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Strengthening Vaccination Systems – how it STARTs

Categories: immunization

On the road to Bukwo District (photo courtesy of George Momanyi)

On the road to Bukwo District (photo courtesy of George Momanyi)

George Momanyi, Public Health Nurse, START Consultant

George Momanyi, Public Health Nurse, START Consultant

George Momanyi, a public health nurse from Kenya, has twice served as a consultant with CDC’s Strengthening Technical Assistance for Routine Immunization Training (START) project in Uganda.  START, funded through a grant from the Bill & Melinda Gates Foundation, provides mentoring and on-the-job training to district-level immunization officers and service providers in areas with high numbers of unimmunized children. START consultants make regular visits to district health officers and service providers, delivering training and reinforcing the application of practical job skills.  START’s objective is to build the capacity of program staff and thereby strengthen the overall immunization system. 

As a START consultant, George worked in eastern Uganda from July-December 2013, and in northern Uganda from February-June 2014. As he was ending his service on the 2nd START team in June, he sent us this blog about his experience. 

Getting Started 

Delivering training at a health center (photo courtesy of George Momanyi)

Delivering training at a health center (photo courtesy of George Momanyi)

I came into the START project having worked in the Expanded Program on Immunization (EPI) in Kenya for more than 10 years and also after having served as a Stop Transmission of Polio (STOP) volunteer in Ethiopia in 2009.  With this background, I had quite some experience, but still was open to learning more from the Ugandan setting.  There were two important factors that enabled the START team’s success before deploying to the field.  The first was the pre-service training we received in Kampala, and the second was a meeting with all the Health Officers from the districts where our team would work to introduce the project and discuss how we would be working together.  In this way the health officers could see this would be a collaboration with them, and not a short-term project imposed on them from the outside. 

After initial training of the district EPI officers, I accompanied them to the health centers, where vaccination services are delivered, to provide on-the-job training to the staff there.  It was not always easy for the district officer to offer training to the health center staff at the beginning, so I did initial health center trainings while the district officer observed, so he could become more familiar with the topics and training methods.  On the follow-up visits the district officer and I trained the health center staff together, increasing the officer’s confidence in doing this on his own in the future. 

Training with district officer at a health center (photo courtesy of George Momanyi)

Training with district officer at a health center (photo courtesy of George Momanyi)

Many times, I sat together with the health center workers and led them through the group exercises.  I engaged health workers while building on what they already knew on the topic before introducing any new concepts.  One of my key mentoring approaches was to understand the workers’ knowledge and skill gaps and to focus on those during our time together.  In order to help slow-moving health centers, I often shared pictures of good practices seen in other facilities as a way to encourage them that it was possible to do even better. 

In order to win their confidence and establish a positive relationship, I often reassured health workers that I was there not as a supervisor but rather as a colleague to support them to improve routine immunization performance.  In that way, the staff were always free to interact with me and even open up to me with details they had not told to their supervisors. One EPI staff person told me, “I admire the way you handle our staff, and they are able to give you details they would rarely mention to us.” While supporting the districts, I used every available opportunity to mentor the teams.  Health workers could call me to seek clarification or even request that I revisit their health facilities at any time, and I always made time for them. 

Working in the field

I met this health center EPI officer on my way to another facility and I took a moment to appraise his EPI micro plan. (Photo courtesy of George Momanyi)

I met this health center EPI officer on my way to another facility and I took a moment to appraise his EPI micro plan. (Photo courtesy of George Momanyi)

As a START volunteer, I came across many challenges but managed to cope.  Many of these were related to routine immunization service delivery.  I often took time to help health workers understand how their own practice had a bearing on overall system performance – that their actions could contribute to the system either performing well or poorly.  Therefore I worked with the teams to try to accurately identify the reasons for problems, and then explore solutions.  Before providing my own suggestions, I always sought ideas from both the district or health center teams about the issues and what they thought they could do on their part.  Where appropriate, I engaged the district health officers for their support.  Some of the common issues encountered included were these: 

  • Getting quality time, especially with the key district EPI officers, was a challenge, because of competing activities
  • EPI data at the facilities was not always available
  • Shortage of data collection forms
  • Health center staff absenteeism  

And there were factors outside the health system like poor road networks, especially as a result of rain. At times we had to spend long hours driving and pulling our vehicle out of the mud, which delayed movement to facilities. Despite this, my spirit grew each day, as a new challenge meant developing newer coping strategies, and this is what kept me moving.  Building a good working relationship with the district teams and my drivers was especially helpful. 

