4.1.2 The campaign to eradicate polio

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This slide cast will introduce you to the realities of infectious disease in rural Ethiopia and how it is being tackled in every village by local health workers with basic training in disease prevention, diagnosis, treatment and control. My aim in giving you an insight into this astonishingly beautiful and hospitable country is to illustrate infectious disease and public health at local level and the impact it can make on a national scale. But I also hope it will challenge the negative image of Ethiopia often presented in the media.

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Ethiopia is in the horn of East Africa. Its largely mountainous terrain can be clearly seen in the aerial view on the right.

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Notice the huge expanse of Lake Tana in the north and the chain of lakes that mark the start of the Great Rift Valley, beginning in central Ethiopia – not far from the capital Addis Ababa – and extending south into Kenya.

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This slide cast focuses on infectious disease in rural Ethiopia. But before we go there I want to make the point that Ethiopia has several large and expanding cities in addition to the capital Addis Ababa. There are grand buildings, modern hotels, busy traffic and many Orthodox Christian Churches, mosques and other places of worship in this intensely religious country. The shanty settlements in the foreground of this photo are being rapidly replaced by apartment blocks. But Ethiopia remains a largely rural country – only about 20% of the population live in urban conurbations.

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Most of Ethiopia’s 83 million people live by farming in distributed rural communities, called kebeles in the Amharic language. The average kebele has about 1000 households and roughly 5000 inhabitants, led by a council of elected representatives. The round thatched houses in this photo are called tukul and are found all over Ethiopia.

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As you can see, the Ethiopian countryside can be green and lush in the rainy season, supporting some of the country’s major exports: coffee, cut flowers and leather goods from animal hides. But the soil is poor after decades of subsistence farming and it soon dries out when the long rains end.

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Animals are vital to the rural economy, but close proximity to their domestic animals exposes the rural population to infectious diseases with reservoirs in animal hosts, particularly intestinal parasites and the bacteria causing diarrhoeal diseases.

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Most farming is done by hand or with simple ploughs pulled by oxen. Here the staple cereal crop, called tef is being harvested. The tiny grains are ground to make Ethiopia’s national dish – a thin pancake called injeera, which is unique to the country. I’ll come back to injeera when I talk about malnutrition in Ethiopia in a moment. First, let’s look more closely at a particular kebele and the infectious diseases that affect its inhabitants.

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This is a map of Fura kebele, a rural area with a population of approximately 5000 people in the Southern Nations, Nationalities and Peoples Region of Ethiopia. The households are distributed across a wooded area, roughly five by ten kilometres, but some kebeles are larger than this. The inhabitants of Fura have carved out small fields in which to grow tef and graze their animals.

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There are no paved roads, no piped water, and no electricity supply to the houses, so they are dark inside and difficult to photograph. Grass partitions divide the living and sleeping areas and the furniture is simple and stands on the mud floor.

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This road in Fura is typical of how people get around in rural kebeles – mostly on foot, walking long distances, sometimes on a bicycle or in a donkey cart. The deep channels in the earth are caused by flood water during the rainy season, when the roads are often impassable, even with a four-wheeled-drive vehicle. The nearest health centre is 15 kilometres down this road, so if people need urgent medical help they may have to be carried there on a stretcher.

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Many of the causes of infection in Ethiopia are related to the lack of clean water, which is a constant problem for many rural communities. Only 38% of the population has access to improved drinking water and many of these are in towns and cities – in the countryside, most people get their water from lakes, rivers and streams.

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Some rural communities have deep communal wells, like this one in Fura. The water table is a very long way down in the dry season. The bucket is made from an old rubber tyre.

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Unsafe drinking water presents a major health hazard to a large proportion of Ethiopia’s population. Here a horse, man and boy drink from the same muddy stream flowing from pasture where cattle were grazing. Shallow streams and pools like these make ideal breeding grounds for malaria mosquitoes and other vectors of infectious diseases such as onchocerciasis and schistosomiasis, as well as harbouring many pathogens causing diarrhoeal diseases.

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People and their animals competing for scarce drinking water also increases the risk of water contamination by human and animal urine and faeces.

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This chart shows the main causes of death in Ethiopia in children aged under five years. The high rate of diarrhoeal disease is one indication of the lack of access to clean water. As you can see from the four bars on the left, diarrhoeal disease, pneumonia, neonatal sepsis (which is mostly due to tetatnus) and HIV/AIDS account for the majority of these avoidable deaths. The 21% of deaths labelled ‘all other causes’ include many important infections such as measles, malaria and tuberculosis.

