Setting up child health and mortality prevention surveillance in Ethiopia

Site specifics

Country. Ethiopia is landlocked covering 1,104,300 km² in the horn of Africa, with borders to Eritrea, Somalia, Kenya, South Sudan, and Sudan. It has ten regional states and two self-governing administrative cities, Adis Abeba (Addis Ababa) and Dire Dawa¹¹. Ethiopia was ruled by a Monarchy until 1974 when the Derg (military council) deposed Emperor Haile Selassie. The Ethiopian People's Revolutionary Democratic Front took power in 1991. In recent times there has been intermittent instability, with states of emergency declared between 2016 and 2019. Despite this, Ethiopia has the fastest growing economy in the region (averaging 9.9% per year from 2007/08 to 2017/18), attributed to increases in construction and services. However, the economy is predominantly agricultural, with a per capita income of $790 and a quarter of the population living in poverty (2016)⁶. Ethiopia is multi-cultural and multi-ethnic; the major religions are the Ethiopian Orthodox church (44%) and Islam (34%)¹¹.

Site general characteristics. CHAMPS in Ethiopia is based in Harar (urban) and Kersa (rural). Harar is on a hilltop (1885m) around 500km from Addis Ababa. Harar is the capital of East Hararghe, a zone of Oromia Region, and the capital of the Harari Peoples Regional state, a small independent city region. Kersa is a rural district around 44km from Harar. The district population is around 173,000 (2007 census), of whom 6.9% live in towns; the population density is low (372 people/km²)¹⁰. Kersa contains highlands and lowlands, and the area is semi-arid and prone to drought, with scarcity of food production. In rural areas water is sourced from springs and wells; there is no supply of electricity. The towns have water mains and are supplied with electricity, but both are frequently interrupted, often up to weeks at a time. There is farming in two seasons -- Kiremt or Meher (June to August) and Belg (September to November)-- of wheat, barley and vegetables in the highlands; sorghum, maize and potatoes are farmed in the lowlands. Khat, a stimulant, is the dominant cash crop.

Demographic Surveillance. Kersa Health and Demographic Surveillance System (HDSS) was established in September 2007¹⁰, including 12 Kebeles (10 rural and two within small towns), the smallest administrative units in Ethiopia (Figure 1). In 2008, the HDSS catchment covered 50,607 person-years; since then 12 Kebeles have been added, for a total of 136,505 person years in 2019. Under-5 child mortality is high at 58-170/1000 live births (Table 1). Harar HDSS was set up in 2012, covering six Kebeles (all urban). In 2019 it covered 58,095 person-years, and under-5 child mortality was reported to be low at 5-20/1000 live births, Table 2. After the initiation of CHAMPS, an additional HDSS, Haramaya HDSS, was set up and enumerated in 2019.

Figure 1. Harar, Kersa and Haramaya Demographic Surveillance Sites (DSS) are within East Hararghe, Oromia, Ethiopia.

Main diseases endemic in the area, according to previous surveillance or research. Despite high mortality in Kersa, there were no prior comprehensive studies of the causes of severe illness in children either in hospital or in the community¹², and cause of death data were from verbal autopsy alone. Verbal autopsy data suggested that severe malnutrition, gastro-intestinal disease and acute lower respiratory tract infections were the leading causes of deaths in children (5–14 years, 2008-13)¹³, and sepsis, birth asphyxia and prematurity were leading causes in neonates (0–27 days)¹². Malnutrition, diarrhoea and outbreaks of cholera and vaccine preventable diseases, such as measles, are common. A mini demographic and health survey for Ethiopia estimated 19% of children (12–23 months) had not had any vaccines in 2019⁷.

Research capacity in the site

Existing capacity

Haramaya University (HU) was set up in 1954 as a University of Agriculture in a large rural campus between Harar and Kersa¹⁰. HU now has a range of education programmes including College of Health and Medical Sciences campus in Harar, established in 1996. Academic staff from HU and Hiwot Fana Specialized University Hospital (HFSUH) contribute to CHAMPS from a range of disciplines, including demography, social science, microbiology, pathology, paediatrics and obstetrics.