Challenging roads during rainy seasons 

Getting a hand from other road users in Kween District and Bukwo District (photos courtesy of George Momanyi)

Getting a hand from other road users in Kween District and Bukwo District (photos courtesy of George Momanyi)

Reflections on my work on the two START teams 

Mentorship at a health center (photo courtesy of George Momanyi)

Mentorship at a health center (photo courtesy of George Momanyi)

Working in Uganda has been a great achievement and a big learning experience for me. Working as a START consultant requires a lot of patience, flexibility and consistency in everything you do. You need to build and gain the confidence of the district teams and staff at the health centers from the outset, and respond to their inquiries promptly.  The START experience exposes one to working closely with the district and health center teams, and one learns what works well and what doesn’t.  The bottom line to me has been to effect some positive change in terms of the teams working consistently towards achieving agreed-upon deliverables and sustaining these interventions, which I call the “START effect.” 

There are times when things went well and other times when nothing seemed to move.  I felt low whenever the teams were slow to implement new techniques.  However, I never showed my frustration to them. Rather, I encouraged them by sharing best practices I seen elsewhere, and used these times as opportunities to share such feedback to the district health officers who I felt had responsibility over their own staff and could hold them accountable.  The most encouraging aspects of working in START were meeting teams who appeared enthusiastic about START and revisiting them to see the wonderful progress they made.  I came across very brilliant health workers who were doing great, and I often made reference of the good work they were doing and even shared their work with others as encouragement. 

Observing a group exercise during health center training (photo courtesy of George Momanyi)

Observing a group exercise during health center training (photo courtesy of George Momanyi)

Despite the challenging situations, some comments from the health workers I interacted with kept my spirits high: 

As a medical doctor I did not know what to supervise in routine immunization, but now I am more skilled in supervision of RI activities” – Medical Superintendent – Bukwo General Hospital 

“These training materials have been very nice and useful for my jobWilliam – DranyaHealth Center 

“The micro-planning process has helped us build a better understanding of our performance, and we will move ahead to develop a micro-plan for FY 2014/15” Alfred – YumbeHealth Center 

While providing feedback to the Koboko District Health Team, the regional officials reported, “There is a big difference in health facilities already supported by the START trainings compared to the other facilities not yet trained.” 

I feel I’ve learned a great deal being on the two START teams.  I gained the ability to interact fairly with people I’m working with.  For future jobs I am better prepared to embrace listening, patience, and courtesy.  My communication skills are stronger too, because I’ve had to mentor and train health workers in a new country.  Working as a START consultant has also increased my intellectual capacity by gaining more expertise about EPI service delivery and its underlying principles.  I can confidently reflect on the differences between where I found health centers at the beginning and the improvements I observed by the end of my mission!  While the impact of START may not be felt immediately, it has enormous potential.  Continued collaborations and support at all levels should continue.  It is my sincere hope that the districts supported by the first two START teams in Uganda will endeavor to sustain the initiatives we began in order to achieve the “START Effect.” 

START is funded through 2016 by a grant from the Bill & Melinda Gates Foundation. The next START teams will be in Uganda and Ethiopia during the second half of 2014. 

Processes improved after mentorship interventions:

Left: This is where we found the immunization monitoring chart at one health center before we began training. Right: Here is the monitoring chart after training – filled out and on the wall! (Photos courtesy of George Momanyi)

Left: This is where we found the immunization monitoring chart at one health center before we began training. Right: Here is the monitoring chart after training – filled out and on the wall! (Photos courtesy of George Momanyi)

CDC Scientist Fights Chikungunya

Categories: chikungunya, mosquito-borne disease

investigation in Comoros in 2005.

Investigation in Comoros in 2005.

Ann Powers, Ph.D., Research Microbiologist and Chief of the Alphavirus Laboratory in CDC’s Division of Vector-Borne Diseases

Ann Powers, Ph.D., Research Microbiologist and Chief of the Alphavirus Laboratory in CDC’s Division of Vector-Borne Diseases

One of the most telling signs of the complexity surrounding chikungunya is that educating people on pronouncing the name correctly is perhaps the easiest challenge.

I’m exposed to that truth more than most.  And for the record, it’s pronounced chick-un-goon-ya.

As a research microbiologist for CDC’s National Center for Emerging Zoonotic and Infectious Diseases, my job is to better understand and occasionally chase (literally) an often overlooked, mosquito-borne, threat to public health; one that holds the potential to spread sickness and misery in the United States.

