Independent Evaluation of Major Barriers to Interrupting Poliovirus Transmission in India

This 26-page report details an independent, external evaluation of the Global Poliomyelitis Eradication Initiative (GPEI) that was carried out in response to a request from the Executive Board of the World Health Organization (WHO). The report is part of a package that consists of an Executive Summary and 5 full reports from 5 separate evaluation teams, focused on: Nigeria, India, Pakistan, Afghanistan, and the international spread of polio.

Members of the evaluation team visited India between August 10-20 2009 to meet with National Polio Surveillance Program (NPSP) staff and relevant groups from the Government of India, United Nations (UN) agencies, Rotary International, and others in the donor community. The team focused on Uttar Pradesh (UP) and Bihar, 2 states in north-central India, where type 1 and 3 polio virus continues to circulate. Each vaccination round in UP engages 200,000 vaccinators and 22,000 supervisors to reach 33 million households. There are 110,000 booths (fixed sites) and 64,000 house-to-house teams. In Bihar, there are 37,000 house-to-house teams plus 10,000 transit, mobile, and special event teams with 95,000 vaccinators and 14,000 supervisors. In 2008 UP conducted 9 rounds and, as of August 2009, there had been 5 rounds. In Bihar, there were 12 rounds in 2008 and 6 in 2009 (January through August).

It is in this context that the evaluation report offers sections on: the polio eradication programme and operations, vaccine performance, epidemiology and environment, and perception of the programme (communications). The present summary will focus on the latter element, with only brief synopses of the other sections.

Programmatic Evaluation (also detailed in attachment 2) - In short, the National Polio Surveillance Project (NPSP) has established "a superbly trained vaccination group and developed novel approaches to reach marginalized groups and identify newborns in the community." The team concluded that "the high coverage observed reflected the most thorough well managed field work that team members had ever seen. In short, program implementation was not viewed as a constraint to elimination of polio."

Vaccine Performance: "Pending and future studies on vaccine infectivity and immunogenicity, seroprevalence, and wild-type carriage in the face of serum antibody in a broad age spectrum and the contribution of IPV [inactivated polio vaccine] and combined OPV [oral polio vaccine]/IPV are needed. Bivalent types 1 and 3 OPV represents the most immediate promise for increasing immunity and eliminating the last lineages of polio."

Environmental Issues: The team urges that vaccination teams (and others) to focus on addressing environmental conditions rife for polio transmission. This involves communication - by vaccination teams and others - that promotes: the use of soap and exclusive use of clean well or purified water for the very young, exclusive breastfeeding, and research (e.g., studies of water quality protection with particular attention to the very young). Further, "[t]he high prevalence of unlicensed healers giving injections is a great worry. We encountered several polio cases with residual paralysis in the legs that had a clear history of buttock injections just prior to onset of paralysis. Informing the public and practitioners of the dangers of injections to ANY child in these areas of polio endemicity are to be encouraged."

Perception of Programme: "The efforts to eradicate polio in India form a highly visible and recognised programme with robust community mobilisation and programme communication components especially in the endemic states of Bihar and Uttar Pradesh. Basic awareness relating to polio symptoms, benefits of OPV, and the target group (children under 5 years) is high, with earlier resistance in minority communities having decreased substantially in recent years, due to the active mobilization of community leaders/ influencers." To assure continuation of this level of awareness/invovlement, recommendations include:

• sharpening the focus of the communication strategy, with greater emphasis on mobile populations, transit points, community-based messaging for collective responsibility (to complement the existing individual focus) and complementary use of mid-media channels rather than a dependence on interpersonal communication alone.
• introducing communication focus on mobile populations and messaging on the link between mobility and polio (greater chances of missing a round and therefore reduced immunity). A message of "make sure your child gets polio drops, especially if you're traveling/away from home" could encourage service-seeking behaviour by mobile populations at source, destination, and transit sites. In minority communities with residual resistance to OPV, messages emphasising the Haj/Mecca requirement that all pilgrims are vaccinated can strike even greater resonance.
• strengthening mobilisation and programme communication at transit points such as train and bus stations. These are busy, congested sites where identification, vaccination, and interpersonal communication (in case of resistant caregivers) can be very challenging. The addition of mobilisation teams to identify and refer caregivers to vaccination teams, establishment of attractive booths and outdoor media/communication activities could trigger service-seeking behaviour, while also reducing the pressure on vaccination teams.
• initiating intensive, high-level advocacy efforts that respond to the growing frustration with delayed eradication objectives, parliamentary questions on vaccine efficacy, and cases of Adverse Events Following Immunisation (AEFI). These efforts must be proactive and pre-emptive, and involve key programme partners, policy makers, high-level government officials, and most notably, the media. Communications should highlight the achievements of the programme (e.g., in developing sophisticated monitoring systems that can benefit other public health programmes) and the criticality of staying the course. Suggested channels for these messages include highly visible fora and media formats (talk shows, debates, editorials, a monthly "polio watch" - e.g., "the respected TV news channel NDTV, which had a long running 'pollution watch' campaign with daily sound bytes on pollution levels in major cities)".
• forging partnerships between groups such as Rotary International and large corporate houses and the Ministry of Defense, for example, to mobilise hovercrafts for immunisation coverage in geographically difficult areas.
• bringing greater visibility to, and advocacy for, two existing national Working Groups (for advocacy and social mobilisation). "Challenges to the program today pertain to some confusion in ownership, with government and key program partners each attributing it to the other. There is a growing frustration among donors and senior government officials with constantly shifting timelines, and not knowing the 'missing link' that hampers eradication objectives despite a highly evolved program. Further, reaching high numbers of mobile populations and geographically inaccessible areas, and sustaining the morale and intensity of the program are further key program challenges. If eradication of polio is shown to depend on improvement in the environment of these young children the message will have to be broadened to include safe water, breastfeeding and hygienic measures."

Editor's note: Some of the key strengths and challenges confronting communication are detailed in Attachment 4 of the report, which begins on page 23. (See "Further details - Communication Assessment") Here is one insight provided there: "An important and often overlooked feature of the program is the role of mobile telephony, especially in remote and difficult terrain. Whether it is to report a polio case, inform mobilisers and vaccination teams in other blocks/districts about the day-to-day movement of a mobile population from one location to the next to ensure coverage during the round, or to report urgent issues such as an AEFI that requires urgent responses, cell phone technology has become a key artery for effective, speedy communication across the program, especially in geographically difficult terrain. During the field visit, when this evaluation team was unable to visit the home of a just-reported polio case; the CMC [Community Mobilisation Coordinator] simply played the recorded case description by the child's mother on his cell phone for the team - thus demonstrating the multiple and innovative uses for this technology."