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Indian Journal of Community Medicine

Involvement of Junior Doctors and Students in Intensified Pulse Polio Immunisation - Some Experiences

Author(s): A. B. Biswas, S. Nandy, R. Misra, P. K. Mondal, K :'Mitra, J. Mitra

Vol. 29, No. 2 (2004-04 - 2004-06)

Abstract

Research question: Can the deployment of junior doctors & domicilliary approach help the Intensified Pulse Polio Immunisation (IPP!)

Objectives:( i) To assess the magnitude of missed cases through booth based approach of IPPI. (ii) To find out whether junior doctors and senior medical students can be successfully utilised in achieving higher coverage.

Study design: Intervention.

Setting: Two urban slums in Calcutta.

Intervention: Junior doctors & senior students of R.G. Kar Medical College were mobilised in the urban slum areas during all the six rounds to sensitize & motivate the slum dwellers as well as to make house to house visits on Day 2 & 3 of IPPI to achieve higher coverage.

Participants: All missed cases of children aged 0-59 months in selected slums who failed to turn up at PPI booths.

Study & Outcome variables: Eligible children vaccinated at home & IPPI booths. Meaningful utilisation of trainee doctors.

Results: On an average about 2,225 eligible children were contacted on 2nd & 3rd days of each of-the six rounds at home. About 31% of these children who would have otherwise missed this opportunity had to be vaccinated. Junior doctors & senior students were all motivated & dedicated to the cause.

Keywords: IPPI, Booth based and home visit approach, missed cases, junior doctors.

Introduction:

Mass immunisation campaigns are now an established strategy for eradication of poliomyelitis1-5 . Intensified Pulse Polio Immunisation (IPPI) c ampaigns using only a booth based approach have not been sufficient to interrupt wild poliovirus transmission in difficult areas where it is most persistent with low immunisation coverage. To arrive speedily to the goal of polio eradication, strategy to intensify the polio immunisation with rounds of IPPI has been finalised by Govt. of India in eight priority states including West Bengal6. Intensification will reach all children who do not come to the IPPI post through house to house search, followed by vaccination. Intensified PPI (IPPI) will have both post based and outreach house to house components. The intensification approach will allow for mobilisation of resources to those areas which need them most. Considering this, Deptt. of Community Medicine, R.G. Kar Medical College, Calcutta, had been entrusted by the Deptt. of Health & Family Welfare, Govt. of West Bengal, to help guide and supervise the work of IPPI, 1999-2000, in some difficult urban slum areas close to the hospital with proper utilisation of services of junior doctors and senior students of the teaching hospital.

Objectives

l) To assess the magnitude of missed cases on only booth based approach of IPPI. 2) To find out whether junior doctors and senior students can be successfully utilised in achieving higher coverage.

Materials & Methods The urban slums situated near the college were selected for the project. One of them was a thickly populated "Lalmaidan" (Ward No. 3) slum area, mostly inhabited by Muslim population and the other was Ghoshbagan (Ward-6) area mostly inhabited by Hindu population. Previous years statistics showed these areas were poorly covered in spite of dual services rendered by CMC (Calcutta Municipal Corporation) and ICDS Workers. Under supervision of the faculty members of the deptt, of Community Medicine, a good number of junior doctors and senior students were mobilized in the slum areas during each of the six rounds of IPPI for four days to strengthen every stage of implementation of IPPI in those areas. Everyday, 8 groups, each comprising of 3 interns and 3 senior medical students under the supervision of 1 (one) faculty member, worked in the fields. The departmental head was the overall coordinator.

The day preceding Day I (Day 0), was utilised for motivation of parents mainly through interpersonal communication carried out by house to house visits by the interns and senior students, so that all eligible children (0-59 months) were taken to the PPI booths on Day 1. Hindi speaking female students were given preference, so were Muslim students to facilitate interpersonal communication. Van-rickshaw manned with eloquent students fitted with portable mike went into every nook and corner of the areas announcing date and venue. IEC materials like handbills, posters and banners were used; and group meetings involving local religious leaders, political leaders, member of local clubs etc, were also held.

