Repurposing Global Polio Eradication's Tool Kit

"India is using polio systems - including microplans, communications networks, personnel, cold chain equipment, and monitoring methods - to improve surveillance and immunization for measles and immunization coverage for other vaccine preventable diseases."

This paper reflects on what is next for the Global Polio Eradication Initiative (GPEI), which has been an 11-year-long effort to eradicate polio worldwide, involving a variety of partners - from non-governmental organisations (NGOs) to universities and foundations, with the participation of many health workers and volunteers. Author Nellie Bristol explores here strategies, including communication strategies, that countries are already using polio resources to address other health issues. Drawing upon her experience as part of a Center for Strategic and International Studies (CSIS) trip to India in late April and early May 2014, Bristol suggests that the success of countries such as India (officially declared polio-free in March 2014) can serve as models.

After providing a brief history and status report on global polio eradication, Bristol provides an overview of legacy planning as envisioned by the GPEI, followed by a discussion of the risks and benefits inherent in the process. She then examines India's efforts to begin broadening its use of polio resources to address measles and other vaccine-preventable diseases and discusses the opportunities and challenges involved in those efforts.

As Bristol explains, the 2-week trip to India involved field visits and interviews with government officials, health professionals, and representatives of international organisations and local NGOs to explore how the Indian government and others participating in the country's health system are capitalising on their polio assets.

An excerpt from the paper follows (footnote numbers have been removed):

"Success in India required continuous real-time data feedback that allowed for immediate midcourse corrections, nuanced and effective communications with those resisting the vaccine, and ownership of and involvement in the program from the national government down to individual neighborhoods. Special strategies were developed for high-risk areas where population density and poor sanitation created reservoirs of poliovirus that led to repeated infections of other parts of the country and the world. Highly sensitive surveillance systems allowed the investigation of nearly every suspected case of paralysis.

There are several key elements to India's polio elimination program now being adapted to support that country's other immunization systems and health programs:

• Planning, supportive supervision, and accountability: Multiple layers of data collection and analysis, planning, and oversight were established and run by a variety of program participants. They included district task forces, overseen by district magistrates, as well as sub-district and block level committees. Participants included program administrators, surveillance medical officers (SMOs), community leaders, and Rotary International officials, along with staff from WHO [World Health Organization], UNICEF [United Nations Children's Fund], and local NGOs. During polio campaigns, vaccinators used microplans to plot their vaccination activities in each neighborhood and to track results. The district task force reviewed the records to determine where children were missed and develop actions for ensuring they were immunized. Sub-district and block-level task forces helped implement corrective actions and provide further oversight. Continuation of these bodies and activities for routine immunization ensures multilevel ownership of the program and provides essential planning and tracking tools.
• Surveillance: India's National Polio Surveillance Project (NPSP) is considered the gold standard in its field. Established through a partnership of the government of India and the WHO, with support from the United States and other donors, the NPSP oversees the entire country for cases of paralysis that could turn out to be polio. The network comprises more than 300 surveillance medical officers, 44 supervisors, and 972 field monitors. Having a quality system to determine disease levels and where they are most concentrated is essential to developing effective immunization systems. The system now is also conducting surveillance for measles and rubella.
• Communications: Strategies involve publicizing and generating interest in polio campaigns along with convincing reluctant parents that the vaccine is safe by making repeated visits to households and engaging the services of local influencers - religious leaders, celebrities, and others admired in the community. A key component was the Social Mobilization Network, or SMNet, established in Uttar Pradesh in 2003 and later in Bihar with support from the United States and other donors. Communicators from UNICEF, Rotary International, and the CORE Group of NGOs examined the social aspects of why poliovirus transmission continued in some areas, amplified communications strategies in high-risk communities to ensure children were getting vaccinated, and explained to parents the importance of other vaccinations. Similar approaches are being used to bolster routine immunization.
• High-risk area strategies: Some communities in India proved particularly difficult to immunize effectively. New strategies developed by Indian polio partners helped vaccinators reach children in slums, among nomads, and in migrant families found in brick kilns and construction sites. In other new strategies, the 107 Block Plan worked to improve sanitation conditions, treat diarrhea through promotion of zinc and oral rehydration solution, enhance routine immunization services, and step up the quality of polio immunization drives. In 2008 the Kosi Operational Plan laid out specific strategies for reaching an area that floods frequently, leaving populations isolated without bridges and roads. Those administering other vaccines will face the same challenges, and similar approaches are being used.
• Partnerships: Polio elimination in India involved intense coordination by local, national, and international partners including medical associations, private health facilities, NGOs, and local and national government entities. The government of India led the effort. It also provided vaccines and implemented vaccination campaigns. UNICEF oversaw communication and social mobilization, monitoring, communications research, and media management. Rotary International also provided communications and social mobilization along with funding and operational support. The WHO provided technical support for surveillance, supplementary immunization operations, monitoring and research. Local NGOs provided communications tools and personnel. The partnership was considered highly successful in providing program support without duplicating efforts. A similar cooperative structure is being developed to improve routine immunization."

The paper concludes with the thoughts of some of the major donors to the GPEI about their potential future support for health activities beyond polio eradication.