Strengthening health systems to restore and sustain child survival gains in the context of

Ebola: Case studies from Liberia

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Strengthening health systems to restore and sustain child survival gains in the context of

Ebola: Case studies from Liberia

© United Nations Children’s Fund (UNICEF), New York, 2015 Knowledge Management and Implementation Research Unit, Health Section, Programme Division UNICEF 3 UN Plaza, New York, NY 10017 October 2015 This is a working document. It has been prepared to facilitate the exchange of knowledge and to stimulate discussion. The findings, interpretations and conclusions expressed in this paper are those of the authors and do not necessarily reflect the policies or views of UNICEF or the United Nations. The text has not been edited to official publication standards, and UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. The editors of the series are Alyssa Sharkey and David Hipgrave of UNICEF Programme Division. For more information on the series, or to submit a working paper, please contact asharkey@unicef.org or dhipgrave@unicef.org.

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Strengthening health systems to

restore and sustain child survival

gains in the context of Ebola: Case

studies from Liberia

__________________________________

Aline Simen-Kapeu, Katherine Faigao, Patrick Sijenyi, Anthony Asije,

Yulia Widiati, Emilia Raila, Anthony Yeakpalah, Tima S. Brewah,

Ngashi Ngongo, Kamrul Islam

Keywords: Liberia, Ebola, maternal health, newborn health, child health, nutrition, water

and sanitation, communication, health system strengthening, mop up campaign

Comments on the studies may be addressed by email to: askapeu@unicef.org cc: asharkey@unicef.org

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Table of Contents ACKNOWLEDGEMENTS……………………………………………………………………………………………………………………. 1

ABBREVIATIONS …………………………………………………………………………………………………………………………….…2

BACKGROUND ........................................................................................................................................ 4

STRENGTHENING FACILITY-BASED SERVICES ........................................................................................ 5

Integrating infection prevention and control into routine maternal and newborn care ....................... 6

Safe management of sewage from Ebola Treatment Units .................................................................. 12

Delivery of nutritional interventions to Ebola affected populations .................................................... 16

STRENGTHENING OUTREACH SERVICES .............................................................................................. 20

Expanding integrated measles campaign through a four-prong communication strategy .................. 21

Getting to and sustaining zero: the integrated Ebola Virus Disease mop-up strategy ......................... 27

STRENGTHENING COMMUNITY-BASED SERVICES .............................................................................. 31

Implementing integrated community case management of childhood illnesses with infection

prevention and control measures ......................................................................................................... 32

Integrated Infant and Young Child feeding and care interventions for a comprehensive child welfare

services .................................................................................................................................................. 35

RECOMMENDATIONS ........................................................................................................................... 38

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Acknowledgements

The authors would like to express their special thanks to Sheldon Yett (UNICEF Representative) and

Fazlul Haque (UNICEF Deputy Representative) for their endless support and strategic guidance during

the development of these case studies.

We are grateful to all UNICEF colleagues in Liberia Country Office who have contributed to the

development and review of the case studies. We specially acknowledge the contribution of Deirdre

Kiernan (UNICEF Senior Emergency Coordinator). The technical review conducted by colleagues in the

UNICEF West and Central Africa Regional Office and New York Headquarters is highly appreciated.

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Abbreviations ACF Action Contre La Faim

ARI Acute Respiratory Infection

CCM Community Case Management

CDC Centers for Disease Control and Prevention

CHT County Health Team

CHV Community Health Volunteer

CHW Community Health Worker

CHX Chlorhexidine

DHO District Health Officer

ECEB Essential Care for Every Baby

EIA Environmental Impact Assessment

ELWA Eternal Love Winning Africa

EPA Environmental Protection Agency

EPI Expanded Programme on Immunization

ETU Ebola Treatment Unit

EVD Ebola Virus Disease

gCHV General Community Health Volunteer

GoL Government of Liberia

HBB Helping Babies Breathe

HBMNC Home-based Maternal and Newborn Care

IPC Infection Prevention and Control

iCCM Integrated Community Case Management

ICRC International Committee of the Red Cross

IMAM Integrated Management of Acute Malnutrition

IMC Integrated Measles Campaign

IMC International Medical Corps

ITN Insecticide Treated Net

KMC Kangaroo Mother Care

LDHS Liberia Demographic and Health Survey

LWSC Liberia Water and Sewer Corporation

MCV1 Measles Containing Vaccine 1st dose

MCC Monrovia City Corporation

MNCH Maternal, Newborn, and Child Health

MoU Memorandum of Understanding

MoD Ministry of Defence

MoH Ministry of Health

MPW Ministry of Public Works

MSF Medécins Sans Frontières

M&E Monitoring and Evaluation

MUAC Mid-upper Arm Circumference

NGO Non-governmental Organization

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OIC Officer-in-Charge

OPV Oral Polio Vaccine

PMU Pentecostal Mission Unlimited

PIRI Periodic Intensification of Routine Immunization

PPE Personal Protective Equipment

PPH Postpartum Haemorrhage

RUTF Ready-to-use Therapeutic Food

RMNCH Reproductive Maternal Newborn Child Health

SIA Supplementary Immunization Activities

SOP Standard Operation Procedure

TTM Trained Traditional Midwife

ToT Training of Trainers

UNICEF United Nations Children’s Fund

WASH Water Sanitation and Hygiene

WFP World Food Programme

WHO World Health Organization

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Liberia made significant progress in terms of reducing under-five mortality rate from 222 per 1,000 deaths

in 1986 to 94 per 1,000 deaths in 2013; the newborn mortality slightly dropped from 68 per 1,000 deaths

to 26 per 1,000 deaths (LDHS 2013). On the other hand, the maternal mortality ratio rise up to 1,072

deaths per 100,000 live births (LDHS 2013), higher than 2007 LDHS figure: 994 per 100, 000 live births.

Mortality of children under five years remains high in Liberia despite the efforts made. Newborn

vulnerability is further exacerbated by the fact that a substantive number of deliveries occur at home

(39%) without the assistance of a skilled birth attendant. Infections contribute to high childhood mortality

as neonatal causes (including sepsis), pneumonia, malaria and diarrheal diseases, together account for

almost 70% of childhood deaths (Situational Analysis of Newborn Health, MoH 2013). Malnutrition is the

underlying cause for one third of child deaths; the current rate of chronic malnutrition is high at 32% (2013

LDHS). The 2011 Liberia National Micronutrient Survey reported that anaemia among children 6-35

months of age is alarmingly high at 59.1% putting these young children at risk of infections, poor growth

and development.

In 2014 the Ebola Virus Disease (EVD) Epidemic devastated the already fragile healthcare system in Liberia.

On 9 May 2015, the MoH reported a total of 10,821 suspected, probable, and confirmed cases with 4,785

deaths. Health workers were most at risk of contracting the disease, with a total of 192 deaths in the

health sector, an extraordinary loss given the few number of skilled health workers in the country. Women

and children were disproportionately affected by the crisis beyond EVD itself with 43% decline in antenatal

visits, 38% in institutional deliveries, 45% in measles, and 53% in DTP3 vaccinations between August and

December 2014 compared to the same period in 2013 (MoH, 2015). This drop in service utilization was

most likely due to closing of health facilities by scared health professionals and the mistrust of

communities toward the healthcare system as the source of EVD spread Health facilities, from the

beginning, were not well designed; they were insufficiently and inappropriately staffed and too poorly

equipped to provide the necessary occupational and patient safety needed for the delivery of effective

health services. The 2014 health facility assessment shows that, out of a total 657 health facilities, 20% do

not have any protected source of water on site; 10% have no functioning sanitation facilities; 37% do not

have functioning incinerators and that the operation and maintenance of existing water, sanitation, and

hand hygiene (WASH) systems in health facilities remain a major challenge.

There is a great need to (1) restore and continuously sustain implementation of equity-focused health,

nutrition, and WASH interventions and (2) strongly engage communities to facilitate the interface

between supply and demand during the EVD outbreak and recovery periods. Only by creating demand for

care with restauration of trust among communities and ensuring access to and delivery of equity-focused

integrated high-impact interventions through universal facility-based services, universal outreach

services, plus universal community care, can we significantly reduce preventable maternal, newborn and

child deaths. In addition, quality health service provision requires infection prevention and control (IPC)

measures.

BACKGROUND

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Strengthening Facility-based Services

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INTRODUCTION

Intrapartum complications constitute an important cause of death in the newborn period, and in some

cases can have long effect and lead to lifetime consequence. While the needs for an effective response

includes skilled birth attendance and resuscitation of affected babies, prevention requires improved

care during labor, delivery and beyond, especially in the first 90 minutes.

