Follow the polio road

 

 

Top: Panacea Biotec workers pack polio vaccine in dry ice. Bottom: A man pedals a rickshaw through the streets of Birgunj, Nepal, as his partner announces an upcoming Subnational Immunization Day.

You’ve seen the photo: a young child, head tilted back, with a Rotarian dropping the polio vaccine in her mouth. But long before that moment, Rotarians in polio-affected countries have been laying the groundwork by monitoring cases of the disease, building support, raising funds, and publicizing immunization days. To complicate matters, each region of the world and each state in each country faces different challenges. In some places, there’s a need to dispel myths in the Muslim community. In others, Rotarians must reach people isolated by massive flooding every year. If it takes a village to raise a child, it takes an entire nation of Rotarians to get that child immunized.

Here, we take a tour of Subnational Immunization Days (SNIDs) held at the end of April 2008 in India and Nepal to see what it takes to vaccinate a child against polio.

The vaccine

The polio vaccine might be the most important thing a Rotarian will ever see in a freezer. Keeping the vaccine cool is as vital a step as getting it into the mouths of the children; the vaccine is made from a live attenuated poliovirus, and it must be kept below 40 degrees Fahrenheit for the weakened virus to survive and stay effective. After the vaccine is manufactured at the Panacea Biotec factory in New Delhi, the vials are packed in boxes (just one box contains 1,000 vials, enough to immunize 20,000 children) and stored in a walk-in freezer until they’re shipped on dry ice to regional or district distribution points, journeys that can last eight hours through heat of 110 degrees Farenheit or more. There, the vials are again kept in freezers, or, for short-term storage, in ice-lined refrigerators for up to a month. In the field, volunteers carry vials of the vaccine in a small cooler that holds four ice packs, completing what is known as the cold chain. One vial contains enough vaccine to immunize 20 children.

 The manufacturer places a label, called a vaccine vial monitor, on each vial. A white circle on the label will turn darker as the temperature rises; when it’s the same color as the surrounding packaging, it must be discarded. “Even the grassroots-level worker is aware as to when and how the vaccine goes bad,” says Deepak Rastogi, deputy general manager of quality assurance for Panacea Biotec.

At the factory, vaccines are manufactured to target all three types of wild poliovirus (the last case of polio type 2 was reported in 1999). The trivalent oral polio vaccine is used during routine immunizations to give protection against all three serotypes, while the monovalent vaccine gives stronger immunity against a single type and is used strategically to supplement the trivalent vaccine.

Surveillance

In the battle against polio, India’s National Polio Surveillance Project, a partnership between the World Health Organization (WHO) and the government of India, is like a spy agency: It gathers intelligence about the poliovirus’s whereabouts, pinpoints where it’s circulating, and genetically maps its origin, with the goal of strategically deploying resources where they are needed most.

Health workers collect two stool samples from children under the age of 15 with acute flaccid paralysis, which is a symptom of polio and other diseases. The samples are sent to one of eight certified labs in the country by means of a cold chain of coolers and refrigerators to keep the virus – if present – alive, so that it can be detected. It’s like distributing the vaccine, but in reverse. The virus must be given time to grow; technicians then test the virus to determine its type. The goal is to finish the testing within 21 days.

Forty thousand children with acute flaccid paralysis were tested in 2007 in India; over 800 were diagnosed with polio. “It’s a very sensitive system that we have in India, and that’s why we’re confident that we will not miss a polio case. That’s extremely important, because if you miss a case at this critical state of the program, it can be a huge disaster,” says Sunil Bahl, technical manager for the project, at his office in New Delhi.

Since polioviruses from assorted geographic areas have slightly different genetic sequences, scientists use genetic testing to determine where the virus originated, tracing its lineage in intricate printouts. They use the data to decide how to target vaccination efforts. “We can go back and see where is the father, where is the grandfather, where is the great-grandfather of this virus,” Bahl says. 

Through the surveillance system, officials are able to tell which types of polio are circulating where, outline high-risk blocks, and use that information to allocate resources. Bahl points to a map of the Kosi River in Bihar, one of the two polio-endemic states in the country (the other is Uttar Pradesh), both of which are targeted in this SNID. “The pink circles that you see are the polio cases,” he says. “The partnership has actually strengthened support to this area, as you can see. There are satellite offices that have been opened in that area.”