Ethiopia has primary, secondary and tertiary levels of health care. Primary care includes health posts and health centres, with each health post serving 3000–5000 people¹⁴. Two health extension workers are assigned to each health post to link into the community. Around five health posts work with a health centre, which serves around 25,000 people¹⁴. Within Kersa HDSS there are currently 19 health posts and six health centres. Secondary care is provided by general hospitals; for Kersa, these are Haramaya District Hospital and Haramaya University Hospital. From there patients can be referred to HFSUH in Harar or Dilchora Hospital in Dire Dawa. In 2015, HFSUH had its own laboratory on site, with microbiological capacity for urine and stool microscopy, molecular testing for TB (GeneXpert), and rapid tests for HIV. It also had a pathology laboratory, which had much of the equipment required to undertake CHAMPS but was in disrepair. There were teaching laboratories in the College of Health and Medical Sciences, but these had limited capacity for diagnostic tests. The regional laboratory for Harari region, also based in Harar, had capacity for more specialized tests, including HIV viral load testing and CD4 counts. The regional laboratory was and is coordinated by the national laboratory, based at the Ethiopian Public Health Institute.

Developing capacity for CHAMPS

In 2017, we established CHAMPS in Harar and Kersa, with site directors from LSHTM and HU to work in partnership. Together these directors identified investigators, recruited a project team and convened a national scientific advisory committee, chaired by the President of HU. The scientific advisory committee comprised members from our partners at the Ethiopian Public Health Institute, the Federal Ministry of Health, Armauer-Hansen Research Institute, the U.S. Centers for Disease Control and Prevention, London School of Hygiene & Tropical Medicine, and the Ethiopia office of BMGF.

Despite difficulties in attracting staff to an unknown project in a remote Ethiopian setting, we recruited a small number of international researchers to provide support in social science, paediatrics and microbiology. In addition, we employed national staff through HU. One of the challenges in this was the reluctance of skilled scientists to relocate to Harar. We developed project management support between LSHTM and HU, and established basic operations for communications, finance, human resource management and operational procedures for communication, procurement, transport, and security. These processes complemented and extended policies and procedures of HU and LSHTM. In our first year of initiation (2017–18) the site team grew rapidly to around 40 staff.

In parallel, we developed infrastructure at the site. At HU’s College of Medical and Health Sciences, we restructured the hospital’s pathology and university’s microbiology laboratories; we also installed three septic tanks, a generator, two large water tanks and built an incinerator. We followed this with internal renovation and equipment installation, and we negotiated service contracts for five years where possible. We developed CHAMPS-specific specimen workflows and trained staff to ensure samples would be safely received, appropriately processed and securely stored. In the hospital we renovated rooms to perform MITS procedures and counsel families. We overhauled the mortuary to provide safe disposal of water and refrigeration to store the bodies of the deceased children and neonates. In addition, we arranged for repair and maintenance of basic clinical equipment such as patient scales or incubators to support inpatient care. We also strengthened collection and recording of routine clinical data, specifically in maternity and paediatrics. For our project team, we created office space through division of classrooms not in use at that time. We started to solve communication problems, which included intermittent and low-strength internet connection, and limited facilities for electronic data collection, data management and storage. We worked on these with the IT lead at the College of Health and Medical Sciences with additional expertise and advice from KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya. We initiated infrastructure development and national applications for a satellite licence with a view to establishing a secure server room and a back-up satellite connection, as well as project-specific systems to support data collection, management and analysis which are now in place.

In Kersa HDSS we recruited staff and developed facilities. We trained two nurses in Kersa Health Centre on CHAMPS and identified ~200 community members drawn from community extension workers, religious leaders, traditional birth attendants, local militia, “Qeerroo” (youth representing the Oromo movement in Ethiopia), other community leaders and HDSS data collectors or supervisors willing to be trained and support timely reporting of deaths. At Kersa Health Centre we built additional rooms for counselling, refrigeration of bodies and MITS. In due course similar facilities will be developed in a health centre in Water (also in Kersa District) and in Haramaya district Hospital.

