Fractional-Dose Inactivated Poliovirus Vaccine Immunization Campaign — Telangana State, India, June 2016

Campaign Planning and Implementation

Twenty-nine surveillance medical officers from World Health Organization-India’s National Polio Surveillance Project were deployed to support the development of campaign microplans and to conduct precampaign training and campaign monitoring. Existing microplans* developed for previous OPV campaigns were adapted for the fIPV campaign. A rapid house-to-house survey was conducted to enumerate all eligible children and to inform families about the campaign. The target population was estimated to be 291,305.

A total of 5,373 immunization sessions were organized during 6 days (Table 1); the number of daily sessions ranged from 719 to 1,227. A total of 1,038 vaccinators supported implementation of the campaign, with 638 vaccinators mobilized from neighboring districts. At least one four-member team that included one vaccinator (an auxiliary nurse midwife), two community mobilizers, and one volunteer managed each session. Auxiliary nurse midwives administer all injectable vaccines during routine immunization sessions. A 1-day training session was organized to instruct all vaccination staff members supporting the fIPV campaign. Social mobilization for the campaign was conducted through print and electronic media, posters, invitation slips to parents of eligible children indicating day and place of immunization sessions, banners, microphone announcements, and community mobilizers.

The IPV vials used in the campaign were 10-IM-dose vials (5 ml per vial) manufactured by Shantha Biotech (Hyderabad, India) with 0.1 ml withdrawn for each fIPV vaccination. Therefore, each 10-IM-dose vial could potentially vaccinate 50 children with fIPV. The multi-dose vial policy permitted use of open IPV vials for up to 28 days from the date of first use (8); partially used opened vials returned at the end of each campaign day were the first priority for use during the next day. A 0.1-ml dose of fIPV was administered intradermally on the lateral aspect of the right upper arm using an autodisabled needle and syringe (with a 0.1-ml mark). An autodisabled needle/syringe is a “fixed system,” in which the needle cannot be removed from the syringe; this system reduces vaccine wastage from the syringe. After vaccination, the nail of the left fifth finger of each vaccine recipient was marked with an indelible marker pen. Parents and caregivers were asked to report any adverse events occurring within a week of receiving the vaccine, including illness, hospitalizations, or death.

Campaign Monitoring

At least one campaign monitor was assigned to each of the 25 blocks/administrative divisions in the districts of Hyderabad and Rangareddy. Areas selected for monitoring were known locations of residence of disenfranchised, mobile, or migrant populations and other groups for which lower than average routine immunization coverage had been reported. A total of 958 (18%) vaccination sessions were observed during the 6-day campaign (Table 2). All monitored team sessions were organized as planned, and 96% of monitored teams had the vaccinator that was listed in the microplan. Among monitored teams, 97% had adequate supplies to conduct vaccination sessions. Because of high vaccine demand, especially on the first 2 days of the campaign, 6% of monitored teams reported a shortage of IPV vials at some time during the session. No frozen IPV vials were reported to have been observed; IPV is freeze-sensitive, and any vials that are suspected to have been frozen must be discarded (9). Also, on the basis of their observance of vaccine vial monitors (heat-sensitive labels placed on vaccine vials that register cumulative heat exposure), monitors reported that no IPV vials reached the discard point, which implied an overall appropriate maintenance of the cold chain. On the first day of the campaign, a median of 48 fIPV doses (range: 41–50) were extracted from each IPV vial. Monitors noted that no vaccine leakage from the vial caps occurred during monitored sessions. In 93% of observed children, a bleb, indicative of intradermal delivery of fIPV, was observed immediately after vaccination. A median of 73 children (range: 10–148) were vaccinated per session per day during the campaign.

Postcampaign Evaluation and Coverage

A total of 311,064 children were reported to have been vaccinated during the campaign, representing 107% of the initially estimated target of 291,305 children (Table 1). The reported coverage in Hyderabad was 87% of the estimated target, and in the Rangareddy district, almost twice the number of initially estimated children (185%) received the vaccine. The high reported coverage in Rangareddy was attributed to a large number of children from nontargeted areas that were adjacent to targeted areas who received vaccine during the campaign. After the campaign, a postcampaign assessment was conducted by 46 monitors to check for the likely number of missed children in a given location. Monitors prioritized areas that were known locations of residence of disenfranchised, migrant, or mobile populations. A total of 2,821 children were randomly checked (through finger marking) by monitors as part of a postcoverage monitoring survey, and 94% of assessed children overall were found to have received fIPV during the campaign (Table 2). The main reasons for nonvaccination included the child was not available on the day of vaccination (29%), the child was sick (21%), lack of parental awareness (16%), fear of injection (2%), and hesitancy and refusal (6.2%). Four nonserious adverse events, reported within a week after receipt of fIPV, deemed to be unrelated to vaccination.

Discussion

Although vaccination campaigns with injectable vaccines have been conducted for other diseases, globally, this was the first campaign to use fIPV, which required vaccinators with experience in administering intradermal injections. Overall, this emergency response to a reported VDPV2 event demonstrates that it is feasible to plan and implement a fIPV campaign within 14 days of the reported event and to achieve high reported coverage. Strong government leadership at the national and state levels, well-coordinated technical and operational support from GPEI partners, clearly defined standard operating procedures for outbreak response, and experience implementing OPV campaigns were critical elements to the success of the fIPV campaign in Telangana state, India.

A number of lessons learned from this experience are likely to aid India and other countries in the successful implementation of future fIPV campaigns, as well as emergency campaigns with other injectable vaccines. Meticulous planning to ensure a sufficient number of vaccination sites that are located strategically and availability of an adequate number of vaccinators with experience in intradermal administration of vaccines, coupled with rapid refresher training of these vaccinators, assisted in ensuring good injection practices and high coverage as determined by postcampaign monitoring.

The Emergency Operations Center established by the Indian government was responsible for the overall coordination of the emergency response, with strong support from GPEI partners. Communication technologies, such as group messaging, helped ensure rapid communication among all stakeholders. Progress in all sectors of the campaign area was shared in real-time during the preparatory and implementation phases, as were challenges and barriers, to ensure faster solutions to identified problems.

Sharing accurate and timely information is important in developing a positive partnership with the media. Extensive publicity of the campaign through mass media, the perceived threat of the return of polio, and the nonavailability of IPV in the private sector, as well as the private sector’s promotion of the campaign, all contributed to high community participation and high coverage.

One unanticipated problem was that the number of children identified during precampaign surveys did not match the number of children who reported to the vaccination sites to receive fIPV, especially in Rangareddy, where only about half the number of children who were actually vaccinated were initially targeted. Therefore, when planning for a time-sensitive outbreak response, resource-intensive precampaign surveys should be avoided. Available resources should be diverted to update existing vaccination microplans and develop communication strategies. Strong mobilization measures using community health workers and volunteers on the days of the campaign were effective in achieving high coverage. This large, emergency campaign with an injectable vaccine required a large number of trained vaccinators to be brought in to the targeted area from other districts; this scenario needs to be anticipated in response plans for future similar campaigns.

The experience in Telangana state, India, demonstrates that operational and logistical challenges to an injectable vaccination campaign can be overcome. Through active government and partner coordination, achievement of high vaccination coverage with intradermal fIPV in an emergency campaign setting is possible.