The EVD outbreak exposed the weakness of health system in Liberia. One of the key bottlenecks which

continues to impede the efforts to reduce maternal and newborn mortality and morbidity is the

inadequate number of skilled health workers able to deal with the emergency situation and their lack

of skills/knowledge to give essential care that can improve the survival of the babies. The other

challenge is that health facilities very often do not have commodities, equipment or logistic support

to ensure an adequate response to keep the baby alive. Regular shortage of drugs such as

corticosteroids and antibiotics contribute to neonatal mortality due to prematurity and sepsis. In

addition, infection prevention and control (IPC) protocols in the health facilities and among the health

care workers are not defined and consistently implemented. Health care workers do not consistently

apply the universal safety precautions; there is not enough supplies in some health centres to prevent

contamination between health professional workers and the patients, and when supplies are present,

they are not routinely used. There is poor infrastructure design and support to run efficient and safety

services including clean water and electricity.

The response to the need of mothers and their newborn(s) extend beyond the EVD and, despite earlier

progress in reducing child mortality, many challenges remain. There is undeniable requirement to

strengthen IPC in routine maternal and neonatal care.

IMPLEMENTATION

The Government of Liberia (GoL) received

technical and financial assistance from many

donors and partners, including UNICEF, to

strengthen the EVD outbreak response. For all

sectors including health, task forces were led by

the GoL and co-chaired by respective partner

organization. UNICEF was part of the IPC Task

Force, along with WHO, CDC and partners, and

contributed to the provision of quality maternal,

neonatal and child health (MNCH) interventions,

INTEGRATING INFECTION PREVENTION AND

CONTROL INTO ROUTINE MATERNAL AND

NEONATAL CARE

Challenges Limited MoH capacity to enforce and sustain

implementation of IPC guidelines in all health facilities

Inadequate storage capacity of regional warehouses causing delays in the distribution of IPC materials

Poor supply chain system due to establishment of parallel mechanisms for the Ebola response

Inadequate supportive supervision to monitor and sustain behaviour change among health workers following IPC training

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including IPC, across the country. The three key strategic interventions included:

Ensuring an enabling environment: leadership and adequate coordination between technical

experts from central, county, district levels during planning phase and training of cadres;

development of IPC policies, protocols and guidelines to be used at the facility and community

levels. WHO provided technical guidance to the IPC Task Force on the development of guidelines

and protocols; UNICEF contributed to the review of documents and committed to print the IPC

materials once developed; these included posters, Standard Operational Procedures (SOPs) for

health facilities, Ebola IPC Training for Hospital, Health Centers, and Health Clinics (Flipbook) and

Ebola IPC in health facilities job aids.

Strengthening the procurement and supply chain: technical support to the MoH in the

procurement and distribution of essential drugs, commodities, and IPC supplies for all health

facilities and selected private hospitals across the country through the county health teams.

Capacity building of health workers: support training of health care workers in emergency

maternal and newborn care to maintain the routine safe delivery of essential package of health

services, including implementation of IPC measures.

RESULTS

Enabling environment to implement IPC measures

The MoH and partners reviewed policies, protocol, guidelines, and job aids for MNCH to emphasize

the importance of IPC. For example, in addition to hand washing with soap and water, the protocol

suggests to use 0.05% chlorine solution and also enhanced Personal Protective Equipment (PPE) for

health works dealing with patients with blood and body fluids, especially when assisting delivery4.

As part of the IPC task force, UNICEF contributed to the technical discussions for the review of policy

documents to include the IPC component during the delivery of health services at the facility and

community levels. In addition, a total of 36,400 posters, 1,400 SOPs, 700 Flipbooks and 1,400 book

were designed, printed, and distributed to 657 health facilities in Liberia (36 hospitals, 47 health

centers, and 574 health clinics) during the EVD outbreak to increase knowledge on IPC measures.

Additional IPC materials were also printed by the US Center for Disease Control and Prevention.

As a result of fears and community distrust, many sick people including mothers and their children,

sought help from the community health volunteers (CHVs). To avoid CHVs getting infected with EVD,

the MoH agreed to implement the “No touch” guidelines for CHVs working in the counties IN October

2014. This adoption was in line with WHO and UNICEF No Touch Policy for CHVs providing Integrated

Community Case Management (ICCM) services1.

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Increased availability of IPC materials and midwifery kits

To ensure implementation of new IPC guidelines, IPC

materials should be available in all facilities. The World

Health Organization (WHO), UNICEF, and partners

supported the MoH in the procurement and distribution of

IPC materials. Specifically, UNICEF worked with the GoL and

NGOs partners to strengthen the procurement, supply,

distribution and management system from national to

health facility levels, including increasing the availability and

management of warehouses at the national and county

levels; this also included improving the last mile distribution

of maternal and newborn essential commodities and IPC

supplies such as examination gloves, aprons, impermeable

gowns, surgical gowns, gyne-gloves, and biohazard bags.

Integrating IPC module in RMNCH trainings for health workers at all levels

Training on Caring for Mothers and Babies at Home

In 2014, UNICEF supported the Family Health Division, MoH to conduct the “Caring for Mothers and

Babies at Home” training which consist of 3 components: Home-based Maternal and Newborn Care

(HBMNC), Chlorhexidine for umbilical cord care, and Kangaroo Mother Care (KMC) for stable small

babies. First the training of trainers (ToT) for health care workers was conducted followed by the

training for Community Health Volunteers (CHVs) in April 2014. In Maryland, 27 health workers (24

from health facilities and 3 from Maryland county health team) and 48 CHVs (gCHVs and Traditional

trained midwives (TTMs)) were trained. In Grand Gedeh, 21 health workers (18 from health facilities

and 3 from Grand Gedeh county health team) and 36 CHVs (gCHVs and traditional trained midwives)

were trained.

In December 2014 after the peak of the EVD outbreak, UNICEF

supported a similar training in Sinoe County, and in that time, the

training included the new IPC component to ensure that both

health workers and the CHVs continue to provide services more

safely (the slogan is “Keep Safe, Keep Serving”). The training

included the “Guide to the provision of safe delivery and

immediate newborn care in the context of an Ebola outbreak”4

and “No touch guidelines for CHVs1”. Thirty eight health workers

(33 from 23 health facilities and 5 from Sinoe CHT) and 103 CHVs

(gCHVs and TTMs) have been trained. The training included

demonstration on using the enhance PPE which is the important

part of IPC during assisting delivery in EVD context.

From observation during the training and reflections from the evaluation, the IPC module seemed to

be not too straightforward for only 3 participants. The most challenging topic was the introduction of

Photo 2: HBMNC training of HCWs in December 2014 – Demonstration during the IPC module

Photo 1: A baby born in a Hospital in June 2014 in Maryland. The baby received umbilical cord care with chlorhexidine gel 7.1% and was breastfed within an hour after birth.

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monitoring and evaluation tools most likely due to the counting of the visitation day (which is different

from normal weight and low-birth weight babies) and understanding and filling the forms. However,

the majority of the trainees reported that all modules were either very easy or easy to understand,

especially the use of CHX for cord care, care for mothers, hand washing, exclusive breastfeeding,

promotion of antenatal care, and facility delivery. The trainees expressed their gratitude for the

opportunity to learn and improve their skills and knowledge for the benefits of their communities.

Figure 1 presents the results of the post-test evaluation for the 38 health workers in Sinoe County.

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Figure 1: Participant understanding regarding the training topic, caring for mothers and babies at home, for Health Workers in Sinoe County, December 2014

0 5 10 15 20 25 30 35 40

Course Overview

Introduction

Interacting with Families

Identifying pregnant women in the community

Promote Antenatal Care

Do and Don’t in the community for CHVs

Promote Facility Delivery

Post Natal Home Visit

Infection Prevention and Control in Health Facilities

Exclusive Breastfeeding

Care of the Normal Babies

Kangaroo Mother Care (KMC) for small babies

Hand Washing

Use of Chlorhexidine for Cord Care

Danger Signs in the Newborn

Care of the Mothers

Assist with Referrals

M&E Tools Introduction to Field Visits

Practice the Facilitator Skills for the Trainer

Field Visit Practice/Demonstration

Review task of Trainers and CHVs

Very Easy to Understand Easy to Understand Not Easy Not Difficult Difficult to understand Very Difficult to understand

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Training on Helping Babies Survive

UNICEF also supported the MoH to conduct the training to improve the skills and knowledge of HCWs

on “helping babies survive”, which includes an IPC component. The training combined the Helping

Babies Breathe (HBB), which deal with the first “golden” minutes, and Essential Care for Every Baby

(ECEB) for the first 90 minutes and beyond. The first training organized by the national level was the

ToT for all counties to train master trainers at the county level. UNICEF subsequently equipped all the

15 counties with the training materials including the NeoNatalie Newborn Simulator, poster, provider

guide, and flipchart. Following the ToT, experts from the central and county levels organized the

cascade training in Grand Gedeh and Sinoe Counties and participants included nurses, midwives, and

physician assistants. A total of 30 health professionals in Grand Gedeh County and 38 health

professionals in Sinoe County were trained and all health facilities including hospitals (in Grand Gedeh

and Sinoe) received newborn resuscitation kits. After the training, all participants concluded that the

training met their expectations and they will disseminate the skills gained from the training to their

colleagues back home in their respective working places1.

The knowledge and skills of health workers were evaluated before and after the “helping babies

survive” training sessions. The analyses of individual scores from health care workers showed a great

increase in acquisition of skills and knowledge at the end of both, ToT and cascade training sessions.

