Immunizations and Public Org India

Immunizations and Public Org India

Vaccinations, associated with the prevention of many once common and deadly diseases that cannot be combated by traditional medicine have saved millions of lives all over the world. As vaccines provide prevention from viruses, pathogens that modern medicine has had very little success with in post-treatment they are indispensable to the ability of medicine to help people avoid serious disease in individual and in large outbreaks. Herd immunity is one of the most important aspects of the success and/or failure of global immunization, as without it diseases that can be prevented through immunizations can recur locally, regionally and even globally among those lacking immunizations. Additionally without herd immunity even immunized individuals are at risk when viruses have the opportunity to evolve in their natural manner through repeated infection, exposure to combatants and increased spreading. "Childhood immunisation programs currently save 3 million lives per year throughout the world and are one of the most cost effective public health interventions" (Ali, Zwar & Wild Web- 833). One of the most troubling aspects of immunization coverage is that the public may begin to become apathetic toward immunizations as soon as incidence of disease begin to decline, something that is a serious concern in the present, because immunization rates are high and donor nations tend to have even lower (or no) numbers of immunization preventable diseases than do developing nations (Mark & Rigau-Perez Web-64).

The World Health Organization and many other national and international health organizations seek to increase vaccination rates internationally as part of struggle that began in the 1970s and has expanded exponentially since, through expanded vaccination schedules as well as broader coverage. The goal of the current administrative policy is to increase immunization rates to 90% for most vaccinations and to do so globally.

When the World Health Organization (WHO) began the Expanded Programme on Immunization in 1974,

According to WHO the expansion of vaccination has been a huge international success as access and routine immunizations have been fundamentally expanded to meet this huge social need, "Since then, increased vaccination coverage has resulted in substan-tial reductions in morbidity and mortality, including a >99% decline in polio incidence since 1988 (4), with eradication on the horizon, and a 78% decline in measles-associated mortality from 2000 to 2008 (5)" ("Global Routine Vaccination…" Web- 1367). In addition WHO notes that combined efforts that support the above outcomes have also expanded with additional vaccinations including the recent: Haemophilus influenzae type b (Hib) vaccine, HepB vaccine, pneumococcal conjugate vaccine (PCV), and rotavirus vaccine into many countries' routine vaccination schedules…" (1367) from that WHO expects great future outcomes.

One document, that opens with the history of the first ever planned and applied vaccination program for small pox in the 19th century goes on to offer the best example in the literature as to the laundry list of goals and needs of a good immunization program:

Current immunization programs must pursue high coverage of a clearly defined target population, manage a reliable logistics and transport system, employ trained health workers, reduce administrative and geographical barriers (with fixed and, if necessary, mobile delivery sites), and inform and motivate the population to make use of the vaccine…. personal involvement of political, religious, and social leadership mobilizes communities; communication is a critical component of a program and uses multiple channels (face-to-face, print, mass media) to deliver the message; staff training provides the technical skills for planning and management; successful programs have a process measure (coverage) as well as outcome indicator (disease incidence); disease surveillance helps focus efforts on areas of greatest risk; decentralization of resources, coupled with a national plan of action, permits more effective and rapid activities; research and development provide a technical basis for advancing program goals; unbalanced concerns over risks, and public apathy toward immunization, as disease incidence declines, must be countered everywhere (Mark & Rigau-Perez Web-64).

The above quote illuminates, better than any other statement the multi-variant tactics that are needed for modern immunization programs for real change to occur in rates. Everything from proper communication tools to adequate program training are essential to the process.

Having said all of this, establishing a need for vaccinations as well as the monumental positive effects of these changes the organization would also like to make sure to express that there is still much work to do as it notes that, "based on an annual global birth cohort of approximately 130 million, an estimated 23 million infants worldwide still do not receive the benefits of routine vaccination (i.e., 3 doses of DTP during the first year of life)" (1367). WHO also goes on to say later in the work that much of this area of weakness occurs locally and regionally, in certain poor areas of the world that lack other basic necessities, such as compulsory education and access to basic preventative medicine (1371).

