IN A NUTSHELL Author's noteCommunication, Vaccination, and Documentation strategies are not only essential for ensuring the successful delivery of the polio vaccine but are also fundamental in building trust, improving efficiency, and ensuring the sustainability of immunization efforts. This article explores the intersection of these strategies with the core skills, illustrating how their synergy is critical to addressing the remaining gaps in polio eradication in Pakistan
Healthcare System, CHIP Training and Consulting
Quetta, Balochistan Pakistan
A Comprehensive Approach to Polio Eradication in Pakistan
Leveraging CBV, SMT, and MT with Essential Skills
Polio eradication remains one of the most significant global public health challenges, demanding coordinated efforts across various stakeholders and regions. The Government and partners have mobilized substantial resources to combat the disease, which has been responsible for disability and death in children worldwide. Over the years, Supplementary immunisation activities conducted three primary strategies have emerged as vital tools for reaching the ultimate goal of polio eradication: Community-Based Vaccination (CBV), Special Mobile Teams (SMT), and Mobile Teams (MT). These strategies aim to ensure that no child is left behind, especially in hard-to-reach areas where polio transmission remains a threat.
While these strategies are central to the success of the polio eradication campaigns, their effectiveness is directly tied to the development and application of three key skills: communication, vaccination, and documentation. These skills are not only essential for ensuring the successful delivery of the polio vaccine but are also fundamental in building trust, improving efficiency, and ensuring the sustainability of immunization efforts. This article explores the intersection of these strategies with the core skills, illustrating how their synergy is critical to addressing the remaining gaps in polio eradication.
Pakistan’s Polio Crisis: 63 Cases and the Urgent Need for a Solution
As of 2024, Pakistan is grappling with a significant polio crisis. With 63 confirmed cases of polio, the country is one of the few remaining places in the world where the virus is still endemic. While much progress has been made in reducing polio incidence globally, Pakistan’s struggle continues, and it underscores the need for immediate action, as several key issues persist.
The country faces multiple challenges that hinder its progress toward complete eradication. These challenges are deeply embedded in the socio-political fabric of the nation and must be addressed for the strategies to be effective. Pakistan’s polio eradication efforts, including CBV, SMT, and MT, have been complicated by systemic issues such as hidden children, mobile and migrant populations, gaps in the Expanded Program on Immunization (EPI), human resource challenges, and cultural resistance.
Key Issues Hindering Polio Eradication in Pakistan
Grey Houses or Hidden Children:
One of the major challenges in polio eradication efforts is the issue of grey houses or hidden children. In Pakistan, some families intentionally hide their children during vaccination campaigns, either out of fear of the vaccine or cultural resistance to immunization. In urban and rural areas alike, vaccinating children in these households is a significant barrier. This contributes to missed vaccination opportunities and results in outbreaks, as pockets of unvaccinated children allow the virus to spread unnoticed.
Mobile and Migrant Populations:
Mobile and migrant populations present another complex issue. These groups, which include labourers, seasonal workers, and refugees, often move across regions, making it difficult to track and vaccinate children consistently. Areas with high turnover rates—such as border regions or migrant settlements—are at increased risk of polio transmission, as children in these populations may not receive all doses of the vaccine.
Incomplete Immunization of Children:
Despite extensive efforts to provide immunization, many children in Pakistan remain under-immunized. Factors contributing to incomplete immunization include logistical barriers, vaccine hesitancy, lack of awareness, and access issues. Children who miss a dose or do not complete the full vaccination schedule are vulnerable to polio, especially in areas where the virus still circulates.
Human Resource Issues:
The polio eradication program has faced significant challenges with its human resources. The issue of appointing the right person in the right position is critical. In many instances, frontline workers, Supervisors, UC level staff and etc are not placed in areas based on merit, which leads to inefficiencies and lack of local knowledge. There is also a gap in adequate training and support for frontline workers, which compromises the quality of service delivery.
Top-Down Strategy Without Ground Reflection:
Polio eradication strategies are often designed and implemented from the top-down, with limited input from the communities affected by the disease. This approach often fails to account for local conditions, cultural practices, and the specific needs of each region. Ground-level issues, such as accessibility and resistance to vaccination, are often not fully reflected in the strategic planning, leading to ineffective implementation in certain areas.
Limited Involvement of the EPI Department:
The Expanded Program on Immunization (EPI), which is responsible for routine immunization, has not been fully integrated into polio eradication efforts. This lack of coordination has led to missed opportunities for strengthening the immunization system and ensuring that polio vaccines are delivered as part of regular health services. The absence of a strong partnership between the EPI department and the polio teams weakens the overall immunization infrastructure.
Community Input and Multi-Sectoral Engagement:
A significant gap in Pakistan’s polio eradication program is the lack of community involvement in planning and implementation. Communities, who are directly affected by the disease, are not sufficiently engaged in the decision-making process. Additionally, other sectors such as education, media, and religious leaders have not been adequately involved in the effort. Cultural resistance to vaccination, particularly in certain provinces, could be mitigated by better community-based interventions, collaboration, and culturally sensitive communication strategies.