Table 1: Helping Babies Survive pre-test and post-test evaluations

LESSONS LEARNED Flexibility of MoH to rapidly adapt policies in the midst of an outbreak (eg: no touch policy). The

MoH is reviewing all trainings modules to include the IPC component for health workers and

community health workers/volunteers providing direct care and support2.

Behavior change among health workers is progressive: the lessons from the field showed that that

it takes up to 8 training sessions (including in-service training) on IPC to successfully change the

behaviour of targeted health workers and ensure constant application of IPC protocols.

Increasing the time for practical sessions or exercises is important to ensure full understanding of

all advanced modules, such as the M&E module. Supportive supervision should also be

strengthened to ensure adequate reporting.

Availability of IPC materials and equipment should be ensured when enforcing implementation of

IPC protocols and guidelines in health facilities through supportive supervision.

Good leadership and coordination from the central level down the county, district, and

community level is required to enhance action.

1 Ministry of Health - Republic of Liberia. (2014). A guide to the provision of safe delivery and immediate newborn care in the context of an Ebola outbreak. Monrovia: UNICEF, WHO and Save the Children. 2 Ministry of Health - Republic of Liberia. (2014). No Touch Guidelines for CHVs in the Counties. Monrovia.

County Training type

Number of HCWs trained and evaluated

Average score

pretest post-test

Gbarnga ToT 48 72% 96%

Grand Gedeh Cascade trainings

30 77% 90%

Sinoe 38 70% 94%

Table 1: Helping Babies Survive pre-test and post-test evaluations

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INTRODUCTION Management of sewage from Ebola Treatment Units (ETUs) is an important component in Ebola

emergency response. The EVD disease is associated with the higher generation of both liquid and solid

EVD infected waste that require utmost care and effectiveness in their disposal process. As a result,

UNICEF continues to support the GoL to safely collect, transport and store Ebola contaminated sewage

from ETUs in Monrovia. The single aim of this intervention is to avoid potential infection to sanitation

workers, the general community and contamination of the environment. Liberia Water and Sewer

Corporation (LWSC), a governmental agency responsible for the safe collection and disposal of

wastewater in the country is leading the process of desludging Ebola contaminated sewage in

Monrovia.

IMPLEMENTATION

Integrating IPC measures into the design, operational and maintenance of WASH facilities

A major approach during the EVD was incorporating IPC measures in the design, operational and

maintenance of WASH facilities. The aim was to prevent healthcare workers and community from

being infected with EVD. UNICEF Liberia in collaboration with partners, established and implemented

the minimum design criteria for WASH facilities which

included the following interventions:

Ensure provision of direct supply of 0.5% chlorine

solution for flushing faecal matter, disinfection and

laundry activities.

Construct and install septic tanks, lined latrines,

holding tanks or poly tanks in areas with high water

table and a series of pit latrines for areas with the low

water table.

Locate sewage collecting facilities in areas outside the

red zone and construct barriers to prevent

unauthorized access.

Other Activities included:

Install a Poly vinyl chloride suction pipe to help avoid a need to opening the manhole during the

desludging process and fixed it with a ball valve to prevent splashes to the crew by sucking air

before decoupling hoses.

Construct IPC facilities in Fiamah community including truck platform with disinfection

capabilities, on-site changing room, waste disposal facilities, spill sumps, shower and toilet

facilities to ensure IPC measures.

SAFE MANAGEMENT OF SEWAGE FROM EBOLA

TREATMENT UNITS (ETUs)

Photo 1: LWSC crew desludging Ebola contaminated sewage at Unity Centre ETU in Monrovia

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Capacity building to GoL to safely manage sewage from ETUs

UNICEF strengthened the capacity of the GoL by providing skills, guidance, equipment, tools, and funds

to LWSC for the safe management of sewage from ETUs. This included:

Guidance in formulating a multi-sectoral monitoring group. The body drew membership from

Ministry of Health (MOH), Ministry of Public Works, Monrovia City Corporation (MCC),

Environmental Protection Agency (EPA) and Fiamah Community. UNICEF equipped the monitoring

group with skills to assess worker safety,

environmental and social Impact or hazards and the

mitigation measures.

Provision of three sewer trucks and two vehicles to

LWSC. One of the vehicles (pick up) was used as an

escort vehicle and it carried sprayers, generators,

suction pipes etc. that was used by the team. The

other vehicle was assigned to the multi-stakeholder

monitoring team. This team comprised of

representatives from LWSC, MCC, EPA, MoH, MPW

and representative from Fiamah community. Other

supplies/equipment provided include poly tanks,

sprayers, generators, pumps, a washing machine, and personal protective equipment.

Training of 25 LWSC workers on the safety protocols, hygiene, safe donning and doffing of PPE,

IPC measures including decontamination of sewer trucks, ground surfaces, and working tools,

management of splashes and spills.

Additional interventions included:

Creating community awareness and mobilization towards safe sanitation: Fiamah communities lost

access to compound which served as defecation area, a place for farming, and pedestrian

pathway/access route for the surrounding community. In response to this, and with UNICEF support,

the Mayor of Monrovia led community awareness and sensitization campaigns including production

and broadcasting of radio jingles, and appearance on radio talk shows by community leaders,

mobilizing community and undertaking drainage cleaning exercise and in planning for construction of

public toilets (whose construction is now being undertaken with support from UNICEF).

In addition to the above, emphasis was placed on

involving leaders, influential person and the entire

Fiamah community member’s right from the initial

planning phase of this intervention. Through the formed

public awareness committee, door to door awareness

raising and sensitization campaigns were conducted not

only on EVD, but also on the planned utilization of the

waste water treatment plant located within their

community as a final disposal site for the waste. These

measures resulted to the community getting actively

engaged in the development, validation and dissemination of safety protocols for the safe collection

and disposal of Ebola contaminates sewage, EIA and mitigation measures. Likewise, they were in

Photo 2: LWSC technicians at UNICEF compound inspecting spare parts for the 3 sewer trucks donated to the Government of Liberia

Challenges Lack of scientific data on the deactivation of

Ebola virus in fecal matters

Initial public opposition to the use of the old digester facility at Fiamah to receive Ebola waste because of fear from the community about this deadly disease.

Poor state of the Fiamah Treatment plant (e.g. stabilisation ponds, lack of controlled access to the Fiamah Plant etc.) raises both public and environmental health concerns.

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charge of site assessments, pilot desludging operations, and were represented in the monitoring and

supervision of desludging processes.

Separately, and as part of the training that was conducted for the LWSC crew, the leaders of Fiamah

community were also trained and subsequently six were identified as monitors who then formed part

of the daily monitoring team. This team was responsible for informing and updating the community

on relevant information (community right to know, sensitization, etc.)

Safe disposal of solid and liquid EVD infected waste: use of an on-site disposal of used personal

protective gear at ETUs and Fiamah was emphasized as a way to avoid the risk of infections during

transportation of solid EVD infected waste. Tools and disposal facilities were installed to allow disposal

of used PPE.

Building partnership and collaboration in developing and implementing safety protocols for the

management of sewage from ETUs: UNICEF played an important role in bringing together in-country

WASH partners (WHO, CDC, OFDA, ICRC, MPW) towards the safe management of EVD contaminated

sewage in Monrovia. The safety protocols developed adhere to the most recent WHO/UNICEF

technical guidance on IPC and waste management.

RESULTS

Safe management of sewage from ETUs: this was achieved through the availability of IPC

integrated WASH facilities and equipment for transporting sewage from ETUs. Likewise, effective

supportive supervision by the monitoring team with members from Fiamah community allowed

smooth operations. Figure 1 below indicates the volume of sewage collected as of June 02, 2015.

Figure 1: Total Gallons of sewage collected from ETUs in Monrovia as of June 02, 2015

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Enhanced occupational health and safety measures: No EVD infections reported among LWSC

crew. They are currently observing safety measures and integrating them into their normal

desludging operations.

Integration of safety protocols, monitoring actions and tools into daily sewage disposal

activities: The development of the safety protocols, and subsequent adoption of safety protocols

among LWSC crew steered its integration into daily operations. The IPC component formed the

pillar of the developed protocols. Accordingly, various monitoring tools are parts of the protocols

and these are used by GoL to monitor regular desludging operations for leakage, environmental

contamination and occupational health of LWSC crew. Over and above the LWSC desludging crew,

the presence of a multi sectoral monitoring team (comprising of representatives from MoH, MPW,

LWSC, MCC, EPA and Fiamah community) provided the much needed oversight to ensure

compliance/adherence to the safety protocols, specifically during the three critical steps (i.e.

waste water collection at ETUs, transportation, and final discharge into storage tanks at Fiamah)

by the desludging crew.

Active partnership beyond Ebola emergency response phase: In early recovery and resilience

building phase, UNICEF to support implementation of WASH interventions in health facilities.

LESSONS LEARNED

Capacity building enhances commitment: capacity

building of LSWC staff ensure adequate management of

sewage in the ETU.

