Programs & Tools:
STOP: Notes from the Field
STOP Team Topics:
Nepal: National Immunization Day
I feel privileged to be a part of the first STOP team. We are literally racing against time (to eradicate polio). Nepal borders one of the last remaining hotbeds of polio in the world: the northern Indian states of Uttar Pradesh and Bihar. People cross the border in both directions every day. Our job will be to set up surveillance networks for polio, especially in Nepal’s poor but highly populated Terai districts on the Indian border. We have to know where the disease is and where it isn’t, and we have to move fast. It’s the most exciting job I’ve ever done.
Our first day in Nepal was a National Immunization Day (NID) for polio. Everywhere we saw little tables under blue signs proclaiming in Nepali script, “National Polio Vaccination Day.” There were vaccination teams at bus stops, at the bazaar, in clinics and by the side of the road. In the temple city of Bhaktipur, we saw roving teams going door to door, vaccinating. We saw a tiny parade of uniformed Nepali scouts marching the cobbled streets announcing by megaphone, “Free polio vaccination! All children under five.”
The vaccine is oral: just two drops in the mouth. It’s about the easiest vaccine in the world to give, which is one of the reasons we think polio can be eradicated. No needles, no shots. It was impressive to see how the community mobilized. There were people from all walks of life, all motivated, all pitching in: nurses, midwives, sports clubs, shopkeepers, politicians, and at least one veterinarian (me). Over three million Nepali children received polio vaccine that day. The previous day, India had vaccinated over 130 million children! Support for polio eradication is so universal that even countries in the midst of war have called cease-fires for NIDs. El Salvador, Sudan, Afghanistan and Sri Lanka all have had cease-fires for NIDs.
Bangladesh: Working Around Strikes
As soon as we arrived in Dhaka, we have been plagued with hartals (strikes) which shut down the city. No cars travel during hartals, but rickshas (bicycle driven passenger vehicles) are allowed to operate. There was a hartal this past Thursday, and we traveled by ricksha to our meeting. It was actually quite fun without the congestion of cars on the road.
Each of us has been assigned to two districts and will work with the surveillance medical officer responsible for this area. I have been assigned to Kurigram and Lalmonihat districts in the Rajshahi Division. This division is one of the largest and is in the northwest corner of the country. It is primarily agricultural (wheat, rice) and is the center of the silk industry. I am impressed with the roads here, which are well paved. My two districts are considered to be “hard to reach” areas. The Lonely Planet guidebook does not even mention them.
I was scheduled to fly to my division last Saturday. However, yet another hartal was planned for Saturday. Fortunately, the hartal was only scheduled for half the day. Exactly at noon, cars appeared on the road, and I was whisked to the airport in time for my 1 p.m. flight.
The surveillance medical officer had scheduled a workshop to strengthen surveillance and routine immunization for one of my districts on Sunday. So, I hit the ground running and spoke to the participants about the importance of surveillance for acute flaccid paralysis (AFP) and their role in polio eradication. Later that day, we did a 60-day follow-up of an AFP case. The child ran away from us as we approached, so it was not a case of clinical polio.
The next day I went to Romari, a sub-district, which is a char (island). I traveled by boat for three hours and then by motorcycle to the health clinic. I only saw one car, the ambulance, while there. The SMO and I gave an orientation on AFP to the nurses and visited an outreach immunization clinic. We then traveled to the Indian border through paddy fields by motorcycle. The sub-district health officer is doing a great job providing services considering the obstacles in his way (shortage of manpower, hard to reach villages).
Hartals were scheduled for Wednesday and Thursday so we traveled back to Dhaka. I'm not sure if I will have e-mail access while in the field. So, I wanted to give you an update while I was in the city.
Ghana: Preaching About Polio
Finally, I am on the Internet, and it is really working well for the first time since I've been here. It's the rainy season, and the storms caused power blackouts. No power today until 4:00 p.m.
Right now I'm in Wa, the Upper West Region. I have been out in some extremely remote villages not too far from Burkina Faso. We went to Hamile, which is on the border, and I sort of made a border guard angry by not asking for permission to take a photo. We have been visiting all the clinics and I've been asking, and preaching, about AFP. Looking around, I can see they really do mobilize and do an excellent job during their NIDs (National Immunization Days). I'm impressed with their hand-drawn maps showing where to go and give the two drops of polio vaccine.
"You are welcome," is the standard greeting. I'm truly happy to be out preaching the message. I'm getting so that I am wishing that I could extend and keep on doing what I'm doing.
