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Eliminating Polio in India: A Case Study in Data Use

This is a case study in how the strategic use of data helped overcome a seemingly intractable public health problem – the spread of polio virus. The primary gains in combatting polio occurred well before the introduction of digital data tools – most of the data collection and reporting formats were paper-based. Data was used effectively at every administrative level to ensure total coverage of vaccination efforts. We have documented this to help identify what the lessons learned might be for combating other public health challenges, such as COVID.



Achieving “polio-free” status in 2014 is one of India’s greatest public health success stories. There are many contributing factors to this success, including the efforts of millions of frontline health workers, community mobilizers, state and national level government agencies, international aid and development agencies and strong political commitment. An important factor that enabled this collaboration was the strategic data use. This case study describes the important role data use played in polio elimination in India – and especially in the state of Uttar Pradesh.



Program Background

India’s battle against polio started in the mid 1990s with an estimated 150,000 polio cases being reported annually. At that time, eradicating polio from the sub-continent was considered to be a complex and challenging task. [1] The population density, birth rate, poor sanitation, widespread diarrhoea, inaccessible terrain and resistance of some communities to vaccines all posed challenges to eradication. [2]


In 1995, the Government of India launched its Pulse Polio program for polio eradication, with National Immunization Day campaigns conducted across the country twice annually. Later, the following four strategies were adopted by the WHO for all countries fighting polio; 1. including routine immunization; 2. supplemental immunization; 3. acute flaccid paralysis surveillance (through lab testing of stool samples) and 4. targeted mop up campaigns.[3]


Progress was not always smooth. Although India only reported 66 polio cases in 2005, it reported 741 in 2009, including 602 in Uttar Pradesh. Achieving sufficient vaccination coverage to interrupt transmission was a challenge.[4] Ongoing “mop-up” campaigns in Bihar and UP every 4-6 weeks eventually succeeded in vaccinating millions of children, managing to contain and then eliminate the virus.


There were several partners active in these campaigns, who together deployed millions of field workers, including government field surveillance officers, members of Rotary, and thousands of Community Social Mobilizers hired by UNICEF and the CORE Group Polio Project (CGPP). The partner organizations trained thousands of people from high-risk communities (both community-level influencers and mobilizers) to visit households with the aim to promote immunization services, track immunization history, encourage vaccinations, and mobilize opinion leaders.


Strategic Use of Data at the District Level

The objective behind the use of data for the campaign was to ensure that every child aged less than 5 years in the country received the prescribed polio vaccinations. The two main ways in which data was collected are through surveillance and monitoring.


Decision makers used data from the National Polio Surveillance Project’s Acute Flaccid Paralysis (AFP) weekly reports to determine outbreak status – which helped identify gaps and prioritize districts and blocks for campaign activity.


In addition, strong monitoring systems were set in place to identify gaps in the preparedness and implementation of the polio vaccination campaign. Coverage and performance data from the monitoring systems were analyzed by the WHO and CDC and provided to decision makers to assess achievements and plan next steps. Over time, as campaign monitoring improved, UP campaign implementers used real time data in government-led debriefing sessions held every evening to support rapid situation analysis and problem solving. Districts and blocks were ranked and bench-marked to identify best practices and determine priority sites. From these nightly meetings, rapid feedback and capacity building support were provided to the field staff. These meetings were led by the District Magistrate at the district level, whose support and authority was key to bringing together different stakeholder types. Polio eradication was given such high priority that DMs were transferred if they did not engage in active data use in these meetings. There were a range of data sources utilized in the meetings, summarized below.


Capacity building was supported at every level. Surveillance Medical Officers (SMOs) had quarterly training sessions with epidemiologists from the CDC and the WHO. The SMOs trained the DMs and the SIOs were also trained.


Summary of Data Sources used in the Polio Eradication Campaign

  • NPSP’s AFP Reports, GoI, Disease surveillance reports based on lab analysis of stool samples of people with AFP symptoms, collected through a network of designated facilities

  • Coverage and performance data, CGPP Program data tracking campaign efforts

  • CMC Community Maps, CGPP, Maps created at the community level and aggregated at block and district levels

  • Household registers, CGPP, Core Group designed registers that track pregnant women and the vaccination status of children under 5.

  • Household codes, Codes marked on the sides of households describing the household’s vaccination status.