Leadership, partnership and collaboration facilitated

the safe disposal of EVD infected sewage: UNICEF’s

efforts of involving WASH partners in the country and at

global level led to great achievements, as partners

brought in vast experience on how to deal with EVD

contaminated sewage.

Community engagement is a powerful tool in Ebola

emergency response: The recognition of the role the community has to play in this intervention

from the outset was key. As a first step, seeking the buy in and working through established

structures (MCC and LWSC) were key in gaining entry and engaging with community (both MCC

and LWSC have long interactions and networks among and within the community); these

strategies were explored and put to use. As a result community was actively involved in the

development, validation and dissemination of safety protocols for the safe collection and disposal

of Ebola contaminates sewage and mitigation measures. Likewise, they were in charge of site

assessments, pilot desludging operations, monitoring and supervision of desludging processes.

Effective communication among partners enhanced safety and enabled prompt desludging of

overflowing materials from septic tanks at various ETUs.

Insufficient information on EVD infected waste disposal required continued learning:

Development of safety protocols for collection, transport and disposal of EVD contaminated

sewage, necessary interventions and EVD waste monitoring activities require continuous learning,

documentation and sharing of experiences.

Photo 3: UNICEF representative Sheldon Yett

responding to queries raised by Fiamah community

members during trial desludging operations at Fiamah, Monrovia

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INTRODUCTION

With the emergence of the Ebola Virus Disease (EVD) outbreak in Liberia, the comprehensive multi-

sector approach management and treatment of EVD patients is not just a necessity but a priority.

Nutrition plays an important role in the prevention, management, and treatment of diseases affecting

the most vulnerable population.

Sound nutritional care and support based on clinical signs, symptoms, and other conditions of EVD

affected population that complements effective application of clinical protocols and strict adherence

to IPC measures contribute to quality treatment and influences survival.

IMPLEMENTATION

Nutritional Care and Support to Patients in Ebola Treatment and Care Centers

The nutrition programme for EVD affected populations required developing guidelines to guide service

delivery, strengthen capacity of key actors on effectively assessing appropriate nutrition support

based on the conditions of the affected individual, and ensure safe preparation and utilization of food

and other nutritional commodities. For the nutritional care and support to patients in Ebola treatment

and care centers, and treatment of severely malnourished children in the context of Ebola, guideline

development provided the foundation for implementation.

In November 2014, the Nutrition Cluster (co-chaired by UNICEF) worked closely with the Health

Cluster in developing, integrating, and implementing a protocol on nutritional management of

patients admitted in Ebola treatment and care centers3. The process involved key partners managing

Ebola Treatment Centers in Montserrado such as ICRC and WHO. By mid- December 2014, 30 clinicians

who served as nutrition focal points in three Ebola Treatment Units in Monrovia (ELWA 1, ELWA 3,

and MoD1) with high bed capacity were oriented on the

clinical protocols including the practical day to day

management of the nutrition services in the facilities. Five

caregivers of the interim care center were also trained on

the protocol with much focus on providing nutrition

support and care to children under-five4, and the

preparation and use of the therapeutic and special

nutrition commodities.

3 Health Cluster. (2014). Liberia Ebola Virus Disease Clinical Management Manual. Monrovia: Ministry of Health. 4 Ministry of Health - Republic of Liberia. (2014). Updated Guidelines on Infant and Young Child Feeding in an Emergency. Monrovia: Ministry of Health and UNICEF.

DELIVERY OF NUTRITIONAL INTERVENTIONS TO

EBOLA AFFECTED POPULATION

Challenges Not clear division of labor between

various coordination committees

Limited human resources capacity of the MoH Nutrition Division

Poor monitoring of key nutrition related activities in Ebola Care Centers

17

Supplementary, therapeutic and special nutrition commodities were supplied to treatment and care

centers by UNICEF and WFP. This was to ensure dietary requirements of patients are met. To

complement the range of nutrition products provided to the patient, family foods were also provided.

Catering companies that were contracted to prepare and supply family foods were screened, oriented

and supervised by the Ebola Operations Center – Catering Services Unit in collaboration with the MoH/

Nutrition Division. This was to ensure food safety guidelines are adhered, and minimum dietary

requirements from the family food according to the protocol are met5. Nutritional support to infants

who cannot be breastfed using ready to use infant formula have been provided to infants below 12

months, and the implementation and results of the intervention have been described in detail in the

Strengthening Community Services section of this compendium of case studies.

Treatment of Severe Acute Malnutrition in Counties Highly Affected by Ebola

The EVD outbreak like any emergency situation poses an elevated

and immediate risk of death especially among children under five

who, apart from the emergency situation, suffer the greatest from

the effects of malnutrition and diseases. In emergency settings,

there is an elevated risk for childhood infections. Malnutrition is also

usually highly prevalent as observed during the disruption of

nutrition service delivery in health facilities at the height of Ebola

crisis from August to October 2014. Children who suffer from severe

acute malnutrition are 5 to 20 times at risk of dying if left untreated.

Meeting the specific nutritional needs and health care requirements

of children under five during emergencies remains a priority.

The Nutrition Cluster made modifications on the national protocol

of management of severe acute malnutrition with emphasis on IPC,

and set out to orient health workers and reactivate nutrition services

in nutrition treatment facilities. The main modifications on the

protocol were: (1) use of basic PPE by health workers; (2)

anthropometric screening limited to MUAC only at the health

facility; (3) use of one MUAC tape per child per visit; and (4) bi-

weekly ration of RUTF instead of weekly.6

From November 2014 to March 2015, 6 County Nutrition Supervisors, and 111 health workers Bomi,

Bong, Lofa, Margibi, Montserrado, and Nimba were oriented. All 61 nutrition treatment facilities in

the six counties highly affected by Ebola were reactivated. One new inpatient facility in Montserrado

was established and managed by MSF and supported by UNICEF.

5 Ministry of Health - Republic of Liberia. (2014). Guidelines on Nutritional Care and Support for EVD Patients in Treatment Units and Care Centers. Monrovia:

Nutrition Cluster. 6 National Nutrition Coordination Committee. (2014). Modifications on IMAM Protocols and Procedures during Ebola in Affected Counties. [Pamphlet]. Monrovia: Ministry of Health.

Photo 1: 3-year old Melvin William from Bong County was suffering from severe acute malnutrition with oedema when he admitted in Phebe Hospital last March 2015. He was discharged from the hospital after 2 weeks and received continuous outpatient nutrition treatment services

18

RESULTS

Nutritional Care and Support to Patients in Ebola Treatment and Care Centers

From November 2014 until February 2015, 10 cartons of therapeutic milk F-75, 196 cartons of ready

to use therapeutic biscuits, 40 cartons of ready to use therapeutic spread and 399 bottles of ready to

use infant formula were pre-positioned for use to patients admitted in treatment and care centers.

Throughout this period, 86% of patients admitted7 in 19 Ebola treatment and care centers in 12

counties were known to receive comprehensive nutritional support and care package for the duration

of their stay in the facility, based on the availability of catering services, supplementary, therapeutic

and special nutritional products.

Table 1: Reported Patient Admissions in Ebola Treatment and Care Centers per County with Known Comprehensive Nutritional Support and Care Package from November 2014 to February 2015

COUNTY Treatment/ Care Center

Location 2014 Admission 2015 Admission Total per

County Nov Dec Jan Feb

Bomi Tubmanburg 11 16 20 14 61

Bong Suakoko 21 51 9 0 81

Gbarpolu Bopolu 0 0 0 1 1

Lofa Foya 0 3 3 1 7

Margibi

Dolo’s Town 0 1 0 0 1

Firestone 22 5 0 0 27

Kakata 0 0 50 43 93

Maryland Harper 0 0 0 2 2

Montserrado

ELWA 2 23 48 17 65 153

ELWA 3 28 99 51 15 193

Island Clinic 30 54 7 0 91

MoD 1 48 70 58 5 181

Unity Conference Center 3 8 12 0 23

Nimba Ganta 2 16 0 0 18

Sinoe Juaryen Clinic 0 4 2 0 6 Total Admission per Month of Treatment and Care

Centers with Known Comprehensive Nutritional Care and Support Package

188 375 229 146 938

Grand Cape Mount

Sinjeh 0 2 16 2 20

Margibi Monrovia Medical Unit 0 19 8 3 30

Montserrado MoD 2 0 0 0 2 2

SKD Chinese 0 44 34 20 98 Total Admission per Month of Treatment and Care Centers with Unknown Comprehensive Nutritional

Care and Support Package 0 65 58 27 150

Total Admission per Month 188 440 287 173 1,088

Treatment of Severe Acute Malnutrition in Counties Highly Affected by Ebola

There was a gradual and steady increase in admission as nutrition treatment activities were

reactivated. A total of 6,269 severely malnourished children from the six counties highly affected by

Ebola were admitted to the programme from September 2014 to July 2015. Because it is a highly

7 Note that patient admission reported beyond February 2015 in Ebola treatment and care centers were outpatient (tested and discharged within a day) and not inpatient thus did not require nutritional care and support

19

populated county, admissions from Montserrado account for about 43% of the total admissions from

the six counties.

