Legacy of Polio-Use of India's Social Mobilization Network for Strengthening of the Universal Immunization Program in India

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Addressing Immunization Inequity—What Have the International Community and India Learned over 35 Years?

Countries around the world established immunization programs over 40 years ago to reach all infants. The maturity of these preventive health programs offers some useful learning on the importance of, and components needed for, population-based services to reach all communities. A public health success, ensuring equity in immunization, requires a multi-faceted approach that includes sustained government and partner commitment and human, financial, and program operational resources. Evidence from India’s Universal Immunization Program (UIP) across stabilizing vaccine supply and services, enhancing access, and generating demand for vaccines in the community provides a useful case study. The political leadership in India took advantage of the two decades of learning from polio eradication and focused initiatives, such as the National Health Mission and Intensified Mission Indradhanush, to reach populations with immunization services. With a goal of leaving no one behind, India’s UIP and partners are bringing essential rotavirus and pneumococcal vaccines nationwide, upgrading vaccine cold chain and supply systems with technologies, such as the electronic Vaccine Intelligence Network (eVIN), and optimizing funding for local needs through the Program Implementation Plan (PIP) budgetary processes and building health worker capacities through training, awareness, and e-learning.

What's in a name? Unpacking 'Community Blank' terminology in reproductive, maternal, newborn and child health: a scoping review

INTRODUCTION

Engaging the community as actors within reproductive, maternal, newborn and child health (RMNCH) programmes (referred to as 'community blank') has seen increased implementation in recent years. While evidence suggests these approaches are effective, terminology (such as 'community engagement,' 'community participation,' 'community mobilisation,' and 'social accountability') is often used interchangeably across published literature, contributing to a lack of conceptual clarity in practice. The purpose of this review was to describe and clarify varying uses of these terms in the literature by documenting what authors and implementers report they are doing when they use these terms.

METHODS

Seven academic databases (PubMed/MEDLINE, Embase, CINAHL, PsycINFO, Scopus, Web of Science, Global Health), two grey literature databases (OAIster, OpenGrey) and relevant organisation websites were searched for documents that described 'community blank' terms in RMNCH interventions. Eligibility criteria included being published between 1975 and 1 October 2021 and reports or studies detailing the activities used in 'community blank.' RESULTS: A total of 9779 unique documents were retrieved and screened, with 173 included for analysis. Twenty-four distinct 'community blank' terms were used across the documents, falling into 11 broader terms. Use of these terms was distributed across time and all six WHO regions, with 'community mobilisation', 'community engagement' and 'community participation' being the most frequently used terms. While 48 unique activities were described, only 25 activities were mentioned more than twice and 19 of these were attributed to at least three different 'community blank' terms.

CONCLUSION

Across the literature, there is inconsistency in the usage of 'community blank' terms for RMNCH. There is an observed interchangeable use of terms and a lack of descriptions of these terms provided in the literature. There is a need for RMNCH researchers and practitioners to clarify the descriptions reported and improve the documentation of 'community blank' implementation. This can contribute to a better sharing of learning within and across communities and to bringing evidence-based practices to scale. Efforts to improve reporting can be supported with the use of standardised monitoring and evaluation processes and indicators. Therefore, it is recommended that future research endeavours clarify the operational definitions of 'community blank' and improve the documentation of its implementation.

Lessons learned from the Global Polio Eradication Initiative: A roadmap for the international COVID-19 vaccination campaign