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An idea of the challenges in rural communities can be gauged from this wall chart from a Health Centre in the small town of Modjo. It shows the top ten causes of serious morbidity (illness) among male children aged under five years who were sent from the surrounding rural kebeles because their condition could not be managed locally. The chart for girls of this age is very similar, but my photo wasn’t as clear. The prevalence of infection among the under fives is striking: the top ten causes of serious illness are non-bloody diarrhoea, pneumonia, acute urinary tract infections, dysentery (that’s bloody diarrhoea), infestation with helminths, infections of the skin and subcutaneous tissue, all other respiratory diseases, malaria, all other skin diseases, and typhoid fever.

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Inadequate food hygiene standards and the practice of eating kitfo – raw beef or ox meat – at important festivals is another major source of infection. Beef tapeworm is prevalent and infestation with other intestinal worms is widespread, affecting over 50% of children, with major effects on their growth and development.

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Ethiopia is commonly associated with famine, but such deep crises of absolute food insecurity are relatively rare. The more consistent problem is generalised protein energy malnutrition. The staple diet is injeera made from tef, which you saw being harvested earlier. Injeera is typically eaten from a communal plate with a hot lentil sauce and perhaps some stewed vegetables. Meat is only for special occasions in most families. Injeera is highly nutritious, but there often isn’t enough food to go around. Children in particular suffer from a persistent shortage of calories in their diet and a lack of vitamin A and iron because of the scarcity of vegetables.

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These data come from the last national survey in Ethiopia conducted in 2005 and published in 2007. At that time, 38% of children under 5 years were underweight and 47% were stunted (short for their age). The extent of iodine and iron deficiency is demonstrated by the high rates of goitre and also of anaemia among young children. These conditions also affect many women of childbearing age. Malnutrition is a major contributor to susceptibility to infectious disease and premature death, and not only among children – over a quarter of women are chronically malnourished, which makes them particularly vulnerable during pregnancy, childbirth and breastfeeding.

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Despite its many health problems, some of Ethiopia’s indicators of public health are better than the average for Sub-Saharan Africa, and steady progress is being made towards achieving the Millennium Development Goals for reducing child and maternal deaths. But there is a long way to go. For example, for every 1000 live births in Ethiopia, more than 4 women die from causes related to pregnancy, childbirth, postnatal infection or haemorrhage. This is roughly 50 times higher than the maternal mortality rate in the UK.

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Faced with all these challenges to public health, in 2005 the government of Ethiopia began an ambitious programme to bring basic disease prevention and health promotion services to the entire population, now totalling over 83 million people. They have built a small Health Post in every kebele staffed by two full-time Health Extension Workers trained and paid by the Ministry of Health. There are now over 12 500 rural Health Posts like these and over 33 000 Health Extension Workers deployed in rural areas.

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Here are two of them – Asafesh on the left and Almaz on the right. The Health Extension Workers are all young women – an innovation in Ethiopia where the majority of nurses and midwives, as well as doctors, are male. Asafesh and Almaz have graduated from the one-year residential training programme and now work in rural Health Posts in different regions of Ethiopia. They each work with another Health Extension Practitioner to take care of the 5000 inhabitants of their communities.

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The vital importance of the Health Posts and their Health Extension Workers to the delivery of health services in Ethiopia is well illustrated by the pie chart on the left. Each Health Post is in a ring of five ‘satellite’ Health Posts, at a distance of 10-15 kilometres from the nearest Health Centre, which supplies and supervises the Health Extension Workers. The provision of health services in Ethiopia relies very heavily on this organisation of primary care, partly because of the remoteness of the rural population from the hospitals, which are all in the cities, but also because of the shortage of medical expertise: there are just 20 hospital beds and 2 doctors for every 100 000 population.

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So what health services do Asafesh and Almaz provide for their communities? This Health Post wall chart lists the main components. Take a moment to read the list. Click on the ‘Pause’ button while you do this.

How many of the service areas are directly or indirectly concerned with preventing or controlling infectious disease? Immunisation and all of the environmental health and disease prevention and control packages are obvious examples, but infection control is also an important aspect of health care during pregnancy, labour and delivery and the postnatal period. It also figures prominently in many of the health education activities that Health Extension Workers conduct, for example, on handwashing, food hygiene and digging latrines.