The overall burden of severe acute malnutrition in the six counties for a year is estimated at 23,000

cases. So far, only 27% of the children expected to suffer from severe acute malnutrition have been

identified and admitted in the programme. Of the six counties, it is only Nimba and Montserrado

counties with a coverage rate of 57% and 42% respectively that are on track to achieve the minimum

recommended coverage for ≥50% for rural areas and ≥70% for urban areas as per the SPHERE

standards. Bong county coverage rate is the lowest at merely 14%. Out of the 6,269 severely

malnourished children admitted in the programme, 4,841 (77%) were discharged from the

programme. Around 95% (4,599) of those discharged were cured and 2% (97) did not respond to

treatment.

Figure 1: Admissions of Severely Malnourished Children in Nutrition Treatment Facilities in Six Counties Highly Affected by Ebola from Sep 2014 to Jul 2015

LESSONS LEARNED

Strong cooperation of Nutrition Cluster Members and the Cluster’s close collaboration with the

Health Cluster facilitated the timely development and implementation of guidelines and

protocols, and ensured standardized delivery of nutritional care and support.

The unclear role and coordination between Ebola Operations Center, Catering Services, and MoH/

Nutrition Division led to lost opportunities to appropriately document nutritional care and support

to patients, and improve the existing EVD clinical guidelines.

The rapid implementation of modified protocol on IMAM at the health facility level led to minimal

disruption and delay in providing critical nutrition services.

The Nutrition Cluster gained additional partners who worked in Ebola response but also have

technical capacity and interest to work in nutrition.

Nutritional support to infants who cannot be breastfed using ready to use infant formula was a

radical move and is documented in the Strengthening Community Services section of this

compendium of case studies

0100200300400500600700800900

1000

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul

Admissions

Bomi Bong Lofa Margibi Monsterrado Nimba Sub-Total

20

Strengthening Outreach Services

21

INTRODUCTION Measles is one of the leading causes of death among children under 5 in Liberia even though a safe

and cost-effective vaccine is available. Compared to other vaccine-preventable diseases, measles is

particularly contagious and is associated with high risk of mortality. The 2010 measles outbreak

affected 2,200 children; a follow-up campaign was conducted in 2011, after series of response

campaigns. In 2013, Liberia achieved a routine immunization coverage of 74% for MCV1.

Owing to the EVD outbreak up to May 2015, this good achievement seriously declined to 53%

for MCV1 in November 2014. The EVD Outbreak disrupted health care services, including routine

immunization services that communities depend on to prevent other epidemic diseases. The decrease

in immunization coverage left tens of thousands of children in Liberia vulnerable to deadly diseases

causing outbreaks of measles in 10 out of 15 counties during the EVD outbreak. Reasons for the drop

in immunization coverage during the Ebola crisis include parents’ fear of contracting EVD in health

facilities, rumours about vaccines and fear of the “ebola vaccine” trial. This reduced services due to

health care workers fear of contracting EVD during service delivery, and closure of health facilities and

interruption of outreach activities during the Ebola crisis.

In order to prevent any further outbreaks, a two round periodic intensification routine immunization

(PIRI) was conducted. This exercise included non-selective measles vaccination for 6–59 months old.

The PIRI helped to fill the gaps among the susceptible by reaching 277,258 children (50.3%

of the target).The coverage for both rounds was low however, particularly in densely populated

Montserrado County, due to rumors about “Ebola Vaccine. Due to the low levels of coverage, the MoH

with support from UNICEF and partners decided to conduct an integrated Polio (0-59 months),

Measles (6-59 months), and De-Worming Campaign (IMC) for all children under 5 years old.

Resistance to immunization due to fear and misinformation has the potential to negatively impact

the campaign and to significantly increase the numbers of children under 5 in Liberia that die of

preventable diseases. Intensive interpersonal communication at community and household levels is

continuously needed to increase understanding of routine immunization, address fears and re-

establish trust in the immunization program.

EXPANDING INTEGRATED MEASLES CAMPAIGN

OUTREACH THROUGH A FOUR-PRONG

COMMUNICATION STRATEGY

22

IMPLEMENTATION

The IMC providing OPV, Measles vaccine, and Mebendazole tablets was planned on 8 May 2015. The

objective was to achieve at least 95% coverage for target populations, especially:

683,573 children 0 months to 59 months of age for OPV

603, 153 children 6-59 months of age for measles

522,732 Children 12-59 months of age for Mebendazole tablets

Implementation of the campaign required strong coordination and support of partners due to the

weakened capacity of local county health teams. Early engagement of partners ensured support for

logistic and monitoring aspects of the campaign. The County health teams conducted daily

coordination meetings ensuring that all partners were informed of the priority of the SIA and provided

necessary support for implementation in a timely manner. Key partners, including MSF and CDC,

provided technical support to strengthen coordination and daily monitoring of planned activities in

specific assigned counties; In addition, MSF for example, facilitated the distribution of the vaccines

and as well as dissemination of communication messages in Montserrado county. Vaccinators

ventured out to provide life-saving vaccines either in a temporary fixed vaccination post or in a health

facility (mix).

In compliance with IPC procedures and WHO guidelines on immunization in the context of an Ebola

outbreak, UNICEF provided not only vaccines and vaccination devices, but also kits that include gloves

and infrared thermometers for vaccinators. Vaccinators were trained on IPC measures, supervision

during immunization activities, and on how to conduct outreach sessions in areas which have not

reported an Ebola case for 42 days. The IMC campaign was reinforced by social mobilization and

communication interventions.

The MOH, with technical support of UNICEF, and in

collaboration with the Carter Center and other partners

developed a four-pronged communication strategy for the

campaign. The four components include 1) advocacy /

sensitization Meetings; 2) social mobilization 3)

community engagement for change, and 4) capacity

building. Planning and monitoring skills of partners,

including both the government and civil society

organizations, were built through technical workshops and one to one meetings. This helped to create

the synergy and momentum on the campaign.

The local administration was involved in pre-campaign advocacy, community engagement and social

mobilization activities to garner support at the local levels. Coordination, implementation and

monitoring mechanisms were in place that ensured the reach and quality of the campaign. The early

orientation and sensitization of the religious and traditional leaders was conducted to ensure

community trust and support the mobilization by community health volunteers.

A comprehensive social mobilization and community engagement plan was developed by MOH with

technical assistance from UNICEF to ensure that (1) parents and community leaders understand the

importance and trust routine immunization for children; (2) caregivers bring the children for routine

Challenges Late community engagement in

EBOLA response efforts

Low level of community trust in health system

Poor coordination between health promotion and community health divisions at the MoH

23

immunization along with the vaccination card;(3) key stakeholders at national, county, district and

community level have skills of strategic communication planning and monitoring.

A multi-media approach was adopted to reinforce the key messages through the use of variety of

channels that include mass media and local outreach communication activities. Special training

sessions of the health workers was done to ensure consistency of messages across different media

channels. Lessons learned from the social mobilization strategy for EVD response and previous

immunization campaign learning were integrated. Subsequently, all partners engaged in social

mobilization across different issues were brought under one umbrella to support the reach and the

quality of the IMC.

Sensitization and activation of traditional chiefs; training and activation of rural women’s network;

training and mobilization of community health volunteers (CHVs) for house to house visits; and use of

town criers were the key triggers for community engagement. Interactive training of key County

Health Team staff, partners, and field support staff was conducted to strengthen their capacity to

implement local activities and equip mobilizers to answer questions and address concerns through

one on one dialogues needed to build confidence of communities to overcome fear. Strategic use of

mass media, especially community radio stations added to the reinforcement of key messages.

Liberia conducted a Post Immunization Coverage survey to assess the quality of the campaign

coverage in June 2015 with technical and financial support from WHO and UNICEF.

RESULTS

The IMC commenced in all 15 counties on May 8, 2014 with a national launch by His Excellency Joseph

N. Boakai, the Vice President of the Republic of Liberia. More than 100 mothers with children of under

five years attended the event graced by the Chief Medical Officer, UNICEF Representative, WHO

Representative, CDC, Minister of Internal Affairs and several partners. At the launching ceremony, the

children received Polio vaccine, measles vaccine and mebendazole. At county level, the IMC was

launched by County Superintendents. A total of 1,529 vaccination teams were deployed nationwide

to vaccinate all children below the age of 5 years.

Immunization

Table 1 shows that the national coverage levels, both for OPV and Measles vaccine, were around 90%.

The lowest immunization coverage was observed in Nimba (OPV) and Grand Bassa (Measles vaccine).

The national estimated mebendazole distribution coverage was around 91% with the lowest

percentage in Nimba (86%). All these estimated were based on verbal history of vaccination only. The

estimated vaccination coverage against measles based on vaccination cards from the campaign was

lower (73%). This is most likely due to a mal-distribution of vaccination cards during the campaign or

a low retention of those cards by the responders. Among those who said they were not vaccinated

(5%) the most common reason cited was the absence of the parents during the campaign (52% of the

reasons).

