Federal Ministry of Health Department of Public Health

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1 Neglected Tropical Diseases REPORT ON PILOT ROLL-OUT MALARIA-NTD-WASH CO-IMPLEMENTATION Report submitted to Federal Ministry of Health Department of Public Health National Malaria Elimination Programme, Neglected Tropical Diseases Programme and Water, Sanitation and Hygiene Programme With support from MAY

2 ACKNOWLEDGEMENT I would like to acknowledge the following individuals for their contributions to the various stages, from the development of National Standard Operating Procedures, harmonization of tools and materials to actual pilot roll-out and the development of this report, Professor Oladele Akogun, Professor Adeyemi Adeyinka, Dr. Peter Edafiogho. From the Federal Ministry of Health are, Dr. Ngige, Director Public Health, for leading the process, Dr Nnenna Ezeigwe, National Coordinator, National Malaria Elimination Programme, Dr. Ifeoma Anagbogu, Head, Neglected Tropical Diseases Division, Dr. Obiagele Nebe, Coordinator, Soil Transmitted Helminths and Dr. Joel Akilah, Head IVM Branch, National Malaria Elimination Programme. I thank the Country Director, Malaria consortium, Dr. Kolawole Maxwell for leading the commitment of Malaria Consortium resources to the exercise; to Miss Ozioma Nwagwu and Mrs. Jennifer Adebambo for their excellent administrative, logistical and operational support throughout the development and implementation phase. I am very grateful to the commitment demonstrated by some members of staff from the National Malaria Elimination Programme and Neglected Tropical Diseases and a lot more people, too many to list in this section, in the States, LGAs and schools whose contributions of resources of time, intellect, local knowledge and know-how has made major impact to the realization of the purpose of the pilot roll-out. 2

3 TABLE OF CONTENTS ACKNOWLEDGEMENT... 2 List of Tables... 3 List of Abbreviations... 4 EXECUTIVE SUMMARY Background and Introduction Specific Objectives Of The Pilot Testing PROCEDURES AND STRATEGY Process Towards Pilot Roll-out on Co-implementing Malaria-NTD-WASH programmes Criteria for selection of Pilot roll-out States Location of Pilot roll-out Materials used for Pilot roll-out Standard Operating Procedures, Meetings, Advocacy vists and Mobilisation Analysis Of Observations FINDINGS AND DISCUSSION Comprehension Of The Guideline In The Hands Of The Implementers The Duration And Structural Design Friendliness Of The Guideline The Layout And The Appropriateness Of The Sequence Of The Steps In The Guideline Gaps Identified That May Further Enrich The Guideline Areas That Appear Redundant Key findings Challenges/constraints Lessons Learned Recommendation For Follow-up Actions CONCLUSIONS... APPENDIX (1 to 6)... ANNEXES (see folder containing annexes)... LIST OF TABLES Table 1 MAMs, LLINs and WASH Co-implementation in Schools... Table 2 Key Activities carried in all States... Table 3 Results/Findings by State... Table 4 Planning & Coordination... Table 5 Monitoring and Supervision... 3

4 LIST OF ABBREVIATIONS ADR - Adverse Drug Reaction BCC - Behaviour Change Communication CHV - Community Health Volunteers FMOH - Federal Ministry of Health HF - Health Facility HFs i/c - Health Facilities in-charge IEC - Information, Education and Communication LGA - Local Government Area LGES - Local Government Education Secretary LLIN - Long Lasting Insecticidal Net MAM - Mass Administration of Medicine MAMHCD - Mass Administration of Medicine and Health Commodity Distribution MC - Malaria Consortium M&E - Monitoring and Evaluation MEB - Mebendazole NMSP - National Malaria Strategic Plan NF - National Facilitator NMEP - National Malaria Elimination Programme NTDs - Neglected Tropical Diseases PSM - Procurement, Supply-chain Management PTA - Parents Teachers Association PZQ - Praziquantel SBMC - State-based Management Committee Schisto - Schistomiasis SF - State Facilitator SMoH - State Ministry of Health SOP - Standard Operating Procedures SPHCDA - State Primary Health Care Development Agency STH - Soil Transmitted Helminths SUBEB - State Universal Basic Education Board TCC - The Carter Center WASH - Water, Sanitation and Hygiene 4

5 EXECUTIVE SUMMARY Background: The Federal Ministry of Health (FMOH) in collaboration with Malaria Consortium and other Partners has been promoting the roll-out of the co-implementation policy in Nigeria including the development and pilot-testing of Malaria-LF guidelines in National Standard Operating Procedures (SoP) for co-implementing activities of the National Malaria Elimination Programme (NMEP), NTDs and WASH has been developed. However, for a nation-wide application of the coimplementation strategy, it was necessary to pilot test the usability of the SoP, harmonized materials and data management tools, to determine the ability of implementers to use it in Schools and/or at the community level. The purpose of the pilot testing is to provide evidence of the feasibility of co-implementing Malaria-NTD-WASH activities in Schools. Methodology: The pilot test took into consideration lessons learned and recommendations from the previous malaria-lf co-implementation in the six geo-political zones in Nigeria. Three states were selected from the previous pilot, namely; Ebonyi, Cross River and Jigawa, to pilot test coimplementation on Malaria-NTD-WASH programmes in schools. A consultant supported the State pilot teams, comprising of national and state facilitators, to train implementers at service delivery points, on delivery of mass administration of medicines (MAMs), long lasting insecticidal nets (LLINs) and assessment of WASH at service deliver point, collect information on the ability of the implementers to use the materials, steps/procedures at the State, Local Government (LG) and school spheres of implementation. In each State, schistosomiasis (schisto), soil transmission helminths (STH) endemicity and malaria prevalence were primary considerations in the selection of one LGA per state and three schools, where co-implementation activities were observed. A mix-met approach combining techniques of observations, interviews, and harmonized school register was used by implementers for data collection. Based on field experience, findings/results, analysis, and lessons learned, recommendations was done at the State level before collapsing to provide a national perspective on the effectiveness, use-ability of the national procedure on coimplementation of key activities: planning, coordination, advocacy, mobilization, monitoring and supervision, logistics management and data management. The synthesis of the information from the states is presented in this report. Findings: In the three states, a total of 2,702 out of 3,405 enrolled (79% coverage), were treated with MEB and PZQ, while 1,139 out of 1,372 (83% coverage) children in targeted classes received LLINs. The steps/procedures was easily comprehended in all the States with varying degree of explanation depending on the level where the implementer operated. It was easier at the secondary school level and least so at the primary school, especially on the use of mobile (smart) phone for data collection. The language and sequence of the steps in the materials and service delivery handbook were well comprehended and it is adjudged to be user-friendly. The structural design and layout of the materials was presented, tested and accepted at this stage because it contained simple, pictorial step-by-step procedures. However, implementers hope to see a more simplified comic-like graphics for pupils in primary 1 to 4, was generally recommended when scaling up. There were minor cases of adverse drug reaction (ADR), which was appropriately managed and observed. Implementers were very pleased with the initiative to feed children irrespective of being fed at home, as it reduced the number of ADR cases that would have occurred. However implementers think that more time should be given to schools to mobilize parents and schoolbased management committees (SBMC), (expanded version of PTA) in general, to gain consent and compliance. 5

6 It is important therefore to focus on advocacy and mobilization at all levels, especially at the level of schools. Main constraints are co-implemented one-day training duration. It was observed and recommended that at least two and half days would be required for co-training on the three programmes. Co-implementation during the 1 st week of school resumption and towards the end of 2 nd term posed a big challenge on coverage, more so, when school management are busy preparing for examination. Implementers recommended earlier or mid-term in the 2 nd term when registration is stabilized and school/class work is standardized. The handling and use of mobile (smart) phones by primary school teachers shown that they required more time for training, to first navigate android phone and the then data collection procedures. Overall, the differences between States are not significant enough to require any alteration to the SOP. The sequence of steps and language of materials are highly appropriate for the audience. Education sector demonstrated passionate acceptance of the procedures and materials and are happy to continue collaboration with health sector on co-implementation of Malaria-NTD-WASH programmes. Conclusion and recommendation: The SoP is use-able by implementers, after trainings, implementation and on-the-job supportive supervision were carried out. Key activities include a general orientation of key stakeholders at the State, LGA and School levels, advocacy and mobilization, training of teachers in their various schools, co-implementing Malaria, NTD and WASH pilot roll-out by administering medicines and distribution of LLIN, IEC materials and handbooks for knowledge management to teachers, students/pupils and parents, as well as WASH activities in schools. The main and immediate task is to hold co-implementation stakeholders dissemination workshop, with the purpose of dissemination of the findings, lessons learned and recommendations of the pilot roll-out, developing scale up implementation workplan and orientation of State implementers on when, what and how-to co-implement main activities, based on pilot roll-out results and recommendations. Detailed report on each of the States is contained in Annexes