The COVID-19 vaccine is lauded by many as one of the greatest accomplishments in modern medicine, with the potential to definitively contain the deadliest pandemic of the last century. With the vaccine rollout now underway in the developing world, a robust, methodical, and swift global distribution effort is required to ensure that it will be done in an equitable manner. Taking into account the vast geographic, socioeconomic, cultural, and political diversity of countries around the world, global vaccination efforts have historically required multifaceted, time consuming, and labor-intensive approaches to be effective. However, with over 33 years of experience from the Global Polio Eradication Initiative - an international health initiative aimed at eradicating poliomyelitis - the COVID-19 vaccination campaign does not have to be approached blindly. Using lessons learned from the Global Polio Eradication Initiative, this paper aims to identify the supply- and demand-side barriers to the success of the international COVID-19 vaccination effort, and ways each can be overcome. Most notably, health systems shortcomings, political and cultural messaging, and civil unrest and violent conflict serve as daunting obstacles to the success of the COVID-19 vaccination campaign. The Global Polio Eradication Initiative has been able to overcome many of these same obstacles with innovative strategies such as context-specific microplanning, robust health surveillance systems, and community-centered education and advocacy programs. Ultimately, while the Global Polio Eradication Initiative is still fighting the battle of polio eradication, it has provided a roadmap for the COVID-19 vaccination campaign to be executed in a more swift and equitable manner.

Are we expecting too much for too long from the vaccinators? A qualitative study on perceived challenges of COVID-19 vaccinators of district Shahdol, India

Background

There is a paucity of knowledge regarding challenges faced by the coronavirus disease 2019 (COVID-19) vaccinators in resource constraint settings like district Shahdol, Central India. Hence, the present study was planned to explore the perceived challenges of vaccinators regarding COVID-19 vaccination.

Methods

In October 2021, district health authorities conducted a one-day workshop with the auxiliary nurse midwives, staff nurses, and lady health visitors who work as vaccinators. It had three distinct but mutually connected phases. In the first phase, a free listing exercise was performed to list out their perceived challenges that are prominent and representative of their cultural domain. In the second phase, the pile-sorting exercise with the challenges mentioned in the above step was performed to produce similar data in the form of a matrix, based on a perceived similarity between them by multi-dimensional scaling analysis. In the final phase, the transcripts generated during the discussion on the free listing and pile sorting exercises was used for the thematic analysis to find plausible explanations for the findings.

Result

A total of 15 vaccinators took part in the workshop. In the free listing exercise, a total of 14 items were identified as perceived challenges for COVID-19 vaccinators. The three items with the highest Smith's S value were overtime duty, no holidays, and lack of monetary incentive. The analysis of pile-sorting suggested that participants clustered their 14 perceived challenges into five groups; 1) beneficiaries related, 2) vaccination schedule related, 3) lack of facilities at vaccination site, 4) lack of monetary incentive, and 5) issues related to digital data handling. Thematic analysis suggested that their main challenges were overtime duty, no monetary incentive, and lack of toilet, food, and transport facility at the session site.

Conclusion

Vaccinators perceive overtime duty and lack of holidays as their top two challenges and expect monetary incentives for this. The study recommends better basic amenities like toilet facility, sustained and effective community engagement, a monetary incentive, and a better ecosystem for digital data handling for the vaccinators.

Vaccine acceptance in rural India: Engaging faith leaders as vaccine ambassadors

Introduction

Religious faith is a key marker of identity and shapes community perspectives and trust. Faith leader involvement in vaccine campaigns in India have been beneficial to counter misinformation regarding infectious diseases such as polio. Faith leaders are influential stakeholders who bear potential to enhance public confidence in vaccine campaigns.

Context

While vaccine coverage has been increasing in India, inequities abound, especially in populations with historically low vaccine confidence. The COVID-19 pandemic has led to major disruptions in delivery of routine immunization services for children. To address these challenges, we co-designed interventions aimed at contextual communication strategies and peer support. Engaging faith leaders was an important part of this intervention. In this report we describe our experience and highlight the perspectives of faith leaders and their expectations of the outcomes for this intervention.

Programmatic elements

The CIVIC Project, conducted from January to December 2021 aimed to engage caregivers, community health workers and key stakeholders, particularly, faith leaders in co-designing interventions to address vaccine hesitancy in Mewat. The project, deeply rooted in community based participatory research, used a three-E approach (Exploration of community perspectives, Establishment of vaccine trust and awareness, Engagement in vaccine promotion activities) to successfully engage faith leaders in the design and dissemination of media messages advocating for vaccine acceptance and uptake.