24

Table 1: Comparison of coverage between survey and administrative data

COUNTY OPV MEASLES MEBENDAZOLE

Admin* (%) Survey (%) Admin* (%) Survey (%) Admin* (%) Survey (%)

BOMI 102 99.0 105 95.5 105 99.0

BONG 105 97.6 102 97.6 105 94.8

GRAND GEDEH 105 99.2 101 99.2 106 98.8

GRAND KRU 111 100.0 110 99.3 109 97.7

MONTSERRADO 109 91.0 104 89.1 104 86.3

RIVER GEE 104 99.2 99 90.7 100 98.3

RIVERCESS 101 95.6 103 94.2 100 95.8

MARYLAND 97 96.0 91 90.7 93 92.6

NIMBA 89 87.0 90 87.1 89 86.2

SINOE 96 93.9 97 94.4 97 94.6

LOFA 95 98.4 90 93.1 91 94.8

GRAND BASSA 100 95.4 98 72.4 99 90.1

GRAND CAPE MT. 100 99.6 97 94.8 96 97.8

MARGIBI 96 98.7 100 89.9 94 97.5

NATIONAL 101 90.4 99 90.4 99 90.8 *Admin: administrative data

Overall, the low performing counties were Montserrado (including Monrovia), Grand Bassa, and

Nimba. When we consider the implementation strategy displayed in figure 1 the clusters covered only

by temporary fix teams have a greatest coverage (95%) compared to those covered only by fix health

facility (88%). These coverage were statically different (P value = 0,0139).

Figure 1: Measles vaccination coverage per cluster by type of vaccination teams

88%

90%

93% 92%

95%

80%

85%

90%

95%

100%

HFO HF TFHF TF TFO

MV

co

vera

ge o

f th

e cl

ust

ers

Vaccination place in the cluster

HFO: Health facility only (100% of vaccinations in the clusters) HF: Mixed but predominantly Health facility (>50% of vaccinations in the clusters) TFHF: Mixed with equal Health facility (50%) and Temporary fix (50%) of vaccinations in the clusters) TF: Mixed but predominantly Temporary fix (>50% of vaccinations in the clusters) TFO: Temporary fix only (100% of vaccinations in the clusters)

25

Social mobilization

Community engagement activities were conducted for 2 weeks across all 15 counties resulting in

229,031 house-to-house visits by gCHVs and 2,760 community meetings. Orientations and trainings

were held for civil society organizations, media houses, CHTs, CHVs, partners, and other stakeholders.

Many stakeholders were engaged through UNICEF support during advocacy, social mobilization,

and outreach activities including:

100 civil society organizations members

4,000 chiefs nationwide were oriented in collaboration with Carter Center

770 government community health volunteers (gCHVs) in Monrovia

1,400 religious leaders across all 15 counties (Inter-religious Council of Liberia)

The intended audiences were reached through various mass media and communication channels:

22 radio stations in Montserrado airing spots

6 major newspaper announcements and 3 press conferences

27 media executive oriented

45 community radio stations aired jingles 2-8 times/day for more than a month

Additional support from other partners were provided to mobilize 2,388 partners in Montserrado,

including Monrovia and 4,200 gCHVs across all 15 counties.

26

LESSONS LEARNED

The comprehensive social mobilization and community engagement plan ensured that key

stakeholders at national, county, district and community level were engaged in planning and

monitoring of the reach and quality of the campaign.

Community involvement, especially traditional chiefs, rural women’s networks, community health

structures, and religious leaders, and strong coordination of partners can successfully address

concerns and rumours.

Investment in strengthening community structures and systems that can support a diversity of

programs at county and district levels is needed and could be especially used for improvement of

routine immunization.

Multi-media approach helped to reinforce the key messages around routine immunization.

Partners’ involvement took a key role in all logistic and technical components. Nothing could be

expected without vaccines transport and data collection that NGOs ensured.

Establishment of coordination team at national and sub-national level has been paramount for

immediate decision making and emergency response to any critical situation in the field.

The time allocated for planning and coordination as well as the emphasis placed on supporting

community leaders (1) allow time for development of standardized information that specifically

address community needs, pre-positioning of essential resources and supplies, and (2) ensure

endorsement and support at decentralized levels, and coordination of partners.

The campaign proved to be expensive with a cost per child four times more than usual; the post

Ebola context raised issues around vaccine safety and lack of trust in the health system. There was

an urgent need to triple the intensification of communication messages and social mobilization

activities through a multi-media approach to ensure all areas and populations were reached; it

was also crucial to engage local representatives, community members, and religious leaders and

gradually work together towards rebuilding community confidence and trust.

The post campaign survey recommendations highlight the importance of:

o Increasing the number of temporary fix vaccination teams; this could have enhanced full

coverage and prevented isolated measles spikes as subsequently observed

o Putting emphasis during the social mobilization on card retention and ensuring that the

vaccination’s teams have sufficient vaccination cards

o Addressing the problem of parent’s absence during social mobilization and

implementation (correct information on vaccination dates in villages/town).

27

INTRODUCTION

The EVD outbreak Response efforts were coordinated across multiple partners to deliver on mutually

agreed strategic areas; a national road map for response was generated and emphasized the need for

community sensitization and engagement on EVD prevention and control, for strengthened logistics

and supply chain management for EVD commodities, strengthened IPC oversight across all EVD

response activities8. Wide and rapid geographical expansion of EVD in Liberia implied all 15 counties

were affected by the outbreak.

In December 2014, the country reported a reduced number of EVD cases, a localization of the outbreak

in places with weak surveillance systems and not fully engaged communities (e.g: ongoing unsafe

burial practices in some areas). Clearly a coordinated response across UN Agencies including UNICEF,

NGOs, governments and other actors (civil society groups, traditional leaders, religious leaders,

women’s groups) was central to the success of any containment effort. There was a need of a

containment strategy that shifted toward an active EVD case hunting led by communities. Thirteen of

the 15 counties hadn’t registered any confirmed case since the beginning of the year 20159. The

remaining cases were only concentrated in two counties: Montserrado and Grand Cape Mount. Over

90% of all the cases in Grand Cape Mount originated from the Fahnbulleh clan in Tewor District, and

many of the cases were either not on the contact lists or identified after death. All contacts and cases

were confined to Tewoh district and all communities, within one hour walking distance between Tenie

and Camp 3, were reporting cases of EVD.

UNICEF conceptualized the “Getting to Zero EVD Mop-up Integrated Strategy” for implementation in

Tewor district, Grand Cape Mount. The mop-up strategy applied a systems approach that allow multi

sectoral collaboration to deliver an integrated package of health, communication, protection and

nutrition interventions. The strategy was based on the following considerations:

Identification of hotspots fueling the Epidemic which dictated a required change in approach from

a passive to a proactive EVD case identification.

The continuing unsafe burial practices due to secret religious practices.

Inadequate detection and late referral of suspected EVD cases in these communities

Opportunities for closing gaps in EVD response through strengthened coordination4.

Strong social, cultural and economic ties to neighboring Sierra Leone increasing the risk for cross-

border transmission of EVD10.

8 WHO Ebola Response Roadmap 9 Liberia Ebola Daily Sitrep no. 235 for 5th January 2015. www.who.int:Ebola Maps; MOHS 2015 Grand Cape Mount County Development Agenda. 10 Grand Cape Mount EVD Response Phase 11 Plan : Gap Analysis

GETTING TO AND SUSTAINING ZERO:

THE INTEGRATED EBOLA VIRUS DISEASE

MOP-UP STRATEGY

28

IMPLEMENTATION

The integrated EVD mop-up strategy was conceptualized as a two-pronged bottom-up strategy

including weekly door-to-door mop-up visits by gCHVs for early identification and referral of suspected

cases and active community engagement by the county, district and town leadership, working

together with members of newly established community task forces. The Strategy was implemented

from January through March 2015 in Grand Cape Mount County11.

Weekly Door-To-Door Mop up Visits

The door-to-door visits aimed to improve EVD prevention practices, promote early detection of EVD

cases, care seeking and access to support services through gCHVs. The content of the delivery package

included a) EVD awareness including prevention through hand-washing, b) search for unsafe/secret

burials, c) active case finding with thermal flashes, d) contact tracing, e) identification of

families/children with needs, and f) referrals of the sick for diagnosis and care. Each pair of gCHVs

was responsible for 50 households (25 households per gCHV). During the incubation period of 21 days,

each pair visited each home at least once every week and all gCHVs marked each household visited

for ease of verification by the supervisors and county administration.

Active community engagement

Within Tewor district, active community engagement

aimed at supporting community, religious and

political leaders to own and lead this intensified

response. In particular, they were to encourage good

EVD preventive practices, early care seeking and

isolation, and on-going unsafe safe burials. The district

and community task forces incorporating chiefs,

imams and pastors, as well as representatives of youth

and women organizations, under the leadership of the

county superintendent, district commissioners and

town mayors, were primarily targeted.

Central and County Implementation support structure

The strategic partnership leveraged the comparative advantage of the respective actors to build a

clear division of labor.