7 1.0 Background and Introduction A multi-year National Neglected Tropical Diseases (NTDs) master plan and a new National Malaria Strategic Plan (NMSP) for were launched in The plans were set within the framework of the National Health Policy, and succinctly articulate the response of the Government of Nigeria to the burden of NTDs and malaria. The strategic goal of Malaria and NTDs is to reduce morbidity, disability and mortality via the control, elimination and eradication using cost-effective approaches by Malaria-NTDs co-implementation will harness available resources in a cost effective manner for the control and elimination of the diseases. There are opportunities and benefits for coimplementation. The use of long lasting insecticidal nets (LLINs) provides protection from the vectors of malaria and lymphatic Filariasis. Mass administration of medicines (MAM) with mectizan, albendazole and praziquantel reduces anaemia associated with most NTDs and malaria. It is envisaged that both programmes will take the advantage of joint communication and social mobilization messages on behavioral change communication (BCC) for LLINs and Mass Administration of Medicine and Health Commodity Distribution (MAMHCD). While many donors or practitioners know of the impact of water, sanitation and hygiene (WASH) on reducing diarrhea, few are aware that controlling and eliminating five of the socalled neglected tropical diseases (NTDs) also requires WASH. The WASH and NTD programmes have a common target population the poorest citizens. This population lacks access to safe and reliable water services and sufficient sanitation or the tools to practice good hygiene behaviors. As a result, they suffer disproportionately from debilitating disease. Although the WASH and NTD programmes work in the same communities, they have historically worked in parallel rather than coordinating their efforts. This lack of coordination is due in part to the different health outcomes on which each sector focuses. The WASH sector focuses on improved health, such as reduced diarrheal disease, and also on additional desired outcomes like improved livelihoods and overall well-being. The Federal Ministry of Health and Government of Nigeria in collaboration with various stakeholders and partners have adopted to pilot test the co-implementation of Malaria, NTDs and WASH programmes in Schools as a first step to learning more about co-implementation of these interventions and possible expansion and scale-up. The standard operating procedures (SoP) for co-implementing Malaria-NTD-WASH will maximize resources and efficiently apply available tools, knowledge and personnel to the control and elimination efforts. 1.1 The Broad Objective of The Pilot Study is to assess the usability of the Malaria-NTDs- WASH guidelines by different levels of implementers in field situation 7

8 1.2 Specific Objectives of the Pilot Testing The specific objectives of the pilot testing are: To assess the comprehension of the material by the users (MoH trainers, school teachers, children, community) To verify whether the proposed duration of the training for communities and teachers is sufficient To identify gaps in the provided training and educational material Based on the teachers and community feedback, and on the whole experience, summarize lessons learned and recommendations to Federal Ministry of Health. The secondary objective will be to assess the cost of implementing malaria, NTD and WASH activities via this co-implementation channel, compared to delivering LLINs, deworming drugs and principles of water and sanitation as separate/stand-alone activities. 2.0 PROCEDURES AND STRATEGY 2.1 Process Towards Pilot Roll-out The Federal Ministry of Health (FMOH) with support from Partners developed the National Guideline on Co-implementation of Malaria-Lymphatic Filariasis, in March For a nationwide application of the guideline, pilot testing it to determine the ability of implementers to use it, was agreed at the dissemination meeting of the report April Pilot testing of the National Guidelines for Malaria-LF co-implementation was conducted in June Where six states from each geo-political zone was selected, namely; Cross River, Ondo, Ebonyi, Jigawa, Niger and Bauchi. Based on the report, the guideline was endorsed by implementers to be use-able, after a period of co-implementing Malaria-LF interventions in the communities. The success of the Malaria-LF co-implementation, triggered the need to develop a more robust co-implementation interventions using school-based channel for mass administration of medicines (MAMs), to pupils in primary 1 to 6, Junior secondary 1 to 2; and distribution of long lasting insecticidal nets (LLINs) to pupils in primary 1 and 4, and junior secondary 1, as contained in the national strategy of both programmes. To pilot roll-out Malaria-NTD-WASH co-implementation, FMOH and Partners, with Malaria Consortium (MC) providing technical, operational and logistics support throughout the process, developed a national Standard Operating Procedures (SOP), harmonized materials and tools from the programmes and produced a roll-out plan on Malaria, NTDs and WASH December March Pilot roll-out of the SOP and harmonized materials/ tools and captured lessons learned in Schools, was conducted in three states, Ebonyi, Cross River and Jigawa April

9 2.2 Sampling and Criteria for selection of Pilot Roll-out States The first consideration in the design of the pilot roll-out, is to select three states from the already piloted co-implementation of Malaria-LF in 2014 and to ensure that the epidemiological and sociocultural diversities of the country are reflected in the site selection since these have direct influence on all other parameters. Ebonyi, Cross River and Jigawa States were selected (Box 1). Multi-stage random sampling technic was used by State Malaria and NTD team to come up with the sample size. The criteria for selection of one LGA and three schools to co-implement was based on the following: LGA with high endemicity of NTDs in the State (Ebonyi, Cross River and Jigawa) NTD cases (Lymphatic Filariasis, Schistosomiasis, Soil Transmitted Helminths, etc.) have been reported in the LGA Willingness of education sector to buy-in and play active participation Safety, security, accessibility and availability of commodities Two primary schools and one junior secondary school were to be randomly selected from the identified LGA. Based on the SoP, all pupils in primary 1 to 6, and junior secondary 1 to 3, are required to be administered with medicines (500mg mebendazole (MEB) and praziquantel (PZQ)), while LLIN shall be distributed to only pupils in primary 1 and 4, junior secondary 1 only. Box 1 selected state for co-implementing Malaria-NTD-WASH Cross River State was selected to represent the South-south; the state shares the marine ecological parameters with rainforest in the south and has a boundary with the Atlantic Ocean. These features represent the South-South Zone of the country for the pilot roll-out of malaria, NTD and WASH co-implementation procedures. Ebonyi a South-Eastern state, created in 1996, is at the transition between rainforest and Savanna ecology, much depleted by erosion and forest clearing thus representing an epidemiological unit that supports the transmission of both malaria and NTDs through the breeding of mosquitoes, soil transmitted helminths. The culture of the people is representative of the eastern part of the country s southern region with ecological settings that would contribute uniquely to the pilot roll-out of the usability of the SoP and materials. Jigawa State is situated in the North West, which represents the North and located at the international frontier with Niger Republic. It is largely typically Sahel Savanna in vegetation with intensive malaria, lymphatic filariasis, schistosomiasis and soil transmitted helminths. 9

10 2.3 Locations to Pilot Roll-out Before moving to the selected states, two stakeholders and six planning meetings were held in Abuja to harmonize existing materials, tools, stand-alone activities being carried out by the three programmes, selection of LGAs and schools by state and quantification of commodities needed by state. At the end of the planning meetings, stakeholders from both federal and state, harmonized data collection tool, IEC materials, steps to delivering of service/commodities, selected one LGA and three schools by state were harmonized. The pilot roll-out took place in Ebonyi, Cross River and Jigawa states. The selected LGAs Ezza North in Ebonyi State, Biase in Cross River State and Birnin-Kudu in Jigawa State (Table 1 and Figure 1). Table 1 MAMs, LLINs and WASH co-implementation in Schools State LGA Schools Pupils / Students Enrolled No. of Teachers Schools, PTA/SBMC adequately mobilized and aware PTA/SBMC, Community leaders consented Ebonyi Ezza 1. Central Pry School, Yes Yes North Umuezeoka 2. Ezekoma Pry School, Yes, used Yes Inyere town crier 3. Community Junior Yes, high Yes Secondary School, Ekka absentees Cross River Biase 1. PCN School 1, Akpet Yes Yes 2. Sacred Heart School, Yes Yes Agwagune 3. Commercial Sec Yes Yes School, Abini Jigawa Birnin- 1. Kiyako Pry Sch, Kiyako Yes Yes Kudu 2. Shungurum Primary Yes Yes School, Shungurum 3. Junior Sec. Sch, Kiyako Yes Yes TOTAL

