There are 120 million children under five in India. They live in houses and apartments, in urban slums and construction sites, in nomadic settlements, on farms, and at factories. Many of their families move from year to year. To end polio, someone needs to find and vaccinate almost every single one of them, multiple times, every year.
It seems like an impossible task, but this month marks one year since India was officially certified polio-free, which means the country has gone four years without a case of wild poliovirus. This is a giant achievement in the global effort to eradicate polio – as recently as 2009, India was home to nearly half the world’s cases and considered the hardest place on earth to stop the disease.
To stay polio-free, India must maintain high immunity levels, so the government, in partnership with WHO and UNICEF, conducts two nationwide vaccination campaigns and three supplementary sub-national campaigns each year.
In November 2014, we went behind the scenes of one of these campaigns in Agra, Uttar Pradesh, to better understand what it took to accomplish the seemingly impossible.
Uttar Pradesh is India’s most populous state (it’s roughly the size of Brazil), and is home to both the breathtaking Taj Mahal and some of India’s poorest communities. With one-third of its population living below the poverty line, Uttar Pradesh reports one of the highest child mortality rates in the world. It was one of polio’s last footholds in India, accounting for more than 600 of the country’s 741 cases in 2009.
The seven-day campaign kicks off with “booth day.” Vaccinators set up a spot – usually right outside a house or shop – where neighborhood children line up to receive two drops of the oral polio vaccine. The excitement is palpable – children, mouths wide open, make their way to front of the line for their turn, while others chant “India, polio-free!” in unison.
Once a child has taken the drops, vaccinators use a purple marker to stain the child’s left pinky nail as a way to track which children have or haven’t been immunized.
In the weeks leading up to the campaigns, dedicated Community Mobilization Coordinators (CMCs) – 99% of whom are women – deployed by UNICEF are responsible for keeping track of all the children in a given area and enlisting local influencers, including religious leaders and older children, to rally families to come out to the booth for the polio vaccine.
On the first day of the campaign, you can see children with visors and whistles running through the streets, which are plastered with bright polio campaign posters and banners.
Thanks to the CMCs’ work, the program is able to immunize up to 60-70% of children at vaccination booths on day one of the campaign.
To make sure no child is missed, vaccinators and CMCs have detailed “microplans” to guide their activities.
These plans carefully track a wealth of information, including the name, age, address, health stats and vaccination records of all children in the community.
While these plans initially only covered polio vaccinations, they now help deliver a range of health services, including measles vaccinations, nutrition services and neonatal care.
After booth day, vaccinators and CMCs will visit houses one by one to find children who weren’t reached on the first day of the campaign. They check pinkies to see who hasn’t received the vaccine, and use chalk to mark houses and doors to indicate whether children were successfully vaccinated (“P” indicates houses in which all children have been vaccinated, whereas “X” indicates houses with missed children).
An “A Team” goes house-to-house for five days, covering 100-150 households per day. A “B Team” will then follow up with any families whose children still haven’t been vaccinated.
The polio vaccines have to be kept cold at all times – a serious challenge, given it was about 80⁰F when we were there in early winter. Vaccinators rely on icepacks and portable coolers to protect the “cold chain.” We were surprised at how light the portable cooler was – it weighed about as much as a shoulder bag with a laptop.
Vaccinators will bring vaccines wherever children live. Uttar Pradesh has a huge population of migrant workers who come and go following the demand for seasonal labor. “Informers” will canvass the region to identify spots where migrant workers and other mobile populations might be living, and make sure they’re included in vaccinators’ microplans.
We followed the vaccination team to a nomadic settlement. It can be especially difficult to bring health care to these communities, and the CMC had spent months establishing trust.
While children lined up for polio drops and played with the small toys the vaccinators had brought as gifts, a father asked a member of the WHO team for help getting tents sprayed with insecticide to prevent malaria. As one of its few links to health services, the polio program has become a partner and a resource to hard-to-reach communities like this in more ways than one.
At one of the city’s many active construction sites, we visited families living in temporary worker housing. The polio program partners with employers and site managers to ensure vaccinators reach all the children in these often isolated sites.
We ended our day at the WHO office, the command center for an elaborate system to monitor and improve the quality of immunization campaigns in the region.
There are shelves and shelves of binders documenting vaccination activities going back decades. The walls are covered with maps that track any suspected polio cases. Strong surveillance like this plays a huge role in helping India stay polio-free.
Campaign results and feedback are analyzed on a daily basis, and every evening a meeting is held with all on-the-ground partners to mitigate risks and take corrective action as needed. This monitoring process has evolved through the years becoming more efficient and effective as teams learn from experiences on the ground.
We’d often heard India’s defeat of polio described as a “miracle.” We disagree. India’s achievement is the direct result of the passion and tireless work of hundreds of thousands of people who masterminded a mind-boggling logistical operation where nothing fell through the cracks.
Today, we’ve eliminated 99% of polio cases worldwide. In the last six months, only two countries have reported cases: Pakistan and Afghanistan. India is the best proof that we can and will rid the world of this disease in our generation.