Lessons learned

The involvement of faith leaders in the intervention benefited the community in two ways. First, faith leaders were spotlighted via videos, often disseminating advice and personal anecdotes about vaccines, thus reassuring caregivers and community members who previously expressed distrust in vaccines. Second, involvement of trusted faith leaders provided a platform for a two-way dialogue for the community to openly discuss and address myths and misconceptions regarding vaccines. This project provided the learning that co-creating interventions with faith leaders who are often gatekeepers of close-knit communities can lead to the development of vaccine positive messaging that community members relate with, motivating increased vaccine confidence.

COVID-19 vaccine knowledge, attitudes, perceptions and uptake among healthcare workers of Pune district, Maharashtra

Background

Healthcare workers play a vital role in vaccine promotion and acceptance through community dialogue, education, and myth-busting. Vaccinated healthcare workers will likely recommend the vaccine to their families and community.

Methods

A cross-sectional study was conducted with healthcare workers (n=357) to understand their knowledge, attitudes, perceptions, and acceptance of the coronavirus disease 2019 (COVID-19) vaccine. The study was conducted in two blocks (Haveli and Velhe) of Pune, Maharashtra.

Results

The findings showed that over 90% of healthcare workers knew about COVID-19 vaccination and had a positive attitude towards COVID-19 vaccination. Among them, vaccine uptake was high (93% with two doses and 4% with a single dose). 98% of healthcare workers believed that vaccine is safe to use. However, few gaps existed around vaccine safety, side effects and allergic reactions, as 27.7% believed that the COVID-19 vaccine could increase the risk of allergic reactions, 51.8% believed that acquiring natural immunity by contacting the virus is better than vaccination, 16.5% believed that it is possible to reduce the incidence of COVID-19 without vaccination, 28.9% believed that vaccine might have side effects and 14% believed vaccine is not the most likely way to control the pandemic.

Conclusions

Addressing the existing gaps and reinforcing the relevance of the COVID-19 vaccine through a structured program is critical to empower health workers to disseminate accurate information to the community, consecutively improve vaccination uptake, and boost vaccination efforts in India.

Challenges for Programmatic Implementation of Oral Cholera Vaccine in India

Cholera remains a major contributor of diarrheal diseases and leads to substantial morbidity and mortality, particularly in low socioeconomic settings. Nonavailability of a national cholera control plan in India, compounded by underreporting of cholera cases and deficient accurate cholera hotspot estimates, has made cholera control a challenge. Obstacles in the programmatic introduction of oral cholera vaccine (OCV) lie within the infrastructure—stockpile, costing, distribution system, cold-chain mechanism, vaccine logistics, and lack of strengthened surveillance systems for adverse events following immunization. Sustained political commitment along with collaboration of people working in the media will also determine the policy outcome of OCV introduction in India.

Addressing COVID-19 vaccine hesitancy: Lessons from the role of community participation in previous vaccination programs

The acceptance of the coronavirus disease 2019 (COVID-19) vaccine has been described as a gateway to attaining herd immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The critical role of community participation (CP) has been successfully demonstrated in previous vaccination programs globally. This perspective therefore aimed to describe how CP could be used to promote COVID-19 vaccination acceptance. To promote COVID-19 vaccine acceptance, it is required that a mapping of community assets, resources, civil-based organizations, and stakeholders is done to gain insight into the community culture and value in relation to COVID-19 vaccine. This will help to address the misconceptions while prompting COVID-19 vaccination sensitization activities that are relevant to each community. It is required that policy makers understand that the adoption of a comprehensive grassroots approach lends a voice to the community and helps to utilize community-initiated and community-driven ideas on promoting COVID-19 vaccine acceptance.