Description of CHAMPS methods. We investigated child deaths using: (i) social science, to investigate community acceptability, practicality and feasibility of CHAMPS and its methods^15,16, (ii) clinical surveillance, to support data capture, mortality notification and MITS, (iii) pathology, for histological assessment^17–19, (iv) microbiology²⁰ to test samples using conventional microbiology, GenXpert and TaqMan Array Cards, and (v) verbal autopsy^5,15–24. These data were analysed by an expert Determination of Cause of Death “DeCoDe” panel who assign a cause of death. Results will inform strategies to improve public health through a data-to-action plan²¹.

Social science work started first. We had recruited ten people to the social science team by May 2017. Following training, we undertook a Participatory Inquiry into Community Knowledge of Child Health and Mortality Prevention Surveillance (PICK-CHAMPS, July-August 2017). This included 20 workshops in Kersa and Harar (437 participants) and aimed to: (i) develop a social history of the community and to hear about the ways in which the community had successfully met earlier challenges; (2) understand community perceptions, beliefs, and practices related to child death, CHAMPS activities, and the MITS procedure; and (3) build relationships and identify common ground with the community through ongoing, two-way communication. From this we developed a programme of community engagement, alongside formative research¹⁶. This helped to overcome fears about MITS in the community, for example beliefs that the procedure would lead to mutilation of the body or unacceptable delays in burial.

For mortality and clinical surveillance, we recruited doctors, nurses, public health officers, health assistants, field workers (FWs), and laboratory technicians, to set up and support structures for clinical data capture and mortality notification. These processes were initially developed in HFSUH in Harar, starting in the neonatal and maternity ward (in February 2019) with extension to the paediatric ward (in May 2019). The mortality surveillance established in HFSUH included a death notification system with initial notification of deaths by hospital staff to a central call centre. Following notification CHAMPS staff conducted an eligibility assessment, requested informed written consent from the legal guardians of the child, conducted tissue sampling via MITS, transport the body, and arrange follow-up (including verbal autopsy). Families received support and counselling from trained counsellors throughout the process. In Kersa (which started death notification and MITS in February 2019), mortality surveillance was conducted slightly differently. Death notification and eligibility assessment were undertaken by health care workers in Kersa Health Centre or by notifiers in the community, usually by telephone. Counselling and obtaining informed consent was led by a counsellor, together with members of the community MITS team, with community members usually joining this process. After obtaining formal written consent, and with consensus, the body was moved to Kersa for MITS, and the specimens taken to Harar for testing. Local pathways were developed for sample transport, sample processing in laboratories, and feedback of results, including notification of notifiable diseases to relevant authorities. The first DeCoDe panel²¹, set up to determine the cause of death with multidisciplinary expertise, was held on the 18–19^th September 2019.

Results from the DeCoDe panel aim to inform public health action – “data to action plans” which have been developed in partnership with the Ethiopian Public Health Institute and operate at subnational, national and international levels. The subnational plan includes sharing of results with families, the hospital, and community health care workers. To support policy-making at national level, we share aggregate data with the Ethiopian Public Health Institute and we plan to share non-aggregated data in the future. Internationally, data from Ethiopia are submitted in real time to the CHAMPS network database, which includes data from all sites.

CHAMPS - Ethiopia was approved in Ethiopia by the Institutional Health Research Ethics Review Committee (IHRERC) of the College of Health and Medical Sciences, Haramaya University (Ref: Dated 07/04/2017), and then nationally by the National Research Ethics Review Committee (NRERC) at the Ministry of Science and Technology (Ref: 3.10/70/2018), and the Armauer Hansen Research Institute (Ref: PO45/17). CHAMPS - Ethiopia was also approved by the London School of Hygiene & Tropical Medicine, UK (Ref:14394). The overarching CHAMPS Network Data Analysis and Technical Support Protocol was approved by Emory Global Health Institute Review Board (IRB00091706), USA.

Underlying data

Summarized data are publicly available through the CHAMPS website https://champshealth.org/data/enrolled-population-summary/. Requests for further detailed data, for research and evaluation purposes, can be made through https://champshealth.org/data/.