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Here is some of the basic equipment in Asafesh’s Health Post. It doesn’t have running water or a sink, so Asafesh carries water in a bucket from a nearby well and washes her hands with soap between patients, using a bowl in a corner of the room.

She has a pressure cooker for sterilising instruments, mainly used when she is attending births; there are syringes for giving immunisations and injectable contraception, and a stethoscope and blood pressure cuff.

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The scales are for weighing adults (mainly pregnant women attending for antenatal care) and there is a delivery couch in a side room. However, around 90% of rural women choose to give birth in their own homes with a Health Extension Worker present or a traditional birth attendant. Postnatal sepsis and haemorrhage are the main reasons for the high mortality rate: remember it was 4.4 maternal deaths per 1000 live births in the bar chart you saw earlier.

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Asafesh also a spirit burner, boxes of disposable syringes, packets of oral rehydration salts to treat diarrhoea, and sachets of PlumpyNut (an energy-rich paste given to malnourished children).

The scales made from a large bowl attached to a spring balance are to check children’s weight and growth rate. There is also a conventional weighing scale for young babies. Identifying children who are underweight is an important responsibility for Health Extension Workers. Supplementing the diet and giving vitamin A capsules help to protect malnourished children from infection.

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Health Extension Workers have a very small stock of medicines for the 5000 people they serve. At the Health Post in Fura, Asafesh has only paracetamol syrup for pain, and mebendazole and trimethoprim sulphamethoxazole to treat intestinal worms. She has anti-malaria tablets (Coartem) and contraceptive pills and the injectable contraceptive suspension Depo-Provera.

There are iron and folic acid tablets for anaemia, tetracycline eye ointment for eye infections in newborns – mainly due to chlamydia transmitted from their mother’s birth canal – a first aid kit, cotton wool swabs, antiseptic, a thermometer, a torch and surgical gloves. That’s all.

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Every Health Post has a kerosene, gas or electric refrigerator for storing vaccines and an insulated vaccine carrier lined with ice packs. The Health Extension Workers use this to collect their monthly supply of vaccines from the Health Centre 10 to 15 kilometres away. Remember that rutted mud road that Asafesh has to walk along to collect her supplies, unless she can get a lift from someone in a donkey cart. She also uses the vaccine carrier to keep vaccines cold when she provides outreach immunisation sessions in remote parts of the kebele.

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Ethiopia follows the World Health Organization’s recommended Expanded Programme on Immunization (or EPI) for low resource countries. A fully immunised infant should receive all the vaccines listed on this slide before its first birthday. BCG vaccine protects them against the most serious forms of tuberculosis. The DPT-HepB-Hib vaccine is also known as pentavalent vaccine because it immunises against the pathogens causing five infectious diseases – diphtheria, pertussis (or whooping cough), tetanus, liver disease caused by hepatitis B viruses, and bacterial pneumonia and meningitis caused by Haemophilus influenzae type b. Ethiopia recently added PCV10 vaccine to the routine immunisation schedule to protect infants against pneumococcal pneumonia. Rotavirus vaccine to prevent the most common cause of diarrhoeal disease becomes routine in 2012.

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Inside the Health Post, wall charts help Asafesh to keep track of her public health targets for the local population, including immunisations. The inside of all Health Posts are covered with monitoring charts like these.

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This wall chart shows how Almaz has been achieving her targets for childhood immunisation coverage in her kebele, which is called Shera Dibandiba. ‘Protected at birth’ refers to neonatal tetanus protection induced by immunisation of the mother with at least two doses of tetanus toxoid during her childbearing years and one during the pregnancy. Neonatal sepsis is a major cause of newborn deaths; note that less than 80% of newborns in this kebele received this protection. Pentavalent-3 refers to infants receiving all three doses of this combined vaccine to protect them against diphtheria, pertussis, tetanus, hepatitis B virus and Haemophilus influenzae type b bacteria. Measles vaccine is given at 9 months in Ethiopia. Almaz is achieving around 90% coverage with pentavalent-3 and measles vaccines.

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Immunisation clinics are mainly held at the Health Post, but all Health Extension Workers spend four out of five days visiting families in the surrounding area and teaching them about disease prevention and health promotion, for example in food preparation, breastfeeding, hand washing, waste disposal and digging latrines.