Partnering for rotavirus vaccine introduction in India: A retrospective analysis

BACKGROUND

The pre-existing partner network created in India for the delivery of polio vaccines was initially used to eradicate polio and later on embedded in the health systems network to promote routine immunization and other health interventions efficiently. The experience from this network offered lessons for strengthening the health care systems and provided a well-established network that could be utilized for other vaccine initiatives. It has also been established that successful partnerships between a broad range of stakeholders provide support, strengthen the health system, and accelerate vaccine innovation, introduction, access, logistics, and communication support. However, beyond polio eradication, there have not been too many documented success stories of vaccine introduction, which could be replicated in other new vaccine introductions and allied health initiatives. The authors have reviewed the successful and time-bound introduction of rotavirus vaccine (RVV) in India in the present article.

METHODS

The review was conducted based on a partnership framework which analysed multiple factors-partnership prerequisites, partnership model, partnership process, and partnership performance, thereby providing a comprehensive insight into the successful utilization of partnership networks for rotavirus vaccine introduction under the Universal Immunization Program in India.

RESULTS & CONCLUSION

The review also highlights the role of a lead agency in creating a fertile ground for lush, efficient, and effective partnerships amongst different stakeholders. The already existing RVV partnership framework reviewed by the authors can be successfully utilized for future new vaccine introductions.

Social mobilization campaign to tackle immunization hesitancy in Sargodha and Khushab districts of Pakistan

Background

Immunization hesitancy is a delay in acceptance or refusal of vaccines despite availability of vaccination services. If people are not engaged appropriately via communication and social mobilization, doubts about the trade-offs between the benefits and potential side effects persist. The objective of this study was to explore strategies for improved social mobilization to reduce immunization hesitancy.

Methods

Mix of quantitative and qualitative approaches was applied to collect data from a diverse group of respondents in Sargodha and Khushab districts. Quantitative data were collected from 329 community health workers, including vaccinators, lady health workers and lady health supervisors, and school health and nutrition supervisors. In addition, qualitative data were collected from top management of Expanded Programme on Immunization (EPI) through key informant interviews (KIIs) and focus group discussions (FGDs) were conducted with parents. Analysis has been done using SPSS software and detailed transcriptions.

Results

Advocacy meetings with local influencers, community group sessions, door-to-door visits by community health workers and mosque announcements are considered the most relevant and appropriate interventions for social mobilization. Community Health Workers (CHWs), cognizant of local culture, are being trusted, though optimum performance is achievable with adequate redressal of hesitancy concerns. However, in some cases negative attitudes of people towards immunization hinder trust towards mobilizers or CHWs. Hence, they leverage active participation of local influencers, teachers and health department officials to convince such stubborn parents. Active community involvement through leveraging support from local religious and non-religious influencers in social mobilization activities increases its acceptance. Community engagement is most effective in rural and hard-to-reach areas when community health workers are skilled in interpersonal communication and information education communication.

Conclusions

Communication committees as oversight mechanism should be established or reactivated to regularly monitor and support mobilization activities through managing affairs like speedy liaison with local administration and local influencers, mobilizers' service related concerns, community-specific hurdles, and deficiencies of awareness-material provision that eventually improves mobilization performance. Resistant community's needs can be redressed through rigorous conduct of men's and women's education sessions by CHWs while giving more time and space to mobilizers to take on board local religious and non-religious influencers to convince conservative/illiterate parents. Higher management should fix policy implementation slippages like training needs assessment of mobilizers and Civil Society Organizations' involvement framework.

Effectiveness of a community-level social mobilization intervention in achieving the outcomes of polio vaccination campaigns during the post-polio-endemic period: Evidence from CORE Group polio project in Uttar Pradesh, India

BACKGROUND

A social mobilization (SM) initiative contributed to India's success in polio elimination. This was the CORE Group Polio Project (CGPP) India, a partner of the Uttar Pradesh (UP) SM Network and which continued its SM activities, even during the polio-free period through a network of multi-level social mobilizers. This paper assesses the effects of this community-level SM (CLSM) intervention on the extent of community engagement and performance of polio Supplementary Immunization Activity campaigns (SIAs) during the post-polio-endemic period (i.e., from March 2012 to September 2017).

