Global Polio Emergency Action Plan 2012-2013
Web Annexes
Web Annex 1: List of Innovations in the India Polio Eradication Program
Broadly, two types of innovations have been used in the India program. Vaccine innovations
have included testing (immunogenicity studies) and deployment of monovalent and bivalent
vaccines and evaluation of their impact through targeted sero-prevalence studies. Secondly, the
program has continued to implement a series of operational innovations, some of which
represented major shifts in vaccine delivery strategies.
The driving objective of all operational innovations has been to identify and vaccinate children
that are being missed by the program. The major operational shifts have included moving from
initial fixed site vaccination to addition of the house-to-house vaccine delivery. The subsequent
innovations aimed to vaccinate children that were being missed during both fixed site and
house-to-house vaccination.
The following is a list of operational and communication innovations and the underlying
rationale:

Finger marking of vaccinated children to help ensure vaccination of children found
unmarked during the vaccination round, for objective supervision and coverage
assessments at the end of the round;

House marking of households visited by vaccination teams. The marking records if all
children under 5 years of age in the house have been vaccinated (marked P) or if one or
more children have been missed (marked X). This ensures follow up of X marked houses
and helps supervision. As part of the standard operation, all X marked houses are
revisited the same afternoon by the vaccination team and those that still remain as X at
the end of the day are revisited by a different team (called ‘B team’) during the
subsequent week. A round-to-round comparison of ‘X generation’ and ‘X remaining’ in
the area is used as one of the indicators of the quality of activity in the area;

The X houses are recorded on the back of the tally sheet with reasons for the X in the
following categories:
o
o
o
o
o
XR = refusal by family
XS = family declines vaccination because the child is sick
XH = child is not at home but will return
XV = child is out of the village/town and is not expected to return before the end
of the round
XL = the house is locked and is expected to remain locked for the duration of the
round.
The X categorization enables specific follow up of children, for example, for XR houses
the local community influencer is mobilized to help persuade the family. For XS, the
local medical officer visits and provides reassurance to the family. For XH, the
vaccination team makes repeated visits to ensure vaccination of children.
X categorization also helps in supervision of teams and analysis of overall performance
based on trends in X generation and remaining ‘convertible’ X houses in the area over
multiple rounds. Convertible X houses include XR, XS and XH. In high XR/XS areas, for
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example, greater attention is given to local community mobilization and engagement.
Increase in remaining XH brings the team performance into question;
A system of bindi marking was also developed in which the Anganwadi workers would
mark the house during the month to identify all children under 5 in the household, and
particularly to identify newborns. The bindi marking was a function of the Indian health
system that greatly facilitated OPV outreach as it informed the vaccination team how
many children (at a minimum) to look for, even before speaking to the mother;

Development of high quality, updated and validated micro-plans. This involves numbering
of every house in the area, rationalization of workload for each vaccination team by
assigning an optimum number of houses to be covered per day (typically not to exceed 150
houses per day per team), periodic validation and updating of micro-plans to ensure all new
houses and settlements are included and dwellings or settlements that are no longer there
are deleted. A good micro-plan also ensures appropriate composition of vaccination teams
for better access into households and acceptance by the community;
A typical micro-plan includes the names of the vaccination team members, local influencers,
identification of the first and the last house for each of the 5 house-to-house campaign days
together with a map that identifies these landmarks and direction of team movement by day.
A high quality micro-plan allows all houses and the population in the area to be covered and
is an important monitoring tool to track vaccination team composition and performance;

Optimizing quality of vaccination teams. This includes ensuring maximum participation as
vaccinators of government workers who can be held accountable by local authorities,
training of vaccinators – in high risk areas the National Polio Surveillance Project (NPSP)
Surveillance Medical Officer (SMO) is required to train every vaccinator himself at least once
in 3 months. The focus was not just on training the vaccinators on the operational aspects of
the campaign but also on their inter-personal skill building so as to equip them to handle the
queries from the communities related to vaccine and polio disease. At least one of the team
members must be a female and at least one from the local community being served by the
vaccination
team
to
ensure
access
to
homes
and
young
children;

New-born identification and tracking. For a variety of cultural and practical reasons, newborns are more likely to be missed by vaccination teams compared with older infants and
children. Every vaccination team in Uttar Pradesh (UP) and Bihar carries a new-born
tracking booklet and specifically asks for new-borns (any child born after the last round in
the area) in each house. When identified, the new-born is vaccinated, registered in the
booklet and tracked for eight subsequent rounds to ensure full vaccination;

Convergence. The India program utilized a comprehensive approach in targeting polio
eradication by including routine immunization, exclusive breastfeeding, the use of ORS and
zinc for diarrhoea, personal hygiene and water and sanitation issues. In the focused 107
blocks the program converged with UNICEF’s WASH, Health and Nutrition program to
ensure the facilitation of service delivery in these high priority areas. The new
communication campaign launched in 2011 also addressed this expanded package of
messages;

A ‘Transit Strategy’ was developed to ensure vaccination of children on the move. Special
transit vaccination teams are positioned on railway platforms, bus terminals and major
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markets and crossing points; in some areas children are vaccinated in moving trains. A large
number of children from XH and XV houses get vaccinated by transit teams. Vaccination
teams are also systematically deployed to cover children in large religious congregations
(melas) attended by hundreds of thousands of families with children;