11 Figure 1a Map of Nigeria showing locations of pilot roll-out Figure 1b Map of States showing LGAs where pilot roll-out was co-implemented. Ezza North LGA, Ebonyi State Birnin Kudu LGA, Jigawa State Biase LGA, Cross River State 11

12 2.4 Materials used for pilot roll-out The following are the documents and materials used for co-implementing Malaria, NTD and WASH activities in the schools, based on the content on Standard Operating Procedures (SoP) Consent form (Material #1) Booklet on Malaria-NTD-WASH on (Material #2): o identify (signs and symptoms) and define diseases, prevent, treat and benefits of prevention and treatment, role of teachers and community members Handbook on service delivery co-implementation in schools (Material #2) Poster/wall chart on steps for pupils taking medicines (Material #3) Handbill on LLIN hanging and use (Material #4) WASH Assessment Form (Material #5) School register - harmonized to collect data on LLIN, MEB and PZQ (Material #6) Procedures on use of mobile (smart) phone (Material #7) Tablet pole for measuring height of children, where the height intervals correspond to the number of tablets of praziquantel to treat school children for schistosomiasis (Material #8) Adverse drugs reactions materials; glucose, ORS, paracetamol, etc (Material #9) Consumables; liquid soap, disposable napkins, water, waste collection bag (Material #9) 2.5 Development of Standard Operating Procedures (SoP), Harmonization of Materials, Meetings, National Training of Trainers, Advocacy and Mobilization Development of SoP and Harmonization of materials and tools Two national consultants (NTD and Malaria) were selected to work with the Federal Ministry of Health personnel, particularly officers responsible for Malaria, NTD and WASH programmes and the Malaria Consortium (MC), to develop standard operating procedures (SOP), harmonized IEC-BCC materials, data collection tool, procurement supply-chain management (PSM), operational logistics issues/commodity quantification and the introduction of electronic data collection device to complement paper-based data collection. Stakeholders also agreed on interventions to be co-implemented, for Malaria-LLIN, NTD-schistosomiasis and Soil Transmitted Helminths, while detailed assessment of WASH activities was collected as required for the pilot roll-out at the service delivery point Meetings with stakeholders Prior to implementation, twice, 2-day harmonization meetings were held, to identify and bring to the table available resources (materials and tools) from planning to reporting, including monitoring and supervisory checklist. The representative from the Carter Center, Dr. Adamu made presentation on data management and tools already being used in the field, incorporating key component of malaria e.g. LLIN delivery and household assessment to identify LLIN gap/need. The NTD programme of the FMOH and NMEP jointly harmonized and finalized the tools for pilot roll-out purpose. Other materials and key implementation tools, such as demand creation activities, procurement, supply-chain management and service 12

13 delivery were harmonized and finalized for piloting. Subsequent discussions and adoption were on the use of the tools for data collection, IEC materials (simple and easy steps to MAM and LLIN distribution), monitoring and supervision of the process and report writing. Participants at the stakeholders meetings in Abuja, were drawn from NMEP, NTD and selected coordinators/managers on Malaria and NTD. State representatives were charged with the responsibility to ensuring adequate mobilization of the education sector, including gaining the consent of parents through PTA and/or SBMC members National Training of Trainers Workshop A 3-day national training of trainers (NToT) workshop was held in Keffi, Nasarawa State on the SoP, harmonized data collection tools, material and activities on demand creation, such as, advocacy visits to key stakeholders/gate keepers, mobilization of stakeholders (PTA/Parents Forum, School-based Management Committees, teachers, etc.), simple IEC materials for cascading and sharing to beneficiaries and use of electronic device for data collection. Trainees where drawn from both NTD and NMEP, along with their state counterparts selected for the pilot roll-out. At the end of NToT, participants identified activities in relation to the objectives and were carried out in all three states; Ebonyi, Cross River and Jigawa (Table 2). Table 2: Key activities carried out in all States on the pilot roll-out. SN Activity Task Persons met/remarks 1 Advocacy visit to key stakeholders/ gatekeepers in the State and LGAs of pilot roll-out in the three states. Explain purpose, objectives and strategies for coimplement Malaria-NTD- WASH At the State level: Advocacy visits to SMoH top officials (Hon. Commissioner for Health, Directors of Public Health, Pharm. Services, Administration. Education sector (Executive Chairman, SUBEB, Focal person school-health. In Jigawa, Executive Chairman, PHCDA was also visited. 2 Training of State facilitators 3. Training of Head of schools, teachers and PTA members/ SBMC executives Procedure for mobilization, demonstrate data collection using co-implementation tools, demonstrate MAM and LLIN distribution using data tools/ device Procedure for mobilization, demonstrate data collection using co-implementation tools, demonstrate MAM and LLIN distribution using At the LGA level: LG Education Secretary, Head of School, PHC Coordinator, Malaria focal person, Representative of PTA/SBMC, Traditional and Community leaders. This activity took place in Jigawa State only. One-day training of state facilitators drawn from NTD, Malaria and WASH programmes One-day training of teachers took place in the three pilot roll-out states. Interactive lectures and demonstrations using wall chart/posters, handbills and practical simulating exercises. School-based data register was shared to class 13

14 3 Co-implement Malaria-NTD-WASH programs field work 4 Paper-based (school register) and electronic data collection (mobile android phone) 5 Data collation and documentation of gaps, lessons learnt, develop state-level report 6 Debrief LGA officials, PTA/ SBMC, Head of Schools Debrief State level top officials 7 Submission of field data forms data tools/ device MAM and LLINs distribution (using data collection using tools/device Present content on both school register and e-data collection device. Collate data collection tools, device by class, by school and LGA Populate report using format Debrief LGA/School management authorities on School/class summaries of MAMS and LLINs distribution including lessons learned Debrief key stakeholders in the State ministries of health and education on the school-based summaries, lessons learned, best practices, challenges, recommendation and next step Return Field data and the checklist teachers. Teachers implemented the activities in their various class. The school register was used to collect data and collation. Paper-based register and electronic data collection device were introduced. The major constraint was primary school teachers not being hi-tech savvy, coupled with time constraints, made the pilot roll-out to concentrate more on data capturing from paper-based only, in all three states. However, few secondary schools teachers were able to practically demonstrate use. Summaries by schools on number of pupils/ students treat with MEB and PZQ and LLINs distributed were collated, including documentation of challenges, lessons learned and recommendations. These were information were used to generate state-level report. Informed LGA health and education officials, PTA/SBMC on observations especially on WASH. The feedback afforded the head teachers, school authorities to proffer solutions on how to improve service delivery within their teaching. Demonstration of WASH activities by teachers made the pupils/students very enthusiastic to emulate their teachers and continuity. Debriefed Hon. Commissioner for Health and top management committee of the ministry. Also, SPHCDA Executive Chairman. Also, the team debriefed Ministry of Education and Executive Chairman, SUBEB and board members. Key findings, and recommendation were highlighted. Their response shown what their states are planning already and their commitment to tackle the challenges identified and scale-up coimplementation. WASH Assessment forms, Consent Forms and paper-based data captured during the exercise are now domiciled with MC Advocacy to key stakeholders and Mobilization of schools As contained in the SoP, State level, advocacy visits to key stakeholders and mobilization of schools and parents was conducted by joint team of Malaria, NTD and WASH. They used the guidelines on demand creation activities in the SoP to carry out all agreed activities (Table 1). 14

