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Indian Journal of Community Medicine

Pulse Polio Immunization in National Capital of Delhi: A Process Evaluation

Author(s): O.P. Rajoura, Sanjiv Kumar Bhasin, P. Chhabra, O.P. Aggarwal

Vol. 27, No. 4 (2002-10 - 2002-12)

Introduction:

Drawing inspiration from the successful smallpox eradication, the World Health Assembly resolved to eradicate Poliomyelitis from the world by the year 2000 AD1. National Immunization Days (NIDs) are mass-compaigns during which supplementary doses of oral polio vaccine (OPV) are given to all children below 5 years of age in a country to interrupt the chain of transmission of wild polio virus2. NIDs are one of the four potential strategies recommended by WHO for Global poliomyelitis eradication3. India too is a signatory to the World Health Assembly declaration to eradicate polio by the end of the century. India accounted for more than 50% of the total world incidence of polio4. Delhi showed the highest incidence in India contributing to about 6% of the cases despite having just 1% of total Indian population5. Delhi was the 1st state in India to start pulse-polio immunization at the state level in 1994. From 1995 onwards, National Immunization Days are being conducted in the country every year. More than 2 million under 5 year old children were given polio drops in 1997-98. The recent trend in Delhi is of a continuous and regular decline in polio cases6. WHO estimates that at least 500,000 cases of paralytic polio will be prevented each year thereby reducing health care expenditure for hospitalization and rehabilitation of the victims of the disease. The major financial benefit comes from stopping polio immunization after eradication is certified. A recent cost-benefit analysis projected that the direct global financial benefit could be as high as $1.7 billion annually7. It is, therefore, essential that to carry out successful implementation of such a gigantic task all the issues pertaining to the staff posted at PPI booths (e.g. availability, training etc.), proper and effective cold chain monitoring system, other problems and obstacles should be carefully looked into. This requires an in depth process evaluation. The present study is a process evaluation of pulse-polio immunization carried out during the 2nd round of NID i.e. on 18th Jan. 1999.

Material and Methods:

The present study was carried out on 18th Jan. 1999 in the National Capital Territory of Delhi, which was second round of the pulse immunization for the year 1998-99. The study was supervised by second author, Reader in Deptt. of Preventive and Social Medicine, University College of Medical Sciences, Delhi. A total of 112 pulse-polio immunization posts spread all over Delhi were randomly allotted to the interns and final year students of UCMS & GTB Hospital. Before carrying out the study, the interns and the medical students were given a training to acquaint them about various aspects of the evaluation considered in the study i.e. various categories of staff deployed at the pulse polio post, maintenance of the cold chain and importance of the vaccine vial monitor etc. All of their doubts were clarified to minimize discrepancies. Information was collected on a pre-tested, structured and semi-open ended proforma which was modified form of "pulse polio immunization (PPI) in India, process evaluation", prepared by department of family welfare, Govt. of India. All the information gathered was then coded and analysed using the software SPSS.

Results:

The data was gathered from 112 pulse polio posts. Of these 46(41.1%) were in slum area, 39(34.8%) in urban area and 21(18.7%) in rural areas. 6(5.3%) mobile teams which covered difficult and interior areas were also observed.

Table I: Different categories of staff present at pulse polio posts and their training status (n=112).

Category Total No. (%) Trained No. (%)
Doctors/Interns 70 (62.5) 55  
Nurses/ANMs/LHVs 97 (86.6) 82 (84.5)
Clerks 22 (19.6) 19 (86.4)
Class IV 67 (59.8) 58 (86.6)
Others (including volunteers) 29 (25.9) 24 (82.7)

Table I shows that a total of 285 health personnel were present at 112 immunization posts. Doctors/interns were present only at 62.5% of the posts and nurses/ANMs/LHVs in 86.6% of posts. The training for all levels of workers ranged from 84.5% for nurses/ANMs/LHVs to 86% for clerks and class IV employees.*

Table II: Status of cold chain maintenance at pulse polio posts (n=112).

Different aspects of cold chain maintenance n %
Place Shaded 97 86.6
  Unshaded 15 13.4
Ice packs in vaccine carriers Present 80 71.4
  Absent 32 28.6
Condition of Ice packs Fully frozen 63 78.7
  Partially frozen 16 20.0
  Not Frozen 01 1.3
Ice in vaccine carriers Present 107 95.5
  Absent 05 04.5
OPV vials kept in ice bowl Yes 110 98.2
  No 02 01.8
VVM present on vials Yes 108 96.4
  No 04 3.6

Table II depicts the status of cold chain at the polio posts. 86.6% of immunization was carried out in shaded area while 13.4% was carried out in unshaded area or open places. Ice packs were not present in 28.6% of the vaccine carriers, amongst them 20% ice packs were partially frozen while in one case it was totally unfrozen. Additional ice was present in 107(95.5%) of vaccine carriers. At 110(98.2%) polio posts, OPV vials were kept on ice while administering to the children. Vaccine Vial Monitor (VVM) was present on the vials in 108(96.4%) of the polio posts. Of these, at 104(96.3%) polio posts the colour of inner square was lighter as compared to the outer circle, which is the recommended norm for effective potency of OPV, while at 4(3.7%) places it had the same colour for both the outer circle and inner square indicating adequate potency of OPV.*

Table III: Time of arrival of vaccine and the first child at pulse polio posts (n=112).

