Strengthening health systems to restore and sustain child survival gains in the context of Ebola: Case studies from Liberia

Strengthening health systems to restore and sustain child survival gains in the context of Ebola: Case studies from Liberia

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. ii

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 iii

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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 v

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. 1

Abbreviations ACF ARI CCM CDC CHT CHV CHW CHX DHO ECEB EIA ELWA EPA EPI ETU EVD gchv GoL HBB HBMNC IPC iccm ICRC IMAM IMC IMC ITN KMC LDHS LWSC MCV1 MCC MNCH MoU MoD MoH MPW MSF M&E MUAC NGO Action Contre La Faim Acute Respiratory Infection Community Case Management Centers for Disease Control and Prevention County Health Team Community Health Volunteer Community Health Worker Chlorhexidine District Health Officer Essential Care for Every Baby Environmental Impact Assessment Eternal Love Winning Africa Environmental Protection Agency Expanded Programme on Immunization Ebola Treatment Unit Ebola Virus Disease General Community Health Volunteer Government of Liberia Helping Babies Breathe Home-based Maternal and Newborn Care Infection Prevention and Control Integrated Community Case Management International Committee of the Red Cross Integrated Management of Acute Malnutrition Integrated Measles Campaign International Medical Corps Insecticide Treated Net Kangaroo Mother Care Liberia Demographic and Health Survey Liberia Water and Sewer Corporation Measles Containing Vaccine 1 st dose Monrovia City Corporation Maternal, Newborn, and Child Health Memorandum of Understanding Ministry of Defence Ministry of Health Ministry of Public Works Medécins Sans Frontières Monitoring and Evaluation Mid-upper Arm Circumference Non-governmental Organization 2

OIC OPV PMU PIRI PPE PPH RUTF RMNCH SIA SOP TTM ToT UNICEF WASH WFP WHO Officer-in-Charge Oral Polio Vaccine Pentecostal Mission Unlimited Periodic Intensification of Routine Immunization Personal Protective Equipment Postpartum Haemorrhage Ready-to-use Therapeutic Food Reproductive Maternal Newborn Child Health Supplementary Immunization Activities Standard Operation Procedure Trained Traditional Midwife Training of Trainers United Nations Children s Fund Water Sanitation and Hygiene World Food Programme World Health Organization 3

BACKGROUND 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. 4

Strengthening Facility-based Services 5

INTEGRATING INFECTION PREVENTION AND CONTROL INTO ROUTINE MATERNAL AND NEONATAL CARE 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, 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 6

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 delivery 4. 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) services 1. 7

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. 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. 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 CHVs 1. 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. Photo 2: HBMNC training of HCWs in December 2014 Demonstration during the IPC module 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 8

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. 9

Review task of Trainers and CHVs Field Visit Practice/Demonstration Practice the Facilitator Skills for the Trainer M&E Tools Introduction to Field Visits Assist with Referrals Care of the Mothers Danger Signs in the Newborn Use of Chlorhexidine for Cord Care Hand Washing Kangaroo Mother Care (KMC) for small babies Care of the Normal Babies Exclusive Breastfeeding Infection Prevention and Control in Health Facilities Post Natal Home Visit Promote Facility Delivery Do and Don t in the community for CHVs Promote Antenatal Care Identifying pregnant women in the community Interacting with Families Introduction Course Overview 0 5 10 15 20 25 30 35 40 Very Easy to Understand Easy to Understand Not Easy Not Difficult Difficult to understand Very Difficult to understand Figure 1: Participant understanding regarding the training topic, caring for mothers and babies at home, for Health Workers in Sinoe County, December 2014 10

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 places 1. 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. LESSONS LEARNED County Table 1: Helping Babies Survive pre-test and post-test evaluations Training type Number of HCWs trained and evaluated pretest Average score post-test Gbarnga ToT 48 72% 96% Grand Gedeh Cascade 30 77% 90% Sinoe trainings 38 70% 94% Table 1: Helping Babies Survive pre-test and post-test evaluations 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 support 2. 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. 11

SAFE MANAGEMENT OF SEWAGE FROM EBOLA TREATMENT UNITS (ETUs) 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. Photo 1: LWSC crew desludging Ebola contaminated sewage at Unity Centre ETU in Monrovia 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. 12

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 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. 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 13

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 14

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. Photo 3: UNICEF representative Sheldon Yett responding to queries raised by Fiamah community members during trial desludging operations at Fiamah, Monrovia 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. 15

DELIVERY OF NUTRITIONAL INTERVENTIONS TO EBOLA AFFECTED POPULATION INTRODUCTION With the emergence of the Ebola Virus Disease (EVD) outbreak in Liberia, the comprehensive multisector 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 centers 3. 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-five 4, and the preparation and use of the therapeutic and special nutrition commodities. 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 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. 16

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 met 5. 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) biweekly ration of RUTF instead of weekly. 6 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 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. 17

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 admitted 7 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 2014 Admission 2015 Admission Total per Location Nov Dec Jan Feb County 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 Dolo s Town 0 1 0 0 1 Margibi Firestone 22 5 0 0 27 Kakata 0 0 50 43 93 Maryland Harper 0 0 0 2 2 ELWA 2 23 48 17 65 153 ELWA 3 28 99 51 15 193 Montserrado 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 18

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. 1000 900 800 700 600 500 400 300 200 100 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Admissions Bomi Bong Lofa Margibi Monsterrado Nimba Sub-Total 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 19

Strengthening Outreach Services 20

EXPANDING INTEGRATED MEASLES CAMPAIGN OUTREACH THROUGH A FOUR-PRONG COMMUNICATION STRATEGY 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 reestablish trust in the immunization program. 21

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 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 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 22

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). 23

MV coverage of the clusters 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). 100% 95% 90% 85% 80% 95% 93% 92% 90% 88% HFO HF TFHF TF TFO 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) Figure 1: Measles vaccination coverage per cluster by type of vaccination teams 24

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. 25

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). 26

GETTING TO AND SUSTAINING ZERO: THE INTEGRATED EBOLA VIRUS DISEASE MOP-UP STRATEGY 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 activities 8. 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 2015 9. 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 coordination 4. Strong social, cultural and economic ties to neighboring Sierra Leone increasing the risk for crossborder transmission of EVD 10. 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 27

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 County 11. 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. 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 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 28

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 29

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. 30

Strengthening Community-based Services 31

IMPLEMENTING INTEGRATED COMMUNITY CASE MANAGEMENT OF CHILDHOOD ILLNESSES WITH INFECTION PREVENTION AND CONTROL MEASURES 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) 32

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. Photo 2: Training of OICs in iccm (top) and health facility OICs posing at the end of the training (down) 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. 33

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. 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 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. 34

INTEGRATING INFANT AND YOUNG CHILD FEEDING AND CARE INTERVENTIONS FOR A COMPREHENSIVE CHILD WELFARE SERVICES 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. 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 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. 35

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. 36

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 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. 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. 37