A key innovation applied in recent years has been the identification and mapping of welldefined migrant and mobile population sub-groups. These include the seasonal brick kiln
labor, construction workers, traditional nomads and large transient migratory populations
in urban and peri-urban slums. These sub-populations were hard to reach and were playing
an important role in sustaining transmission and geographic spread of poliovirus. The
program also utilized community informers from nomadic/migrant communities to inform
social mobilizers and district officials about population movements, or new settlements. This
was essential to reaching these high risk groups;

Independent monitoring. NPSP uses its field volunteers and temporarily hired external
monitors to monitor the implementation and coverage of the campaign. The monitoring
plan for each monitor is developed by the SMO. During the preparatory phase monitors
assess the quality of micro plans, training quality and involvement of the district and subdistrict government officials.
During the campaign the monitors assess the operational processes that influence the
quality of the immunization activity such as composition, work load and training status of
vaccination teams, quality of vaccine being used, involvement of local influencers and
leaders in the campaign, vaccination at transit sites and other high risk and hard to reach
areas, such as brick kilns, construction sites and river banks. They also randomly visit
houses where vaccination teams claim to have immunized all children to look for any
unimmunized children in such houses and make an overall assessment of the houses with
potentially missed children in each area. These monitors also conduct end of the round
survey of children, preferentially in high risk areas. Approximately, 1% of the total target
houses and target children are monitored during a campaign round (the target population of
children in a SNID in UP, Bihar and other high risk areas is around 70 million). In addition
to monitoring the campaign, the SMO also monitors the monitors for quality assurance and
validation.
To make data utilization and analysis much more efficient the program initiated an online
database with the Dev. Info. platform to generate tables, graphs and maps based on the
indicators from the communication profiles, which are generated after every SIA. These can
then be complemented with polio case data and operation data to relate communication
issues to epidemiological and other health challenges that may impact the polio eradication
effort;

Campaign accountability linked to objective monitoring data. Information on
implementation and monitoring data with a standard set of indicators are reviewed every
evening in a meeting chaired by the district magistrate or the chief medical officer. The
monitoring information and compiled data are used to take corrective actions for the next
day. Monitoring feedback is also shared by monitors with block medical officers earlier in
the evening in each block. Each district in UP and Bihar has at least one meeting of the
District Task Force chaired by the District Magistrate before each campaign where a detailed
review of the previous campaign is conducted using the monitoring data provided by NPSP.
Based on this review, the gaps in implementation get highlighted and responsibilities for
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actions are fixed – both for the health staff and other sectors that have a role in polio
campaigns, such as education, social welfare, general administration and transport;

Evidenced-based strategy. Knowledge Attitudes and Practices Studies have been conducted
annually to assess community acceptance and understanding of the polio programme as well
as the polio plus messages. The studies provide insights into underlying perceptions of the
polio campaign by the target audience and illuminate areas of risk (such as the strength of
prevailing myths over vaccine safety), and identify gaps in presently available data. The
indicators from these studies have helped sharpen the strategic focus and responsiveness of
the communication campaign;

The ‘High Risk Approach”. A major strategic aspect of the program has been identification
and concentration of resources and efforts in high risk areas and sub-population groups. In
addition to examples above (newborns, migrants, etc.) the program was substantially
intensified in 107 high risk blocks in UP and Bihar. Special operational planning and
resources, such as satellite offices and night shelters, were established in the Kosi River flood
plains of Bihar;

A series of innovations have been undertaken to mobilize Muslim community members and
religious and academic leadership in support of the program. Muslim influencers have been
inducted in the program in every neighbourhood and imams in mosques have been
mobilized to announce vaccination rounds and encourage the community during Friday
sermons to actively participate in the campaign;

Engaging the private sector to increase visibility and reach. As the private sector had a
comparative advantage in advertising broadly across multiple mediums and geographic
locations an outreach campaign was created with the help of a facilitating foundation to
expand messaging to critical target groups like migrants and mobile populations. Through
this initiative a number of key communication mediums were sponsored by businesses such
as IEC booths at major transit location, mobile vans displaying communication materials,
city buses with the new campaign slogans and photos, SMS and voice messaging services,
public service announcements on polio in cinema halls and local theatres, magic shows,
street theatre and wall paintings, etc. Public spaces like railway stations; buses, bus stops,
markets, dairy booths, banks and schools have been successfully negotiated for maximum
visibility of messages;

Establishing a national brand ambassador and involving celebrities. The campaign identified
a key symbol of national unity that could rally collective action towards the goal. Amitabh
Bhachchan's contribution to polio eradication in India is immeasurable. He has been
involved in the campaign for a decade and is a key generator of community support for polio
vaccination. Besides Amitabh Bachchan, the cricketers have also played a critical role over
the past decade with the Bowl Out Polio campaign and UNICEF and Rotary have been able
to engage a number of celebrities to be involved in the program.
The program in India has been painstakingly improved through refinement of these innovations
over many years. This was needed in India mainly due to the unique epidemiologic challenges
that required a very high population immunity threshold to stop transmission. Secondly, this
intricate web had to be weaved to minimize the escape of even a fraction of children from the
program net. This fraction in India translates into millions of children.