In response to this concern WHO has collaborated with UNICEF to create a comprehensive action plan called the Global Immunization Vision and Strategy (GIVS). The goal of the plan is to assist challenged nations in strengthening their immunization programs and overall in vaccinating more individuals. The overall goal of the program is to create a 90% DTP 3 dose vaccination in all nations among children by age 12 months by 2010 and to maintain this into the distant future (1367).

India is one of the largest nations in the world and has one of the largest populations of poor in the world as well. For this reason many children have limited access to health care and education, on a regional basis. Among the 23 million children who have not received the 3 dose DTP by age 1 year about half of them live in India and Nigeria and neither nation is expected to meet the 2010 percentage goal (1371). It must also be noted that India lags behind on nearly all its immunization rates, including polio, which was once on the brink of eradication but has resurfaced in India and other nations (Hull Web-300). The vaccination rate is improving but the concern is that there are still many holdouts, particularly in minority faith communities in the nation (Web-300). Lastly, it must also be noted that immunization documentation and reporting is one of the most important aspects beyond actually providing vaccinations to children as without record there is no way to know what real immunity rates are, as was evident in the Australian, practitioner visit model where teachers visited health clinics to teach practitioners how to report vaccinations and rates improved dramatically (Ali, Zwar, Wild Web- 833-835). Having established what we know in a general sense about immunization needs and rates this work will then go on to provide a systematic review of immunization rates in India.

Evidence Review

From an extensive review of relevant literature comes an illumination of the particular case of India. In a review of a recent failed attempt to eliminate Polio in India, an endemic nation, there is a profound message about how and why certain strategies have failed there. "In the midst of these virological considerations, the key lesson that emanates from the Indian experience is that the social determinants of programme implementation are as important as the technical ones -- and this lesson has a significant bearing on other disease elimination programmes as well" (Arora, Chaturvedi & Dasgupta 232). What Arora, Chaturvedi & Dasgupta found is that small pockets of unimmunized individuals in densely populated underdeveloped areas, with limited access to health care, poor hygiene conditions, intestinal parasitic and other common ailments exist nearly all the time as well as a general undernourishment exist in the population even very high rates of immunization will not counter occasional outbreaks of disease, in this case polio. The reason for this is that these small populations that are disenfranchised can carry low levels of the disease and spread it to each other or to outsiders as a matter of their living conditions. The consensus among these researchers is that these areas are particularly troubling not simply because of lack of access to affordable (which means free in many cases) access to routine vaccinations and medicine in general, though access is highly essential (Sahu, Pradhan, Jayachandran & Khan) but also because they also harbor resistant populations who object to vaccination on several levels

In areas of poor development and inadequate health care, marginalized communities, regardless of religion or social group, are mistrustful of SIAs [supplemental immunization activities]. Some circulating rumours pointed to elements of religious and cultural resistance as well.7 Allaying the fears and suspicions of these marginalized segments of the population will require improved primary health care and the visible involvement of volunteers from local communities in the microplanning of SIAs (Web- 233).

The researchers above conducted research in just such areas and attempted to determine why polio was again on the rise despite monumental attempt to eradicate it. The resulting information points to the idea that there are more factors at play than simply developing and then providing vaccination doses to developing nations. The action plans that produce better results are paramount to success, and factors of social significance are just as important as or more important than having enough clinicians or clinics to administer the immunizations. The idea that community based and local volunteers would be needed to help administer and do family teaching about immunizations in India is also supported by Prinja, Gupta, Singha & Kumar who stress that in their large trial, associated with timely vaccinations of children in India with the DPT vaccination the results were far better when local volunteers were recruited as the presence of these individuals as well as their supportive education helped individuals better understand the need for their children to get the vaccination (Web-97). Another concept that is raised in the literature as a potential and real barrier to improved urban immunization rates is a special focus on migrant populations and especially new migrants to the area. It is noted by Kusuma, Kumari, Pandav & Gupta that as the overall economic and education levels of the migrant mothers improved over time immunization rates for children improved but new migrants were a particularly vulnerable population (Web-1326).