Chikungunya is viral disease that is transmitted to people by two species of mosquitoes that are present in the United States. Aedes aegypti and Aedes albopictus, often called the Asian tiger mosquito, can be found in about a third of the U.S.  They are the same mosquito species that transmit dengue in much of the tropics.  And while chikungunya does not kill people, the toll it inflicts ranks high on the misery index; it hits fast and hard and with almost no subtlety. People infected with chikungunya typically experience high fever and severe joint pain soon after they are exposed. Sometimes those problems are long-lasting.

World Cup serving as real-world test for new disease detection technology

Categories: global disease detection, global health security, health systems strengthening, infectious disease

 

World Cup soccer ball

 

With the World Cup underway in all its frenzied glory, you can be forgiven for missing another major effort currently underway in Brazil that represents the first large scale, real-life, real-world test of important new technology.

And no, it’s not the goal-line technology that’s being used for the first time at soccer’s biggest competition.

This technology uses computer tablets, sophisticated software designed by CDC and public health experts from Brazil’s Ministry of Health (MOH) trained in the Field Epidemiological Training Program (FETP) to provide the most complete, detailed and timely information about disease threats and other public health concerns.

Polio Eradication, Microplanning and GIS

Categories: child health, immunization, polio

A Bugagi child travels by camel near Lake Chad in Borno State, Nigeria. Photo courtesy of Thomas Moran/WHO.

A Bugagi child travels by camel near Lake Chad in Borno State, Nigeria. Photo courtesy of Thomas Moran/WHO.

Victoria Gammino, PhD, MPH, Epidemiologist, CDC Global Immunization Division

Victoria Gammino, PhD, MPH, Epidemiologist, CDC Global Immunization Division

Geospatial data have been used in public health since John Snow mapped cholera cases around the Broad Street water pump during the London cholera epidemic of 1854.  And, while global positioning system technologies (GPS) are so ubiquitous in the United States that virtually all new smartphones, tablets and cars have this technology embedded, in many areas of the world, health care workers in the field are often without the most basic two-dimensional paper maps.

So what do maps and map literacy have to do with polio?  Polio is a crippling and potentially fatal infectious disease. There is no cure, but there are safe and effective vaccines. Therefore, the strategy to eradicate polio is based on preventing infection by immunizing every child to stop transmission of the virus that causes polio, and ultimately make the world polio free.   The four pillars of polio eradication all rely on “microplans”— detailed logistical blueprints that guide the planning and implementation of vaccination campaigns, routine immunization outreach, and surveillance for polio cases by providing critical data on the size and location of the target population in a given geographic area.  These target population numbers determine the amount of vaccine required, the number of health care workers and supervisors to deliver the vaccine, and the cost of transportation to get the vaccine and health care workers where they need to go.

CDC Staffers Take No Refuge From Helping Refugees Around the World

Categories: infectious disease, refugee health

A child plays with a kite in a tent camp after the earthquake, Port-au-Prince, Haiti, 2010.

A child plays with a kite in a tent camp after the earthquake, Port-au-Prince, Haiti, 2010.

For anybody wondering why CDC has a branch dedicated to helping refugees or why the United Nations has formally recognized World Refugee Day every year since it was created in 2001, the answer can be found in a single, stark statistic: In 2013, a person became a new refugee or internally displaced person every 4.1 seconds.

Michelle Dynes, PhD, MPH, MSN, CNM, RN, EIS Officer/Epidemiologist, CDC Emergency Response and Recovery Branch

Michelle Dynes, PhD, MPH, MSN, CNM, RN, EIS Officer/Epidemiologist, CDC Emergency Response and Recovery Branch

Cyrus Shahpar, MD, MBA, MPH, Medical Epidemiologist, CDC Emergency Response and Recovery Branch

Cyrus Shahpar, MD, MBA, MPH, Medical Epidemiologist, CDC Emergency Response and Recovery Branch

That translates to “a population of concern” of nearly 40 million refugees or internally displaced people worldwide every year, according to the United Nations.

It also translates to a lot of illnesses and suffering. And that’s the reason Cyrus Shahpar, Michelle Dynes and approximately 50 other staff in CDC’s Emergency Response and Recovery Branch (Division of Global Health Protection) have their bags packed and are constantly ready to deploy to the field.

Communication Matters in Global Health Deployments

Categories: global health security, infectious disease

During the simulation exercise, ECN trainees deployed to the site of a mock disaster in Avully, Switzerland.

During the simulation exercise, ECN trainees deployed to the site of a mock disaster in Avully, Switzerland.