15 2.5.4 Cascade training The SoP recommended a 2-day training for School Teachers. However, due to logistical issues, a one day centralized training was originally planned. Considering that health sector does not wish to interrupt school activities, sustainability and scale-up, teams agreed on decentralized trainings at various schools to run concurrently. With that in mind, FMOH nominated trainers from NMEP and NTD programmes as federal facilitator, from those trained at the NToT workshop. (Appendix 3). Each team comprised a Consultant, federal NTD programme and NMEP technical officers. At the state level, NTD coordinator, RBM manager and two statebased facilitators were part of the team composition. Participants trained were; head teacher, class/form teachers, representatives of PTA/SBMC, LGA health (PHCC, NTD and Malaria), LGA Education (Education Secretary, Head of Schools, Desk officer) and Health facility staff located within the catchment area of the school. Materials deployed at the cascading were already harmonized to reflect key activities on Malaria, NTD and WASH (Appendix 4, Material #1 - #10). 2.6 Analysis of Observations An appreciable momentum for preventive and co-implementing Malaria, NTDs and WASH has been generated within the pilot roll-out States. The objectives of the piloting phase include: Joint planning, advocacy, sensitization and mobilization of the Schools and their immediate communities towards promoting healthy lifestyles with a view to reducing diseases and attendant social burdens; Knowledge and skills acquisition by the class teachers who are the ultimate implementers and drivers of the co-implementation interventions; Feedback mechanisms between State Ministries of Health, Education, LGAs and Schools with a view to improving communications and improved services for enhanced quality of life free from the burdens of malaria, common NTDs and WASH. The observations and summaries of MAMs treatment and LLIN distribution were collated and harmonized centrally. A feedback and national report writing meeting was held on 4 th of May, 2016, to develop a national report, from shared results, lessons learned and recommendations. 15

16 3.0 FINDINGS AND DISCUSSION Quick results, findings and discussions by states (Table 3, figure 2 and figure 3) below. Table 3: Results/findings and Discussion by State ACTIVITIES EBONYI CROSS RIVER JIGAWA NTDs programme (MAM steps, procedures, etc adhered to SoP) Note: Minimum therapeutic coverage standard of 75% A total of 763 out of 1,041 (73%) pupils and students sampled. Low coverage due to 1 st week of school resumption. MAM s procedures and adherence to guidelines was demonstrated during implementation, mainly where ADR was observed. Three cases of ADR were observed and appropriately managed. A total of 683 out of 894 (76%) pupils and students sampled. MAM s procedures and adherence to guidelines was demonstrated during implementation. Only one case of ADR was observed and managed accordingly. A total of 1,144 out of 1,499 (76%) pupils and students sampled. MAM s procedures and adherence to guidelines was demonstrated during implementation. Two cases of ADR were observed and appropriately managed. The services of town announcers were employed to inform parents on the need to feed their children adequately on the morning of implementation day. Malaria programme (LLIN distributed in line with SoP 295 out of 378 (78% coverage) pupils in primary 1 & 4 and junior secondary 1 students present on day of distribution got LLINs. The low coverage was due to absenteeism in the secondary school. Distribution of LLINs to targeted children was carried out using the class register. Each child was given a copy of handbill 390 out of 408 (96% coverage) pupils in primary 1 & 4 and junior secondary 1 students present on day of distribution got LLINs. Distribution of LLINs to targeted children was carried out using the class register. Each child was given a copy of handbill for use to educate parents at home. 454 out of 506 (90% coverage) pupils in primary 1 & 4 and junior secondary 1 students present on day of distribution got LLINs. Distribution of LLINs to targeted children was carried out using the class register. Each child was given a copy of handbill for use to educate parents at home. 16

17 Schools received IEC materials/ tools and trained for use to educate parents at home. The schools received enough IEC materials to train teachers and pupils/ students, and then shared extra copies to pupils to take home. The schools received enough IEC materials to train teachers and pupils/ students, and then shared extra copies to pupils to take home. The schools received enough IEC materials to train teachers and pupils/ students, and then shared extra copies to pupils to take home. PTA/SBMC adequately aware and mobilized from both Head of school and State- LGA officials Some PTA executives and parents were somewhat mobilized. Town announcers assigned to schools were used to inform parents to give their children good on day on implementation. PTA members were amply mobilized. Town announcers assigned to schools were used to inform parents to give their children good on day on implementation Weak mobilization was carried out. SBMC/PTA members not adequately briefed. Class/form teachers trained, received materials/ tools for coimplementation according to SoP One-day training given to all Class/form teachers Teachers with one copy each of the IEC materials. One-day training given to all Class teachers Teachers issued with 1 copy of IEC material One-day training given to all Class teachers. Teachers issued with 1 copy of IEC material The SOP recommended a 2- day training Consent form Consent was issued and signed by Head Teacher/Principal. Consent was issued and signed by Head Teacher/principal. Consent was issued and signed by Head Teacher/principal. Commodity quantification Quantification were carried out by states and shared prior to pilot. Quantification were carried out by states and shared prior to pilot. Quantification were carried out by states and shared prior to pilot. 17

18 Figure 2: Chart on MAMs treated/sampled in pilot roll-out states, including percent coverage Figure 3: Chart on Number of LLINs distributed by State in all three schools 18

19 3.1 Comprehension of the SoP in the hands of the implementers State NTD, Malaria and WASH programme managers had studied the SoP either previously or had the first contact with the guideline at the time of the NToT and/or pilot roll-out. Both officers easily comprehended the co-implementation procedures as soon as they studied it. Comprehension by the LGA focal persons (NTD and Malaria), PTA/SBMC and community leaders was initially difficult. An explanation of the objectives of the co-implementation and the purpose of the co-implementation resolved initial difficulties. This was made easy after training on steps and procedures to implementing and use of school register and electronic data collection, including IEC materials. At the School level, the language of the SoP and materials used for training was easy to understand in English, simple and devoid of technical jargons, direct and activity-oriented. It is however observed that some areas not easily understood were verbally translated into local languages during the training. The target audience is the teacher at the School levels, and it is possible to replicate the strategy for community use Planning and Coordination Planning and coordination is critical to the co-implementation of services towards elimination of diseases. All States had a co-implemented planning for advocacy visit and mobilization as well as for logistics planning before activities began. The coordinators of the programmes jointly planned and coordinated the series of activities in these States. There was no clear pattern of particular coordinator (Malaria or NTD or WASH) taking lead in this aspect. Also each state had two state facilitators to support the activities. The selection of LGAs, schools and the training plans were co-planned at the State level after an understanding had been reached on what needed to be done. The commodities for delivery (LLINs, MEB and PZQ) were not available in all selected LGAs, but were at the State warehouse. Malaria Consortium supplied materials for ADR, (glucose, ORS, paracetamol, etc,) to all states for the purpose of treatment of pupils/student when reactions occur (Table 5). Table 4: Planning, Coordination, Advocacy and Mobilization Aspect of the guideline being observed Planning Coordination Advocacy Co-implemented activities Ebonyi, Cross River and Jigawa, had coimplemented the planning for advocacy visits, mobilization and logistics before commencement of the pilot out activities There was integrated coordination in all states All the States had advocacy visits at the same Comment 19

20 Mobilization time using joint resources Mobilization of officials at the LGA, community and schools was co-implemented in all three states Overall, mobilization needed more time to reach all relevant stakeholders Monitoring, Supervision and Evaluation The federal and state teams formed a joint monitoring teams in all states but each programme had its monitoring tool and supervisory checklist. Although observed as necessary and important there had been attempts to harmonize available monitoring tools, to ensure coimplementation monitoring at the implementation level. During monitoring it was noted that the commodities (LLINs) were leaving the warehouse on the day of implementation. For coimplementation to be effective, the commodities must be available and adequate. A summary of the observations made on co-implementation of these aspects are presented in Table 6. At the school level, the register for commodity consumption will need to be reviewed and produced in duplicate or carbonized form. Table 5: Monitoring, Supervision and Reporting Aspect of the guideline being observed Monitoring Supervision Reporting forms Co-implemented activities All States were able to carry out joint monitoring teams activity at the school level. Joint supervision was carried out in all the States Reporting forms were not yet available but each programme can report on consumption, until harmonized for joint reporting Comment Need to clarify responsibilities during the joint monitoring is required. Monitoring forms will also need to be harmonized, especially with the education sector. Need to harmonize joint supervision tools and define responsibilities with respect to the supervision activity with the education sector Costing and budgeting At the level of the implementers (schools), there were little or no costing and budgeting required. Also at the LGA and State levels, their resources or input to pilot roll-out coimplementing Malaria-NTD-WASH programmes was mainly on human resources availability. Malaria Consortium, being the funding partner, provided all necessary logistics and operational cost to the pilot roll-out. The pilot roll-out states (Ebonyi, Cross River and Jigawa) all confirmed availability of medicines (MEB/ALB and PZQ) and LLINs. 20

