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AdvocacyJanuary 11, 2013

Q&A: How India Stopped Polio

By, Eric Porterfield

This Sunday, January 13, is the anniversary of India’s major polio milestone – marking two years without reporting a single case of polio – remarkable progress for a country which just four years ago contributed majorly to the global polio case count. To learn more about just how remarkable this milestone is, we called our partners at UNICEF to talk with Jeffrey Bates, a Polio C4D Officer (Communication for Development) and one of the many faces of UNICEF’s polio eradication efforts.

India went from having half of the world’s polio cases in 2009 to becoming free of the disease in 2012. How did India accomplish this significant milestone in the fight against polio?

Every year from about 2006 to 2009 India was faced with over 500 polio cases. But, in 2009, some new initiatives were introduced that looked at narrowing in on population segments that were being missed. We found that most of the children being missed during campaigns were migrants, people in transit, people living in areas prone to flooding or difficult to access, or populations that were working in brick kilns and construction areas, people that were just generally left out of the system of polio eradication efforts.

Along with looking into population gaps, communication and media also lent momentum to improvements and more of a public embracement of the initiative. Indian film actor, Amitabh Bachchan, was doing spots through mass media. Social mobilizers and partnerships with key institutions helped us reach a critical mass where refusals, which had traditionally been a key barrier in many places in India, dwindled to the point where they were almost nonexistent.

This left us simply needing to get the vaccine out. In 2008, the ‘107 block plan’ came about. This took the highest-risk blocks for polio and looked at how the polio initiative could integrate with other services – water sanitation, safe water handling, hand washing – things that gave the community a feeling that they were doing something locally relevant as opposed to something that maybe the federal or state governments were asking them to do. By bringing together a number of these initiatives, some of them had been in place for a number of years, some of them were new – but each one helped India reach a point where they were reaching 99% of the children consistently, and then building on the natural immunity.

The announcement that India has become polio free was a major accomplishment. How was this recognized in India?

There was immense joy and satisfaction. The Indian public was thrilled and embraced this achievement as well as the Indian government and polio partners like the Global Polio Eradication Initiative. But in general, I think just the level of satisfaction and sigh of relief that people felt was something almost palpable.

Why is this milestone so significant? What does this mean for polio eradication efforts around the world?

This milestone is an accomplishment that was not only beneficial for India, but globally demonstrated that if we can stop polio transmission in places like Moradabad or the Koshi River Basin, than the other areas of the world are certainly doable. This gave a lot of momentum and motivation to the polio partnership to renew their efforts, it gave donors some confidence that the millions and millions that they’ve put into the initiative were paying off, so I think the benefits for the eradication initiative are almost incalculable.

Also, because of this milestone in India, our discussions are now around endgame –  how do we go from these national efforts to immunize millions of children to efforts that focus on keeping the immunity levels high in high-risk areas and talking about what potential outbreak response would look like.

Unless polio is eradicated rapidly from the remaining endemic countries – Afghanistan, Nigeria and Pakistan – it will continue to re-infect polio-free countries. What is India doing to share their success story and effective strategies with these countries?

Hamid Jafari, who was leading the global effort in India on behalf of the WHO, has been able to take his several years of leading the Indian effort and put that into the context of the global initiative. He’s not going to take what was done in India and try to apply it in northern Nigeria or Afghanistan – but he’s working to understand the mechanisms behind the systematic approach to identifying problems, come up with local solutions, and develop strategies for working with local leaders to create institutional partnerships.

Staff from both WHO and UNICEF programs in India have gone on missions to other countries to help look at their programs and see what lessons could be applied. They are looking at their social mobilization networks and give them inputs on how to tighten up the management, establish monitoring frameworks, look at training.

UNICEF brought staff from Nigeria, Afghanistan and Pakistan into India for tours to look at how they use data at the local level, capacity development initiatives, and recruitment and training. From WHO, a group of 15 medical officers went to India for several months looking specifically at micro-planning. A major outcome of the trip was to move from community-based micro-planning to a household-based micro-plan. Instead of chalking out a large area on a map and sending in vaccinators, you actually count the households and monitor how many households were visited, mark the households individually, and record the information, so you can tell very quickly which households were missed, why they were missed, and then follow up on activities to ensure the children receive vaccine.

Governments have gone on the trips to India as well, as a source of motivation to see how the Indian program has come together under the government and with partners working together toward similar goals and objectives, so they can come back from the trip with the understanding that yes, they can do it to, but it really requires that government leadership and commitment.

In addition, UNICEF has created the India Polio Learning Exchange, a process through which a number of different levels of interaction with polio-affected countries can take place such as teleconferences, video conferences and sharing of information. India has a stockpile of materials and training manuals which they have made available online and can also package and send to countries as needed. We’ve already been using some of the training materials in Nigeria for their volunteer community mobilizer network.

What did India have to do over the past year to continue to stay polio-free? Did they follow the same game plan that they had already established, or were there new elements?

For the first year, there was still fear that they might find a virus, either one that had been circulating undetected or that could be imported. However, India had the benefit having reached a level of immunity almost unheard of. Studies were finding that consistently 99% of children under six months of age had antibodies for the polio virus. So, for the first year, India focused on keeping up that momentum and maintaining a fairly rigorous set of campaigns.

In 2012, India saw some cutback, but along with that cutback came a number of new initiatives that honed in on populations that maybe weren’t being reached with the consistency and quality of the general population. These new initiatives also focused on creating an outbreak response mechanism so that in the case where the polio virus did come in, the response would be massive and rapid – immunizing millions of children within a 12 day period of detection. Just like we see in other outbreak countries, like China and Tajikistan, a massive response can stop transmission in a very short time.

We really are this close to ending polio. What can each of us do to ensure that more countries join the list of places free from this preventable disease?

Donors and communities outside of Afghanistan, Pakistan, and Nigeria, as well as inside, need to maintain their optimism. They need to be assured that we can stop polio, and that we’re making the right decisions to do so. Here in the United States, we need to remind people that polio is still a problem in parts of the world, that we need to keep our funding on, and that we need to demonstrate our willingness to support countries so that they maintain their commitment.

Over the past year, the General Assembly and key global leaders such as Bill Gates, the President of Nigeria, leaders of Pakistan and Afghanistan, and the Prime Minister of Australia all came together to reaffirm their commitment. These commitments help motivate and reassure these countries that we’re with them through this struggle as long as they continue to provide the leadership and to show progress, that we aren’t going to abandon them.

Polio eradication was a prominent issue in our discussions in 2012, and now 2013 could be a monumental year. What does 2013 look like for polio eradication efforts?

Over the past four years we’ve seen that the global discourse around polio eradication has gained momentum. Now, with the World Health Assembly coming together last year to declare polio a global emergency, polio is becoming a national priority. The recent attacks on polio workers in Pakistan garnered a lot of media attention, which was an unfortunate way to do it, but the result brought discourse around polio eradication into the public sphere.

In 2013, I think we are looking at more intense discussion and country leaders getting involved given that we now only have three polio endemic countries. Most of the countries have set rather ambitious, but achievable, goals of stopping transmission in 2013, and the partners, the donors, and the global public health community have all jumped at this. We’re seeing communities get more excited as they realize that progress is being made, and that they might be part of a historic event. And, funding is coming in more than ever. The funding gaps that we faced in the past, although they still exist, are being closed, because donors are realizing how close we are and want to be a part of ending this disease for good.