Advocacy

In 2007, 70 percent of polio victims in Uttar Pradesh were Muslim. As of mid-2008, the proportion had plummeted to 29 percent. The difference? A Rotary-led initiative of Muslim leaders educated Muslim communities about the safety of the polio vaccine.

The Ulema Committee for Polio Eradication was established by Rotary International in July 2007. These experts in Islamic law (Ulema means scholar) have been giving speeches, going door to door, and even administering polio drops to convince Muslims that providing the polio vaccine is consistent with Islamic beliefs, and to dispel myths that the polio vaccine causes infertility.

Working with the Ulema committee, India’s National PolioPlus Committee published a booklet linking polio vaccination to the duties of parents as explained in the Qur’an. The publication, called a fatwa, or ruling on religious law, includes the names and phone numbers of Ulema committee members who can be contacted to clear up any misconceptions. The booklet is shown to parents who have questions about the polio vaccine.

“You can very easily spread any myth in a locality which is deprived of education,” says Kalbe Sadique, a Shia theologian and member of the Ulema committee. “But if you involve Muslim doctors – responsible Muslim doctors – and the Ulema … I think the myth will be eradicated.”

Rotary’s advocacy work with the Ulemas will help pave the way for the upcoming immunization day. Rotarians work with people at all levels – from mothers to possible donors to the highest-ranking politicians – to raise public awareness, financial support, and political commitment long before the first child receives a drop of vaccine. One way to look at the role of a Rotarian in the fight to eradicate polio: professional relationship builder. Says V.N. Singh, past District 3120 governor and a member of the Rotary Club of South Varanasi: “We can show the path, but we need help, no matter what project we initiate. We identify the problem, then the solution, and then we solicit cooperative relationships.”

“Rotary is uniquely qualified, because the approximately 100,000 Rotarians that we have all across the country are living and working with Indian citizens in every state of India,” says Deepak Kapur, India PolioPlus Committee chair and member of the Rotary Club of Delhi South. “Be it in New Delhi, be it in Bombay … a Rotarian somewhere will have the right connections with the concerned politician at the state level and at the central level.”

Rotarians and other health officials also educate the public about the need to be immunized. According to Nita Chowdhury, principal secretary of medical, health, and family welfare for Uttar Pradesh, one of the most common questions is why does polio require multiple doses of vaccine when other diseases sometimes need only one? The answer: Frequent vaccinations boost immunity in places where the poliovirus is circulating, and children are subject to other harmful enteroviruses. “You may be the neatest person, taking the vaccine on time,” she says. “But, should there be laxity on the part of anybody else in your close community, that has consequences for you.”

Through their advocacy efforts, Rotary and its partners have mobilized US$4.125 billion from public sector donors for global polio eradication. In India, for example, the government has committed nearly US$700 million to efforts to eradicate polio.

Social mobilization

Banners promoting an upcoming immunization day in Bihar hang on town monuments and on shacks. They’re suspended from tree branches, draped over bridges – even used by local residents as shawls. The advertising campaign rivals McDonald’s during the Olympics for its pervasiveness.

Just across the border in Birgunj, Nepal, a hired town crier rides in a rickshaw, using a microphone to drum up interest in the days and hours before the Subnational Immunization Day on 26 April. Tehmas Manekshaw, Nepal PolioPlus Committee chair, walks alongside, stopping to talk to groups of women about the importance of the polio vaccine and telling them where and when to go to immunize their children.

Rotarians and other volunteers and health officials use these and other strategies to reach as many children as possible on a typical immunization day. Appeals by movie stars are broadcast on popular local cable stations. Stickers on newspapers notify readers of the date of the next round, and local cinemas play slideshows to promote the polio campaign and address local concerns. Many of these of these social mobilization materials are funded by Rotarians through PolioPlus. An example: the 80,000 banners used in India cost about US$70,500; 100,000 posters hung in businesses, about $4,750.

Prepping for immunization day

With a population of 112,000, Birgunj, Nepal is a major business and trade center. Indians and Nepalis travel back and forth across the open border, which means the poliovirus does too. While the last case of wild poliovirus was reported in Nepal in 2000, several isolated cases have been imported over the past few years from India, one of four remaining polio-endemic countries (the others are Afghanistan, Nigeria, and Pakistan). When a case is confirmed, an additional SNID is scheduled to contain the outbreak.

