Our first slides look at whether caregivers recall having contact with a CGPP volunteer/worker. And we decided to include two of our primary social mobilization activities: Door-to-door counseling and group education sessions.So, the first graph here represents the question do you recall being visited by a CGPP volunteer/worker at times other than during a vaccination campaign?Figures in orange are for Angola. We actually collected this data at baseline in Angola, and the numbers seem to be comparable.Dark blue is the midterm figure for Ethiopia and the dark green is the midterm figure for India. [Read numbers].We followed this question by asking those that recalled being visited what they recalled discussing. You can see that the vast majority recalled discussing a polio-related topic. And in fact, in Angola, this figure rose significantly between baseline and midterm.
This is identical to the previous slide except that we’re looking at figures for group education sessions. At baseline, we collected this data in India, and so you’ll see we have comparative data for India. You’ll see that these are a bit lower than door-to-door counseling. But again, the vast majority recall discussing a polio-related theme.So, together these figures could suggest that while we don’t necessary have the reach that we would like with these activities, the contact that does occur is of such quality that caregivers would spontaneously recall discussing polio-related topics.
Here you can see vaccination rates for 7 vaccinations (OPV0 – OPV3 and Penta1 – Penta3). The light orange are baseline figures and the dark orange are midterm figures.You can see an overall positive trend in vaccination rates across all the vaccinations. You’ll note statistically significant differences between baseline and midterm for both OPV3 and Penta3. This is interesting and very positive actually because it suggests that there are fewer drop-outs. For example, at baseline there was a 15 percentage point drop between Penta1 and Penta3. At midterm the difference was only 7 percentage points.
You can see here again the three regions (agrarian, semi-pastoralist, and pastoralist). To keep it simple, we’re showing you four vaccinations for each (OPV0 in blue, OPV3 in green, Penta1 in orange, and Penta3 in yellow).Other OPVs and Pentas follow the same pattern and that is, project areas saw a statistically significant increase in OPV0 rates in all three areas, which is great news in Ethiopia where, as you can see, OPV0 rates are much, much less than other doses because of cultural and logistical factors.Beyond, OPV0, agrarian areas saw small decreases or small increases in vaccination rates, but nothing significant.Whereas the two other areas, saw statistically significant increases in vaccination rates for all doses of OPV and Penta. Catching up to agrarian areas, which remained steady. All OPV0 significant; OPV3 S and P significant; Penta1 S and P significant; Penta3 S and P significant.BCG and measles – data quality a question for baseline.Same pattern OPV1 – Penta3 – S and P significant while A is not.
And here we have vaccination rates for project areas in India. The light green represents baseline figures and dark green represents midterm figures. You can see that the overall trend is positive, although, in some cases only by tenths of a percentage point. Measles at the very end is the only vaccination with a statistically significant improvement over the two years. You could question whether something similar to Angola is happening at a smaller magnitude, and that is that perhaps the data are suggesting that children are finishing the vaccination series more than they had been. The latter vaccinations (OPV3, DPT3, and Measles) had the largest, albeit still small gains, when compared to other vaccinations.Measles is only significant.
Onto our next leg of polio eradication – supplementary immunization activities.First thing to note here is that we have not included Ethiopia data here. There are very few campaigns in Ethiopia as their last case was reported 3 years ago. The comparisons between baseline (conducted just after last cases) and midterm is not meaningful.We have three indicators to explore supplementary immunization activities. First, caretakers were asked whether their child ever received polio vaccination in a campaign. Second, they were asked whether their child was vaccinated in the last campaign. And third, they were asked whether a vaccinator visited their home during the last campaign.Baseline figures are in the lighter colors (light orange for Angola and light green for India). Midterm figures are in darker colors (dark orange for Angola and dark green for India).So let’s begin with Angola in the orange. Campaigns and campaign quality were identified as the largest barrier and therefore the biggest priority in Angola to stop the ongoing transmission of polio there. It’s an ongoing struggle in Angola where political will has been weak. Dora can attest to this. You can see by the numbers that there have been significant improvements in all three SIA indicators in Angola in the two years since baseline. [Go over figures for first two indicators].As a project, we do not have as much control over the third indicator. CGPP volunteers are not the vaccinators in either Angola or India. Our NGO staff helps to coordinate and our volunteers often accompany vaccination teams. In India, supplementary immunization activities happen almost monthly in our project areas. It’s a finely coreographed dance in which CMCs play an integral part. Through various activities, they mobilize community to participate before and during campaign; they work polio booths during booth days; and then work as part of vaccination teams, in particular helping to gain entry into resistant houses. India must have high campaign coverage in order to eradicate polio; and so you can see from the numbers that in project areas it’s really about maintaining high participation levels. [Go over numbers for first two indicators].Finally, we, and in particular the India team, were shocked to see the figures for the final indicator. 100% of households should be visited by vaccinators during campaigns. The figure of 80% does not fit with internal project figures or official campaign figures external to the project. And we can only explain it by thinking it’s just an artifact in the data.