Cultural and Religious Resistance:
In certain areas, polio vaccination campaigns are met with resistance, either due to cultural beliefs or religious misconceptions. This resistance is further exacerbated by misinformation, which is often spread through social media or local networks. Despite the efforts of health workers, these areas remain difficult to penetrate, and children remain unvaccinated, contributing to outbreaks and transmission.
The Role of CBV, SMT, and MT in Addressing These Issues
Despite these challenges, strategies such as CBV, SMT, and MT remain crucial in addressing the gaps and ensuring every child is vaccinated.
Community-Based Vaccination (CBV):
CBV addresses some of the key challenges, such as grey houses and incomplete immunization. By engaging local community CHWs (community health workers), often from the community itself, this strategy builds trust with families and ensures that no child is missed. In Pakistan, CBV has proven effective in reaching unban, remote areas and Tier 1, Super high risk areas persuading families to vaccinate their children.
However, to make CBV more effective, communication strategies need to be tailored to address local cultural beliefs and resistance. Local leaders, teachers, and religious figures must be engaged in spreading accurate information to combat misinformation.
Community-Based Vaccination (CBV) is a pivotal strategy in Pakistan’s ongoing battle against polio, particularly in areas that are difficult to reach or where families are more resistant to vaccination. This approach involves trained frontline workers who conduct door-to-door campaigns, vaccinating children under five years old. CBV relies heavily on community engagement to build trust and ensure acceptance of the polio vaccine, addressing concerns and overcoming vaccine hesitancy. These workers, often familiar with the local population, are in a unique position to address myths and misinformation, providing critical education about the benefits of vaccination.
One of the core challenges of CBV is the logistical complexity, including maintaining the cold chain to preserve the vaccine’s efficacy, and ensuring timely delivery in remote areas. Furthermore, accurate and reliable documentation is essential, as it helps track the vaccination status of each child and informs future campaigns. Proper door marking and recording of data also help identify children who may have missed previous doses. Despite these obstacles, CBV has successfully reached vulnerable populations, significantly reducing the incidence of polio, especially in high-risk districts.
While CBV has demonstrated success, its effectiveness is often contingent on the involvement of various sectors, including local government, health authorities, and the community itself. Integrating CBV into broader healthcare and social mobilization strategies ensures that more children are immunized, and polio transmission can be stopped. Nevertheless, maintaining quality control, adapting to local cultural nuances, and addressing resource gaps remain critical for enhancing the impact of CBV in polio eradication efforts.
Special Mobile Teams (SMT):
SMT plays a critical role in reaching high-risk populations, particularly those that are mobile or reside in difficult-to-reach areas. In Pakistan, SMTs are deployed to areas with large migrant populations or where grey houses are prevalent. They have been instrumental in responding to outbreaks and vaccinating children who may have missed their scheduled doses.
SMT are temporary two-member teams hired exclusively for polio campaigns, typically for a duration of 10 days. These teams operate in areas with mobile, migrant, or underserved populations, ensuring children under five years old are vaccinated against polio. SMT members are tasked with a triad of responsibilities: communication, where they engage with parents to provide accurate vaccine information and address concerns; vaccination, ensuring the administration of oral polio drops following standard operating procedures (SOPs) and marking each child to track coverage; and documentation, accurately recording vaccination data and door marking to reflect the status of each household.
Mobile Teams (MT):
These are temporary, volunteer-based teams covering most areas of the country. They typically work in pairs, visiting door-to-door to vaccinate children and record data. MTs are particularly effective in regions without dedicated local vaccinators, though their temporary nature can limit sustained impact.
Essential Skills for Effective Polio Vaccination Campaigns
To tackle the issues faced by the polio eradication program in Pakistan, enhancing the skills of frontline workers is critical. These skills—communication, vaccination and documentation—serve as the backbone of any vaccination strategy and play a significant role in overcoming existing challenges.
Communication Skills:
Effective communication is vital for engaging communities and addressing vaccine hesitancy, particularly in regions with cultural resistance. It is essential to use culturally sensitive messaging, involve local leaders, and ensure that frontline workers can engage with families effectively.
Frontline workers often encounter parents or caregivers who may have questions or concerns about polio vaccination. It is essential for FLWs to ask operational questions that help them understand the specific situation of each child. By asking questions, FLWs can identify any gaps in vaccination coverage, potential refusals, or other issues that may prevent a child from receiving the vaccine. The aim is to ensure that the child receives the vaccine at the right time, and any concerns are addressed professionally.
Parents’ cooperation is crucial for successful immunization campaigns. FLWs need to effectively communicate the importance of the polio vaccine, dispelling myths and addressing any concerns. This can include: Explaining the safety and effectiveness of the polio vaccine, highlighting that it is a critical tool in protecting children from lifelong disability. Answering any questions regarding side effects or misconceptions, ensuring that parents feel heard and supported.
Using culturally appropriate methods of communication to make sure the message resonates with families. For example, if parents are concerned about the vaccine’s safety, FLWs might explain the rigorous processes the vaccines go through before being approved.