METHODS

This study followed a quasi-experimental design. We used secondary, cluster-level data from CGPP India's Management Information System, including 52 SIAs held from January 2008 to September 2017, covering 56 blocks from 12 districts of UP. We computed various indicators and performed Generalized Estimating Equations based analysis to assess the statistical significance of differences between the outcomes of intervention and non-intervention areas. We then estimated the effects of the SM intervention using Interrupted time-series, Difference-in-Differences and Synthetic Control Methods. Finally, we estimated the population influenced by the intervention.

RESULTS

The performance of polio SIAs changed over time, with the intervention areas having better outcomes than non-intervention areas. The absence of CLSM intervention during the post-polio-endemic period would have negatively impacted the outcomes of polio SIAs. The percentage of children vaccinated at polio SIA booths, percentage of 'X' houses (i.e., households with unvaccinated children or households with out-of-home/out-of-village children or locked households) converted to 'P' (i.e., households with all vaccinated children or households without children eligible for vaccination), and percentage of resistant houses converted to polio acceptors would have gone down by 14.1 (Range: 12.7 to 15.5), 6.3 (Range: 5.2 to 7.3) and 7.4 percentage points, respectively. Community engagement would have reduced by 7.2 (Range: 6.6 to 7.7) percentage points.

CONCLUSIONS

The absence of CLSM intervention would have significantly decreased the level of community engagement and negatively impacted the performance of polio SIAs of the post-polio-endemic period. The study provides evidence of an added value of deploying additional human resource dedicated to social mobilization to achieve desired vaccination outcomes in hard-to-reach or programmatically challenging areas.

Overcoming vaccine deployment challenges among the hardest to reach: lessons from polio elimination in India

After more than 30 years of efforts to eliminate polio, India was certified polio free by WHO in 2014. The final years prior to polio elimination were characterised by concentrated efforts to vaccinate hard-to-reach groups in the state of Uttar Pradesh, including migrant workers, religious minority Muslims and impoverished communities with poor pre-existing social support systems. This article aims to describe the management strategies employed by India to improve the deployment and acceptance of vaccines among hard-to-reach groups in Uttar Pradesh in the final years prior to polio elimination.

Three main management principles contributed to polio elimination among the hardest to reach in Uttar Pradesh: bundling of health services, local stakeholder engagement and accountability mechanisms for public health initiatives. In an effort to market the polio campaign as an authentic health-oriented programme, vaccine acceptance was improved by packaging other basic healthcare services such as routine check-ups and essential medications. India also prioritised local stakeholder engagement by using influential community leaders to reach vaccine hesitant groups. Lastly, the accountability mechanisms developed between non-profit organisations and decision-makers in the field ensured accurate reporting and identified deficiencies in healthcare worker training. The lessons learnt from India’s polio vaccination programme have important implications for the implementation of future mass vaccination initiatives, particularly when trying to reach vulnerable communities.

Genetic Epidemiology Reveals 3 Chronic Reservoir Areas With Recurrent Population Mobility Challenging Poliovirus Eradication in Pakistan

BACKGROUND

Pakistan is among 3 countries endemic for wild poliovirus type 1 (WPV1) circulation that are still struggling for eradication of poliomyelitis. Active clinical and environmental surveillance with meticulous laboratory investigations provide insights into poliovirus transmission patterns and genomic diversity to inform decisions for strategic operations required to achieve eradication.

METHODS

We analyzed epidemiological and virological data to comprehend the current epidemiological status of WPV1 in Pakistan during 2015-2017. Stool specimens of patients with acute flaccid paralysis (AFP) and sewage samples collected from 60 environmental sites were tested. Viral culturing, intratypic differentiation by real-time polymerase chain reaction, and nucleic acid sequencing of the VP1 region of the poliovirus genome to determine genetic relatedness among WPV1 strains were applied.

RESULTS

Poliovirus isolates were grouped into 11 distinct clusters, which had ≥95% nucleotide homology in the VP1 coding region. Most of the poliovirus burden was shared by 3 major reservoirs: Karachi, Peshawar, and Quetta block (64.2% in 2015, 75.4% in 2016, and 76.7% in 2017).

