Health sciences and medicine : Eradication of polio in India - Research Paper Example

?                                    Eradication of polio in India Screening 1 Background to the Policy Polio has been eliminated to a large extent in the world, but it remains endemic in four countries- Afghanistan, India, Nigeria and Pakistan (Unicef, 2011). India has been trying to eradicate polio with a vigorous effort involving program development and policy implementation.. This year only one polio case was reported in India to date, compared to 741 cases in 2009 and 42 in 2010 (Khera, 2011).The only polio case reported this year was on 13th January, in West Bengal (Global Polio Eradication Initiative, 2011). The traditional polio-endemic states, Uttar Pradesh and Bihar have not yet reported any polio cases this year. The programme ensures each and every child is protected with Oral Polio vaccine immediately after birth, and each time it is offered thereafter. In kosi river area in Bihar, which is the core endemic area in India, the vaccination coverage has only reached 65% (Doshi et al, 2011). There have been a large number of un-vaccinated children detected in field huts in Bihar in 2010 (Khera, 2011). Hence, intensive supervision and monitoring schedule is needed for the programme to become successful. However, there is observed a lack of vaccination coverage and awareness among the people. People have displayed a reluctance to use the vaccines provided by the government owing to various misconceptions and rumors. The misconceptions largely relate to the efficacy and potency of the medicine as well as the fear of the medicines being spurious (Roberts, 2004). There are also rumors about the whole programme is to help multinational pharmaceutical companies. The widespread misconception and lack of information had caused much harm for the implementation of the program (Grassly et al, 2006). As such, a revised communication strategy was launched under the Polio Eradication Programme to create awareness and acceptance for the polio vaccination medicines. 1.2 The Proposed Policy The Polio Eradication Programme in India is a collaborative effort between the Ministry of Health and Family Welfare (MOHFW), WHO’s National Polio Surveillance Project (NPSP), UNICEF, Rotary International, and the U.S. Centres for Disease Control. The aim of this programme is to eradicate polio from India by immunizing every child less than 5 years with oral polio vaccine (OPV).This programme is working to ensure:   1.      Improved vaccination coverage using voluntary workforce, micro planning and supervision 2.      Coverage during major religious occasions 3.       Focus on Migrants Populations 4.      Identification of high risk areas and target approach to Immunization 5.      Adopting a multi-sector approach and partnership with Unicef, WHO and other organizations. 6.      Preparedness for combating any outbreak with b OPV (Khera, 2011) 1.3 Stakeholders for the Policy The various stakeholders for the policy include: 1.      World Health Organization (WHO) 2.      Ministry of Health & Family Welfare, Central Government 3.      State Governments/ Union Territories’ Administrations 4.      Community Worker 5.      National Polio Surveillance Unit 6.      Anganwadi Workers 7.      Parents and Children who receive Oral Polio Vaccines (OPV) 1.4 Background Information on Immunization in India   The Pulse Polio Immunization (PPI) program has been initiated to eradicate Poliomyelitis, a vaccine preventable disease. This programme was launched in the year 1995, with the stated objective of eradicating polio from India by the year 2000. However, the program has failed to achieve its target, and the objectives have been revised several times over the past decade. The target was revised to make complete eradication of polio in India by 2002, and again by 2007. Both the revised targets too have resulted in failure as there were reported cases of polio (Nathanson and Kew, 2011).  The following table presents a summary of the cases of Acute Flaccid Paralysis (AFP) as well as Wild Polio Virus that can lead to the incidence of Polio. (Source: Khera, 2011) In addition, the following chart depicts the unimmunized percentage of children across the different states in India (Source: Khera, 2011) l  1.5 Potential Obstacles to Polio Vaccination  There are various problems and obstacles for program implementation that have made it unsuccessful. These include: 1.      Lack of strategic planning and management 2.      Lack of reliability in surveillance and reporting 3.      Lack of objective measurement and understanding of parameters used to detect incidence of polio 4.      Lack of education and awareness campaigns (Bagchi, 2007; (Ramani and Mavalankar, 2006) 1.6 Potential Equity Issues Arising From the Policy   To eradicate polio from India, or from anywhere in the world, the first thing needed is the awareness campaign, explaining the whole aspects of the disease among the people. The horrible nature of the disease visualizing severe cases of attack and their social implications must be brought to the notice of the target population. This will create an ardent desire among them to get rid of this calamity and automatically they will find the effectiveness. However, India has a highly diverse population, including income disparities, regional disparities, educational disparities and access to heath-care related problems (Stephenson, 2006). The diverse nature of the target population requires that any policy implementation too should be targeted in a differentiated manner. 2. SCOPING   EFHIA is to be conducted with the help of information collected by several sources like a literature review, perusal of stakeholders’ websites or publications and interview of members from  the stakeholder organizations.  2.1 Literature Review  A survey of the available literature will be undertaken using sources like books, journal articles, authentic websites and newspapers. The aim of the literature review is to collect evidence based research and information that shed’s light on the following topics:  1.      The historical overview of the polio eradication programme in India, its antecedent conditions and factors that led to the initiative for the programme. For this, numerous books and newspaper articles will be consulted in order collate a time line for the events and ocurances that preceded the development of a concerted programme of polio eradication in India 2.      