21 Key cost elements on budgeting by the funding Partner included: Meetings (venue, tea/coffee breaks, lunch, per diem) Logistics for advocacy visits, mobilization and movement of commodities (e.g. vehicles, fueling, allowance for driver) Procurement of consumables and materials, such as, liquid soap, disposable napkins, sachet water, waste collection bag, etc Procurement of adverse drug reaction materials, such as glucose, ORS, paracetamol, buscopan, etc. Trainings (venue, refreshments, transport reimbursement, per diem) Stationeries (biros, jotters, folders, pencil, eraser) and communications (recharge cards) Production of consent form, IEC materials, posters, handbill, teachers booklet, school/class register (carbonated), WASH assessment form, tablet pole for measuring height of children 3.2 The training of implementers at service delivery point (e.g. Head Teachers, Class/Form Teachers, PTA/SBMC, Health facility staff, etc) The training of teachers, health workers, LGA NTDs, Malaria and Education focal persons was held in all States. The SoP recommended a 2-day training for School Teachers. Due to constraints of timing, the training was shortened to only one day. It is hoped that subsequent wider roll-out, the planning should take cognizance of the need for Teacher (implementers) to fully comprehend the tenets of the booklet and contents of the programmes. The participants were trained on the overview of NTDs (Schistosomiasis, Soil Transmitted Helminths), Malaria (LLIN) and WASH. The harmonized handbook was used to train on distribution, transmission, sign/symptoms, treatment, prevention and elimination; the management of adverse drug reactions, handling and use of LLINs, data management (paperbased & e-data capture). Also participants were trained on waste management and personal hygiene. A total of 167 participants, comprising of head teachers, class/form teachers, LGA focal persons, including PTA/SBMC officials were trained. 3.3 The duration and structural design friendliness of the SoP, materials, tool/device The duration of the training was quite short (1 day) to cover Malaria, NTD and WASH interventions. In all States, LGAs and Schools, the structure of SoP, training materials (service delivery handbook, booklets, posters, handbills) on steps to MAMs delivery, LLIN distribution and WASH assessment in schools were regarded as very friendly, in the right sequence and in a step-wise form that is easily comprehended. However, for wider roll-out, the posters and handbills should be developed for different category of pupils, such as comics and graphics impression of children sleeping inside LLIN for primary 1 to 3. 21

22 Data capturing was to be in two formats; paper-based and electronic devices using mobile (smart phone) application. Due to exigencies of timing and other practical issues related to friendliness of teachers in using smart phones, it was not feasible at the pilot roll-out to fully train teachers and deploy the use of mobile devices for data collection. Implementers recommended a day dedicated to train on electronic data collection device and with practical/hands-on sessions. 3.4 Gaps identified that may further enrich the SoP Some aspects of the SoP and service delivery handbook that was noted for inclusion are: Integrated community case management, where pupils/students are tested and treated for malaria on the day of implementation. Implementers (State, LGA and Schools) and community response to adverse drug reactions during co-implementing programmes Mass malaria treatment (Seasonal Malaria chemoprevention) Clear tasks, specific roles and responsibilities within a co-implemented sectoral (health and education) collaboration programme. School register/data collection form should include name of school and be reformatted Joint monitoring and supervision framework, including involving education sector. 3.5 Areas that appear redundant There were no redundant areas but each section has varying degree of relevance to different audiences. For example, some areas of costing and budgeting may not apply strongly to schools, as it does to State and LGA implementers. Also advocacy is targeted at gatekeepers/stakeholders, while the section on implementation is centered on the schools in the LGA, led by the head teacher or principal. 3.6 Key findings The main findings of the pilot roll-out of the SoP are that: It is easily comprehended at all levels. This success is mainly due to simple language used in the materials, posters and handbills. Equally, co-implementation is easier to implement at the school level than at the community level. Service delivery personnel are already trainers and transfer of knowledge is made simpler and friendly. Education sector demonstrated high commitment through their active involvement at state, LGA and school levels. Co-implementation in schools was led by health officials but driven by the education sector; SUBEB school health focal person, LG Education Secretary and Head Teachers. A one-day training is inadequate for training on co-implementation of administering medicines, distribution of LLINs, hygiene, sanitation and data capture, collation and reporting. Joint supervision, monitoring and reporting tools not yet available. Language and sequence of the steps are well comprehended and user friendly. 22

23 3.7 Challenges/constraints The main constraints at the moment are: Challenges/constraints One day training was inadequate to ensure effective impartation of knowledge for the three co-implemented programmes Co-implementation during the 1 st week of school resumption posed a big challenge on coverage as some of the pupils and students were yet to resume. Most of the teachers in the sampled schools had little or no knowledge of the electronic data capturing tool (Smart phone), thus handling and using them was a challenge Late movement of commodities to implementation sites on day of implementation due to logistic issues as well as inadequate storage facilities Use of non-project field vehicles for smooth implementation Hard to reach areas caused delay in daily startup of activities. Inadequate advocacy visits, mobilization and sensitization of members of the Schools and PTA/SBMC prior to implementation Inadequate involvement of nearby Health facility staff during the pilot roll-out in some States. Specification of personnel responsibilities within the co-implementation plan at the different levels was a gap. 3.8 Lessons Learned Joint planning and coordination of the three programmes Education sector s strong buy-in at the State, LGA and school levels, resulting to effective operational planning, coordination and implementation. Possibility to deliver large quantities of LLINs and MAM annually with a strong and supportive education sector. Reaching a high proportion of targeted pupils/students, with no major logistical hurdles or operational challenges by using class teachers. Implementation on the 1 st week of resumption, conflicts with opening school/class activities and high absenteeism by pupils/students observed. The use of mobile (smart) phones for capturing data was quite difficult for most of the teachers due to insufficient training duration. SoP and IEC materials are user friendly and easy to comprehend. This co-implementation has shown to work well in all settings (urban/rural areas, secondary/primary school). 23

24 3.9 Recommendation for follow-up actions on: Planning and Coordination: Nearest health facility staff must be involved in the entire implementation process, which includes training, storage of commodities (PZQ, ALB/MEB, ADR kits and LLINs), MAM, LLINs distribution and management of ADR cases. States should be contacted to provide project vehicles to avoid been faced with road security agents. Advocacy and Mobilization Allow enough time for parents teachers association (PTA/SBMC) to be sensitized and mobilized to gain their consent. Very high coverage can be achieved when the parents give their consent. Continued collaboration of health and education sectors, including involvement of CBOs and faith-based organizations. Provision of logistics for mobilisation activities IEC materials Development of different types of IEC materials for children in primary 1-3, such as comics, graphics impression of children sleeping inside LLIN Immediately hold a 2-day meeting to harmonize the current IEC materials in one poster, in a step-wise approach; o Steps 1 & 2 in the poster on algorithm for MAMs should be inter-changed i.e 1 becomes 2 and vice versa. o The picture on LLINs handbill should be replaced with a more appropriate demonstration on handling of nets. o The consent form should have a brief explanation on the purpose, benefit and risk and should bear the name of the organization administering it. Training Increase duration of training from 1 to 3 days; where 1 day is focused on overview and understanding the burden of the diseases in Nigeria, day 2 should deal with training the teachers on the steps/procedures to delivery MAM, LLIN and WASH assessment, while day 3 is solely dedicated to data management, with focus on electronic data collection, exercises and data collation. Co-implementation day (MAMs, LLIN and WASH) Based on field experience on school-based Malaria-NTD-WASH co-implementation, the strategy using similar materials and tools, can be easily implemented at the community level Implementation should not be carried out on the 1 st week of school resumption, rather between the 6 th and 7 th week (mid-way) in the 2 nd term of school calendar, where class registration is stabilized and less activities in the schools such as examination for junior and senior secondary students, inter-house sports, etc. 24