CONCLUSIONS

Environmental surveillance reveals importations and pockets of unimmunized children that dictate intensive target mop-up campaigns to contain poliovirus transmission. A decrease in the number of orphan isolates reflects effective combination of AFP and environmental surveillance in Pakistan. The genetic data reflect sustained transmission within reservoir areas, further expanded by periodic importations to areas of high immunity reflected by immediate termination of imported viruses. Improved immunization coverage with high-quality surveillance is vital for global certification of polio eradication.

Significance of a social mobilization intervention for engaging communities in polio vaccination campaigns: Evidence from CORE Group Polio Project, Uttar Pradesh, India

Background

Globally, community engagement is an integral part of most public health programs and the social mobilization (SM) intervention of India’s polio eradication program is one such example that contributed to eliminating polio from the country. CORE Group Polio Project (CGPP), a partner of Uttar Pradesh (U.P.) SM Network executed its activities through a network of social mobilizers called Community Mobilization Coordinators (CMCs). These were deployed in polio high risk areas to perform awareness generation and trust-building activities with communities and achieved high coverage of polio vaccination during Supplementary Immunization Activity campaigns (SIAs). This paper measures the extent and outcomes of CMC community engagement in SM interventions and polio SIAs.

Methods

This study used secondary, cluster-level data from Management Information System of CGPP India, including 52 SIAs held between January 2008 to September 2017 in 56 blocks/polio planning units, covering 12 districts of U.P. We used five indicators that reflected community engagement in polio SIAs and constructed a Community Engagement Index (CEI). Further, we estimated the difference in the CEI between CMC and non-CMC areas, using Generalized Estimating Equations (GEE) and also estimated treatment effects through Difference-in-Differences (DID) method using STATA.

Results

Overall, 78.6% (95% confidence interval (CI) = 78.3, 78.8) of families from the study area were engaged in the polio SIAs and the extent of community engagement increased over time. The mean CEI of entire study period in CMC areas (85.8%; 95% CI = 85.6, 86.0) was significantly higher (P < 0.001) than that of non-CMC areas (71.3%; 95% CI = 71.1, 71.5). Over time, the SM intervention led to at least 11 percentage points increase in the CEI of CMC areas with about 17% of this achievement attributable to CGPP India’s SM efforts.

Conclusions

The study findings suggest that intensive social mobilization efforts can significantly increase the extent of community engagement. The community engagement learnings of polio SM Network may be useful to achieve the desired outcomes of public health programs such as the National Health Mission (NHM) of India, that serves communities for multiple health issues.

Evaluation and design of public health information management system for primary health care units based on medical and health information

OBJECTIVE

The objective is to understand the role of information management systems in the public health perspective of primary care units more accurately.

METHODS

A public health information management system for primary medical units, which is based on electronic health records, virtual private network technology, real-time data storage, and other technologies, is designed on the premise of economical and straightforward operation. Besides, Xinhua Community Health Service Center Around the Wulong Street, Longsha District, Qiqihar City is selected as the experimental unit of the public health information management system, and the work efficiency of the system in the public health perspective of the primary medical unit is evaluated after 12 months of system operation.

RESULTS

The public health information management system of primary medical units has following comprehensive management functions: health record management, child health, maternal health, health of the elderly, health of patients with chronic diseases, health of severe psychiatric patients, health education, infectious diseases and public emergencies, health events, health supervision, and management information. In addition, after 12 months of information management system operates in the grassroots units, the results show that patients and doctors have a very high satisfaction rate with the system. The system not only cultivates the excellent health and disease prevention awareness of residents but also improves the efficiency of primary care institutions, as well as reducing the number of patients seeking medical cares.

CONCLUSION

The public health information management system of primary health care units based on medical and health information design is rich in functions with prominent work efficiency, which significantly improves the public health of grass-roots medical units. The research is useful and significant for follow-up studies on public health care systems.

