A glimpse at the planning and preparation needed to successfully implement schistosomiasis and soil-transmitted helminths control programmes

A lot of planning and preparation goes into the implementation of schistosomiasis (SCH) and soil-transmitted helminths (STH) control programmes. It is not as simple as turning up at a school with a pot of pills, asking a child to swallow their dose and then moving on to the next school. Here we are going to tell you about the preparation that went into the first mass drug administration (MDA) campaign in Ethiopia for SCH and STH, which took place in April 2015 and treated over 3 million children. These processes are standard SCI working procedure in all countries where we assist the Ministry of Health to successfully deliver a national SCH and STH control programme. Through such rigorous planning and preparation we ensure those most in need get treated as well as enabling SCI to demonstrate to donors and stakeholders the efficacy of the work being done to tackle these diseases.

In Ethiopia SCI has partnered with Evidence Action to provide technical and financial support to the Government of Ethiopia. Utilising the results from the national SCH and STH mapping programme (completed in March 2014 - please refer to article in SCI Newsletter December 2014 p.2) the treatment needs across the country were determined.  With the supply of available drugs far lower than the demand across Ethiopia, areas with a high burden of disease were prioritised. Once treatment areas had been selected it was possible to establish treatment numbers and calculate the amount of tablets required. It is at this point that the procurement process began. A request for donated tablets was submitted to the WHO. The tablets are generously donated by the pharmaceutical companies Merck KGaA (praziquantel) and Johnson & Johnson (mebendazole). The size of the April MDA campaign was constrained by the number of tablets of praziquantel available. Securing customs clearance, in-country distribution and suitable storage facilities completes the procurement process.

With insufficient tablets and funds to treat all those in need, the Ethiopia Federal Ministry of Health (FMoH) prioritised school-aged children (5-14 yeas old), opting for school-based treatment.  With over 3.4 million children targeted during this round of treatment, in 95 woredas (districts) with the highest burden of disease, considerable human resources were required. Training began with the Regional Planning Workshop, held in January 2015. The two main objectives of the workshop were to develop region-specific implementation plans and budgets, and to conduct the first stage of the training cascade – the Central Level Master Training. Representatives from the Regional Health and Education Bureaux of the five regions that took part in the April campaign (Amhara, Benishangul-Gumuz, Oromia, Somali, and SNNPR) attended this workshop, along with representatives from the Federal Ministries of Health and Education (FMoH and FMoE). The engagement of both health and education ministries is crucial as the platform used to deliver deworming treatment to children is school-based. The SCI provided technical and financial assistance to the workshop and key experts from the FMoH’s partners at Evidence Action – Deworm the World Initiative (Laban Kilui and Lorina Kagosha) attended and facilitated the meeting to share the experiences of the Kenyan deworming programme. 

The attendees at the workshop were introduced to the concepts and approaches to deworming, as well as undertaking role-playing exercises on completing the reporting and recording forms that have been developed for the programme. Prior to the campaign, the FMoH, with technical assistance from SCI and Evidence Action, developed recording and reporting forms, to help ensure accurate coverage data are available as soon as possible after the campaign as well as forms to record any serious adverse events (SAE). Fortunately SAE tend to be very rare for NTD control programmes, but ensuring a robust system is in place is crucial to ensure the programme is being effectively monitored.

The Central Level Training Workshop marked the start of the Training Cascade. Each region took the lessons and the materials from the central workshop and conducted regional level workshops which were attended by representatives from the zonal level, then zonal training which was attended by woreda representatives, and then woreda training which was attended by teachers and health extension workers (HEW), who are the ones actually conducting the treatment campaign. A team of one HEW and two teachers per school were recruited and received training in order to implement deworming. The HEWs administer the pills to the children, whilst the teachers are responsible for the logistics and organisation of the day, including registering the children.

Ensuring the target community know about the campaign and that school-aged children attend treatment is crucial. In order to achieve this, a social mobilization strategy was developed based on local expert knowledge and lessons learned from previous health campaigns in Ethiopia. The methods used to mobilise the communities included posters describing the infections, their symptoms and treatment (Figure 1); a radio play developed by experts at the FMoH which was broadcast several times during the 10 days prior to MDA; and vans with megaphones travelling through villages announcing when treatment is going to take place, who the treatment is for, what the treatment is and where to come and be treated. These activities culminate in an official launch event that demonstrates political commitment and attracts media interest. The launch event was held at specially chosen school in Oromia region, and was attended by central, regional, zonal, and woreda level officials (Figure 2). The FMoH and its partners prepared a press brief for distribution to the national and regional TV stations attending the launch.

In order to monitor the impact of the programme, baseline parasitological surveys are conducted to understand the level of infection prior to any treatment. Children from a representative number of sample schools are surveyed. These schools are chosen at random so they are not always easy to access, not that that prevents the teams getting there (Figure 3). Urine and stool samples are taken from 125 children at each of these schools to assess the level of infection (Figure 4).  These were conducted in February and March 2015, as close to the campaign itself as possible.

The results of this pre-treatment survey provide a baseline with which to compare the results from similar surveys in future years. The FMoH is utilising the SCI standard protocols that have been developed, implemented, and fine-tuned in many other SCI-supported countries over the last 12 years.

With all of the aforementioned preparations complete, teams of independent monitors observe the treatment campaign itself. As well as observing the campaign, these independent monitors interview students, teachers, and parents to identify ways in which future campaigns can be improved. Amongst other things they check the availability of sufficient drugs, the quality of staff training, the knowledge of children and adults of the infections, and their attitude to treatment.

Following the campaign coverage validation surveys will be conducted in a representative number of sites. These surveys involve interviewing all individuals in selected households to independently ascertain the programme treatment coverage figure. This is done to verify the accuracy of the reported treatment figure and ensure published results of the programme are as accurate as possible.

We look forward to reporting back the results as soon as they are available!