25 Data Management (paper-based and electronic device) Co-implementation register should be produced Develop school level, LGA and State summary forms in duplicate Where class/form teachers are unable to effectively use mobile (smart) phones for data collection, they should be encouraged to use the school register. When this is the case, a designated teacher should collate the registers from each school and enter into one mobile phone and upload into the cloud server. Costing and budgeting Conduct detailed cost benefit analysis on co-implementing Malaria, NTDs and WASH interventions and compare with distributing LLINs, MAMs and principles of water and sanitation as stand-alone activities. Post implementation / Next steps Host a national dissemination workshop on results and lessons learned on the innovative co-implementation of Malaria, NTDs and WASH programmes Collaborate with education sector at State and LGA levels to regularly monitor key WASH interventions in schools, such as, availability of safe drinking water, availability of clean latrines, hand washing materials, etc. Scale-up to all schools in the State, based on evidence from in-process monitoring on its effectiveness, efficiency and equity 4. CONCLUSIONS In conclusion, the guidelines, materials, co-implementation school register and programming of data capturing device are user-friendly and simple to comprehend by State and LGA level implementers including head teachers and class/form teachers, for whom it is primarily designed and much less so by the community level implementers, for future scale up. The steps to both MAMs and LLIN distribution are logically organized and the language of materials, school register are simple and acknowledged as appropriate to the target audience at the service delivery point. The co-implementation is accepted by the education sector, with much enthusiasm and observations across the States and showed that it can be scaled up and useable for co-implementing Malaria, NTD and WASH programmes in Nigeria. The immediate next step is to hold co-implementation stakeholders dissemination workshop, with the purpose of dissemination of the findings, lessons learned and recommendations of the pilot roll-out, developing scale up implementation workplan and orientation of State. 25

26 APPENDIX 1: CO-IMPLEMENTATION FEEDBACK TOOL #1 - PLANNING AND COORDINATION Aspect of the guideline being observed PLANNING List activities that were coimplemented List activities that were not co-implemented Comment on How this aspect was comprehended; Recommend follow-up actions with respect to the Malaria-LF guideline. COORDINATION INTERVENTION MEBENDAZOLE + PRAZIQUANTEL & LLIN DISTRIBUTION SIDE EFFECT MANAGEMENT WASH ASSESSMENT IN SCHOOLS 26

27 #2: ADVOCACY, MOBILISATION AND TRAINING Aspect of the guideline being observed List activities that were coimplemented List activities that were not co-implemented Comment on How this aspect was comprehended; Recommend follow-up actions with respect to the Malaria-LF guideline. ADVOCACY MOBILIZATION TRAINING MATERIALS (include IEC materials, tools and device used in the process) #3: MONITORING, SUPERVISION AND EVALUATION Aspect of the guideline being observed MONITORING List activities that were coimplemented List activities that were not coimplemented Comment on How this aspect was comprehended; Recommend follow-up actions with respect to the Malaria-LF guideline. SUPERVISION EVALUATION Reporting forms 27

28 APPENDIX 2: PERSONS MET Ebonyi State: 1. Dr. Umezurike H.A. Daniel - Hon. Commissioner for Health, Ebonyi State 2. Dr. Mike Urom - Director, Public Health. SMOH 3. Chief Hyacinth Ekpor - Executive Chairman, Ebonyi SUBEB 4. Mr. Ekechi Okorie - Board member, SUBEB 5. Dr. C. Christopher - The Carter Centre, Ebonyi State 6. Mr. Nworie C. Bishop - Ezza North LGA Education Secretary 7. Mr. Nworie Corlienus - Ezza North LGA, Head of Schools 8. Mr. Mgbada Uzoamaka - Ezza North LGA, PHC Coordinator 9. Mrs. Uzor Nwali - Ezza North LGA NTDs focal person 10. Mr. Nweke Sunday - Ezza North LGA Education Officer/Accountant 11. Mr. Nwanga Friday - Ezza North LGA Malaria focal person Jigawa State: 1. Dr. Abba Zakari - Hon. Commissioner for Health, Jigawa State 2. Dr. Kabiru - Executive Secretary, SPHCDA 3. Dr. Umar Bulangu - Director, Public Health, SMOH 4. Alhaji Aliyu Musa - Deputy Director, SUBEB, School health coordinator 5. Mr. Chris Ogoshi - HANDS (Health & Development Support) 6. Dr. Innocent Emereuwa - HANDS (Health & Development Support) 7. Alhaji Salisu - District Head, Kiyako District, Birnin Kudu Cross River State: 1. Dr. (Mrs) Inyang Asibong Hon Commissioner for Health, Ministry of Health 2. Elder E. O. Omini Director of Administration, State Ministry of Health 3. Mrs. Glory Ogban - Biase LGA (SUBEB) Education Secretary, Biase 4. Community /District Head of Akpet Village HQ, Biase LGA 5. Representatives of PTAs for the 3 Biase LGA Schools implementation sites 6. Health Officers at the nearest Health Facilities to the 3 implementation Schools 7. Head Teachers of the 3 Biase LGA Schools where implementation occurred: 8. Mr. Owai Out Ugom Head Teacher, PCN School 1, Akpet 9. Sebastian O. Umet Principal, Community Secondary School, Abini 10. Upe Agoh Upe Head Teacher, Sacred Heart Primary School, Agwagun 28 P a g e

29 Appendix 3: National and State Team Composition Scope Ebonyi Cross River Jigawa Facilitators Mr. Nwokocha Ogbonna NMEP Mrs. Nyior Audrey Iveren - NTD Mrs. Rita Omohode Urude - NTD Mr. Lawrence Nwankwo - SMEP Mr. Igwe Cletus State NTD Mr. Stanley Ede State Facilitator Mr. Tochukwu Nwokwu State Facilitator Mr. Ekpenyong Edem NTD Ms. Obunezi Chi Ogwurugwu - NTD Mt. Omo-Eboh Momodu - NMEP Dr. Iwara Iwara/Asuquo - SMEP Mr. Thomas Ibang State NTD Ms. Emembong Friday Udo - State Facilitator Mr. Asuquo A. State Facilitator Prof. Adeyemi Adeyinka M.C Mr. Jacob Solomon NTD Mr. Emeka Uzoma - NTD Mrs. Hope Obokoh - NMEP Miss. Grace Adamu - NMEP Dr, Umar Bulangu Director PH, SMoH Alhaji Surajo Nuhu RBM Manager Alhaji Shehu Mohammed DD (PH), SMoH Alhaji Aliyu Musa SUBEB (Health officer) Mr. Garba Moh d Bulangu State Facilitator Pharm. Gbenga Jokodola M.C. 29 P a g e

30 APPENDIX 4: MATERIALS USED ON PILOT ROLL-OUT IN THE STATES Material #1: Consent form Malaria-NTD-WASH Co-Implementation in Schools INFORMED CONSENT To be completed after information sheet has been read. (Signature or thumbprint required) The information sheet for this study has been read to me and fully explained and necessary clarifications made. I understand that my participation is voluntary and I agree to take part. Participants/Parent Full Name Participant/Parent s Signature Date Participant s Thumbprint: OR Respondent Agrees to Be Interviewed.1 Respondent Does Not Agree to Be Interviewed..2 End 30 P a g e

