: After Laboratory result is received and 60 days follow up is done. Search for other cases in the neighborhood/village: We actively searched by asking the health care providers and the parents about the other AFP cases in the nearby houses but could find no other case of AFP there. Major Strengths of the AFP Surveillance System · There is a good system of case reporting from the grass root level to the top (Federal level) · All the localities has a sufficient and efficient sentinel network · The Sennar was the first State in Sudan to involve the community Surveillance force for the case reporting especially the women social organization. · The operational officer for the State is very well trained, motivated and has a full control over his subordinate staff · The active and passive AFP Surveillance visits are well conducted and documented · Simple AFP Case definition is displayed and understood in all the sentinel sites and health facilities. · There are regular monthly meetings at the level of each locality and at the state level to share experience and information among the administrative unit focal persons and locality operational officers which is chaired by the state operational officer. · Data and record keeping is very good at all levels and the data is analyzed regularly. · All the performance indicators are satisfactory and meet the criteria for international standards of certification. Constrains of AFP Surveillance System · Long distances, rough roads and bad vehicles which often get breakdown in the way and the work is suffered. · The focal persons and the operational officers are at a time doing double duties i.e. they supervise the routine EPI as well as AFP Surveillance and always get double minded to prioritize their plan of action. · The nomads and internally displaced people (IDP) is a constant problem to the focal persons and sometimes they are even unaware that new nomadic camps have arrived in their area of assignment. · Some of the health care providers show least interest in the AFP case reporting · Some of the AFP Surveillance focal persons lack the basic knowledge of case definition, case reporting reverse cold chain and data analysis. · The financial support from the government is very meager which the main motivation stimulus for the poor workers. · Lack of sustained Federal or international level supervision in Sennar which I think was the foremost cause in getting their non-Polio AFP rate down in 2006 as there was no upper level supervision in this year. · Lack of Regular trainings to the focal persons and the operational officers · Less involvement of the community surveillance workforce especially in Sennar locality. The NIDs Activities during the pre-Campaign Phase Social Mobilization Activities · There was a big opening ceremony in the Dinder Locality which was chaired by the Health minister in Abu Hashim village. There was Polio songs and other exciting celebrations in which the local community took great interest. The Commissioner for Dinder locality Mr.Ahmed Mansoor was also present on the occasion. There were very good speeches by the minister health, locality commissioner, the state operational officer and Dr EL-Sadiq EL-Majoob the federal AFP Surveillance coordinator regarding the importance of the NID and motivation and sensitization of the public to play their roles for the protection of their children against the deadly Polio Disease by ensuring the instillation of OPV drops. · Except this big inauguration there were also small administrative units inaugurations in all the administrative units of Sennar. · I helped the Sennar Health Authorities in making the various plans 1. Like Logistic distribution plan 2. Social Mobilization Plan 3. Training Plans 4. Supervision Plan § I helped the Sennar Health Authorities in the updating of the micro plans and maps § I conducted and facilitated trainings of the Trainers TOT § I conducted and facilitated trainings of the Supervisors § I conducted and facilitated trainings of the Team Leaders § I conducted and facilitated trainings of the Vaccination Teams § I helped the Health Management Team to organize a very good social mobilization meeting at each administrative unit level and one very big social mobilization and opening ceremony festival at the State level. Training of the Supervisors at DG Office Singa Summary of the training This training was arranged by the Director General of the Sennar State The attendance was 100 % .The supervisors were trained about: · What is Polio · What is Polio Eradication Initiative · The current status of PEI in Sudan · What is AFP Surveillance and why it is important for the PEI · The participants were trained about how the high level of immunity interrupts the virus circulation, why we do repeated NIDs and the objectives of the NIDs was also discussed. · They were detailed about the IPC · How to supervise the teams and team leaders in the field 1. like before approaching to check a team you must check a few houses and ask inside whether all the children are vaccinated or not 2. whether the team has done good IPC by asking how many families are residing inside the house and how many children in each family (Micro census) 3. See the finger marking of the children and door marking on the doors 4. ask in few houses whether the team is asking about the AFP cases or not 5. After checking their recent work then the supervisor should approach the team and check the tally sheet filling, vaccine wastage and various age group covering whether they are covering all the age groups or leaving and missing the small babies by checking the various age groups columns. 