India: A "Refreshing" Story
On Sundays, if there are no acute flaccid paralysis (AFP) cases to investigate, we generally have that day off to relax and rest for the next week. However, being cooped up in a hotel room all day gets old, so I decided to go for a serious hike around Muzaffarpur (along the mid Indian-Nepal border area).
Starting at noon I walked for two hours in one direction outside of town. Realizing I was on the verge of heat exhaustion as I had stopped sweating, I decided it was time to head back which again took two hours (I drank pump water along the way).
Arriving back in town I stopped by a shop and got an ice-cold Limca (lemon-lime drink) which tasted great as I was pretty dehydrated at this point. Noticing a nearby well I decided to take a picture with my digital camera just to have a reference shot of standard water sources in India. The shop owner who was standing next to the well asked if I wanted my picture taken also so I decided what the heck, I didn't have a single picture of myself so far during my stay in India. As I stood by the well about 20 people rushed in quickly to be in the picture (other shop owners and people standing nearby). I guess they thought I was a photographer for National Geographic or something!
As one of the men rushed in at the last second to squat down on the front row he fell into the person standing to my left who fell into me (elbow to my sternum), and I then fell backwards over the low wall of the well into the water, taking another person with me. Fortunately, the well mouth was easily large enough for both of us to fall in without hitting our heads, and the water was only eight feet from the top of the well. It was shallow enough so that I could touch bottom too.
Upon surfacing and overcoming my shock I realized three things. First, the water felt incredibly great, and this accident was a sort of blessing. Second, that there were about 25-30 faces staring down at me from above, and third, something was nibbling on the back of my neck! Turns out there are fish in the well.
Within a couple of minutes we had been hauled out using bamboo poles and about seven minutes after that I was almost completely dry as it was so hot. Sadly, the man working my digital camera never did figure out how to work it and was too excited once I fell in to take a shot of me dog paddling inside (which I'm almost thankful for).
India: Expanding Surveillance By Working With A Local Priest
This last week has been the most rewarding so far and I am starting to see the results of my efforts. I had left for our mid-assignment break in Delhi wondering if I was making any sort of difference, but after a restful and food-filled weekend and another week in the field, I definitely feel like I am contributing, at least in some small way.
My best meeting was with a priest at a temple that is famous for seeing paralysis patients. After some discussion and assuring him that we didn't want to take away any of his business, the priest indicated that he would be more than willing to help us, and if we gave him a register he would keep track of the (paralysis) cases, obtain their addresses, date of onset, and symptoms. He said that if we sent a community health worker each Sunday (when cases come to the temple) he would pass the information along. The next step was to go to the local Primary Health Center. There I was able to round up five community health workers - ANMs (auxiliary nurse midwives) and MPWs (Multi-Purpose Workers). I had a great meeting with them and their enthusiasm was wonderful; they were really willing to listen, learn, and participate in acute flaccid paralysis (AFP) surveillance. It was agreed that Mr. ______, an MPW, would go to the temple each Sunday evening and look for cases. I left there feeling like I had actually reached some key people, but was unsure if I had left a system in place and wondered if the community health worker would really go to the temple on his day off.
I returned from Delhi and went directly to the field without returning to my base, and we arrived at the temple around 6 p.m. Apparently, patients start arriving at the temple Saturday afternoon/evening, rituals are performed Saturday and Sunday. On Sunday at midnight, some final rituals are performed and then the cases must leave. Depending on the case, the patient must come back for several weeks. When we arrived, there were at least 100 people milling around - quite different from the quiet place we had visited in the afternoon the week before. Families were caring for sick family members, and both my driver and translator knew people there who had brought their sick mother or paralytic child (an indication of how famous this place is).
But the most rewarding experience was when I got out of the vehicle. The MPW who I had trained a week and a half before was standing there like he was expecting us and handed me a register of all the information he had collected last Sunday and this Sunday! I was so happy to see him, and it was clear that he was proud of the work he had done. We proceeded to the nearby public health clinic, found the doctor, and with the District Immunization Officer (DIO), formalized a system where the MPW and the doctor would go to the temple each Sunday, and the DIO would call each Monday morning for a report. Then we all went back to the temple and examined the cases - all of which were chronic cases. But, I really think this will work and that there is great potential here to find cases. I am going to make sure that I return one more time before I go and I am definitely taking that MPW a present!
India: Learning To Be More Effective
You were right about the final month in the field being our most effective period. I actually feel very comfortable in the field now, like I know which questions to ask and when to refuse that third cup of chai (tea). I've verified three ORIs (outbreak response immunizations) and they are really being done and very quickly.
