The Polio Eradication Programme in India is a collaborative effort between the Ministry of Health and Family Welfare (MOHFW), WHO’s National Polio Surveillance Project (NPSP), UNICEF, Rotary International, and the U.S. Centres for Disease Control.
The programme aims to eradicate polio from India by immunizing every child under 5 with the Oral Polio Vaccine (OPV). India, together with Afghanistan, Nigeria, and Pakistan, is one of the four polio-endemic countries left in the world.
UNICEF India Country Representative, Ms. Karin Hulshof in conversation with the Indian Association of Parliamentarians on Population and Development (IAPPD) talks about the Polio Eradication Initiative in India.
IAPPD: The Global Polio Eradication Initiative is one of the largest public health programmes in the world. What have been the most critical achievements of the initiative in India?
KH: Tremendous progress has been made in the last several years to interrupt polio transmission in India. India is only two states away from being polio free and the virus has become increasingly localized to only 100 blocks of Uttar Pradesh and Bihar.
Eighty per cent of all polio cases in Uttar Pradesh have come from only 10 districts in the western part of the state. In Bihar, 85 per cent of cases have come from six districts centered around the Kosi River area. In 2002, India registered 1,613 polio cases. Today, there are 685 cases per year.
This is a significant achievement, particularly when you think about how many newborns are born each month in the endemic states of Uttar Pradesh and Bihar who need to be identified and protected with the oral polio vaccine.
IAPPD: What are the immediate priorities for the Polio Eradication Programme?
KH: The Polio Eradication Initiative’s immediate goal is to re-interrupt Type 1 polio transmission in western UP and stop transmission in Bihar. Type 1 polio transmission was interrupted in Western U.P. in 2007-2008 and we need to do it again.
At the same time, we must control the Type 3 virus. In order to achieve these goals there are several immediate priority areas that need to be addressed:
First, newborns and children under two years of age need to be reached with the Oral Polio Vaccine (OPV) as a matter of priority due to their underdeveloped immune system.
In 2009, 66 per cent of polio cases nationally occurred in children under two years of age. About 230,000 children are born each month in Bihar, and in U.P., over 400,000 children are born each month.
The programme is working to ensure that each and every one of these newborn children – as well as all children under 5-years-old - are identified, listed and protected with OPV immediately after birth, and each time it is offered thereafter.
Second, the programme must reach socially vulnerable families and their children, especially migrants and mobile groups who put every state at a potential risk of poliovirus importation if they are not adequately immunized.
Fifteen per cent of the total polio cases in U.P. and Bihar from 2007-2009 occurred in migrants. In cases outside of UP and Bihar during the same time period, 40 per cent of cases occurred in migrants.
These groups are often not home when vaccinators go house to house with OPV, so the programme is trying to reach them as they travel. Vaccination teams have been placed at railway stations, high traffic roads, and even on trains and buses.
Finally, and perhaps most crucially, stronger linkages are being made with routine immunization (RI), which is essential to interrupting polio transmission and sustaining it.
Bihar has made tremendous progress in this area. Polio vaccination coverage is consistently high - with an average of 98 per cent, while the Routine Immunization coverage increased from 41% to 55% within the last 12 months.
In some areas of the Kosi River area, the core of the polio epidemic, routine coverage has reached over 65 per cent. This kind of progress needs to be scaled up consistently across Bihar and U.P.
IAPPD: What is UNICEF’s role in the polio programme?
KH: To eradicate polio in India, or anywhere in the world, people must have knowledge about what polio is, the will to do something to prevent it, and to have access to the vaccine to do so.
UNICEF, with support from Rotary International and the CORE Group of NGOs, communicates to parents and families about polio and how to prevent it (by taking the Oral Polio Vaccine). We communicate through the Social Mobilization Network (SMNet), which is perhaps the largest public health communication effort in India, and possibly in the world.
The SMNet, as it is commonly called, is a network of over 6,000 community mobilizers who work at the village, block, district and sub-regional levels across high risk areas of U.P and Bihar.
Each month, these SMNet workers go house to house with the vaccination teams to ensure every child takes OPV each time it is offered. Before the polio round, the SMNet workers have listed each child under five years old in their area.
Throughout the month, they will have organized mothers meetings, community meetings, Ijtemas (religious congregations), and will have enlisted the support of local leaders and influencers to communicate with families and explain the importance of taking OPV and Routine Immunization.
Parents who resist the vaccine, or have doubts about taking it, are counseled by SMNet workers and other influential leaders in the community to clear up misconceptions.
We have also helped bring national influencers on board to promote the importance of vaccination. Mr. Amitabh Bachchan has been involved with the polio programme for years, as have players from the Indian National Cricket team.
These kinds of spokespersons make an enormous contribution to maintaining public commitment and support for the programme.
IAPPD: Has the communication campaign been successful?
KH: In 2009, resistance to OPV has been reduced to an all-time low. Among the total houses each month that have not been reached with OPV, only 2.6 per cent of these have overtly resisted the vaccine in Uttar Pradesh. Five years ago, this figure was 4 per cent, and it was common for clusters of over 100 households to band together and resist the vaccine.
Vaccination teams were often forbidden to enter the community. Today, this kind of resistance is almost non existent and people see the polio programme as a critical health service, as well as a link to other health services. They know the vaccination teams will come back almost every month and this has created a sense of trust in the programme.
This trust has sometimes led to other demands of the vaccination teams, and threats to stop taking OPV unless demands for other services - like improved sanitation or health camps - are met. This creates another kind of resistance, and another set of communication challenges for the polio programme.
People know the importance of OPV and with a little persuasion, resisters who initially refuse for these “developmental reasons” usually take the vaccine. To me, the additional demands are a sign of confidence in the programme.
They know it is possible to have a consistent and effective health service like OPV each month, and they want more to be done in their communities.
IAPPD: What are the challenges in the programme right now?
KH: In addition to the epidemiological challenges of maintaining the highest levels of immunity across the population and the required strategies to do so, which I mentioned at the start of the interview, there is also a challenge of fatigue that we must overcome.
Information alone is not sufficient to encourage behaviour and social change amongst high-risk populations to accept the oral polio vaccine.
The twofold communication challenge has been to: first, engage and convince caregivers of the benefits of vaccinating their children and second, ensure that families remain motivated to continue vaccinating their children month after month.
The timeline for eradication has been longer than anyone expected. But if we are to achieve eradication in India, we need everyone on board until the goal is reached. This includes parents, religious leaders, community influencers, district magistrates, policy makers, celebrities, and society at large.
We must do this together, and we must keep going until we have reached the goal. The goal is to eradicate polio.
IAPPD: Do you believe polio eradication is possible in India?
KH: I do think it is possible. It requires a continued effort, and perhaps in some areas, a redoubling of efforts. The programme is constantly re-examining its strategies.
It’s an extremely dynamic and evidence-based programme and the Government is guided by bi-annual advice from national and international experts who compose the India Expert Advisory Group (IEAG). The IEAG has continued to state that India is on the right track, and interruption is possible in the near future.
We must continue to do everything we can to give the children of India a polio-free childhood. We are only two states and 100 blocks away from the goal.