SMNet Analysis: Progress in 2008 Puts the Programme on Good Footing

This article explores the positive results traced to shifts in the operational and communication strategy as developed by the Polio Eradication Programme since the 2006 polio virus type 1 (or "P1") outbreak in India. As 2008 came to an end, the Programme closed the year with 556 cases of wildpolio virus (WPV), 73 of which were P1 cases. Following the most devastating floods in the history of Bihar, the programme succeeded in containing P1 cases to 3 - the lowest number ever for Uttar Pradesh (U.P.).

Another success concerns the fact that the higher incidence of WPV cases among Muslim communities was reversed for the first time in 2008. Whereas 70% of all polio cases occurred within Muslim underserved communities of U.P. in 2007, this proportion was reduced to 37% as of January 2009. In 2006, the partnership realised that support from locally influential people was vital to acquiring community support. So, voluntary Muslim influencers were assigned to vaccination teams in high-risk areas to convince resistant families to take the oral polio vaccine (OPV). As a graph within the text illustrates, since then, the number of community influencers allocated to accompany each team, as well as their actual attendance, has nearly doubled and the proportion of polio cases within these communities has almost halved.

An even tighter connection to religion is illustrated by the practice of using public announcement systems to make mosque announcements for polio immunisation on or just prior to "booth day" or on the Friday before the booth day. Some mosques make additional announcements during the team's house-to-house visits as well, and many mosques conduct a special Taqrir or sermon which includes messages on the benefits of polio vaccination.

A conscious effort was made to reach newborns with OPV doses within the first month of life in U.P. Once registered, the child was to be followed up, through the Social Mobilization Network (SMNet), with subsequent doses of OPV from routine immunization (RI) and supplemental immunisation activities (SIA). Specific figures are shared here to illustrate this impact. For example, between January and November 2008, a total of 65,083 immunisation sessions were expected in select high-risk areas covered by the SMNet; 81%, or 52,716, were actually held. Reportedly, social mobilisation efforts, counselling of families, and information, education, and communication (IEC) activities have helped sustain and improve the impact of OPV immunisation. With a focus on newborns and younger children, the average number of doses received by a 1-year-old child increased from 10.3 in the period May 2006 to April 2007 to 10.7 across the period December 2007 to November 2008.

According to the report, Western U.P. has historically posed the greatest challenge for the interruption of P1 transmission, and 2008 was the first year the number of doses in the sub-region reached an average of 9 or more (a map shows this). The challenge for 2009 will be to maintain the high number of doses, together with consistent and optimally-spaced immunisation rounds.

Also explored here is the strategy of household visits made by community mobilisation coordinators (CMCs). During SIAs from January to November 2008 in high-risk areas of U.P., CMCs made about 19,016,627 visits, with less than 0.2% blatantly resisting vaccination. Developmental issues related to roads and sanitation issues "continue to come up as bargaining chips for sporadic organized resistance to immunisation. Visiting these areas and talking to residents before a round has generally been a successful strategy to overcome this type of resistance."

Community meetings with mothers, religious women's meetings (Ijtema and Milaad), and neighborhood meetings are held before each round to talk about the benefits of immunisation in each CMC area. On an average, 2 meetings are held in each CMC area, with an average of 16 in attendance, of which 3 are generally from families who had a missed vaccination. In addition, each CMC conducts a polio class in the local school before each round, and a rally one day before booth day. Each CMC also organises 3 groups of children so that they may attract other children to the booth. Based on these observations, the Partnership plans in 2009 to focus on several groups, including:

• In addition to existing networks with Anganwadi workers, auxiliary nurse midwives (ANMs), and private practitioners, CMCs are fostering networks with local traditional birth attendants (TBAs) and nursing homes to identify all pregnancies early. All identified pregnancies are then counselled for immunisation and good childrearing practices, using Facts For Life messages (see "Related Summaries", below).
• Migrant families must continue to be closely tracked. Approximately 75% of returning migrants report they have been given a dose of OPV in the states they migrated to. "However, advocacy with these states is required to continue immunizing children of migrant workers throughout the six to eight month period they are out of U.P."
• A recent innovation includes the tracking of guests and their children for immunisation in CMC high-risk areas. The community mobilisers mark the number of guest children in the field book so that they can ensure their immunisation during the house visit.