Communication for Polio Eradication - India Update

This PowerPoint presentation was part of a June 2005 joint United Nations Children's Fund (UNICEF)/World Health Organisation (WHO) meeting dedicated to examining communication in the context of the final global push to eradicate polio. At this meeting, country-specific presentations were made by communication practitioners in 16 of the 21 countries which have experienced cases of wild poliovirus in 2004 and/or in 2005 (to June). The total number of global poliovirus cases increased from 784 cases in 2003 to 1,255 cases in 2004, with 1,004 cases reported to August 9 2005 (548 for the same period in 2005). Communication strategies presented at this meeting were primarily focused on:

1. Analysing the results of programmes implemented to June 2005, and
2. Detailing the planned communication programme for the next 6 to 12 month period, designed to support a reversal of the above trend and achievement of the goal of eradicating polio worldwide.

According to this presentation, India (one of 6 polio endemic countries), experienced a decrease in the number of poliovirus cases of 41% from 2003 (225 cases) to 2004 (134 cases). As of June 2005, 18 cases of poliovirus had been reported. The profile of a typical polio case for 2004-2005 is described as being under two years of age, male (slightly more) and located in underserved communities. These individuals are more highly vaccinated than ever before and the immunity gap in high risk and general populations is the lowest ever recorded (immunity gap refers to children who have received less than four doses of Oral Polio Vaccine [OPV]).

The 2005 cases are concentrated in identified high-risk districts located in Uttar Pradesh (U.P.) and Bihar. These areas are now the focus for improving operations, communication and the deployment of human resources. It was recently concluded by the India Expert Advisory Group for Polio (IEAG) in May 2005 that "India has made its most important progress to date during 2004 and early 2005" as evidenced by the following:

• polio is highly focal and prevalence is at very low levels,
• Type III is almost eliminated allowing mOPV1 (monovalent Oral Polio Vaccine Type 1) use,
• High risk areas are being effectively vaccinated.

The IEAG concluded that "polio can now be interrupted completely by sustaining and improving the innovative approaches being taken to reach every child."

Key challenges which remain are identified as:

• Still too many missed children, but generally, it is known now who they are and where to find them.
• Insufficient protection against the virus for newborns.
• Resistance still exists…but is more subtle and hidden.
• Families are not convinced by explanations for the repeated polio campaigns…the "message base" needs to be expanded.
• There is a deep sense of fatigue and frustration amongst polio workers…and the answer is??
• After three years of "emergency" work, Polio Eradication Initiative (PEI) communication managers are burning out or moving on…managing transition is now a critical task.

The central components of the India communication strategy continue to be: political advocacy, social mobilisation and behaviour change communication. However, in order to reach the last case of polio, the strategy has been refined to incorporate the following:

• 100% coverage in high risk areas - including more community mobilisers and detailed tracking on every child's immunisation status;
• Greater acceptance by the Muslim community - detailed plans of action to involve local leaders and influencers;
• Better knowledge of the virus - genetic clustering and joint technical-communication case reviews - are helping get in front of the virus;
• More children on the move immunised - a more aggressive transit strategy, conducted more widely, for longer periods; and
• A more conducive editorial media environment - proactive, strategic approach to media to mitigate negatives associated with child deaths, monovalent Oral Polio Vaccine (mOPV), campaign fatigue.

The communication goals in the high-risk areas/districts of U.P. and Bihar by the end of 2005 are to achieve:

• 90% awareness and acceptance of polio immunisation among families and communities of children under the age of five;
• 15% increase in participation by local "influencers" on booth day and during house-to-house activities over January 2005 rates
• achieve and maintain 80% conversion rates of "X" marked households to ”P” in high risk areas during supplementary immunisation activities (SIAs)
• 30% increase in booth coverage over November 2003 booth coverage.

The social mobilisation network in Uttar Pradesh is discussed. Community Mobilisers (CMCs) are key to the strategy, with a total of 6,158 members in the social mobilisation network as of May 2005. Three organisations contributed to the Social Mobilisation Network (SMNet) - UNICEF India, Rotary India and the CORE Group of international, faith-based non-governmental organisations (NGOs). Various tools are discussed, including a “Grid Micro-plan”, which is a strategically made resource map of the CMC area used by UNCIEF and CORE to systematically track, map and engage the community and neighbourhoods via small planning units, less than 50 households in size. Data documenting the positive impact of the door to door CMC strategy is also provided.

A team approach involving CMCs and Muslim influencers in underserved areas is discussed and the positive impact reported.

A comprehensive transit strategy was implemented at key transit points, and on Bihar-bound trains from U.P. including:

• Separate training, with special emphasis on communication, for 10,575 vaccinators
• 1,000 polio "tents" (kiosks) set up at key transit points
• Wide distribution of other information, education and communication (IEC) materials - posters, whistles, handbills
• Joint planning by partners to increase number and quality of transit teams, improve supervision, ensure best placement

Finally, data is presented detailing the sources of information regarding Oral Polio Vaccine (OPV), and the impact of media spots, as well as some specific steps taken in connection with the introduction of monovalent Oral Polio Vaccine (mOPV).

The presentation concludes that both scale and intense microplanning are key components of the overall approach; that interpersonal communication is more critical than ever to help break transmission chains, and that partnerships (including the underserved, local government and celebrities) are helping to create new ways to reach families.

Additional information, provided after the meeting:

Absolute reduction in polio cases was from 1,600 nationwide at the end of 2002 to 25 cases, as of early August 2005. The number of infected districts reduced from 159 districts in 2002 to 21 in 2005. The immunity status of India children has never been higher: 97% of children 6 months to 5 years received four doses or more of Oral Polio Vaccine.

A nation-wide mass media campaign was implemented over three years. Media reach and recall surveys show that polio is the most widely recalled social marketing campaign in India. 77% of people surveyed (in U.P., West Bengal and M.P.) in November 2004 cited polio as the campaign they most remembered in the past month, compared with 34% for child health. 61-67% of audiences could recall the most recent polio television advertisement during surveys in 2003, 2004 and 2005. Recall of the radio ads was much lower, at 46% (November 2004).

There was an absolute reduction in the number of families in Uttar Pradesh (U.P.) who refuse to accept OPV, following the implementation of a major social mobilisation campaign. 48,320 households refused to allow children to be immunised in April 2003. That number was reduced to 16,011 state-wide by July 2004. Resistant cases are now further reduced to small pockets, clustered in urban centres in western U.P.

60% of households in areas with intensive communication support by UNICEF where a child is not immunised when the vaccinators first come to the home are eventually "converted" to immunisation status before the end of the particular round. This is approximately 10% higher rate of conversion than areas without UNICEF support (source: GOI/NPSP monitoring data January 2004-July 2005). The same monitoring data shows an increasingly better performance in UNICEF-supported areas in terms of children immunised at fixed-site booths (a proxy indicator of community support). In September 2003, booth immunisation was approximately 48% in both UNICEF and non-UNICEF areas. By January 2005, 62% of eligible children were immunised at the booth in UNICEF-supported areas, compared to 46% in non-UNICEF areas in U.P.

The difference in immunisation status between Muslim and Hindu children in Uttar Pradesh shrank considerably between 2003-2005 following intensive operational and communication activities to reach out to Muslim families and communities. In 2002, 11% of Muslim children in western Uttar Pradesh had received less than four doses of OPV. By April 2005, that had shrunk to 1%, which was the same as Hindu children.

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