In the days leading up to the immunization day in April, Rotarians hang banners and posters, hand out pamphlets, and draw up maps. The logistics are complex: a small army of volunteers needs to be coordinated, and the polio vaccine, which was shipped to Nepal by air, needs to be unloaded and transported, sometimes to remote areas, while keeping the cold chain intact. Volunteers are trained to administer the polio vaccine: how to give it, how many drops, how to use the vial monitor.

The open border poses one challenge here; weather and geography, another. At the SNID in India, health officials are eager to get these logistics nailed down and another round of immunizations underway before monsoon season, when residents of Bihar flee into the uplands to escape the flooding Kosi River, known as the “Sorrow of Bihar.” (Later, in August 2008, the worst flooding in 50 years displaced millions of residents after a dam on the Kosi broke). The flooding only compounds the sanitation issues inherent in polio transmission.

“During flood times there is no way you can commute up there. And they are the high-risk areas that have the most polio cases,” says Pragati Sinha, District 3250 PolioPlus committee chair and a member of the Rotary Club of Chanakya in Bihar. “We have got to make the grave of polio in India, it’s as simple as that. And that grave has to be dug in Bihar.”

Rotarians are working to increase vaccination rates in these remote high-risk blocks in northern Bihar by constructing makeshift shelters, called serais, where families can rest overnight during multiday journeys to an immunization booth to get their children immunized. India PolioPlus Committee Chair Deepak Kapur coined the term after the small resting places built during the Mughal dynasty in India. “These little resting places ensure that the lady or the team will have a place on the way to spend the night and then go on and have the motivation to go that little extra mile to get immunized,” he says.

Subnational Immunization Day

On immunization day in Nepal, vaccination booths sprout up everywhere: in markets, mosques, town squares, homes, even the middle of a dirt road. In rural areas, small kiosks that sell tobacco and snacks offer a spot for vaccinations. A district public health center acts as the central point for vaccine distribution, surrounded by dozens of booths staffed by government workers and volunteers.

Rotarian, Rotaract, and Interact volunteers gather at a hotel owned by a Rotarian to decorate their cars and get dressed in Rotary aprons and caps. They start the day in urban Birgunj, waving down rickshaws and stopping families on motorcycles to check for the telltale sign that the children have been immunized: a purple pinky finger on those under the age of 5. Children without painted fingers are directed to nearby booths. Later, the teams head out to rural areas. While Rotarians set up in the homes of local residents, Rotaractors walk down dirt pathways and yell out the locations of these makeshift booths.

More than two million children were targeted for vaccination during this SNID in Nepal. At the SNID held the next day in India, 72.9 million children were immunized. During these events, Rotarians vaccinate children with an efficiency that would be the envy of many a business owner: at a typical National Immunization Day in India, 6,000 children per second are immunized.

Mop-up campaign

Ajay Saxena walks door to door through the dirt paths of a village outside of Lucknow, Uttar Pradesh. A member of the Rotary Club of Lucknow Rajdhani, he is joined by Rotarians from nearby clubs and government health workers to vaccinate children missed during the SNID: the “mop-up” phase of an immunization day.

Saxena has worked persistently to build relationships with Muslim Ulemas and government figures. To the Muslim families he encounters, he hands out one of the green fatwa booklets printed by RI’s Ulema Committee for Polio Eradication, of which he is secretary. The community health workers, called ASHAs (accredited social health activists), translate and keep statistics. It’s evident by the low level of resistance that some of these families have seen this information before.  

During a mop-up, health workers and volunteers check the pinkies of children to see who has been immunized, give the vaccine to anyone missed, and mark homes with chalk to note the date and the number of children immunized.  

If they do find a polio victim on these visits, Rotarians get involved too. At one home, Saxena encounters the family of Shanu, a 12-year-old boy who has had polio since birth. Saxena talks to Mohammad Kamil, Shanu’s father, and writes down the name of a nearby polio rehabilitation center where the boy can get some help.

Says Nita Chowdhury: “Rotary is the type of organization that is able to do this work because of the conviction people feel flowing from their actions. Rotary has always been identified as an organization that acts for the greater community good and achieving community action. Rotary does not play the benefactor role. That is why Rotary has been successful. Nobody, not even the poorest person in the world, wants to feel obligated to you. Rotary feels the necessity and shows sympathy for the people they are working with.”