By encouraging a dialogue and ensuring all concerns are addressed, FLWs can enhance the likelihood of parents allowing their children to be vaccinated.
Vaccination Skills:
FLWs must be well-trained in proper vaccination techniques and ensure the vaccines are administered correctly. They also need to be able to manage the logistics of immunization, such as cold chain maintenance, to guarantee that the vaccines remain effective throughout the process.
When it comes to administering the oral polio vaccine (OPV), frontline workers follow strict Standard Operating Procedures (SOPs) to ensure the vaccine is delivered correctly: Administering 2 drops of the OPV to each child under five years of age, following precise guidelines to ensure correct dosage.
Monitoring for compliance with vaccination procedures to prevent any missed opportunities or errors. For example, if the child spits out the drops or is unable to swallow, FLWs must ensure a second dose is given to ensure full vaccination.
Maintaining the cold chain is vital for preserving the effectiveness of the polio vaccine. FLWs are responsible for: Ensuring that the vaccine is stored at the correct temperature and transported properly to prevent any loss of potency.
Carrying portable cold boxes to keep the vaccine at the required temperature when delivering it in remote areas or communities with limited access to refrigeration.
Proper cold chain management ensures that the vaccine remains effective and safe for use in all areas, especially in difficult-to-reach regions.
After administering the vaccine, FLWs mark the child’s finger with indelible ink (usually purple) to indicate that the child has been vaccinated. This mark serves several purposes:
Visual confirmation: It helps other vaccinators and community members see that the child has been vaccinated, reducing the likelihood of missed doses.
Prevention of double vaccination: In some areas, especially those with mobile or migrant populations, it is essential to ensure that children who have already been vaccinated are not given additional doses.
While the marking is critical for ensuring proper tracking, finger marking should not be used for tracking vaccination coverage. It is simply a method of confirming that a child has received the vaccine during a particular campaign.
Documentation Skills:
Accurate and comprehensive documentation is essential to ensure that every child is vaccinated. Data collection allows teams to track progress, monitor vaccination coverage, and identify areas that need further attention. It also ensures accountability and transparency in the program’s implementation.
Accurate documentation is essential for monitoring the success of immunization campaigns and identifying areas where further action is needed. Frontline workers must:
Document the vaccination status of each child at the time of visit. This includes noting whether the child has received the polio vaccine during the current campaign, as well as tracking their overall vaccination history.
Update door marking: Each house or household is marked with a symbol or sign to indicate the vaccination status of the children inside. This ensures that vaccinators know which households have been visited and whether any children need a follow-up dose. Door marking is a key component of ensuring that all eligible children are vaccinated during a campaign.
During post-campaign reviews, the data collected by FLWs on missed children is analysed to identify trends and hotspots. This enables the program to:
Plan for follow-up visits in areas where vaccination rates are low.
Target high-risk populations, such as those in mobile or migrant communities, who might be harder to reach during routine campaigns.
Accurate and thorough documentation plays a crucial role in ensuring that every child receives their vaccination, even if they miss the initial round.
Conclusion: The Path Forward
Pakistan’s struggle with polio is a complex issue that cannot be solved with a one-size-fits-all approach. Addressing the root causes—such as hidden children, mobile populations, gaps in immunization, human resource issues, and community engagement—requires a multi-pronged effort. By improving the integration of CBV, SMT, and MT strategies with better training in communication, vaccination, and documentation skills, Pakistan can make substantial progress in its fight against polio.
To achieve a polio-free Pakistan, the following steps must be prioritized:
- Engage local communities and cultural leaders in the planning and execution of vaccination campaigns.
- Strengthen the partnership between the EPI and polio teams.
- Improve the human resource system to ensure the right people are in the right places, and provide proper training and support to health workers.
- Address gaps in communication to overcome resistance and improve vaccine acceptance.
In the fight against polio, communication, vaccination, and documentation are interconnected and critical components of the operation. Frontline workers must engage with parents and communities to ensure understanding and cooperation, administer vaccines safely while maintaining cold chain standards, and keep accurate records of vaccination statuses to guide follow-up efforts. When these three skills are applied effectively, they ensure that no child is left behind in the battle to eradicate polio. By focusing on these skills, the polio eradication campaign can achieve greater success, overcome challenges, and move closer to a polio-free world.
By addressing these issues and continuing to improve the effectiveness of vaccination campaigns, Pakistan can eliminate polio and contribute to the global goal of polio eradication.
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By the same Author on PEAH Empowering Gray House Communities Towards Vaccination Efforts: Navigating Fake Vaccination, Mobilizing Influencers, and Cultivating Trust Bridging the Gap: Elevating Preventive Healthcare in Pakistan’s Health Agenda Polio Eradication Strategies and Challenges: Navigating Hidden Risks The Gray Houses Polio Eradication Initiative: A Case Study on Identifying and Vaccinating Hidden Children Balochistan Primary Healthcare: What Has Been Done and What Needs to Improve? Decision Makers’ Perception of the Performance and Salary of UC Polio Officers in Pakistan Polio Eradication Programme in Pakistan: Critical Analysis from 1999 to 2023