In 1988, the estimated number of wild poliovirus cases worldwide was 350,000 . However, by the end of 2012, the total number fell to 223 . As of 6 March 2013, the total number of 2013 wild polio cases worldwide is nine compared to 22 by this date in 2012; all cases (9/9) are in the remaining three endemic countries of Afghanistan, Nigeria and Pakistan . There have been no reported cases of wild poliovirus in India since January 2011 . This is a remarkable accomplishment, especially in India.
Questions have arisen as to how the tremendous polio eradication effort in India may have affected routine immunization programs for polio and non-polio antigens. Loevinsohn et al. (2002) reviewed several studies and found no association globally between polio eradication efforts and a decrease in funding for routine immunization or a decrease in routine immunization coverage , but raised concerns about shifting the time of primary health workers from duties such as routine immunization to support polio eradication campaigns. Yadav et al. (2009) found that polio eradication efforts in India had led to interruptions in primary health care services . Bonu et al. (2003) found an association between polio eradication efforts in Northern India and an increase in the first dose of polio and non-polio routine immunization vaccines, but found no increase in receipt of 2nd and 3rd doses--- indicating little synergy between eradication and routine immunization efforts . The importance of improving very poor routine immunization coverage levels in India alongside intensive polio eradication efforts, however, has been argued as critical for eradication (e.g., helping prevent importation of the polio virus), for equity purposes, and for health systems development [7–9]. Since 1996, the US Agency for International Development (USAID) has provided support to the global polio eradication effort and has included the strengthening of routine immunization systems as a core part of its strategy . One USAID-funded polio eradication project that follows this part of the strategy in India is the CORE Group Polio Project.
The CORE Group is an umbrella organization of non-governmental organizations (NGOs) that collaborate on international health and development programs . In India, the CORE Group Polio Project (CGPP) works across twelve districts in the state of Uttar Pradesh (UP). CGPP is a collaboration of the following NGOs: Adventist Development & Relief Agency (ADRA) India, Project Concern International (PCI) and Catholic Relief Services (CRS), as well as their ten local NGO partners. CGPP is a member of the Social Mobilization Network (SM Net) in India that also includes Unicef, Rotary, the Indian Government’s and WHO’s National Polio Surveillance Project (NPSP) as partners. The SM Net was created in 2003 to work in the northern state of Uttar Pradesh (UP). The SM Net supports polio eradication with the following efforts: identifying high-risk areas and working with underserved communities in planning, implementing and monitoring social mobilization and other immunization activities in those high-risk areas. The primary effort of the SM Net is carried out by a three-level network of community mobilizers (community level, block level, and district level) .
The Community Mobilization Coordinator (CMC) interacts with families and community members at the village level. As the backbone of the SM Net, s/he is assigned responsibility for mobilizing about 500 households in either a rural or an urban area, and keeps records of the immunization status of all children less than five years of age in those households. CMC areas are groups of communities in a block where the SM Net deploys CMCs. The SM Net selects these communities for additional social mobilization efforts based on past communication and operational challenges for immunizing children. Most of the CMCs are deployed in areas designated as High Risk Areas (HRAs). Jointly with key partners (Unicef, MOH and CGPP), NPSP defines the criteria for HRAs; these criteria are reviewed periodically and modified. The most recent criteria for HRAs take into account the following information: the number of wild polio virus (P1) cases during low transmission seasons since 2003; the presence of high risk groups (slum dwellers/nomads); the number of acute flaccid paralysis cases that were compatible with polio in last two years; if 40% or more of the population is Muslim; and, the percent of households that have unvaccinated children (called X houses). Once an area is identified as an HRA, the SM Net arranges for CMCs to work there. A CMC has to be 18 years or more, preferably female and from the same community. The partnership periodically revises the areas designated as an HRA. See Weiss et al. (2011 & 2013) for more details about the polio eradication activities of the CGPP [12, 13].
In addition to other intensive polio eradication activities such as social mobilization for mass polio vaccination campaigns, CGPP India supports routine immunization (RI) since high RI coverage forms one of the main pillars of polio eradication. Each CMC is responsible for ensuring that all children in her allocated households are given all childhood vaccines, in addition to oral polio vaccine (OPV). She does this by doing home visits to track all eligible children and explain the importance of RI to the mothers. Just a day before the RI session, she distributes RI invitation slips to the mothers of eligible children. She also explains the importance of a Government RI Card that is completed by the auxiliary nurse midwife (ANM) after each immunization is given. She gives a specially designed Congratulatory Card to all families with newborns; this card has key health messages in an illustrative format. Apart from this, RI Camps are held in high risk areas where it is the CMC’s responsibility to see that all missed children are given the appropriate vaccine. Specific activities of CMCs that support RI are described below.
Interpersonal communication (IPC) meetings
The interpersonal communication (IPC) meeting with mothers and caregivers---especially with those who express resistance to polio vaccination---is a major CMC activity during the interval between mass vaccination campaigns for polio eradication. The mass campaigns are also called supplemental immunization activities or SIAs. The purpose of an IPC meeting is to address misconceptions, rumors and fear through face-to-face dialogue. During IPC meetings, the CMC shares information about polio: how the virus is transmitted, and how transmission can be prevented. S/he also promotes routine immunization of all antigens, as well as polio immunization during each SIA. We expect that successful IPC meetings will lead to an increase in both routine EPI vaccines and supplemental polio vaccines.
Apart from IPC meetings with the mothers, the CMC also conducts meetings with groups of mothers of children up to five years of age. Although she discusses the importance of giving OPV each time there is an SIA, she also discusses the importance of completing all childhood vaccinations to prevent common childhood diseases (in addition to discussing other health issues like care of the pregnant women, breastfeeding, management of diarrhea through ORS, sanitation and its link with disease, etc). Like IPC meetings, we also expect that successful mothers’ meetings will lead to an increase in both routine and supplemental vaccinations.
Information education communication (iec) activities used during ipc and mother’s meetings
The CMC is equipped with various IEC materials, including small games, behavioral charts, flip books, flash cards, storytelling, etc., that she uses both at IPC meetings and mothers’ meetings. At every contact (IPC and mothers’ meeting), the CMC assesses perceptions and present behaviors of mothers and, according to their level of understanding, she then discusses the issues and conducts relevant IEC/BCC activities.
In this paper, we examine the performance of routine immunization services, alongside intensive polio eradication efforts in the CGPP areas. We document achievements in access and coverage of routine immunizations and compare these to state-level estimates. Our hypothesis is that CGPP activities to promote routine immunization have helped prevent the potential disruption of routine immunization services by the intensive polio eradication efforts in the same areas. Earlier analyses have explored determinants of the performance of mass campaigns of oral polio vaccine (supplemental immunization activities in addition to routine immunizations) in CGPP areas . In this paper, we investigate the determinants of routine immunization performance. Our additional hypothesis is that the determinants of routine immunization performance---requiring a series of at least seven vaccinations over the first year of life---are likely to be different than determinants of performance of mass campaigns that seek to vaccinate all children under age five once over the course of a few days. Much effort and many resources are being used to strengthen immunization systems in support of polio eradication. Information that can help program managers rationalize which routine immunization promotion activities should be continued, among many, will help improve the efficiency and effectiveness of immunization efforts in UP.