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Eradicating polio in India -- PCI and the Core Group Polio Project

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After completing three full years without reporting any case of polio, India celebrated a landmark achievement in public health in February 2014 – the victory over polio. In the global effort to eradicate polio, India has been a success story. For a country which, until 2009, reported more than half of the global polio cases, India has shown unprecedented progress. PCI can proudly say that they have helped aid this success.

Experts predicted India would be the last country to stop this debilitating disease. To find and immunize more than 170 million children — to reach the millions who didn’t even exist on a map — presented itself as an incredibly daunting task. The endemic pockets in parts of Uttar Pradesh and Bihar were among the most difficult places in the world to eradicate polio. The combination of poor sanitation, high population density, poor health conditions, and extreme weather conditions created the perfect climate for virus transmission.

Nevertheless, it was a task PCI chose to undertake and believed we could achieve. The Core Group Polio Project (CGPP) was formed — led by PCI and implemented with additional partners. The CGPP continues to operate to ensure that India remains polio free.

The process

Working in the most high-risk districts of Uttar Pradesh, where resistance to polio immunization was previously high, the CGPP has succeeded in doubling levels of routine immunization to above 90% through community mobilization coordinators, health camps where vaccines are provided by the Government of India, and promotion of hygienic practices to reduce new infections, especially in children under 5 years of age.

Children are also recruited to support the effort by participating in rallies, announcing dates of vaccination drives and teaching the adult members of their communities about preventing disease. Citizens who were reluctant to trust health workers have been far more willing to listen to members of their own communities, and children are especially convincing since they are fighting for their future.

Cultural resistance to the polio vaccine

Early on, a pervasive and inaccurate myth circulated, convincing many that the polio vaccine was a government conspiracy designed to make young men impotent to stem the community’s population growth. Muslim community members believed that the vaccine contained a Haraam ingredient (forbidden under Islam), that the program was aimed at sterilizing them, and thus refused to participate. Others asked themselves, “Why are they only bringing us this vaccine when we need so much more?” Thus, they refused to take the drug, thinking it useless.

Mobilizing the community

As a result of the strong initial cultural resistance to the drug (and foreign interference), PCI began to identify and call upon people that could break down barriers within the community – school children, mothers, religious leaders and other influential people – who soon came to be known as Community Mobilization Coordinators (CMCs).

CMCs work hard to build strong human relationships within the community, particularly wherever a family has a pregnant female or child under five. These relationships are not confined only to the polio vaccination round period. Our CMCs work persistently all year long for the welfare of their community. It took one CMC, Reshma, between five and six visits per month over a five year period to finally persuade one family to stop resisting immunizations. Other CMCs, such as Sushma, are polio survivors – which makes their case much more compelling. Sushma says she desperately doesn’t want to have to watch children suffer from the same disease that has debilitated her. The CMCs are truly the backbone of the CGPP – the success of the program would not have been possible without their support and influence.

Children play a vital role as part of the community mobilization program. Acting as agents of change, children would lead large rallies (polio rally, kukro koo rally, bulawa tolli rally), each with their own job- be it chanting a slogan, holding a banner or ensuring the presence of parents. The children are enthusiastic as their role gives them a sense of pride and importance. Between 2007 and 2012 over 5,000 children participated in 29,683 rallies in 44 rounds of polio vaccinations.

PCI has been particularly effective in obtaining the support of influential religious leaders in India’s Islamic communities, who hold the trust of and have a direct impact on the Muslim families. These religious leaders are playing a similar role to other CMCs; countering rumors and misinformation about polio vaccinations that keep some Muslim parents from immunizing their children.

Mothers’ meetings include both mothers of immunized and non-immunized children to increase acceptance of the polio vaccine and routine immunization coverage. Other topics such as personal hygiene and sanitation, managing the common cold, fever and diarrhea and the importance of breast feeding are also covered. Information is shared through demonstrations, charts, games, pamphlets flashcards, and personal appeals.

PCI’s capacity building for female mobilizers is excellent. After gaining the respect of the women in a community, much can be accomplished – mothers will go far lengths to protect their children.

Routine health camps

With the arrival of health camps, villagers saw that doctors were coming to them and giving out medicines free of cost. This, along with the large tents full of beautiful decorations, created incentive for many families to attend the camps. Foreigners and people from further afield, such as Delhi, also held the ability to influence community members, as their presence enforced the gravity of the situation. People assumed they would not have travelled so far unless it was for a good cause. To avail themselves the free medications, families were requested by the CGPP to bring their children with them.

Health camps also include a small stall led by teachers, encouraging visitors to send their children to school. With a better education comes better health and hygiene practices. The CGPP’s approach is multi-faceted. Each step towards immunization compliments the development and progress of a community as a whole.

As well as improving basic sanitation conditions to make the spread of Polio through oral-fecal route more difficult, the CGPP need to give the Polio Vaccine to every child under five. Each child requires 2 drops of the vaccine. After this is administered, the index finger of the vaccinated child is marked with a marker pen, and a record is made of his/her vaccination. Fieldworkers then go into villages to find the children that remained at home and did not receive their dose of the vaccine. Where children have taken the vaccine these houses are labelled P for Polio in the CMC’s register and on the outside of the door. Where they have not, the homes are labelled X. This is either because they cannot be reached (they are brick layers, field workers etc.) or because they have refused the first time around.

A different group of CMC’s return a few hours later to attempt to vaccinate children from the homes labelled X.

Routine Immunization- In addition to the oral polio vaccine, the CGPP strongly encourages the BCG for tuberculosis, DPT for diphtheria, whooping cough and tetanus, measles, hepatitis and Vitamin A.

A child’s basic immunity needs to be maximized if they are going to be exposed to the polio virus. The OPV may not be enough. Experts claim that if just one case is found where a child has weakness in limbs, it is likely the virus will have entered the intestines of between 300-500 other children.

A celebration in Moradabad -- the district experts claimed would never be polio free

On the 13th March 2014, in a small village in Moradabad (a district in Uttar Pradesh), over 700 men, women and children gathered to celebrate the eradication of polio in India at a jamboree held by the CGPP. The community were honored for the incredible work and continuous efforts they have put towards eliminating polio in Moradabad – an extremely ‘high risk’ town which previously produced the most cases of polio per year of anywhere in India. Children from the community performed songs and dances, community mobilisers gave speeches, and all were awarded gifts for their extraordinary efforts in working with the CGPP. The room was filled with a humble atmosphere of pride and celebration; a reminder of the struggles they have overcome, but also with an enormous sense of accomplishment. Because PCI works with the community, this really was the success of a community.

It was wonderful to see so many female Community Mobilisers, both in the audience and as speakers- the backbones of our program. They spoke with such confidence about the work they’ve done, and continue to do. In this way, it was not only a celebration for the feat over Polio, but also a celebration for the women of Moradabad, for their independence, and for the tightening of a community.

Maintaining polio free India

With as many as 200,000 new cases in 1994 alone, India has now been polio free for over three years. The CGPP continues to work at maintaining a polio free environment, as there will always remain a threat of reinfection from other countries in the region due to migration.

India’s success against Polio is an example to the rest of the world, and one that should be shared as World Immunization Week approaches. In the global effort to eradicate polio, India has been a success story and PCI can proudly say that they have helped aid this success.

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