Several engagements with the county administrative and health sector resulted in an alignment

of the Mop-U strategy to existing local context, in terms of EVD response coordination, data

reporting, social mobilization, and community engagement with community leaders

UN Country team: Advocacy for support across UN country teams, resulted in the provision of

financial and logistical support to fill in gaps identified in EVD response. UNFPA and Global

Communities led on active case finding with referrals and contact tracing. UNICEF primarily

responsible for C4D, protection, and nutrition.

The county administration and CHT with support from partners intensified cross-border

engagements with Sierra Leone and port health posts conducted strengthened screening of all

persons entering and leaving Liberia through Grand Cape Mount.

11 UNICEF contribution to GCP

Challenges

Low capacity to sustain real-time monitoring and reporting from the field on a daily basis

Weak engagement of county administrative at the initial stage of implementation

Limited funding allocated to EVD outreach response interventions

Impact of weak alignment across local actors on strengthening oversight of community/household centered interventions

29

Management and Support System

UNICEF provided financial and logistic support, including transportation and communication, to

ensure an effective implementation, monitoring and reporting of their activities. The gCHVs and

community leaders were both incentivized to carry-out their assigned roles and responsibilities as

per the mop-up strategy agreed upon by all stakeholders.

Governance and oversight: The Task Force convened weekly with the gCHVs and gCHV supervisors

to review progress, discuss success and challenges, and agree on the activities for the coming

week. Each team supervisor was responsible for 10 pairs of gCHVs each, who also had the added

responsibility to ensure the development and implementation of the team micro-plan.

Community-based information system: The gCHV supervisors reported daily on the number of

households visited, EVD BCC, identified cases, contact tracing followed, secret/unsafe burials, and

families/children with immediate needs. The regular performance review of data collected

through door-to-door visits allowed real-time actions e.g. district of handwashing kits, referral of

separated kids for care and support, communication on community mistrust toward ETUs

RESULTS

UNICEF Liberia’s Mop-Up strategy (Jan – March 2015) in Grand Cape Mount provided an opportunity

for transitioning from EVD containment to restoration of essential services through tracking the last

few cases of EVD and ensuring a maintenance of zero new incidences within an international border

zone. A total of 150 gCHVs visited 6,672 households. Of the total population reached, 19,252 were

children; 67 individuals had their temperature (T°) >38°C including 14 boys and 13 girls. A total of 124

individuals (including 9 boys and 67 girls) were identified with other EVD-like symptoms and referred

early for further clinical review; suspected cases referred also included the 67 individuals with T°

>38°C. In addition 237 household members were found to be in needs for health care or psychosocial

support. As of March 1st, 2015, Liberia reported no new cases of EVD.

Figure 1: Diagram showing the results of the ‘Integrated EVD Mop Up campaign’

30

The mop-up strategy provided an opportunity for identification of gaps in knowledge on EVD

prevention and control, and early identification of suspected cases of EVD and referral to health facility

for case investigation. The mop-up strategy allowed UNICEF to take the EVD response back to the

communities to accelerate efforts for getting and staying at zero. The. It also provided an opportunity

for community leaders to engage with their population on unsafe burial practices and cultural and

religious practices that perpetuate the EVD epidemic. Based on identified gaps in households, the

gCHVs applied necessary corrective actions, including education and referral of suspected cases.

LESSONS LEARNED

Community engagement was found to be an effective entry point in strengthening the delivery of

emergency response interventions and ensuring timely referral during the EVD outbreak. Religious

leaders, especially Imams and Pastors, were actively engaged in their communities and supported

implementation of EVD preventive interventions; they promoted EVD prevention messages (safe

burial, hand washing, case detection) during their religious services and through the media.

Linking community engagement with service delivery and real-time monitoring allows

communities to focus on current issues.

The strategic use of a community-based information system to tack the response and timely take

corrective actions rapidly restore community confidence.

Hunting the EVD through door-to-door visits accelerate the identification and care of the EVD

infected and affected individuals

Involvement of local authorities was a key to success; Chiefs, commissioners, and traditional

leaders were trained on how best to facilitate and conduct effective house-to-house visits

alongside the gCHVs.

Appropriateness of integrated EVD mop-up approach for strengthening health and child

protection interventions at community and household levels should be considered.

31

Strengthening Community-based Services

32

INTRODUCTION

Under-5 mortality is 94 per 1,000 live births. Around 1 of every 11 Liberian children died from

preventable and treatable diseases such as malaria, pneumonia, and diarrhea before their first birth

month (LDHS 2013). The causes of deaths are mainly due to limited access to better health care in

most parts of Liberia where 63% of mothers have to walk more than 1 hour before reaching health

facility with their sick children. Rural areas remain challenging and underserved in Liberia. Road

conditions are extremely poor, leaving many communities with little or no access to basic health care.

In order to minimize the possibility of delays in seeking care for underserved and remote communities,

the MoH through the Community Health Services Division, the National Malaria Control Program and

its health partners have planned a rapid scale up of integrated community case management (iCCM)

of childhood illnesses in all communities of Liberia in 2013, after a successful pilot phase in 2011/12.

The iCCM program is expected to serve approximately 29% of the estimated 4 million people who lack

access to healthcare, defined as living more than 5km from a health facility.

iCCM is a strategy to deliver lifesaving curative services at the community level by Community Health

Volunteers (CHVs), non-professional, trained in CCM to ensure children under 5 years of age with

diarrhea, malaria and pneumonia received adequate and timely treatment. The objectives of the iCCM

program are to (1) build the capacities of CHVs to provide iCCM interventions; (2) increase access and

utilization of community based treatment; (3) improve delivery of essential supplies to facilitate

community case management, and (4) improve community members awareness on community case

management of malaria, pneumonia and diarrhea.

IMPLEMENTATION

The 2014 EVD outbreak unexpectedly slowed

down the implementation of life-saving

interventions including the iCCM program in most

counties in Liberia. Since the beginning of the EVD

outbreak, a “NO TOUCH” policy was introduced to

reduce the chain of transmission at the

community level. Training contents were adapted

in order to apply the Infection Prevention and

Control (IPC) guidelines and keep CHVs safe while

they provide community health services. They

were instructed not to touch patients and,

Photo 1: The Community health volunteers posing at the end of the iCCM training workshop in Glofarken Town, Barrobo Distrct, Maryland County. (July 2015)

IMPLEMENTING INTEGRATED COMMUNITY CASE

MANAGEMENT OF CHILDHOOD ILLNESSES WITH

INFECTION PREVENTION AND CONTROL MEASURES

33

instead, treat patients on signs and symptoms. The policy is still valid until further review is conducted

by the MoH. Additional materials on recognition of EVD signs/symptoms and the revised management

protocols in EVD have been incorporated in all trainings for facility health workers and community

health volunteers.

RESULTS As a part of the process of rebuilding and strengthening Liberia’s health system post-EVD, the MoH and UNICEF organized a series of refresher trainings while considering the IPC component:

A five-day training of trainers workshop for 34 Community Health Services Supervisors (CHSSs) from five counties (Maryland, Sinoe, Rivergee, Grand Kru and Grand Gedeh) was conducted in Grand Gedeh county in July 2015. The mandate of these CHSSs was to return to their respective counties and then train officers in-charge (OICs) in health facilities and CHVs who are directly implementing the iCCM program.

In this light, the training of 549 CHVs was subsequently conducted in July and August 2015 on the provision of iCCM services in 4 out of 5 counties including Maryland (134); RiverGee (96), Sinoe (225), and Grand Gedeh (94). The training was facilitated by the OICs, District Health Officers (DHOs), and CHSSs through practical exercises, role plays and drama. The facilitators used the iCCM ledgers and flip books to help participants better understand and resolve the problems they were facing the field while implementing the program.

UNICEF liaised with the County Health Teams and provided logistics support to ensure the distribution of the iCCM drugs to all the training sites so that all the CHVs could be supplied with drugs on the last day of their training.

Social mobilization activities were also conducted by CHVs to increase awareness in the community. A total of 43,511 people were reached with health education on the cause of malaria, ITN use, danger signs recognition & prompt treatment seeking; community mobilization for malaria campaign activities (eg, ITN distribution).

Since 2014, CHVs were able to provide treatment to 15,620 under five children for malaria, 18,956

treated for ARI and 6,520 treated for diarrhea across the four counties. A total of 1,994 children

were referred for diarrhea cases while 633 children were referred due to complicated malaria.

Photo 2: Training of OICs in iCCM (top) and health facility OICs posing at the end of the training (down)

34

LESSONS LEARNED

Training location: gathering the gCHVs in one place for

the training seems to be a better option wherein every

gCHV gets the same message from the facilitators; In

addition trainings should be conducted as close to the

CHVs as possible, preferably at the district level.

Continuous training: all partners used the supervisory

visits as opportunities for continued in-service training

and mentorship. The supportive supervision

mechanism should be clearly defined with a feedback

mechanism to improve performance.

Coordination and partnership: the leadership of the government at the county and district levels

needs to be strengthened; partners should remain involved and engaged at this earlier stage of

implementation to ensure a successful roll-out of the iCCM.