And on to our final polio eradication leg and our final three indicators from the household survey.Caregivers were asked whether they had (1) ever heard of Acute Flaccid Paralysis or sudden paralysis in children. Just a little background, not all cases of AFP are polio cases, but we use the AFP case definition to find children and test them further for polio, which includes collecting a stool sample in a timely way and sending it to a certified laboratory. If the caretaker had ever heard of AFP, we also asked them to describe the signs of AFP, which are essentially limp limbs and/or the child suddenly stops walking or crawling. And finally we asked those who had heard of AFP who they would contact is they suspected that their child had AFP. Here we’re wanting them to say that they would contact a health facility (formal health system) or a CGPP project volunteer (rather than, for example, a traditional healer, in which case the case may never remain invisible to the formal surveillance network.The graph you see looks at figures for those three indicators for both Angola and India (figures for Ethiopia are on the next slide). Figures for Angola are again in orange (light is baseline; dark is midterm) and figures for India are in green (again light for baseline and dark for midterm).Angola – You’ll see that the percentage who had ever heard of AFP dropped about 9 percentage points in the past two years, which is a statistically significant drop. Those who would contact a health facility or project volunteer also dropped – about 5 percentage points. India – Figures for India remained steady across all three indicators, with only tenths of a percentage point between baseline and midterm.
Evaluation of the CORE Group Polio Project Presentation to the Global Health Council Annual Meeting Henry Perry, MD, PhD, MPH Department of International Health Johns Hopkins Bloomberg School of Public Health 15 June 2011
Global Polio Eradication Initiative Began in 1988
Project Background Donors: 1999 – September 2012 December 2008 - December 2013 Current USAID project cycle: October 2007 – September 2012
OUTCOMES PROJECT ACTIVITIES Community-based Social Mobilization Door-to-door counseling + child tracking Group education sessions Influencer involvement Key surveillance informants Other Country-specific activities Increased routine vaccination rates Increased/sustained participation in quality SIAs Capacity-building for Local Health Systems Training opportunities Technical assistance for microplanning Child tracking Increased/sustained reporting of suspected AFP cases Country-specific high-level contributions Campaign quality monitoring – Angola Regional advocacy workshops – Ethiopia SMNetpartner - India
Community-based Human Resources Community-based workers are the basic “building blocks” of the CGPP In India they are paid full-time workers In Angola and Ethiopia, they are volunteer part-time workers
CORE Group Polio Project Expenses by Country, October 2007 – September 2010(Headquarters and In-country Expenses Combined, US dollars)
CGPP Volunteer/Worker Contact DOOR-TO-DOOR COUNSELING * *Represents statistically significant difference (at alpha = 5%) between baseline and midterm figures.
CGPP Volunteer/Worker Contact GROUP EDUCATION SESSIONS *Represents statistically significant difference (at alpha = 5%) between baseline and midterm figures.
Immunization Coverage Levels of OPV coverage and coverage of routine immunizations are similar in the CGPP catchment areas to levels of coverage in lower-risk areas, and this is a major achievement considering that these areas contain the hardest-to-reach/hardly reached populations (because of their geographic isolation, mobility, or social resistance to polio immunization) These levels have remained the same or increased modestly since baseline There are still “hard core” pockets 5-10% of unreached children not participating in polio Supplemental Immunization Activities (SIAs)
Routine Immunization - Angola * * *Represents statistically significant difference (at alpha = 5%) between baseline and midterm figures.
Acute Flaccid Paralysis Surveillance * * *Represents statistically significant difference (at alpha = 5%) between baseline and midterm figures.
Complementary Activities Beginning in India (with Gates Foundation Support) Health camps Attended by physicians, nurses and auxiliary nurse midwives, Provide immunizations, malaria prevention, vitamin A supplementation, de-worming treatment . Demand is more for ‘routine’ primary health care, rather than such incentivized piecemeal services
Status in CORE Group Polio Project Countries Angola – 4 polio cases confirmed in 2011 so far (and 5 by this date in 2010, and 33 cases identified in the entire year of 2010) Ethiopia – No cases identified so far in 2011, in 2010, or 2009 (last case in the spring of 2008) India – No cases identified in Uttar Pradesh so far in 2011 (but 1 case from West Bengal), and 21 identified by this date in 2010 and 42 cases identified in the entire year of 2010
Conclusion The CORE Group Polio Project is well-positioned to play an increasingly greater role in the Global Polio Eradication Initiative