When Asafesh and her colleague are away from the Health Post they use this cardboard dial to indicate the direction they have gone in that day, so they can be found in an emergency.

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One of Asafesh’s most successful campaigns has been to persuade and support the inhabitants of Fura to build a latrine for every household. Until everyone has access to a latrine, open defaecation in the fields remains very common. This is a major transmission source for parasitic worms and for the bacteria and viruses causing diarrhoeal diseases. Fura kebele, where Asafesh works, was the first village in the southern region to be declared ‘open defaecation free’ because every household had its own latrine. This one is in the yard behind the Health Post. Notice the yellow can of water for washing hands.

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Handwashing is one of the simplest, cheapest and most effective of all public health measures against infectious diseases. Health Extension Workers have promoted the installation of handwashing sites like this one on latrines all over rural Ethiopia.

A 30% reduction of diarrhoeal diseases can be achieved by washing hands with clean water after defaecation and before food handling. Using soap reduces diarrhoeal illness by over 40%.

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Another of the main activities of Health Extension Workers in malarious areas is to mobilise the community to keep their water tanks covered and to drain water collections where mosquitoes breed, like those on the left of this slide. Only 33% of Ethiopia’s children were sleeping under insecticide-treated nets at night in 2007, but the coverage is rising rapidly, thanks to the distribution of nets to every household by the Health Extension Workers. However, there are still over three million reported cases of malaria in Ethiopia every year. Asafesh and Almaz can diagnose malaria with the rapid test kit shown on the right and treat non-urgent cases themselves with simple drugs. But patients with malaria complications have to be referred to the nearest Health Centre, 10-15 kilometres away, for more specialised treatment.

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This is Godino Jitu Health Centre, where Almaz refers patients that she and her colleague can’t manage in the rural community. It serves the surrounding population of 36 700 people and sees up to 300 clients every day. There is no operating theatre and it doesn’t have a fully qualified doctor.

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Godino Jitu Health Centre has a staff of about 24 health workers, including 8 Health Officers with a shorter medical training than doctors, 10 nurses and 2 healthcare assistants, 2 laboratory technicians, a pharmacist and a druggist. It also has clerical staff to register patients and keep records.

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Health Centres deliver services that cannot be provided at Health Posts, including HIV-testing and prescription of anti-retroviral drugs and medication to treat tuberculosis. The pharmacy at Godino Jitu is well stocked, mainly with drugs to treat infectious diseases.

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One of the diagnostic tests that the Health Centre can provide is microscopic examination of blood films from patients with suspected malaria. The sink on the left is where the slides are stained for confirmation of a malaria diagnosis, but more important is the identification of the Plasmodium species so that the correct treatment can be given – for example, to children and pregnant women with acute malaria crises. This is beyond the scope of what Health Extension Workers can currently provide.

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However, Health Extension Workers like Almaz and Asafesh are keen to increase their knowledge and skills, so they can offer even more health services to their local communities. The Open University is proud to have been involved in a unique programme to support the upgrading of Ethiopia’s rural Health Extension Workers, as Vice Chancellor Martin Bean saw for himself when he visited Almaz at her Health Post in 2011.

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1000 Health Extension Workers began studying 13 upgrading modules in 2011, which were produced by Ethiopian health experts with the support of The Open University’s HEAT (Health Education and Training) team. If you are interested, you can see all the modules on the HEAT website. The focus in the modules is on infectious disease and its prevention, diagnosis, treatment and control, but the curriculum also includes modules on non-communicable diseases and mental health.

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There is an increasing focus in many low and middle-income countries on the rising rates of chronic conditions such as hypertension, diabetes and heart disease. Ethiopia is ahead of the curve in planning to train all its rural Health Extension Workers in these new areas of health concern, which The Open University has helped to develop.

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But Almaz and Asafesh – like the other 33 000 rural Health Extension Workers – will still be focusing most of their attention on improving the life chances of beautiful children like these, through immunisation, nutritional support and education on domestic and environmental hygiene. Their efforts are steadily raising the health indicators in Ethiopia, despite the challenges of an often harsh environment and a widely distributed rural population. Ethiopia’s local approach to public health provided on a national scale is leading the way in tackling infectious disease in Africa.

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Amehseghinalehu – thank you!