On Day 1, 2 IPPI booths in Lalmaidan and 1 in Ghosh Bagan area were opened, manned by the students, interns and faculty. When the booths were relatively empty, some of them also went through each lane and by - lane of the area to motivate and help eligibles attend the nearest PPI booths. Day 2 and Day 3 were utilised for house-to house visit to search for unvaccinated beneficiaries and vaccinate them as well as marking the house appropriately. On Day 0, 2 and 3 about 325-350 households were allotted to each group comprising of 7 members (6 interns and senior students & 1 faculty). Adequate logistic and vehicular support were also ensured to make the intensification process of IPPI successful. An independent process evaluation of IPPI in the project areas was also conducted by the faculty members of the deptt, of Community Medicine in a pretest and predesigned proforma.

Results & Discussion The exercise showed that it was possible to achieve a very high coverage in the service areas by involving the junior doctors during subsequent supplementary intensified house to house immunisation rounds. On an average about 2225 eligible children (0-59 months) were contacted on 2nd and 3rd days each of the six rounds of IPPI by junior doctors and senior students.

It (Table I) was surprising that the number of eligible children reached by us in six rounds of IPPI varied from 1,679 to 3,047, which shows an average number of children per households reached on successive rounds to be 0.9, 0.7, 0.7, 0.9, 0.9 and 0.8 respectively. The comparatively lower values in round 2 and 3 may be attributed to the following reasons: i) There were no clear-cut delineation of the areas to be covered and the areas were too vast for complete coverage in each round. Thus the students and interns were not confined to a particular and fixed territory in all the rounds, but were rotated to cover different zones, sometimes with overlapping. Hence, equal number of households could not be covered on all the rounds. ii) Comparatively more households of Hindu dominated Ghosh Bagan area were reached on rounds 2 and 3. iii) Migration of some inhabitants, specially females and children during the year end to their native villages may have contributed to some extent, though the precise reason of such exodus could not be pinpointed.

Table I: Distribution of children immunised at booth and at home in different rounds of IPPI.

Rounds
(Months)
(a)
No. of
houses
visited on
day 2&3
(b)
No. of eligible
children (0-59 months)
reached during IPPI
(c)
percentage of Children
vaccinated
at booth
(d)
percentage of
Children vaccinated
at home
(e)
1st (Oct.) 2307 2089 (66.8) (33.2)
2nd (Nov.) 2425 1679 (76.1) (23.9)
3rd (Dec.) 2856 1875 (77.3) (22.7)
4th (Jan.) 2318 2166 (70.4) (29.6)
5th (Feb.) 3304 3047 (74.1) (25.9)
6th (March) 3052 2490 (52.0) (48.0)

About 31% of these children (22.7% - 48.0%) who would have otherwise missed this, opportunity had to be vaccinated at home. The population of eligible children missed in IPPI booth was much higher as compared to 10­ 15% of eligible children missed in earlier PPIs observed by MCHFW I UNICEF in their Action Research on PPI non-acceptors 6 . The higher proportion of missed cases observed in the present study might have reflected complacency of slum dwellers in the study areas (specially in Lalmaidan area) towards the yearly drive without proper prior sensitization regarding the purpose of such drives.

The reasons for non-immunisation at booth put forward by the parents and perceived by the visiting teams were more or less similar as those cited nationwide eg. floating population, for socioeconomic reasons mainly, lack of faith or interest on vaccination, fear of side effects, non availability of escorts in the household. It was observed in the present study that after introduction of home visit component of IPPI, some parents were finding it more convenient to get their children vaccinated at home. This habit may in the long run be counter productive. However if properly motivated, parents are expected to take their children to a booth according to their convenience, rather than waiting throughout Day 2 and Day 3 for visiting team to arrive.