Supportive policies: the community health policy should be reviewed to allow the provision of

monetary incentives to the gCHVs to ensure a high retention rate, especially in remote and hard -

to - reach areas. However it will be important to assess and consider long term measures for

sustainability as well as ensure that this does not undermine other priority programmes.

Community involvement: Memorandum of understanding between gCHVs and community

structures, including Community Health Committees and Community Development Health

Committee, will strengthen implementation. Community forums are important platforms where

gaps in implementation of priority interventions could be effectively addressed.

Challenges Lack of CHW motivation to

continuously provide services in remote areas

IPC integration was slow due to inadequate monitoring and supportive supervision in health facilities

Frequent stock outs of iCCM drugs

Poor coordination at the county and district levels

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INTRODUCTION

In Liberia, 55% of children under 6 months of age are not exclusively breastfed. This means that apart

from breast milk, they are also given water, fluids and other foods as early as two months. As a result

of this practice, more than a thousand infants get sick from highly preventable diseases such as

diarrhoea on an annual basis. Breastfeeding is a vital emergency response to protect a child from

infections and ensure good nutrition. Even under non-emergency circumstances, infants who are not

breastfed are five times more likely to die from pneumonia and fourteen times more likely to die from

diarrhoea, than infants who are exclusively breastfed. Thus, appropriate infant and young child

feeding and care are a fundamental approach in preventing malnutrition and child mortality.

Close contact of mothers and/or caregivers presenting signs and symptoms of Ebola to infants and

young children is a high risk behaviour for the transmission of the disease. It has been documented

that Ebola can be transmitted via breastfeeding. Additionally, it is expected that many infants and

young children will be orphaned when one of both of their parents die as a result of Ebola. Following

the adopted guidelines on infant and young feeding in Ebola context, only during such exceptional

circumstances, is alternative feeding option considered and advised by a health worker working in a

public health facility.12

IMPLEMENTATION

Liberia adapted the global recommendation on Infant

Feeding in the context of Ebola to suit the local setting

following a consultative process among members of

Nutrition, Health, and Child Protection clusters. The local

guidelines ensured that key recommendations were

consistent and complement the protocols and guidelines

for Ebola developed by the Health and Child Protection

clusters.

To ensure that health workers, social workers and psychosocial workers promote the consistent and

clear messages on breastfeeding to mothers affected by EVD, and mothers residing in areas where

there was no EVD incidence, a training was conducted, and close supervision by implementing

partners were encouraged.

12 Ministry of Health - Republic of Liberia. (2014). Updated Guidelines on Infant and Young Child Feeding in an Emergency. Monrovia: Ministry of Health and UNICEF.

INTEGRATING INFANT AND YOUNG CHILD FEEDING

AND CARE INTERVENTIONS FOR A COMPREHENSIVE

CHILD WELFARE SERVICES

Challenges Poor coordination between nutrition

and other sectors delayed implementation

Poor information system leading to inconsistency in data availability and quality

Limited budgetary support for nutrition interventions

36

Social workers and psychosocial workers referred infants who were orphaned or those who could not

be breastfed for further assessment to nutrition treatment sites. Orphaned infants or those who could

not be breastfed seen by health workers and not referred by social workers were likewise referred to

a social worker or psychosocial worker to ensure child welfare and psychosocial support were

extended to the mother or caregiver.

Although county warehouses were stocked with ready to use infant formula, nutrition treatment

facilities were only stocked by the County Nutrition Supervisor with a minimum supply upon

confirmation of eligibility for alternative feeding by a trained health worker.

Eligible infants were assessed for malnutrition and other medical conditions every two weeks. To

ensure participation from mothers and/or caregivers, take home supply of ready to use infant formula

were only adequate for two weeks. Mothers and/or caregivers received nutrition counselling on the

use of the products. For those with infants above 6 months, mothers and/or caregivers received

further guidance and advice during the counselling session on safe preparation of nutrient dense

complementary foods using locally available products.

Eligible infants below 12 months received ready to use infant formula fortnightly until they reach the

12 months. Upon discharge from the programme, mothers and caregivers of infants who reached 12

months were required to attend another counselling session to receive guidance / advice on (1)

feeding the child timely and adequately; (2) assessing the child for physical signs of nutritional

deterioration; and (3) encouraging medical consultation when a child becomes ill.

The importance of breastfeeding for mothers who do not present any EVD-related signs and

symptoms remained supported. Promotion on the importance of exclusive breastfeeding continued

at the facility and community levels in districts where there were no incidence of EVD.

37

RESULTS Following the endorsement of the guidelines,

county level actors were oriented on exceptional

conditions wherein alternative breastfeeding is

recommended as well as ensure supportive

counselling and adherence to referral

mechanisms. From November 2014 to March

2015, 6 County Nutrition Supervisors, 111 health

workers, 69 social workers, and 35 psychosocial

workers from Bomi, Bong, Lofa, Margibi,

Montserrado, and Nimba were oriented and

provided with job aids.

A total of 38 infants below 12 months from

Montserrado, Bomi, Bong, and Rivercess counties

were referred by trained social workers and

psychosocial workers and found to be eligible to

receive alternative feeding support. By the end

July 2015, 12 infants in Bong and Rivercess

counties out of the 38 infants identified had not

yet reached 12 months, and continued to receive

alternative feeding support. There were two pairs

of twins and one set of triplets out of the 38 infants who benefitted from the programme. Thirty three

mothers and/caregivers received nutrition counselling from trained health workers.

LESSONS LEARNED

Implementation guidelines need to complement existing guidelines and protocols of other

sectors. This is beneficial to ensure not just consistency but clear interconnection of interventions

and clarity of roles of different actors on the ground.

Close collaboration with social workers at the district and county levels have allowed health

workers and county nutrition supervisors to reach highly vulnerable infants and young children

There is a need to improve on information management of children affected by Ebola by age

group, county, and gender.

Adaptation of communication messages to ensure adequate young child feeding practices

depending on the context while maintaining the consistency and accuracy of these messages

delivered by different professional bodies (for example health workers or social workers).

The gains made in working closely with child protection cluster need to continue beyond the Ebola

response. Social workers and psychosocial workers can also be utilized to conduct regular

nutrition assessment of children receiving child welfare services.

Photo 1: Twins, Prince and Princess, from Bong County were orphaned when both their parents died from Ebola. They were left under the care of a certified midwife, Martha, in a Bonota Health Clinic, Sanoyea District, Bong County when they were 5 months old. They received ready to use infant formula until they reached 12 months in June 2015.

38

The following recommendations (list non-exhaustive) mainly derived from field experiences

(described in this compendium) in providing support to government, in collaboration with partners,

to enable a joint and effective implementation of critical child survival interventions during the EVD

outbreak and recovery periods.

HEALTH SYSTEM

COMPONENT KEY RECOMMENDATIONS FOR FUTURE OUTBREAKS

Enabling

environment

(Leadership,

governance,

coordination,

partnerships)

Advocate and implement collaboration and coalition-building across sectors at all levels to optimize the use of resources

Establish national cross-sectoral coordination mechanisms and clearly define their terms of reference

Strengthen local governance by reinforcing / revamping existing community structures and groups

Strengthen coordination by integrating the departments of community health and health promotion

Ensure early integration of IPC measures into relevant policies and guidelines including SOPs and job aids and define mechanisms to reinforce implementation

Develop competencies of county health teams in public health/epidemiology

Establish and expand district health teams (from one district monitoring officer to a full district health management team)

Financing Increase budgetary support for emergency preparedness and response taking into consideration the need for integration of services provided by different sectors

Increase budgetary provision to procure emergency supply of pharmaceutical products when need arise

Establish an incentive scheme for community health workers

Health workforce Build capacity of staff in IPC as part of the basic standards for quality of care; prioritize district teams and front-line workers at health facility and community levels

Maintain an updated mapping of community health workers to facilitate rapid deployment in emergencies

Procurement and

supply chain

management

Preposition IPC materials and essential commodities including vaccines with a clearly defined last mile distribution strategy (ensure system in place)

Assess management and storage capacity at the subnational levels and address identified gaps to reinforce routine system and avoid establishment of parallel system to respond to outbreaks

RECOMMENDATIONS

39

Quality integrated

service delivery

Institutionalize basic IPC in all health facilities and establish functioning supportive supervision system to monitor adherence to IPC guidelines

Maintain provision of minimum essential facility, outreach and community services with IPC at the facility and community levels

Integrate child survival interventions (health, nutrition, protection, WASH, community engagement) to enhance expected gains whenever possible

Information system Establish a functioning community information system

Establish mechanisms for the use of local data to facilitate real-time monitoring of activities and performance at community, district and county levels, to track progress and for decision making

Community

engagement

Build community trust and increase demand for care by engaging and enabling communities to take ownership and control over their own health (community leaders, religious leaders, front-lines volunteers, etc)

Define harmonized, locally adapted, and culturally sensitive social mobilization and communication messages to support implementation of health interventions (integrated immunization campaigns, mop-up strategy, etc)

Support the functioning of district and community task forces/committees as a mechanism for ongoing engagement of communities with the health system

40