  • UNICEF Routine Immunization monitoring application

  • MCTS/ RCH, GoI, Monitoring routine immunization through individual patient records


Microplanning and Household Coding

Despite these rich data sources and active monitoring, there were still gaps. To drill down to the household level, Community Mobilization Coordinators (CMCs) created micro plans comprising of an exhaustive beneficiary list and community maps to track and implement outreach activities. This information was then aggregated at the block and district levels by decision makers for planning. CMCs also used CGPP designed household registers to track outreach activities at the individual level. Pregnancy and vaccination trajectories of all newborns and infants up to 5 years of age were recorded and shared with the supervisors on a daily basis. Each household was marked with a code to indicate the vaccination status,. Clearly demarcating households that were, for example, seasonal migrants (coded "XV") and were out of the campaign coverage area allowed teams to focus their efforts elsewhere, where they could actually make a difference. This information helped facilitate a more targeted and efficient response.



Another strategy was biphasic outreach which created efficiencies and improved data quality. [5] As per this strategy, vaccinators worked in teams of two; team A would enumerate the household and vaccinate as many children as they could. They would also document any households that were missed as “X”. They were encouraged to be honest about numbers reached and missed. The “B” team would then visit all the remaining “X” households to work with families to overcome resistance. Both teams included CMCs who were trusted in the communities and would therefore be more persuasive.[6]


Impacts

These data-informed strategies worked. In 2010 there were only 42 cases in India – with 10 in UP. The last confirmed case occurred in West Bengal and on February 25th 2012 India was removed from the polio-endemic country list.


The success of polio eradication in India reinforces the importance of strategic use of data for improved targeting and operational efficiency and effectiveness. Data was generated and used by program stakeholders at all levels. The use of microplans comprising of community maps, beneficiary lists and household registers helps frontline program delivery teams to reach out to the beneficiary households more effectively to achieve the stated program goals. However, the impact of data use may not have happened in the absence of a strong political will and partner support. The campaign highlighted the need for all decision makers to be data informed and program driven.


Key Lessons Learned

System capacity for strategic use of data already exists in Uttar Pradesh: Decision makers and field workers can use data strategically in the context of strong political will, and support from the District Magistrate. The digital tools available now can only expedite these capacities.


Digital tools and an MIS is helpful but not necessary for strategic use of data: Polio eradication involved active use of paper based data collection, aggregation and analysis tools.


The importance of external partner support: The WHO and CDC led the effort to analyse the monitoring and surveillance data, making it available in a timely manner, relevant to the needs of the decision maker.


Strategic data use requires drilling down to the household level: Microplanning to ensure coverage of every household was important for achieving the appropriate level of vaccination coverage.


The importance of a system-wide approach: Data use was fostered at every level of the health system.



Acknowledgements

This was put together by Anna Schurmann, Manu Panjikaran, Girdhari Bora and Vishal Shastri. Thanks to Dr Ved Prakash, Director of Immunization, NHM, Uttar Pradesh; Deepti Pant, State Lead – Uttar Pradesh, Catholic Relief Services; Raj Ghosh, Senior Advisor, Vaccine Delivery of BMGF India Country Office; Rakesh Singh – World Bank; and Manojkumar Choudhury, M&E Specialist, CGPP.




[1] Coates, E. et al. 2013. “Successful polio eradication in Uttar Pradesh, India: the pivotal contribution of the Social Mobilization Network, and NGO/UNICEF collaboration” Global Health: Science and Practice. Vol 1, [2] Patralekha Chatterjee, “How India managed to defeat polio.” https://www.bbc.com/news/world-asia-india-25709362 [3] Government of India, 2005. Field Guide: Surveillance of Acute Flaccid Paralysis, Third Edition. http://www.searo.who.int/india/topics/poliomyelitis/Field_guide_for_Surveillance_of_Acute_Flaccid_Paralysis_3rd_edition.pdf. Accessed 15th August 2019 [4] Weiss et al. 2013. “Determinants of performance of supplemental immunization activities for polio eradication in Uttar Pradesh, India: social mobilization activities of the Social Mobilization Network (SM Net) and Core Group Polio Project.” BMC Infectious Diseases. 13:17. http://www.biomedcentral.com/1471-2334/13/17 [5] Coates, E. et al. 2013. “Successful polio eradication in Uttar Pradesh, India: the pivotal contribution of the Social Mobilization Network, and NGO/UNICEF collaboration” Global Health: Science and Practice. Vol 1, Number 1. [6] Weiss, W. et al. 2011. “Outcomes of polio eradication activities in Uttar Pradesh, India: the Social Mobilization Network (SM Net) and Core Group Polio Project (CGPP)”. BMC Infectious Diseases, 11, 117. https://bmcinfectdis.biomedcentral.com/track/pdf/10.1186/1471-2334-11-117?site=bmcinfectdis.biomedcentral.com

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