31 Material #2: Handbook on Malaria, NTD and WASH A BOOKLET ON MALARIA-NEGLECTED TROPICAL DISEASE (NTD) - WATER, SANITATION & HYGIENE (MALARIA-NTD-WASH) 1. Malaria What is Malaria? Malaria is a mosquito-borne disease caused by a parasite; intra erythrocytic protozoa of the genus Plasmodium (e.g., P. falciparum, P. vivax, P. ovale, and P. malariae among other species). What is the cause of malaria? Anopheles species are the main vectors of malaria and transmission is through the bite of an infected female anopheles mosquito during blood meal. Who is affected by malaria? (Susceptibility) It is estimated that up to 97% of the population are at risk of malaria infection. How serious is the problem of malaria? Why should I worry about it (Seriousness)? a) Malaria accounts for 30% childhood mortality. b) The most prevalent species of malaria parasites in Nigeria is Plasmodium falciparum (>95%) which is responsible for the most severe forms of the disease. What are the signs and symptoms of malaria?? a) Symptoms include fever, chills, sweats, muscle ache, headache, nausea vomiting and other nonspecific flu-like symptoms. b) If suitable drugs are not administered quickly or there is parasite resistance to treatment, the infection can result in life-threatening anaemia, coma and death. c) Severe malaria particularly in children, symptoms include severe anaemia, fever and convulsions, problems with breathing, cerebral malaria, extreme weakness, hypoglycaemia, circulatory collapse, oedema, septicaemia, and occasionally kidney failure and coma. How is malaria treated and where? Every episode of Malaria is treated after diagnosis using Rapid Diagnostic Tests or microscopic examination of blood at the health facility or by community Role Model Care Givers (RMCG) by administering ACT. Refer all severe adverse events, non-response cases and severe malaria to the nearest health facility or health personnel for management. 31 P a g e

32 How can malaria? be prevented Prevention is by using integrated vector management such as use of LLINs, IRS, Larval source management and effective case management supported by BCC, M& E. What are the benefits of prevention and treatment of malaria? a) Sleeping under insecticide treated nets can reduce overall child mortality by 20 per cent b) Prompt access to effective treatment can further reduce deaths from about one in six of all childhood deaths. c) Intermittent preventive treatment of malaria during pregnancy can significantly reduce the proportion of low birth weight infants and maternal anaemia. d) Peaceful and uninterrupted sleep. e) Reduction in Economic Burden due to Malaria. Every year, the nation loses over N132 billion from cost of treatment and absenteeism from schools, Work, and farms. What is the role of the community in prevention and treatment of malaria? a) Community engagement and participation to own and drive prevention and treatment of malaria. b) Encourage and entrench prevention and treatment-seeking behaviour. 2. Neglected Tropical Disease (NTD): Schistosomiasis. What is Schistosomiasis (Schiz) a. Schistosomiasis is caused by infection with parasitic blood flukes, which live in the veins leading to the urinary and intestinal tracts. There are two main types of schiz: a) the one that affects the liver and intestines, and b) the one that affect the bladder and the genital area b. What is the cause of schiz.? Schiz (also known as or Bihariais) is a chronic disease caused by parasitic worms that live in certain types of freshwater snails. The snails become infected when urine and feaces of infected people contaminate the water body in which they live. Children and adults become infected with Schiz when they come into contact with water bodies such as river or streams harboring freshwater snails that have been infected. c. How is Schiz transmitted The parasites of schiz leaves the infected snail and enters the skin of children and adults when they are inside the river or stream, while bathing, swimming, or performing daily activities, such as washing clothes, fetching water, and getting animals to drink water. The eggs of these schiz parasites cause massive damage to tissues and organs, resulting in illness and even death. d. How is Schiz detected in human ( How do I know If I have Schiz) Any person, particularly person below 15 years old, with blood in the urine. Examination of the urine and stool in the laboratory for the eggs of the schiz worms e. Who is affected by Schiz and where (susceptibility)? Children and adults who come into contact with water that contains these snails are at risk of infection f. How serious is the problem of schiz, and why should the disease be of concern (Seriousness)? 32 P a g e

33 Schiz is considered second only to malaria, as the most devastating parasitic disease in tropical countries. Schiz is in 74 tropical countries in Africa, the Caribbean, South America, East Asia, and the Middle East, but main burden of the disease (62%) is in 10 countries in Africa. In black Africa, more than 200,000 deaths per year are due to schiz. The disease causes renal and bladder dysfunction or liver and intestinal disease, and it contributes to anemia and growth retardation in children. g. What are the signs symptoms of schiz? Schiz of the liver and intestine results in damage to the liver, and Schiz of the bladder and genital area can increase the chances of a woman contracting HIV, human papilloma virus (HPV), syphilis, herpes, and other sexually-transmitted infections (WHO, 2012). The sign and symptom of the two main types of Schi are as follows: Schiz of the liver and intestine Abdominal pain Diarrhea Blood in stool Enlargement of the liver, spleen when it is very severe/advanced Can result in death Fatigue and ill health resulting in reduced ability to concentrate and learn in school Schiz of the bladder and genital area Blood in urine; Schiz of the genital area in women causes vaginal bleeding and pain during sexual intercourse. Schiz of the genital area in men causes disease of the components of male organs and other organs, which may lead tom infertility and possible bladder cancer h. How is Schiz treated and where? The major intervention used to control the disease is the treatment with praziquantel, accompanied by the provision of safe water. WHO has developed guidelines for community treatment of schistosomiasis with praziquantel. i. How can Schiz be prevented Although schistosomiasis is not yet eradicable, the prevention and control of the disease with a single annual dose of praziquantel in one year. In addition, schiz control measures include improved water and sanitation hygiene as well as reduction or elimination of intermediate host (snails). These could sustain and/or enhance control of transmission in endemic areas. j. What are the benefits of prevention and treatment of Schiz? The benefits of effective prevention and treatment of Schiz include Healthy children with adequate growth and development, Children with ability to concentrate and learn in school, Saving money and time on treatment. Saved money can be used for other family needs. k. What is the role of the teachers and the community is prevention and treatment of Schiz? Many children infected by Schiz are in school just as many others are in the community. The parents, teachers, health workers, and community leaders can help to prevent and control of Schiz through: Being a volunteer to be trained to participate in the mass administration of medicines (MAM) for the treatment of Schiz and soil transmitted worms. Identification of children who may be having schiz by asking children about history of blood in urine. Any child suspected of having Schiz should be referred to the health center for prompt and proper treatment 33 P a g e

34 Collaboration with government, nongovernment organisations (NGOs) and other stakeholders to organize community outreach every year for mass administration of medicines (MAMs) for the treatment of Schiz and soil transmitted worms Advocacy to government to provide potable water supply and sanitation facilities to reduce the risk of infection with Schiz. For a healthy community, I will join in the efforts to prevent and control Schistosomiasis 2. Neglected Tropical Disease (NTD): Soil Transmitted Helminthiasis (STH) What is Soil Transmitted Helminthiasis (STH)? Soil Transmitted Helminthiasis (STH) is a form of parasitic infestation caused by 3 parasites (i). Roundworms (Ascaris lumbricoides), (ii). Whipworms (Trichuris trichura) and (iii). Hookworms (Necatur americanus or Ancylostoma duodenale). These parasites live in the soil in warm and humid climates, and are spread through contact with faeces of infected people. Infection is caused by ingestion of and contact with the eggs from contaminated soil (A. lumbricoides and T. trichiura) or by active penetration of the skin by larvae in the soil (hookworms). What are the causes of Soil Transmitted Helminthiasis (STH)? They are spread through contact with faeces of infected people. Infection is also caused by ingestion of and contact with the eggs from contaminated soil (A. lumbricoides and T. trichiura) or by active penetration of the skin by larvae in the soil (hookworms). Who is affected by Soil Transmitted Helminthiasis (STH) and where (susceptibility)? STH are spread through contact with faeces of infected individuals. Anyone who eats with unclean hands after contact with fecal contaminated soil or foods will get the infection. When you step on faeces containing larvae in the soil. The larvae penetrate bare skin when pupils walkover or step on infected faeces in the neighborhood. ow serious is the problem of Soil Transmitted Helminthiasis (STH)? Why should I worry about it (Seriousness)? Many concerns about this parasitic infections because are: It decreases the cognitive ability of the students. Academic performance is poor. There is blood loss (anemia) because the parasites are feeding on food nutrients that the body need to grow. In the community, infected people have poor productivity level and suffer economic losses. What are the sign signs symptoms of Soil Transmitted Helminthiasis (STH)? STH infection can cause (i). Blood loss (anemia), (ii). Nutritional deficiencies which is harmful to children. (iii). Limited physical development and (iv). Cognitive growth. Girls are particularly affected due to lost educational gains and productivity. At community level there is additional economic loss because of decreased productivity 34 P a g e

