13 Intensified pulse polio immunization: Time spent and cost incurred at a primary healthcare centre KAPIL YADAV, SANJAY K. RAI, ADITYA VIDUSHI, C. S. PANDAV ABSTRACT Background. Despite launching the polio eradication initiative in 1995, India is among the world’s largest reservoir of wild poliovirus with 559 cases of poliomyelitis reported in 2008. This continued failure has been criticised for its negative impact on routine healthcare delivery. We assessed the impact of the pulse polio immunization programme at the primary health level in terms of services, time and cost. Methods. All activities during a single round of intensified pulse polio immunization were modelled on actual requirements at the primary health centre at Dayalpur in Haryana. Total person-hours and cost per child vaccinated at the primary health centre were computed. Results. Almost all routine healthcare services at the primary health centre were suspended during the round. Total person-hours consumed were 4446 and the total direct cost was Rs 24.2 per child vaccinated during a single round of the intensified pulse polio immunization programme. Conclusion. A single round of intensified pulse polio immunization consumes a substantial number of person-hours and leads to a temporary suspension of routine services provided at the primary health centre. This should be factored in while planning any future strategy of polio eradication or control and suggests the need to re-think the ‘intensified pulse polio strategy’. Natl Med J India 2009;22:13–17 INTRODUCTION In 1988, the World Health Assembly (WHA) passed a resolution (WHA 41.28) which committed WHO to global eradication of poliomyelitis by the year 2000. 1 According to WHO, polio remains endemic in 4 countries—Afghanistan, India, Pakistan and Nigeria—with 1506 reported cases of wild virus poliomyelitis in 2008. 2 India is among the world’s large reservoirs of wild poliovirus (WPV) with 559 confirmed cases of poliomyelitis (wild virus) being reported in 2008 and the zero polio scenario remaining as distant as it was in 1995 when the government adopted the polio eradication initiative (PEI). The initial target of polio eradication and its certification, which was aimed to be achieved in India and globally by the year 2000, was shifted to 2004 and then to 2007. India witnessed a surge of poliomyelitis type 1 (P1) in 2006 with as many as 648 cases, which declined to 83 in 2007. However, in the same period, the number of poliomyelitis type 3 (P3) cases increased from 28 in 2006 to 792 in 2007 (3 cases reported a mixture of wild P1 and P3). 3,4 The WHO once again reset its target to achieve interruption of type 1 poliovirus within 2008, interruption of type 3 by the end of 2009 and certification of no cases of WPV by the end of 2012. 5 There has been intense debate over the intensified pulse polio immunization (IPPI) strategy for polio eradication in India with both its supporters and detractors being equally vocal. 6,7 The ‘clarion’ call ‘2004—Now More than Ever: End Polio Forever’ given by WHO is counteracted by statements such as ‘the goal of Global Polio Eradication Initiative (GPEI) was flawed from the time of its conception and is unlikely to achieve its stated objectives this year or in the coming years’ issued by a group of public health scholars. 8 The debate focuses on eradication or control, pulse polio or routine immunization, oral polio vaccine (OPV) or inactivated polio vaccine (IPV), monovalent or trivalent OPV, vaccine-associated paralytic poliomyelitis (VAPP) or wild virus and the role of improved sanitation. The IPPI strategy provides an opportunity to the students of epidemiology, health economics and health management to study the successes and pitfalls of this public health initiative. Both in terms of intensity as well as the amount of work involved and resources spent, IPPI is unlike any other national health programme implemented at the primary health level. Reasons for the failure of IPPI may be numerous and varied. We limit ourselves to the impact of pulse polio immunization campaigns on routine healthcare delivery at the primary health level. We studied the effect of IPPI on services at a primary health centre (PHC), total person-hour expenditure and total direct cost of an IPPI round at a PHC. METHODS All the activities during a single round of IPPI were modelled on actual requirements at PHC Dayalpur in Haryana catering to a population of about 45 000. PHC Dayalpur is situated approximately 40 km from Delhi and is part of the intensive field practice area (IFPA) jointly run by the All India Institute of Medical Sciences (AIIMS) and the Government of Haryana. The resources dedicated to the IPPI were computed in terms of human resources and time. Costing was done for all the inputs used in one round. The calculated costs included the cost of OPV vaccine at the rate of Rs 69.5 per vial with a wastage factor of 1.33, and was Rs 5 per child vaccinated. 9 The operational cost in terms of mobility support, logistics, social mobilization, training, salary and remuneration given to workers was estimated at Rs 4 per child immunized. 9 © The National Medical Journal of India 2009 All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India KAPIL YADAV, SANJAY K. RAI, C. S. PANDAV Centre for Community Medicine ADITYA VIDUSHI Department of Medical Oncology Correspondence to C. S. PANDAV; cpandav@gmail.com THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 22, NO. 1, 2009