6. After checking the tally sheet and vaccine wastage the supervisor is supposed to follow the team for the next few houses and see the vaccination and IPC skill of the team and if there is any deficiency they should correct it on the spot. 7. In the end the supervisor should write his comments date and time on the tally sheet and go to check the next team/Team leader. 8. The supervisors were also trained in how to make a good supervisory plan by putting the time of checking the teams/team leaders like from this time to this time they will check team number 2 and then team number 3 and so on. They should spend more time with new or poor performers and comparatively less with the good ones as they need little help. They were advised to make such supervisory plan on daily basis and to leave one copy at their respective reference points so that other supervisors could easily check their tour routes. Team Leaders Training for the NID The team leaders of various administrative units were trained in the good ways of supervision and proper methods of team selection. Criteria for team selection 1. The team must have some experience of the NID or be previously trained. 2. Preferably should include at least one female member for the easy entry inside the house as in Sudan they don’t allow the male teams to enter into their houses. 3. The team should be selected from the local community so that to be familiar with the area of assignment and know the language and tradition of the community. 4. The team should be a mature adult person as the minor usually are not serious towards their responsibly 5. At least should be minimum literate to fill the tally sheet properly and be able to do simple calculations and door chalking 6. Be a motivated person to do the follow up of the missed children and other difficult tasks willingly 7. Should have a good communication skill to do IPC during the house to house vaccination. 8. They were also trained in the proper ways of teams checking in the morning before going to the field, in the field and while coming back to the center after finishing the day’s long work. Supervision during Campaign · All fixed sites transit sites and teams were supervised by the team leaders, administrative unit, locality, and state supervisors on daily basis the federal supervisors and the STOP Team also supervised the teams and checked the houses for the children coverage. · The field observation issues/problems were shared on daily basis in the evening meetings and corrective measures were planned and implemented. · The nomadic populations remained under special focus through out the campaign. · The refusals were also covered by the supervisors, state operational officer and the STOP Team. Post Campaign Monitoring · Independent monitors were trained to evaluate the coverage of the children less than 5 years. · The monitors were taken from education department NGOs and other personnel who were not involved in the campaign. · The monitors were also supervised by the STOP Team to check their area selection and the way they evaluate the coverage any deficiency was rectified on the spot. Final impression of the campaigns Positive Aspects: · The attendance in every locality remained almost 100 % in all category of trainings. · Social mobilization was very good both in the state level as well as in the administrative units’ level. · The government was fully committed and owned the program. · There was a good setup for the information delivery, the administrative units had a separate control room which was receiving the information from the grass root level and the feedback received was regularly sent forward to the locality control room and from here to the state control room and finally to the Federal Control room. · There was a regular evening meeting during the campaign to rectify the problems on daily basis. · The teams remained working in the field till late up to 4:30 pm showing a good commitment. · The team leaders were checking the teams and also the supervisors were objectively checking the team’s leaders and the teams and were filling their own checklists. Constrains: · No posters were sent by the Federal EPI cell to the Sennar state. · Except Red Cross and Red Crescent no other international organization like UNICEF, or Rotary international was involved to help or support our programme. · The trainers and teams supervisors were two different staff members which should be the same. Those who train the teams should also supervise the teams so that they know which team is weak and needs more support than the other. · Most of the teams were not having the team map with them. · Some teams were very poor in the IPC skills and they were not performing their duties well and were missing the children without properly recording their names and address especially in the Sennar State. · Most of the trainings were lecture type only; which is not the effective way of training. · The nomads were just put on the micro plan without a proper map and location so to search them was difficult especially for the campaign supervisors. Conclusive Summary Main Constrains: The main constrains in the Sennar