Surprisingly large proportion - 48% of children, did not come to IPPI post but had to be immunised at their home during the sixth round. This abnormal increase may be attributed to some factors like accumulation of large number of migrants eligible in the area due to festive occasion (e.g. Id-ul-Fitr in the proceeding week in a Muslim dominated area). More over the temperature and relative humidity increases abruptly in the last week of March in Calcutta and people preferred to stay inside rather than going out to the IPPI post as they know that the doctors would come to vaccinate their children at home. Thus the table justifies involvement of junior doctors and students in intensification approach which allows for targeting resources to those areas which need the most.

An independent process evaluation of IPPI in the project areas was conducted by the faculty members of the Deptt. of Community Medicine, and following observations were recorded.

Distribution of PPI booths were not uniform; For example, in Lalmaidan area only one booth was arranged for immunising about 2000 children. As a result, large number of clients in Lalmaidan area did not find location of PPI booth convenient to them. Moreover, long queue outside the booth, late arrival of vaccines prompted many clients to leave without immunisation, specially during first round. Communication materials and cold chain equipments were used in all PPI booths and the records were maintained in tally sheets. Gentain violet was applied by booth workers for marking the immunised children. Age of the children was not checked before immunising in most of the PPII booths. Exit interview with people leaving the booths, revealed that on the first day of IPPI of first round (13th October, 1999), 13-14% children were immunised against polio for the first time and about 50% of them belong to age 0-11 months. Most of the respondents did not know how the immunisation this time will help their children or our country or how many more times they have to come back for remaining rounds of IPPI. This problem was more acute in Lalmaidan area as compared to other areas. However, junior doctors were the most common source of information by interpersonal communication, followed by Anganwadi workers.

Conclusion & Recommendations

Based on the experience gained during the whole exercise following measures can be suggested to make the future programme successful : The deployment of junior doctors in IPPI was found to be very effective and their active involvement also prepares them for taking up other programmes as a public health movement. Proper and uniform distribution of booths at the rate of one booth for 250-300 eligible children must be ensured. Appropriate IEC strategy, particularly in Lalmaidan area, needs to be developed and followed consistently in order to improve routine polio immunisation coverage as well. For proper delineation of the area, local map with clearly outlining boundaries must be drawn and booth-wise estimate of child population as well as list of localities must be made available prior to the next round of IPPI. Involvement of senior school children as well as college students in IPPI, specially in high risk areas is urgently needed in order to achieve 100% coverage. The faculty members of Deptt. of Community Medicine may be involved in Independent monitoring and evaluation of IPPI & provide feedback to the State Authority.

Acknowledgements:

All the junior doctors & senior students who have participated in IPPI campaign as well as the faculty members and other staff of the department of Community Medicine, R.Cx Kar Medical College, Calcutta.

References

  1. Sabin AB: Strategy for elimination of poliomyelitis in different parts of the world with the use of oral polio vaccine, Rev. Infect, Dis. 1984; 6:391-396.
  2. Cruz R.R. Cuba: Mass Vaccination Programme, 1962-1982. Rev. Infect. Dis. 1984; 6(2): R.: 408-412
  3. Risi JB: The control of Poliomyelitis in Brazil. Rev. Infect Dis. 1984; 6(2) P : 400-403
  4. Quadros CD, Andrus .1K, Olive JM, Macede CG Polio eradication from the western hemisphere, Annu. Rev. Public Health, 1992; 13: 239-252.
  5. Harry F. Hull. Nicholas A Ward, Barbara P Hull, Julie B Mistion, Cire Quardres: Paralytic Poliomyelitis: Seasoned strategies, disappearing disease, Lancet. 1994; 343: 1331-1337.
  6. Govt. of India: Pulse Polio Immunization in India: Revised operational guide for Intensification in 1999-2000. Ministry of Health & Family Welfare 1999; 2-3.
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