The factors that are responsible for the spread of polio and any specific regional or ethnic issues that may have led to the large breakout of polio among Indian children. This is essential to understand as any programme to combat the polio epidemic needs to take into account the specific and endemic reasons that are at the root of the problem. In order to obtain information on this aspect, research articles on sociological and health related journals are to be consulted. 3.      To develop a time line and measure of effectiveness of the current polio eradication programme in India. The Pulse Polio Immunization (PPI) was initiated in 1995 and its objective has been revised several times. The literature and research that comments on the growth, development and spread of this initiative across India will provide an insight about the utility of the programme and its effectiveness in eradicating polio. In order to obtain information on this aspect, information will be assessed from public documents, books or journal articles that have covered the progress of the Pulse Polio Immunization (PPI) programme in India 4.      Current level of threat of polio and the efficacy and the availability of the vaccines. This will help in assessing the potential for a population impact of the proposed policy 5.      The uptake of the vaccine and any reasons for the non-uptake or in adequate uptake. The factors that impede the attainment of the goals of the Pulse Polio Immunization (PPI) programme. It has been observed that there are several cases of polio every year, that defeat the actual aim of the program which is to attain a complere eradication of polio from India (Ramani and Mavalankar, 2009). The literature review will therefore cover any research or news that related to the factors that may be affecting the progress of Pulse Polio Immunization (PPI) programme. This is expected to provide insights about solutions that can be enacted in order to increase the efficacy of the programme. 6.      Any population interventions that have been undertaken in order to enhance the uptake and coverage of the vaccine, especially in areas that are marginalized or disadvantaged socially or economically 7.      Any evidence on the effectiveness as well as safety of the vaccine that is being used in the programme.   2.2 Stakeholder’s Websites In addition to the literature review, a perusal of stakeholders’ (as identified in  the previous section) websites will be undertaken. The websites of the stakeholders like the WHO, Ministry of Health & Family Welfare, Central Government, State Governments/ Union Territories’ Administrations and National Polio Surveillance Unit need to be studied in order to obtain accurate statistics related to the programme implementation (National Polio Surveillance Project, 2011). These websites contain statistics that pertain to the area served or the population covered and may also provide useful information on the initiatives and interventions that are in progress in alignment with the proposed policy. As such, it is expected that real time, accurate and updated inputs about the proposed policy can be obtained from the stakeholders’ websites. In addition to the official websites of the governmental and non-governmental stakeholders, a perusal of parent’s forums or blogs related to the health and vaccination issues, and especially about the Pulse Polio Immunization (PPI) programme is needed. This is expected to provide an added insight about the problems, issues, and concerns that parents and the society may have related to the proposed policy. 2.3 Interviews of Stakeholders’ Representatives  Interview of representatives from important stakeholder organizations including: 1.      Officials from the Ministry of Health & Family Welfare, Central Government, State Governments/ Union Territories’ Administrations and National Polio Surveillance Unit 2.      Community workers and any NGOs (Non-Governmental Organizations) 3.      Parents and Community members While the information collected from all the three sources is useful, it is expected that the literature review will reveal the most comprehensive and objective information regarding the policy and its impact.  3. Impact Identification 3.1 The Target Population The Pulse Polio Immunization (PPI) programme targets all children under the age of 5 years in India.  Income India is a country with large income disparities based on a rural urban divide and regional inequalities and caste based economic discrimination.  Top 10% of the Indians control 33% of the income while around 30% of the population of India remains below the poverty line ($0.4/day) (CIA Factbook, 2011)  Education There is an average literacy rate of around 80% which drops to 49 by the primary level education (Unicef, 2009). This figure drops further to around 4% at the college level (Unicef, 2009)  Employment India has an unemployment rate of 10.8 % (CIA Factbook, 2011)  Accommodation  There are over 80 million homeless people in India (CIA Factbook, 2011)   The above statistics reveal that a large section of the Indian population is poor, homeless, less educated and unemployed. These indices indicate that there is a high likelihood of low or no access to any form of health care to this vast section of the Indian society. The proposed policy is likely to face resistance in the case of poor population where the costs of medications are considered to be dispensable, and also where there is lack of awareness and eduction about prevention or treatment.  3.2 Literature Evidence for an Association between the Policy and Health Inequality There is some evidence that reflects on the factors of failure of implementation of the policy in several states of India. For example, it was seen that during early days of the programme, Bhavnagar in the state of Gujarat was hostile towards the health workers who established vaccination booths (Stephenson, 2006). The reasons cited for low coverage of the vaccine was that parents believed that the vaccine is harmful or at best useless against polio. Similarly, there have been cases where parents have reported that their children were affected inspite of vaccination, and also certain incidents where severe side effects of the vaccine were observed. In addition to the fear of the side effects (like fever and loose motion) and possible detrimental long term impacts like infertility or even death, there are other reasons why there is low acceptance of the vaccines. It has been reported that the nurses and the doctors are not committed (Loevinsohn et al, 2002), there is evidence of loss of vaccines due to black market sales (Roberts, 2004), and lack of incentive for the community level workers for participation (Cochi and Kew,2008). 