While the primary focus of the above to research traditions stress interpersonal communication with trusted volunteers from the region as the most effective tool in very hard to reach areas Obregon, Chitnis, Morry, Feek, Bates, Galway & Ogden stress that it is usually a combination strategy, with regard to awareness campaigns that is most effective. According to Obregon et al. The research conducted for polio eradication communication; "…illustrates how evidence-based and planned communication strategies -- such as sustained media campaigns, intensive community and social mobilization, interpersonal communication and political and national advocacy combined -- have contributed to reducing polio incidence in these countries" (Web-624). The work goes on to stress that planned communication strategies, including all of those mentioned above help by, "…mobilizing social networks and leaders; creating political will; increasing knowledge; ensuring individual and community-level demand; overcoming gender barriers and resistance to vaccination; and reaching out to the poorest and marginalized populations" (Web-624).

While interpersonal communication may not be the most efficient rate of either education or compliance with immunizations the issue bears a more expansive look. The reason for this is because the research, from past experiments, clearly indicates that at this stage in the game, i.e. when much has been gained with many of the immunization rates the most important group of unimmunized individuals are all part of a marginalized social group. Among these individuals are multiple barriers to access but overall and sense of mistrust for outsiders. This social barrier can be fundamentally overcome by allowing a member of the same said group to participate in education and implementation of immunizations by simply providing appropriate social cues about the importance of immunizations and most importantly from a trusted "inside" voice.

In another article addressing the need to better educate health care providers regarding the implementation of immunization programs an existing system was measured. The system (ISDS) is a visiting supervisory program where visiting supervisors go to clinic locations teach clinicians and support staff proper procedural process and provide corrective action for incorrect procedures. The interventions recur three times and are relatively costly, due in large part to personnel and travel expenses. The work attempts to determine the cost and effectiveness of this system in an attempt to recommend the system be adopted locally, to reduce costs and possibly improve outcomes as effectiveness was rated very high but over half the cost of the ISDS program was associated with personnel and travel expenses (Web-221).

Sahu, Pradhan, Jayachandran & Khan also point out that access is exceedingly important but that as far as India goes there are also several sets of unknowns even when the researchers used due diligence to provide the most factors in their assessment. The researchers note that though the 2010 90-100% immunization rates for tuberculosis, measles, whooping cough, diphtheria and polio will likely go unrealized, "Universal immunization can be achieved by providing services at community level and information about the available services and their benefits to the community. There is a considerable, unexplained variation in the immunization coverage between different communities, even in the most complex model used in this study, which could explain the entire heterogeneity of immunization coverage among Indian states" (Web-332).

Conclusions establish what we know and what we don't know

From this relatively concise but comprehensive review of literature on the overall immunization issue as well as the Indian issue with regard to immunization rates and hold out communities there are several things that we do know. We do know that India is unlikely to meet international and national deadlines for the immunization of 90-100% of all children for all the desired disease types and that there is still much administrative work to be done to resolve the issue, with when this goal will be met. We also know that much of the work above is focused on single vaccination types, though there are a few exceptions. We also know that the literature is clear that special attention needs to be paid to small hold-out populations that produce serious risk for low level endemic disease that can cause serious disease outbreaks. We also know that a combined effort utilizing a list of education and communication tools is the most effective manner in which large increases can be seen in vaccination rates. Lastly, the literature is very clear on the fact that local volunteers capable of developing interpersonal communication with marginalized populations are one of the most effective interventions that can be done in India and this is evident in many research studies.

We do not know if the literatures' reflection of single vaccine focused programs are the standard for vaccination. It would seem that a combined vaccination effort would address access and the fact that opportunities for giving a single dose of any one vaccination are limited and therefore a combined effort seems logical. This perception may be a trick of the literature, and not be the case but there is limited mention in the literature of the combined tactic, as is common in developed nations. This also seems to be despite the Indian national interest in a whole range of vaccination standards. Another issue that may be a party to this perception of single vaccine focused campaigns is the fact that many of the programs associated with vaccination that are not administered by the local administrations themselves are supported by non-governmental organizations (NGOs) and other charities who might have a particular disease eradication focus. Administrative focus on this issue seems paramount as opportunities for vaccination, especially in disenfranchised populations seem to be very few and therefore a combined vaccination effort would seem logical. Lastly, though this may not be possible in all areas due to the nature of Indian Education, though very recently the government adopted compulsory free education for all children ages 6-14 (Pokharel Web) a discussion of compulsory immunizations for entrance into school might need to be addressed. At the very least school site mobile clinics may need to be developed and evaluated.