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The Four Pillars of Polio Eradication and the Essentials of Polio Campaigns

Watch as Wakgari Deressa describes the four pillars of polio eradication. (Step 1.10)
WAKGARI DERESSA: Now we are going to start The Four Pillars of Polio Eradication and the Essentials of the Polio Campaigns. There are four pillars of polio eradication initiative. The first one is the routine immunization, the second one is the supplemental immunization activities, the third one is polio surveillance, and the fourth one is targeted “mop-up” campaigns. We will start from the routine immunization. This is the first pillar of the polio eradication initiative. Especially during the early phase of the polio eradication initiative, these four pillars of polio eradication were developed. Improving routine immunization, particularly in polio-infected areas across the world, was the first pillar, particularly in the Americas.
The idea was that the polio would be a banner disease, increasing public enthusiasm and support for routine immunization more broadly. Over the years, this pillar has often been given less attention because some people within the initiative thought that polio eradication is difficult with improving the route of routine immunization, because improving the routine immunization, it’s quality seems to be complex. They thought, also, that it would take too much time to do this activity. Due to this, there were recent additions of different partners, like Global Alliance for Vaccine Initiative, GAVI.
The vaccine alliance serve to the polio eradication initiative, and attention is returning to routine immunization with growing agreement that high-quality routine immunization is, in fact, a very important part of eradicating it from the world. z So this is the first pillar. We will continue with the next pillar, which is supplementary immunization activities. In this slide, you can see there are key terms which we need to define, like national immunization days, subnational immunization days, and house-to-house or fixed post campaigns. These are the key terms that we need to learn from this slide.
Supplementary immunization activities are the most visible part of polio eradication activities as part of the campaigns where health workers leave the health facilities and go to the community, because they supplement the routine immunization with additional outreach. And during the campaigns, health workers operate in a different method. They go through the fixed outreach posts near the community. For example, in this slide, you can see this is a native community where mothers and children are coming to the fixed post. And often, they target all children in an entire community for the campaign to happen– children under the age of five. And when it includes the entire country, as well, this termed as national immunization days.
Often, they target all children in the country as a whole. And sometimes, the campaign also targets only high-risk areas of a country, subnational, or some parts of the country. This is termed as subnational immunization days. Below this, there are issues in which the vaccinators, the polio campaign people, the health workers, go from house to house to search for children to vaccinate children in addition to the fixed posts they have in the health facilities and [INAUDIBLE]. So this is very important in supplementary immunization activities supplementing the routine immunization, making it complementary, making it stronger, and so on. The third pillar, which is very important, is also polio surveillance. This is the third pillar of polio eradication.
The issue is that we need to identify their acute flaccid paralysis or children with acute flaccid paralysis in the community where the virus is found. That’s why we have termed it here acute flaccid paralysis. And again, especially with Asia, most cases of acute flaccid paralysis are not polio. So let us see this video, and this video you about the polio surveillance system, which is available on the link. So let us see this, and please follow this link strictly, and we’ll have some discussions after the video is finished.
The fourth pillar of the polio eradication initiative is the targeted “mop-up” campaigns. This is the final pillar for polio eradication, which is termed as targeted “mop-up.” This is where we have a kind of special attention given to at-risk areas where, in order to get those risk areas where polio is a hiding, where the virus is hiding– especially in the case of the hard-to-reach of the country, where those areas are not easily accessible and so on. There is a campaign that this can be easily done. And of the video is about this one. This video is about responding to a polio outbreak.
When there is an outbreak, then we need to make a “mop-up” campaign to prevent or to control this outbreak. This video is showing that one, and the link is here. You can watch the link, and later on, we’ll have discussions. We will go now to the essentials of the polio campaigns. What are the most important parts? What are the most essential parts of the polio campaigns? We will see issues like the cold chain strategies, how to target every last child, and also the staff of the polio eradication, as well as how to mark the households and how to track the children in the community. The first is essentially the cold chain system.
And as we know, oral polio vaccine contains a weakened live vaccine virus. This vaccine must be kept cold. If it’s not kept cold, it’s not effective, so to maintain its efficacy, we need to maintain the efficacy of the cold system, and so on. This means that there must be an unbroken chain of fridges and iceboxes from the vaccine manufacturer’s point of view, all the way from the central warehouse to the community, to the vaccinator, to the child. We need to maintain the cold system for polio vaccine.
