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How to ensure smooth Covid vaccine rollout — India’s polio programme has some lessons

India, which began a polio immunisation programme in 1995, recorded its last case in 2011. The interim 16 years was marked by misinformation, vaccine hesitancy and scientific hurdles.

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New Delhi: In 2004, Dr Prabir Chatterjee, then a district surveillance officer, travelled to the Pakur district in eastern Jharkhand to promote the polio vaccination among families there.

Chatterjee was not very confident about his pursuit because the villagers had turned a doctor away earlier even though the polio virus was raging at the time. But one unexpected factor aided him.

“In the particular village I was going to, the women had migrated from West Bengal and tended to be a little more educated than the men, so I struck up a conversation with them. They happened to trust me because I spoke Bengali and my name was Chatterjee. And they agreed to vaccinate the children,” Chatterjee, who now works as a community health doctor in West Bengal’s Bankura, told ThePrint.

“The doctor before me was from Bihar. The women told me, ‘We don’t trust Biharis’, which is why they refused the vaccination last time,” he added.

This is just one of the anecdotes from one of India’s foremost public health success stories — making India polio free.

In a feat that was widely considered impossible, India was declared polio-free in 2014 after a 16-year-long immunisation programme that began in 1995. The last known case of polio was recorded in 2011, in Howrah, West Bengal.

According to public health experts, the journey was paved with several such moments of faith, trust and thorough communication. This was accompanied by a rigorous disease surveillance system that had multiple people on the ground and support from the Indian government, the World Health Organization, Rotary International and countless civil society organisations.

Now, as India awaits the Covid-19 vaccines, experts note that there are several lessons that can be drawn from the country’s experience with polio.

Also read: Polio immunisation falls casualty to Covid as fear, staff shortage halt drive across India

How it all started

It all began in 1981 when Dr T. Jacob John, then an associate professor at the Christian Medical College (CMC), Vellore, decided to conduct an experiment in the city to see if polio vaccines could help reduce the prevalence of the disease in the area.

Polio is transmitted most commonly through faecal to oral contact, after which it multiplies in the intestine and travels to the nervous system, causing paralysis.

“Tamil Nadu was notorious for high cases of polio at the time because of the bucket latrine, which was widely adopted. Someone would empty the bucket that was filled with faecal matter, increasing their chances of catching and spreading the virus,” said Chatterjee.

The CMC along with the local rotary club decided to administer the polio vaccine to children in the region. They conducted in-depth research on the vaccine and found that it worked effectively when given simultaneously to all children under the age of 5 in two doses, one year apart.

“That’s why it’s called the ‘pulse’ polio programme, because it has to be done at a set interval period,” Dr John told ThePrint, referring to India’s polio immunisation programme launched in 1995.

The story of Vellore’s success in reducing polio cases interested the global rotary movement and John was invited to be part of a committee in the US to plan the rotary international’s centenary celebrations, which had decided to implement a 20-year polio eradication programme in various developing countries.

“This in turn interested the WHO. In 1988, the WHO passed a resolution to eradicate polio all over the world,” John said.

The WHO’s decision closely followed the worldwide eradication of smallpox, which was declared in 1980.

“The scientific rationale for this resolution was that it was scalable and achievable. At the time, there were around 3,50,000 cases, of which India had contributed a large sum,” said Dr Chandrakant Lahariya, a public health specialist.

Also read: WHO likely to give nod to novel polio vaccine before end of 2020, says report

India’s polio programme

India’s polio programme, called the ‘Pulse Polio Programme’, was launched in December 1995. At the time, it is estimated that the country was seeing 50,000 to 1,50,000 cases a year.

The programme was made up of an elaborate network of health workers who carried out disease surveillance across the country. On immunisation days, over 2 million health workers manned a network of more than 5,00,000 posts and visited millions of houses to vaccinate 172 million children per day.

“What made it easier is that it was an oral vaccine, which didn’t require much specialisation and could be administered even by a volunteer,” said Chatterjee.

But several problems cropped up over the course of time.

First and most significantly, the vaccine wasn’t very effective in India, initially. It required multiple rounds and was especially ineffective in Bihar and Uttar Pradesh.