I heard of a case of acute flaccid paralysis yesterday in Mirzapur, so we headed there this morning. The MOIC (medical officer in charge) had already completed the outbreak response immunization, and the child had just returned home to the village. The child was definitely malnourished, and I felt, along with the MOIC, that the present neck weakness was secondary to hypokalemia and dehydration. The child was continuing to have 4-5 bouts of diarrhea a day but was eating, according to the mother. Anyway, the MOIC wrote out a prescription for some supplements, and I asked that an auxiliary nurse midwife return with the child to the public health clinic for oral rehydration at least. The villagers have been educated about homemade sugar/salt solution but prefer the ORS packets. We'll have to return after the child is hydrated and diarrhea is gone to reassess and make sure that the neck weakness has resolved. This is one of those iffy cases -- hard to call right now. It was a Muslim village and the first time I encountered real resistance to vaccination. They were pretty much OK with oral polio vaccine since it's oral but completely refused injectable vaccines. Some think the vaccines will sterilize their children.
India: Overcoming Rumors About Vaccines
We just finished the second round of the National Immunization Day. It was very exciting, especially since one of my districts was also having an enormous Mela (fair) on the same day. Apparently this time of year about 1 million people come to Ayodha to take a holy dip in the river and also walk 52 kilometers around the city--barefoot. In fact some people travel the whole 52 kilometers on their hands and knees! As you may guess this made planning the immunization day a little difficult in the area.
My greatest success so far has been convincing a village to accept the polio vaccine. There is a rumor going around that the vaccine causes sterility, so many families are refusing to vaccinate their children. On this particular day, the nurse had visited the village three times to vaccinate children but the people refused. I went with the nurse to the village to talk with the women. I was able to find a local woman who was a supporter of the vaccine and brought her with me to talk to the people. At first the women didn't want to vaccinate their children, but after we spoke with them about the benefits of vaccination, they agreed.
Haiti: "People Are Genuinely Kind And Generous"
The voice from the tropics is back! I'm recuperating from three grueling but very rewarding weeks in the south of Haiti.
I arrived there with a group of four WHO consultants (an Algerian doctor and three Haitian nurses) to find a vaccination campaign that was supposedly finished but had covered only 30% of the target population. We paired up with two local nurses, worked 12 hours a day, six days a week, and I'm proud to say that we were able to reach over 100% of the children! (There has been a serious underestimation of all age groups because there hasn't been a national census here since 1982 and the population growth has greatly surpassed anything any of us imagined.) I spent most of my time evaluating vaccination coverage and planning the revaccination of areas with low coverage. Now, I am back in Port-au-Prince where I am analyzing data, writing reports, and trying to find a wheelchair for the little girl with polio I visited while in Delmas.
The Département du Sud is beautiful; truly another Haiti as compared to Port-au-Prince. It is very green and lush, with rolling hills, rocky roads, numerous rivers and beautiful vistas of the Caribbean Sea. I had the opportunity to perfect my Creole (Kombien timoun gen nan kay la? Tout timou té vacsiné kont maladi polio?) as few people understand French. The level of education is very low and families are large. I could spend ten minutes sitting in someone's yard trying to figure out how many kids lived there. Often, parents (especially dads) couldn't recall the number of children they had or how old they were. But the people were genuinely kind and generous. I left houses with small piles of mangos or avocados under my arm or would slurp down coconut milk from a freshly plucked coconut people would offer (a surprisingly refreshing and rehydrating drink, perfect for this hot and clammy climate). They were extremely curious about me, the blanc with the funny hat and thermos in hand. Often, half a dozen kids would gather round us when we went into homes and followed us around for the next two hours.
Pakistan: Phenomenal Local Efforts To Eradicate Polio
From my one afternoon of SNID (subnational immunization day) monitoring and from the others in my group who have many days exposure in this work, it's clear that many people here in Pakistan are making phenomenal efforts to eradicate polio. Just imagine in your own town if you were asked to knock on the door of every home and convince the parents to let you immunize all their children under age five for a disease that is now relatively uncommon.
Now imagine doing it for over 20 million children spread over an area larger than France in 100 degree weather for the grand sum of 80 rupees ($1.60)/day and having people refuse because they believe it's a surreptitious form of birth control -- a not uncommon belief here. I'm sorry but I'm sure I'd drop out by the second day. It's expected that this will likely have to be done twice a year for the next two-three years here in Pakistan!
Content last reviewed on August 16, 2004
Content Source: National Center for Immunizations and Respiratory Diseases