Mobilize to vaccinate: lessons learned from social mobilization for immunization in low and middle-income countries

Creating and sustaining demand for immunization services is a global priority to ensure that vaccine-eligible populations are fully protected from vaccine-preventable diseases. Social mobilization remains a key health promotion strategy used by low- and middle-income countries (LMICs) to promote vaccination demand. In this commentary, we synthesize illustrative evidence on successful social mobilization efforts promoting the uptake of immunization services in select LMICs. The first example focuses on Sierra Leone’s routine immunization program during the Universal Child Immunization initiative in the late 1980s. We then give an example of India’s establishment of a social mobilization network in the early- to mid-2000s to support polio elimination in high-risk communities. Thirdly, we highlight the complexities of social mobilization in a humanitarian emergency during the 2017–2018 diphtheria outbreak among displaced Rohingyas in camps and settlements in Bangladesh. Lastly, we draw upon examples from the introduction of the human papillomavirus vaccine in several countries. We then critically examine recurring challenges faced when implementing social mobilization for immunization in LMICs and offer practical recommendations for improvement.

Lessons Learned from the CORE Group Polio Project and Their Relevance for Other Global Health Priorities

Despite numerous setbacks, the Global Polio Eradication Initiative has implemented various community strategies with potential application for other global health issues. This article reviews strategies implemented by the CORE Group Polio Project (CGPP), including pursuit of the missed child, microplanning, independent campaign monitoring, using community health workers and community mobilizers to build community engagement, community-based surveillance, development of the capacity to respond to other health needs, targeting geographic areas at high risk, the secretariat model for non-governmental organization collaboration, and registration of vital events. These strategies have the potential for contributing to the reduction of child and maternal mortality in hard-to-reach, underserved populations around the world. Community-based surveillance as developed by the CGPP also has potential for improving global health security, now a global health priority.

Trust, Communication, and Community Networks: How the CORE Group Polio Project Community Volunteers Led the Fight against Polio in Ethiopia's Most At-Risk Areas

The last case of wild poliovirus in Ethiopia was reported in 2014. Until the disease is eradicated globally, the risk of reimportation remains high. In 1999, the CORE Group Polio Project (CGPP) began its community-centered polio eradication efforts in Ethiopia, using community volunteers (CVs) to ensure that no child has missed polio vaccine. This article documents the efforts of CVs and highlights innovative strategies, successes, and contributions. Qualitative data were collected from the CGPP implementation areas in 85 border woredas (districts) of Benishangul-Gumuz; Gambella; Oromia; Southern Nations, Nationalities, and Peoples' Region; and Somali. A total of 151 in-depth interviews were conducted with CVs, parents, CGPP partners, and project stakeholders. Results of the study showed that CVs secured the buy-in of community members through open and fair eligibility and selection processes, thereby ensuring representation of community needs and perspectives. Community-driven participation consisted of identifying and choosing credible, trusted individuals who were willing to actively engage as caretakers of the community. Community volunteers then received specialized training and supportive supervision to build and expand their command of child health and vaccination information and interpersonal skills, fortifying the legitimacy of health messages and supporting the community's sense of collective efficacy. The robust network of CVs built by the CGPP continues to effectively reach the most remote, rugged, and underserved areas of Ethiopia. Stakeholders credit the CGPP with playing a significant role in keeping Ethiopia polio-free and increasing the population coverage of polio and routine immunizations.

Documentation of vaccine handling and service delivery at outreach immunization sessions across 27 districts of India

Background

Objective

Method

Results

Conclusion

'We All Work Together to Vaccinate the Child': A Formative Evaluation of a Community-Engagement Strategy Aimed at Closing the Immunization Gap in North-West Ethiopia

