A collection of resources and commentary providing an introduction to supply chain management and related systems for students, practitioners, and anyone else interested in learning more about how to design, manufacture, transport, store, deliver, and manage products.
Tuesday, February 26, 2013
Polio did not leave India overnight!
via the faecal-oral route, poliovirus invades the central nervous system and as
it multiplies, destroys the nerve cells that activate muscles, causing
irreversible paralysis in hours. Of those paralysed, 5-10% die when their
breathing muscles become immobilized. There is no cure for polio, but there are
safe, effective vaccines which, given multiple times, protect a child for life.
If sufficient numbers are immunized against polio, the virus is unable to find susceptible
children to infect, and dies out.
India was removed from the list of polio
endemic countries after completing a year without reporting any case of polio In
January 2012, a major milestone in the history of polio eradication. Understanding
how a country so huge, so diverse and so poor managed to stop polio
transmission offers important lessons both for the complicated international
effort to eradicate the disease for good and for India’s own health care
system. The oral polio vaccine was introduced in India in 1978, a year before
the U.S. was declared polio-free. In 1985, Rotary International launched its
global effort to end polio everywhere. India was a signatory to the 1988 WHO
treaty committing participating nations to be part of that effort. But on the
ground in India, “there was not much happening,” says Dr. Naveen Thacker, a
past president of the Indian Academy of Pediatrics and a member of the expert
advisory group to the Indian government for polio eradication.
It wasn’t until 1994, when the local
government of the New Delhi capital region conducted a hugely successful mass
immunization campaign targeting children, that the idea began to gain momentum
that India might actually be able to tackle this disease. Though other Indian
states like Kerala and Tamil Nadu had conducted similar campaigns before, it
wasn’t until the national government saw tangible progress that officials were
sufficiently convinced they could make a difference.“That’s when
India decided to go after polio in a big way,” says Thacker. Routine
immunization — in which patients sought out the vaccine themselves
— had reduced polio but couldn’t stop it from spreading. Reported
immunization coverage across India was officially as high as 90%, but the
disease was still being transmitted.
In 1995 and ’96, the government started
to organize annual national immunization days, and in 1997, India established
the National Polio Surveillance Project. In 1999, it set up an expert advisory
group that monitored the program and provided continuous evaluation of how the
disease was behaving around the country. Eventually, that group, which Thacker
was a part of, decided the best way to fight the disease was to focus on the
states of Uttar Pradesh and Bihar, two of the poorest areas in the country
where polio transmission was uninterrupted. Crucially, the group also decided
to target migrant workers moving in and out of those states and started
vaccinating along the trail that migrants followed.
It worked. By
2009, 741 cases of polio were reported in India, says Thacker. By 2010, that number
dropped to 42, and by 2011, only one case — as of today, India’s last — was
reported in the entire country. Today, officially 71% of children in India are
immunized against polio, with 98% of children in the highest-risk areas having
been immunized. In the process, the National Polio Surveillance Project became
India’s most extensive public-health surveillance system. There are currently
27,000 reporting units across the country, run through a combination of funding
from the government, WHO, UNICEF, the Bill & Melinda Gates
Foundation and the CDC, among other groups. India has become one of the
world’s largest donors to global polio eradication, putting billions of dollars
into fighting the disease at home and also lending its hard-won expertise to
Pakistan, Afghanistan and Nigeria, where the virus is still being actively
The strategy to make it happen
A number of major interventions and
innovations have been made over the years to strengthen the polio eradication
initiative in India and overcome the challenges and barriers that the programme
faced. These interventions and innovations were reviewed, assessed and
improvised to match the intensive efforts which became increasingly focused to
address issues in the key vulnerable areas and among the most susceptible populations.
The interventions covered all aspects of the programme – surveillance,
supplementary immunization activities, vaccines, communication and research – and
were strongly evidence-based, with detailed data to support why and where they
were being introduced.
identification – Initially, polio cases were classified based on the clinical
features of polio or on a laboratory confirmation. In 2001, the case
classification scheme was changed to a virological scheme where cases were
classified as polio based only on a laboratory confirmation. This is a more
accurate and reliable system of case identification.