Time Vaccine arrival
No.(%)
Arrival of the first child
No.(%)
Before 8 A.M. 1 (0.9) 1 (0.9)
8 A.M.-8.30 A.M. 54 (48.2) 24 (21.4)
8.31 A.M.-9 A.M. 37 (33.0) 36 (32.2)
After 9 A.M. 20 (17.9) 51 (45.5)

Table III depicts the time of arrival of vaccine and that of the first child at pulse polio post. At 92(82.14%) polio posts the vaccine had arrived before 9 A.M. which was the scheduled time for the arrival of vaccine while at 20(17.9%) posts it arrived late. At 61(54.5%) of polio posts the first child had arrived before 9 A.M.

The main difficulty encountered by the staff posted was that there was no place to sit at 10(8.9%) polio posts. Late arrival of the staff (7.9%) and late arrival of vaccine at polio post (6.2%) were cited as other major problems faced by the community.

Discussion:

The only true indicator that NIDs have been successful is a precipitous decline in the circulation of wild polio viruses. While such a decline may not be noticeable until the next high season for polio-virus transmission, a number of evaluation activities should be conducted both during the NIDs themselves and between the two rounds.

During the NIDs, WHO recommends that supervisory visits should be conducted using a standard checklist to evaluate the function of immunization posts. The information collected should contribute to a simple process evaluation at all levels immediately after NIDs8. The process evaluation should be used to improve the next rounds and include logistics, social mobilization, quality of services at the immunization posts, safety of immunization practices (particularly if injections were given), effectiveness in reaching underserved populations and expenditures.

In the present study, there was shortage of all types of personnel including Doctors. This is extremely important that there should be adequate attendance of all levels of functionaries for the smooth conduct of the pulse polio immunization. Though few years back, in another study a low attendance of 36% of doctors had been reported at the polio posts9, the staffing was much better for all categories of staff in the study conducted by us last year10. Similarly, the training of all categories of staff has also declined this year. Though not alarming right now, it indicates that complacency is setting in the staff on account of success in the previous years.

Another factor of concern was the maintenance of cold chain system, 13.4% of the immunization was carried out in un-shaded area, ice packs were absent at 28.6% of the vaccine carriers and only partially frozen ice packs were used at 20% of the polio posts. Though the vaccine vial monitors (VVM) indicating of effective potency of OPV were present at majority of the polio posts but the overall situation regarding maintenance of cold chain left a lot to be desired. In another study at Varanasi also all the OPV vials were provided with VVM and they also indicated effective potency of the Vaccine11. Perhaps extremely low temperature in January saved the vaccines from losing their potency. Another issue adding to the confusion was different kinds of OPV vials being used. At 66(58.9%) polio posts squeezable vials were available while at 40(35.7%) posts glass vials were supplied and 6(5.3%) posts had both types of vaccine vials. At 102(91.1%) polio posts the vials had pink coloured vaccine and at others i.e. 10(8.9%) posts the vaccine was colourless. The fact that at 54.5% of the polio posts the first child had arrived before 9 A.M. indicates the high level of awareness and participation by the community which is a very heartening sign.

To conclude, the study shows that there is a need for strengthening of the quality of services at Pulse Polio posts. This can be achieved by training of the manpower posted at the posts on the importance of the pulse polio immunization campaign, cold chain maintenance and improving the immunization coverage further.

Recommendations:

To achieve the objective of poliomyelitis eradication, presence of all categories of trained personnel including voluntary workers must be ensured at all the immunization posts. To protect the vaccine from direct sunlight, the immunization should be done at shaded places. To maintain the potency of live oral polio vaccine proper cold chain system should be ensured by supplying fully frozen ice packs and ice pieces in the vaccine carriers.

References:

  1. Grachev VP. Long-term use of oral polio-virus vaccine from Sabin strains in the Soviet Union. Rev Infect Dis 1984; 6(Suppl): S321-2.
  2. Hull HF, Ward NA, Hull BP, Milstien JB, de Quadros C. Paralytic poliomyelitis: seasoned strategies, disappearing disease. Lancet 1994; 343: 1331-7.
  3. Strebel PM, Sutte RW, Cochi SL. Epidemiology of poliomyelitis in the United States one decade after the last reported case of indigenous wild virus associated disease. Clin Infect Dis 1992; 14: 568-79.
  4. Mittal SK. Pulse polio programme a National perspective. Indian J Pediatr 1996; 63: 1-8.
  5. Government of India. Eradication of Poliomyelitis National Child Survival and Safe Motherhood Programme. MCH division, Ministry of Health and Family Welfare, Government of India 1994; 41-9.
  6. AFP Alert. National Polio Surveillance Project. Mar-Apr 2000; Vol. 5, No.2.
  7. Bart KJ, Foulds J, Patriarca P. The global eradication of poliomyelitis: benefit-cost analysis. Bull World Health Organ 1996; 74: 35-45.
  8. Expanded Programme on Immunization. Field guide for supplementary activities aimed at achieving polio eradication. Geneva: World Health Organization, 1995; Publication No. WHO/EPI/GEN/95.
  9. Banerjee K, Suresh K. Repeat process evaluation of Pulse polio immunization. Indian Padiatr 1997; 34: 357-65.
  10. Kumar P, Pandit K, Chhabra P, Bhasin SK, Aggarwal OP. Process Evaluation of Pulse Polio Immunization in Delhi. Indian J Pediatr 1998; 65: 593-6.
  11. Mohapatra SC, Gupta JNP, Shukla KP. Exit evaluation of pulse polio immunization by independent members: A case study of Varanasi. Indian J Mat Child Hlth 1999; 10: 65-6.

O.P. Rajoura, Sanjiv Kumar Bhasin, P. Chhabra, O.P. Aggarwal

Deptt. of PSM, U.C.M.S. & G.T.B. Hospital, Dilshad Garden, Delhi - 110095

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