35 How is Soil Transmitted Helminthiasis (STH) treated and where? WHO guidelines list three components of a worm control program that can interfere with the transmission cycle of STH and schistosome infections: How can Soil Transmitted Helminthiasis (STH) be prevented? a. Drug treatment: Aimed at reducing morbidity by decreasing the worm burden. This will result in an immediate improvement in child health and development, and in the case of schistosomiasis (also known as bilharzia), to prevent the development of irreversible effects in adulthood. b. Health education: Aimed at reducing transmission and re-infection by encouraging healthy behaviours. c. Improved sanitation: Aimed at controlling transmission by reducing soil and/or water contamination. What are the benefits of prevention and treatment of Soil Transmitted Helminthiasis (STH)? The burden of disease resulting in anemia and reduced cognitive behaviors of the pupils are reduced or eliminated. Students will perform at high levels in the classroom and outside the classroom. The members of the community will not become sick such that they will not be able to be economically productive and suffer no economic and morbidly losses d. What is the role of the community is prevention and treatment of Soil Transmitted Helminthiasis (STH)? Acquire skills to undertaking improved personal hygiene practices as demonstrated by stakeholders in this project. There should be determined efforts to provide potable water that will facilitate demonstration of improved personal hygiene methods 3. Water, Sanitation and Hygiene (WASH) WASH WASH is Water, Sanitation and Hygiene. Access to safe and potable water, toilets and practicing good hygiene is important to our health. Our community should ensure we have adequate and equitable access to water and sanitation, as well as the tools to practice good hygiene (WASH). These serve the basis for prevention of the NTDs and other disabling diseases WASH Intervention for integrated NTD Control In schools or areas where multiple NTDs are present, a single WASH intervention can impact multiple NTDs. The table below shows how water and sanitation interventions can be implemented to target multiple diseases thus: Type of Intervention 35 P a g e WASH Message Safe water for personal hygiene (washing hands, Face, or Body & laundry Water for environmental sanitation (cleaning latrines) Disease Impartation L-F, Schistosomiasis, Trachoma & STH STH, Schistosomiasis

36 WATER SANITATION HYGIENE Increasing access to safe water for drinking & food preparation Monitoring water resources, Waste water management, sanitation & Vector breeding levels Reducing open defecation Disposing of infant/child faeces properly Increasing improved sanitation coverage Promoting maintenance & cleaning of latrines Emphasizing the importance of : Handwashing Face washing Wearing shoes outside Daily washing with soap, of swollen limbs, feet, and between toes to prevent bacterial infection Washing of soiled clothing / bedding Avoiding physical contact with contaminated surface water Se of safe water for bathing, clothes washing, and swimming Trachoma Schistosomiasis Schistosomiasis Schistosomiasis STH, Schistosomiasis, Trachoma STH, Schistosomiasis, Trachoma STH, Schistosomiasis, Trachoma STH Trachoma STH L-F Trachoma Schistosomiasis Schistosomiasis 36 P a g e

37 Material #3 MAM Steps for Pupil/Students Medicine Material #4 Handbill on Net hanging and use 37 P a g e

38 Material #5 WASH Assessment Form National Schistosomiasis and Soil Transmitted Helminths Control Programme School Information Form of visit... SC1 Team No SC2 State Name SC3 State Code SC4 LGA Name SC5 LGA Code SC6 Community Name SC7 School Name SC8 Community/School Code Annex 001 Date SC9 SC10 SC 11 SC12 SC13 SC14 SC15 Lat: Long: Elevation School Enrolment No of Male Enrolled No of Female Enrolled No of students sampled WS1 Is there a source of drinking water in the school? N0=0; Yes=1 WS2 WS3 WS4 If yes, what type of water source? Are there sources of drinking water close to the school If yes, what type of water source? Unprotected spring=1 Protected spring=2 Unprotected dug well=3 Protected dug well=4 Hand pump/tube well/borehole=5 Surface water (river, dam, lake, stream, canal)=6 Public piped water/tap/standpipe=7 Rainwater collection=8 Sachet/Pure water=9 Other=99 (Specify): N0=0; Yes=1 Unprotected spring=1 Protected spring=2 Unprotected dug well=3 Protected dug well=4 Hand pump/tube well/borehole=5 If WS1=0, GOTO WS3 If WS3=0, GOTO WS5 38 P a g e

39 WS5 Are there accessible water bodies close to the school Surface water (river, dam, lake, stream, canal)=6 Public piped water/tap/standpipe=7 Rainwater collection=8 Sachet/Pure water=9 Other=99 (Specify): No=0; Yes=1 Is there a latrine in the school (observed)? No=0; Yes=1 PL1 PL2 Evidence of latrine usage observed (faeces in pit)? No=0; Yes=1 Pit latrine without slab or open pit=1 Pit latrine with slab=2 PL3 What type of latrine is present Ventilated improved pit latrine (VIP)=3 Flush or pour flush toilet=4 Other=99 Poor=0 (Presence of flies, offensive odor and visible stool on floor, absence of roof/door) Fair=1 (Presence of roof/door but dirty floor) PL4 What is the condition of the latrine? Moderate=3 (clean, absence of roof or door) Good=4 (Clean, odorless, no flies, presence of roof and door) Excellent=5 (Very clean, odorless, presence of roof, door and availability of water) Always PL5 Is there water or Tissue for use after defecating?. Sometimes Never Others, (Specify) Is there provision for hand washing after toilet PL6 use? No=0; Yes=1 No=0; Yes=1 No water=0 Water only=1 What type of hand washing facilities? Water and soap=2 Water, soap and napkin=3 Water, soap and Disposable napkin=4 PL7 Others= Specify If PL1=0, END 39 P a g e

40 Material #6: Class / School Register 40 P a g e

41 Materials #7: Steps on use of electronic data collection device FMOH M/NTD/WASH User Guide Step 1 =====> Launch the Google Playstore App on your Phone Step 2 =====> Search for and Download Fulcrum (by Spatial Networks Inc) Step 3 =====> Open the App on your device and sign with username: kontactolu@yahoo.com. password is password123 Step 4 =====> Click on the Menu Icon Choose App at the top left hand side of the screen and FMOH M/NTD/WASH or FMOH M/NTD/WASH School Info) Step 5 =====> Click on the + icon at the bottom right part of your screen to fill in a new record. When you are done, click on the icon at the top of the screen to save a record. Note: Fields marked with a red * cannot be left empty. Materials #8: Tablet Pole for measuring height of children (photo class teacher initiative on the class black board) cm cm cm 2 ½ cm cm 1 ½ cm 41 P a g e

42 Materials #9: Adverse drug reaction consumables for States S/N ADR Medications Packaging 1 Glucose D 3 x 400g Tins Paracetamol tablets Chlorpheniramine tablets 4mg Hyoscine Butyl Bromide tablets Oral Rehydration Solution 8 x 12 Sachets x 1000 pieces x 1000 pieces x 6 pieces 6 Sachet Water bags x 20 bags 7 Napkins x 12 pieces 8 Liquid soap x 1L 9 Disposal cups x1 10 Trash Bags x1 Materials #10: Other consumables for MAMs and WASH for States S/N Item 1 Cartons of Biscuit 2 Rolls of bin bag/bin liners 3 Hand wash liquid soaps 4 Disposable cups 5 Disposable spoons 6 Paper towels/serviettes 7 Bags of sachet water 42 P a g e

43 APPENDIX 5: PHOTOS Picture 1: Advocacy visit to HCH, Jigawa Stater Picture 2: Mobilization of Community leaders Picture 3: Mobilisation of Head Teacher in Cross River Picture 4: Teachers during training session in Schools Picture 5: Use of electronic data collection device, during teachers training session in Schools 43 P a g e

44 Picture 6: Children been fed before administration of medicines Picture 7: Delivery of MAMs Picture 8: Delivery of MAMs Picture 9: Pupil received net from their teacher Picture 10: Pupils received their net and happy 44 P a g e

45 Picture 11: Hand washing demonstrated by Head Teacher to Pupils/Students Picture 12: Hand washing demonstrated by Pupils and Students Picture 14: Happy Children with their nets Picture 13: Teachers undertaking waste disposal 45 P a g e