Communication matters.

Gaya Gamhewage, MD, Coordinator, WHO Communication Capacity Building Team; Founder, WHO Emergency Communication Network

Gaya Gamhewage, MD, Coordinator, WHO Communication Capacity Building Team; Founder, WHO Emergency Communication Network

That’s not a new idea. Many of us have learned this the hard way. This concept is being applied in a new, more comprehensive way for a key purpose—to help the World Health Organization (WHO) communicate more effectively, with more clarity and purpose during humanitarian and public health emergencies.

The idea is to better integrate communications specialists from WHO, CDC, ministries of health and a wide array of other humanitarian and global health organizations into a cohesive, specially trained team that can be dispatched on short notice when public health or humanitarian emergencies occur.

The logic is based on the idea that communications is part and parcel of emergency health response. Communicating in a crisis not only provides the public and policy maker clear and critical information, it also can help the technical side of the response. It connects those affected with those willing to help and can make sure that resources are aligned to the most important needs.

Voices from the Central African Republic: FELTP residents remain committed to strengthening disease surveillance and outbreak response in CAR

Categories: child health, immunization, infectious disease, refugee health

CAR refugees forced from their homes by rebels

CAR refugees forced from their homes by rebels

Dr. Els Mathieu, Resident Advisor, CAR- FELTP

Dr. Els Mathieu, Resident Advisor, CAR- FELTP

The Central African Republic (CAR) is a landlocked country in Central Africa, bordered by Chad in the north, Sudan in the northeast, South Sudan in the east, the Democratic Republic of the Congo and the Republic of the Congo in the south and Cameroon in the west.  CAR is one of the world’s least developed nations and has experienced several periods of political instability, as well as deadly attacks and violence by rebels that have forced nearly 1 million people from their homes in search of refuge.  With so many civilians fleeing to refugee camps in the capital, Bangui, and the provinces, there is an increased need to strengthen disease surveillance and response.

A Call for Action: Responding to the Tobacco Epidemic and the Price of Cigarettes

Categories: cancer, cardiovascular disease, noncommunicable diseases (NCDs), tobacco

Woman smoking tobacco

“Raising taxes to increase the price of tobacco products is the most effective means to reduce tobacco use and encourage smokers to quit.” – WHO Report on the Global Tobacco Epidemic, 2013

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Samira Asma, DDS, MPH - Chief, CDC Global Tobacco Control Branch

Real People, Real Stories

Mehmet Nuhoğlu started smoking when he was in middle school at the age of 12 after hearing that real men smoke. Little did he know that 45 years later his two pack a day addiction would lead to a heart attack and then cancer. “I never thought it would happen to me. I still can’t believe it,” he says.

Featured in national ads similar to the US Tips campaign, Mehmet was one of the real-life people featured in Turkey’s anti-tobacco mass media campaign that was launched in the later part of 2011. He tells of his experience with cigarettes and what daily smoking ended up costing him- his voice and his health. Now speaking with the help of an electrolarynx (a device that helps users who have lost their voice box produce clearer speech), he confesses that he regrets smoking.

Public Health Informatics in Action in Malawi: Making life easier for healthcare workers and patients while improving quality through an innovative national Electronic Medical Record System

Categories: child health, global health security, HIV/AIDS, women's/maternal health

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Instituting an Electronic Medical Record System reduces the need to manage and store growing volumes of patient charts, a major challenge in resource-limited settings.

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Denise Giles, M.P.H., Health Scientist, CDC-Malawi

Keeping track of even one patient undergoing treatment for HIV/AIDS can be complicated enough.

Doing it for over 472,865 patients when you’re a low income country coping with high demand and a sputtering economy magnifies the complexity.

Which is why Malawi’s story – and its solution – is attracting attention and praise. It’s a story of how Electronic Medical Record System (EMRS) technology is being used and the foresight needed to bring it to reality.

You don’t have to look far to see the positive results.

CDC Protects Families: My favorite stories

Categories: child health, malaria, tuberculosis (TB), women's/maternal health

Terri Still-LeMelle

Terri Still-LeMelle

As we celebrate families on Mother’s Day, May 11, and the International Day of Families, May 15, I am especially proud to work in CDC’s Center for Global Health.  As one of the Center’s  health communication specialists, I have the privilege to write or edit many stories about how CDC’s programs impact the lives of families around the world.  In honor of this season, I’d like to highlight a few of my favorite accounts about brave mothers, determined families, and CDC’s global health programs.

 
 
 
 

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