The oral polio vaccine or OPV combined all three strains of the virus — Types 1, 2, and 3 — to fight the illness.

“Each round of the vaccine was proving to be only 10 per cent effective in those states. Yes, there was a problem of vaccine hesitancy among certain communities, but we were not able to find a plausible scientific explanation for the performance of the vaccine in Bihar and UP,” John told ThePrint.

According to Lahariya, the public health systems and surveillance techniques in both the states were inadequate, posing a major problem.

In several areas, only some of the children were vaccinated, which made the vaccine less efficient. The polio vaccine is the most effective when every child in an area is inoculated.

“To counter this, vaccination camps were held multiple times a year, and children were given much more than two-three doses of the vaccine but it still wasn’t working, and that made people suspicious,” said Lahariya.

There was finally a breakthrough in 2005 when John referred to some of the research he had done in the 1970s and found that the vaccine against the Type 2 strain of the polio virus was twice as effective as the vaccine they were using at the time.

After receiving the requisite permissions, the Type 2 polio vaccine was administered in both states and the cases finally began to reduce there.

Also read: If you’re travelling to these 17 countries, you could need a polio vaccine

Vaccine hesitancy in UP and Bihar

Aside from vaccine ineffectiveness, another unforeseen issue that the health workers faced, especially in Bihar and Uttar Pradesh, was hesitancy.

“Once, before the rumour afflicted any minority communities, I had gone to a village near the Jharkhand-Bihar border, where the men of the families refused to allow us to vaccinate their children. They were Rajputs, and said it would cause impotence among their children. So I told them I had just one daughter and I wanted a son and then grandchildren, and took two drops of the vaccine myself in front of them,” Chatterjee recalled.

“The women started giggling, and the men were totally baffled. Finally they let us get on with the vaccination.”

But not everyone was so easily convinced.

By 2002, 59 per cent of the children paralysed by polio were from Muslim communities in Uttar Pradesh, where a rumour that the vaccine was a conspiracy to reduce the minority population had taken a strong hold.

To counter this, the government partnered with the Aligarh Muslim University and the Jamia Milia Islamia to demonstrate that the vaccine was safe.

UNICEF also stepped in and advised that religious leaders should be involved in countering misinformation — but it was far from easy.

According to a UNICEF policy document, “A core group of religious leaders was formed to train and mentor religious leaders at the community level. This had a positive impact, since other religious leaders were more receptive to absorb information and follow instructions from their peers or seniors.”

Among the institutions roped in was the Darul Uloom Deoband, the second-largest seminary of Islamic learning in the world.

Clerics, imams, hajis and other leaders were all encouraged to distribute pamphlets and create awareness about the benefits of the vaccine.

“Through these initiatives, an environment of trust was successfully created among the religious leaders. Though the process of bringing about a change in perceptions was a time-consuming one, it was ultimately sustainable,” the document notes.

Also read: Poor campaign, aversion to medicines — why India is unlikely to eliminate filariasis by 2021

Anticipating the Covid vaccine

The news of Covid-19 vaccines showing high efficacy against the virus has ignited a sense of optimism across the world, including in India. While no vaccine has been approved for use in the country, the government has been gearing up for the upcoming Covid vaccine rollout.

India’s polio eradication programme proves that it is capable of successful wide-scale inoculation. However, the Covid vaccine will be markedly different from the polio one.

“What will make it more difficult is that it will most likely be an injectable, which cannot be done by volunteers, it will need a level of specialisation. Secondly, it will be for adults. With Covid, all kinds of rumours have already been spreading about the infection and why people are admitted to hospital, so countering misinformation will be especially difficult,” said Chatterjee.

What India should fall back on, according to Lahariya, is strengthening channels of communication and the country should invest in adequate planning to avoid last-minute hiccups when it comes to implementation.

“You need a strong health system, one that is used routinely and not temporarily, to successfully carry out the implementation of a vaccine like this. Ad hoc measures won’t do, and every possible last-mile problem must be thought out and addressed. We have the experience to tell us that,” he said.

Also read: As we fight Covid-19, here’s how Edward Jenner developed the world’s first vaccine

Dr Chandrakant Lahariya’s comment in this report has been updated to accurately reflect the number of smallpox cases.

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