A large network of health facilities – over 33,700 sites, including public and
private health facilities (ISM practitioners and quacks and faith healers
included) have been enrolled as reporting sites for acute flaccid paralysis
(AFP – suspected polio) cases in India. This has resulted in an increase in the
number of AFP cases detected for investigation across the country, thereby
increasing sensitivity of the system including amongst migrant populations.
sensitivity of AFP surveillance – In 2004, the case definition of AFP was
to make the surveillance more sensitive
for AFP case detection. There has been a dramatic increase in the number of AFP
cases reported and investigated since.
Change in laboratory
testing methodology – A new methodology for testing stool specimens was introduced in the
laboratories in 2007, reducing the laboratory testing time by half. The new
system takes about two weeks, thus ensuring a more speedy action after
detection of wild poliovirus. The earlier laboratory methodology for testing stool
sample for detection of wild poliovirus cases took up to five weeks for
confirmation of a case.
surveillance for polio – Wild poliovirus transmits through the faecal-oral route.
Therefore, environmental sewage specimen
testing was started in Mumbai in 2001 to detect wild poliovirus to supplement
the AFP surveillance. This has been subsequently expanded to Delhi
in 2010 and to Patna in Bihar and Kolkata
in West Bengal in 2011.
of wild poliovirus – Genetic mapping and matching of every wild poliovirus
is conducted to determine the origin of
the virus, track the spread of transmission, and also to determine the number
and spread of genetic clusters of the virus. This helped the programme carry out
immunisation and follow-up action effectively, not just in the area the wild
poliovirus was detected, but also the origin of the virus/area of importation
and areas at highest risk of further spread.
Innovations: Polio Immunization
When the programme started, the Pulse
Polio was a booth-only activity where
children were given oral polio drops on the supplementary immunization activity
days. To improve immunization coverage, the booth activity was extended to
house-to-house immunization to actively search for and vaccinate missed
missed children – To facilitate identification of missed children, finger marking of
every vaccinated child was launched in 1999. The little finger on the left hand
of the child was marked with indelible ink. In order to ensure completeness of
coverage, the vaccinators marked houses as P (all children in the house
immunized) or X (children missed) based on whether all eligible children in the
household had been vaccinated or not by the polio vaccination team.
Categorization of X
houses visited – Categorization of X houses into sub-categories such as locked houses,
houses with a sick child, houses that resist vaccination etc was introduced to
facilitate appropriate follow up for vaccination. Using this categorization,
houses with sick children can then be visited by doctors, refusal families can
be visited by influencers, and so on.
Back-up ‘B’ team – The back-up team
concept was introduced to ensure immunization of children who had missed being
vaccinated despite revisits of the vaccinators to the household during the days
of the campaign. These missed children are
usually those who are at school, sleeping in the morning,
with their parents at their places of
work, or those whose parents have refused vaccination. After
the vaccination team ‘A’ has completed the
morning visit to each and every household as
per the micro-plan, a ‘B’ team visit was
started to vaccinate the children missed by team ‘A’.
The polio programme has been integrated with
the National Rural Health
Mission (NRHM). The NRHM is aimed at
ensuring effective healthcare through a range
of interventions at individual, household,
community, and most critically at the health system levels.
The community worker ASHA – a trusted
member of the community- is involved in mobilization and vaccination for polio.
vaccination strategy –Children on the move often miss polio immunization. In order to
vaccinate them, transit vaccination teams are deployed at train stations, on
running trains, bus stands, highways, markets, prominent road crossings to give
polio vaccine to children in transit.
vaccination – Large gatherings at fairs and festivals provide regular opportunities
for the poliovirus to spread and also for the programme to vaccinate the vulnerable
immunization is carried out at all fairs and
festivals in and around polio-endemic states – both at the
venue of these gatherings, and also all
along the routes which people take to reach these venues.
Newborn tracking – With data showing that
most polio cases occur in children less than two
years of age, a system was introduced in
2006 to identify, track and immunize every newborn child in the highest risk
areas of Uttar Pradesh and Bihar. By ensuring newborns are quickly added to
microplans and introduced into the routine immunization system, each child in
these vulnerable areas receives up to eight doses of OPV through polio rounds
as well as the routine doses before the age of one year.
The complete report: http://www.unicef.org/india/Polio_Booklet-final_(22-02-2012)V3.pdf