State Routine, SIAs and AFP Surveillance system can be divided into the following main categories. (5 Ms) Man, Money, Material, Management and Migrations Man. (The EPI and the Surveillance Staff): The staff is insufficient in number to meet the system work load and demand and their knowledge is also inadequate. Money: (The Financial Problems) the incentives/salaries for the workers are very meager and it cannot meet their daily needs with this poor salary and hence they are not fully motivated to work willingly. Material: (The Logistics): The distances are long the roads are rough and the Vehicle are old and also less in number. Some of the Cold Chain Equipments in Sennar state are not working properly there were no posters and banners in the March NID in Sennar Sate. Management: The EPI Staff are managing double duties i.e. routine EPI as well as the AFP Surveillance duties and they are often found mystified about prioritizing their duties. Migrations: (The Nomadic and the internally displaced people) In the whole Sennar State frequent and unpredictable migrations of the internally displaced people and the nomads pose a great problem in the routine immunization, SIAs, AFP Surveillance and also in estimating the target age group. Recommendations: 1. Recruiting more staff to meet the high work demands. 2. The KAP (Knowledge, Attitude and Practice) of the existing staff should be improved by regular trainings. 3. The government needs to increase the budget for the crucially important programs of preventive health like EPI programme. 4. The programme needs more vehicle and the already working cars needs repair the Federal EPI Cell has to send all the social mobilization materials like Caps,Jackets,Banners , posters and other print material well before the campaign so to serve the purpose of sensitizing the public in time . 5. Some of the cold chain equipments needs repair to ensure vaccine safety. 6. The AFP and Routine EPI staff needs to be separated to assign specific person to the specific duty. 7. There should be special strategy for vaccinating the migrating people like 4 Ds Strategy/formula i.e. · Detect: Early detection of the IDP and nomads. · Determine: Determine the target age group. · Develop: Develop a good micro plan and Map. · Do: and do the vaccination as soon as possible. In addition to the above recommendations the community should also be sensitized about the importance of the immunization through Public Festivals, Behavior Change Communication (BCC) Seminars, IPC, by utilizing the print and electronic media like mosque announcements, Radio TV etc Except the international Red Cross and Red Crescent there is no base of any other international organizations like UNICEF, Rotary international in the Sennar State to help boost our activities I will suggest here to establish their bases/offices in the Sennar State to help the programme in boosting the social mobilization and the provision of the logistics etc. The training methodologies at all levels needs to be changed from the lecture type to the demonstrations, participatory/interactive and role plays/hands on practice as it is more effective way of training because when the teams and supervisors are given chances during the trainings to do some practical work imitating the actual work which they are supposed to do in their fields will have long lasting effects and is more effective than simply giving them lectures, as the famous Chinese Proverb reveals its importance When I hear I forget, When I see I remember, When I do I learn. The End STOP TEAM 24 PLAN OF ACTION Year 2007 Activities Planned April Mach February Month 4 3 2 1 4 3 2 1 4 3 2 Week Orientation and Briefing at Khartoum Meeting with MOH and administrators to plan STOP Mission Visiting various sentinel sites for supportive supervision/on spot training in AFP Surveillance Training of Doctors and other health workers in AFP,NNT and Measles Surveillance Supporting the state in the micro planning Conducting field Visits for 60 days follow up of the AFP cases Meeting with the community/Religious leaders to sensitize them regarding the importance of vaccination/PEI Supportive Supervision of the campaign and conducting PCM by the independent Monitors Attending the monthly health workers meetings. TOTs and Training for the polio vaccination staff Supportive supervision to the health facilities to strengthen the routine EPI activities in state Debriefing and submission of final report in Khartoum to the Federal EPI authorities. Finally a little bit of relief…… June 2, 2007 by drnraza Finally its June, the heat is on and i am finally free after hectic schedules of training in the last couple of weeks. My last activity was successfully concluding the Health Management Training Program for District and Agency TB Control Officers in NWFP, a Program which was sponsored by AGEG/ GTZ Strengthening TB Control Program in NWFP/ FATA, a dynamic program under the leadership of Dr. Sameh Youssef, a leading Public Health Expert from Egypt, and his team. Further details of the training are available from http://drnraza.editboard.com/Public-Health-Events-f16/Management-Training-Course- for-Provincial-TB-Control-Program-t105.htm Pages About Archives August 2008 June 2007 Categories Uncategorized (3) Blogroll WordPress.com WordPress.org Meta Log in Valid XHTML XFN WordPress Blog at WordPress.com. Entries (RSS) and Comments (RSS).