The role of community engagement (CE) in improving demand for immunization merits investigation. The International Rescue Committee developed a CE strategy to implement a vaccine defaulter-tracing tool and a color-coded health calendar aimed at increasing uptake of immunization services in north-west Ethiopia ('The Fifth Child Project'). We report findings from a formative evaluation of this project. In May/June 2016 we conducted 18 participant observations of project activities, 46 semi-structured interviews and 6 focus groups with caregivers, health workers, community members/leaders. Audio-recordings and fieldnotes were transcribed, anonymized, translated and analyzed thematically using inductive and deductive coding. Additional data was collected in November 2016 to verify findings. The project was suitably integrated within the health extension program and established a practical system for defaulter-tracing. The calendar facilitated personalized interactions between health workers and caregivers and was a catalyst for health discussions within homes. At the community level, a regulation exercise of sanctions was observed, which served as a deterrent against vaccine default. Pre-existing community accountability mechanisms supported the CE, although varying levels of engagement between leaders and health workers were observed. The benefits of shared responsibility for immunization were evident; however, more transparency was required about community self-regulatory measures to ensure health-related discussions remain positive.

Addressing the Challenges and Opportunities of the Polio Endgame: Lessons for the Future

The Global Commission for the Certification of the Eradication of Poliomyelitis certified the eradication of type 2 poliovirus in September 2015, making type 2 poliovirus the first human pathogen to be eradicated since smallpox. The eradication of type 2 poliovirus, the absence of detection of type 3 poliovirus worldwide since November 2012, and cornering type 1 poliovirus to only a few geographic areas of 3 countries has enabled implementation of the endgame of polio eradication which calls for a phased withdrawal of oral polio vaccine beginning with the type 2 component, introduction of inactivated poliovirus vaccine, strengthening of routine immunization in countries with extensive polio resources, and initiating activities to transition polio resources, program experience, and lessons learned to other global health initiatives. This supplement focuses on efforts by global partners to successfully launch polio endgame activities to permanently secure and sustain the enormous gains of polio eradication forever.

Experiences and Lessons From Polio Eradication Applied to Immunization in 10 Focus Countries of the Polio Endgame Strategic Plan

Nine polio areas of expertise were applied to broader immunization and mother, newborn and child health goals in ten focus countries of the Polio Eradication Endgame Strategic Plan: policy & strategy development, planning, management and oversight (accountability framework), implementation & service delivery, monitoring, communications & community engagement, disease surveillance & data analysis, technical quality & capacity building, and partnerships. Although coverage improvements depend on multiple factors and increased coverage cannot be attributed to the use of polio assets alone, 6 out of the 10 focus countries improved coverage in three doses of diphtheria tetanus pertussis containing vaccine between 2013 and 2015. Government leadership, evidence-based programming, country-driven comprehensive operational annual plans, community partnership and strong accountability systems are critical for all programs and polio eradication has illustrated these can be leveraged to increase immunization coverage and equity and enhance global health security in the focus countries.

Transition Planning For After Polio Eradication

The Global Polio Eradication Initiative (GPEI) has been in operation since 1988, now spends $1 billion annually, and operates through thousands of staff and millions of volunteers in dozens of countries. It has brought polio to the brink of eradication. After eradication is achieved, what should happen to the substantial assets, capabilities, and lessons of the GPEI? To answer this question, an extensive process of transition planning is underway. There is an absolute need to maintain and mainstream some of the functions, to keep the world polio-free. There is also considerable risk-and, if seized, substantial opportunity-for other health programs and priorities. And critical lessons have been learned that can be used to address other health priorities. Planning has started in the 16 countries where GPEI's footprint is the greatest and in the program's 5 core agencies. Even though poliovirus transmission has not yet been stopped globally, this planning process is gaining momentum, and some plans are taking early shape. This is a complex area of work-with difficult technical, financial, and political elements. There is no significant precedent. There is forward motion and a willingness on many sides to understand and address the risks and to explore the opportunities. Very substantial investments have been made, over 30 years, to eradicate a human pathogen from the world for the second time ever. Transition planning represents a serious intent to responsibly bring the world's largest global health effort to a close and to protect and build upon the investment in this effort, where appropriate, to benefit other national and global priorities. Further detailed technical work is now needed, supported by broad and engaged debate, for this undertaking to achieve its full potential.