As you can see from this picture, these people are using donkey while the vaccine is in the icebox where the people are taking this vaccine to the next community or to the next village. They are trying to maintain the cold system using the cold box. It’s very, very important, because if we do not maintain the cold system, then the efficacy of the vaccine is under question, and it doesn’t work. So in most remote communities in the world, we do use such kind of system to deliver the vaccine, including many places where there is no electricity, where there is no transportation facility, and so on.
So polio eradication’s cold chain infrastructure is very important, and due to the polio eradication initiative, the cold chain infrastructure has been developed very well in many countries, in many systems. And this infrastructure has also been used for a range of other health commodities, like the vaccine for measles, other vaccines, neonatal vaccines, and so on. This system is not only for polio, but for other vaccines, as well. This slide is about reaching every last child. It’s very important because we need to reach every last child in the community, and this video is showing the system how to reach every last child.
Where there is a polio virus in the community, the polio virus is attacking children under 5 or children under the age of 15 years, so we need to track all system, and we need to reach all these children and vaccinate them. This slide is very important, and it shows the practical aspect of how the community is reaching every last child in the community. The next one is the polio staff. This is about health workers, about to vaccinators in the community with supplemental immunization activities. There are millions of volunteers around the world. Because the polio campaign is really a campaign, it is resource-intensive, labor-intensive, many people are involved in this one. And there are volunteers, there are health workers.
When we say volunteers, people are paid small paradigm or some kind of cash or incentive to work on the campaign for a short period of time. And this is a great aspect where it really helps the polio eradication campaign, particularly at the local community. It’s very difficult to have all health workers to be employed during the campaign. Community engagement, community participation using the volunteers is very, very critical. As we know, the campaign activity is temporary. It’s not done throughout the year. It’s not done most of the time during the year. It’s temporary work, and during this time, it’s very, very essential to mobilize the community, particularly in terms of volunteer vaccinators, and so on.
This is something which is very important. There is a link about how staff is working, how health workers, the vaccinators, are working. It shows something which is a very important with this regard. Please pause this presentation and watch the video on reaching the last child. The next one is marking houses and the children, and this is the essential part of the polio campaign. Here you can see from this picture, a woman is marking a household here on the door or on the outer side, and these are the children, the women, the mothers. And, in fact, when vaccinating every child under five years old in the entire country, as we have said, the national immunization campaign, good recording is very essential.
If children are not at home, for example, during the campaign then the health workers need to return to vaccinate those missed children. And for this, several strategies have been proven very effective with this regard. For example, house marking for the households and finger marking for the children. So in the case of the house marking, as shown here, this is in India in Bihar. The campaign workers write on each house they visit. Usually they use chalk or marker or ink. Then they write down how many children under five live in the household, how many of these children were able to be vaccinated during that time, and the date that the household children were visited and vaccinated.
And in case there is unvaccinated children in the household, then we need to give a reason for those unvaccinated children, why they were not vaccinated. If children are vaccinated, then we need to have a finger marking for all vaccinated children. During the next visit, if they are not finger marked, then they are unvaccinated children so they need to get vaccinated during the second visit. So children who are immunized are marked with a finger marking, usually with a permanent marker on their pinky finger nail so supervisors can check to ensure that each child was reached.
During the second visit, then we can track those children who are not marked, who are not vaccinated, and they will be vaccinated if they found that they are not vaccinated during the first visit. In summary, we have seen the four pillars of polio eradication. The first one is the routine immunization, the second one is supplementary immunization activities, the third one is polio surveillance, the fourth one is targeted “mop-up” campaigns. And in addition, we have also seen the essentials of the polio campaign– for example, the cold chain system, which is very important. And also, the polio eradication staff. That’s very important. And also, marking houses and children, which is also very, very important.
And I think these are the main four pillars of polio eradication, and they are very fundamental in order to eradicate polio from the world. Thank you.

Wakgari Deressa, MPH, PhD School of Public Health, Addis Ababa University, Ethiopia

Each of these videos are referenced in the lecture:

This is an additional video, hosted on YouTube.

This is an additional video, hosted on YouTube.

This is an additional video, hosted on YouTube.

This is an additional video, hosted on YouTube.

Reflect on these videos and the reading A Public Health Achievement Under Adversity: The Eradication of Poliomyelitis From Peru, 1991, and consider:

What do you think some of the planning and management challenges in implementing these strategies would be?

Post your thoughts in the discussion.

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