3.3 Anticipated efficacy and safety of the polio vaccine: There have been several researches that have found that the Oral Polio Vaccine has irregular efficacy and is also displays genetically instability (Kuss, 2011). There is also a large amount of wastage of the oral polio vaccine, as revealed by a study undertaken by the Indian Council of Medical Research (ICMR).  The research found that at the point of administration, there was an average wastage of 14.5% while unopened vials wastage amounted to 19-13 vials. The large amount of wastage is attributed to the lack of proper storage and refrigeration, which may have affected the efficacy of the vaccine used (Mukherjee et al, 2004).  3.4 Discussion with stakeholders: This section removed to protect confidentiality  4. Assessment of Impacts  4.1 Degree of Impact   It is expected that the PPI programme will reach limited success as there are several factors that are found to be working against its effective reach to the target population. There is low awareness about the programme as well as an active fear of side effects or harm from the vaccine itself.  4.2 Is the Differential Uptake of the Vaccine Between Different Groups Avoidable The data collected on the demographic differences among the target population indicate that there is a large probability that there is differential impact of the policy on the different groups. However, it is also possible that the differential impact is avoidable to some extent. This is because the PPI programme in India is operational at the very grass-root level, where the government has enlisted the help of NGOs and local community workers to reach out to the people in their homes. This means that even low income groups and poor households, that may not have access to normal health care, can still be targeted and covered. Moreover, there is a massive promotional campaign run through the national media that helps in creating awareness and reaching out to even those who may be low on eduction or awareness. These two methodologies – of reaching out to the target population physically and creating large scale communication strategy to spread awareness, can help in removing the differences due to health inequity in India.  5.      Recommendations  There is a need to increase coverage and reach of the programme Better Reach and Coverage can be ensured through more vigilance and motivated work force. It has been observed in the brief review of the literature that there is a lack of motivation and commitment on the part of the health workers, doctors and nurses (Stephenson, 2006), that can lead to omissions and faults in vaccine administration. Moreover, as there has been observed an inherent reluctance on the part of the parents, especially in the rural regions to give their children the vaccine, it is important that the health care workers be considerate, empathic and appease the fears and inhibitions of the target population. Also, since the majority of the target population is under privileged and does not have access to proper health care, it becomes important that the free vaccines and other supplies reach this target population intact, without any pilferage or wastage.  There is a need to Create More awareness and education   It is recommended that more awareness campaigns and promotions be undertaken in order to apprise the target population about the impacts of polio and how the Pulse Polio Immunization programme is available to them. At the moment, the Ministry of Health, Government of India runs TV and print media advertising to promote the days on which free immunization is available. However, there is a need to expand this awareness programme and include schools, day care centers, pre-schools, anganwadis (these are creches for the rural workers’ children)  Better Management of Supply Chain   As was seen in the literature review, there is a substantial amount of wastage of the vaccines due to lack of proper storage facilities or due to the lack of skills of the workers involved in the programme. Since there have been cases where vaccination has resulted in severe side effects or even led to the death of infants, there is a substantial amount of fear and misconception about the intention of the government. Further, in several cases, children have been found to have contracted polio even after they received the scheduled vaccinations (Gentleman, 2006). These facts have led to the development of concerns about the efficacy and potency of the vaccine (Kuss, 2011). Vaccine efficacy can be ensured with better sourcing and supply chain management. For this, it is also recommended that further research be undertaken and best practices in vaccine handling across the world be studied and emulated. 6. Evaluating and Monitoring   This EFHIA was not aimed at obtaining a practical impact as it can not be expected to provide a direction for the major initiative of the government of India regarding the PPI programme. However, this EFHIA  has highlighted the fact that there are several typical factors that make it difficult for India to achieve its polio eradication aims using the PPI programme. The government’s initiative is targeted as it recognizes the income disparities and the fact that the majority of the Indians may not have access to adequate health-care. Additionally, the PPI initiative has taken into consideration a large section of the population that lives into remote and rural areas, or which is migrant. The EFHIA has also highlighted that there are several steps that need to be undertaken in order to enhance the possibility of a complete polio eradication under the PPI scheme. The recommendations made by EFHIA are aimed at increasing awareness among the masses who are largely uneducated and have little faith in modern medicines, and also at increasing the coverage of the medicine so that the entire target population – irrespective of income or accommodation status, can be accessed References Bagchi, S. (2007).Polio eradication setback in India. Canadian Medical Association Journal, 176 (3): 311 CIA Factbook (2011) India. https://www.cia.gov/library/publications/the-world- factbook/fields/2129.html Cochi, S. L. and Kew, O. (2008). Polio Today.The Journal of The American Medical Association, 300(7):839-841. Doshi, S. J., Sandhu, H. S., Venczel, L. V., Hymbaugh, K. J., Deshpande, J. M., Pallansch, M. A., Bahl. S., Wenger, J. D. and Cochi, S. L. 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