Calling the shots – A pandemic story of community mobilization and immunization recovery in West Bengal, India

Authors: Dr. Kayur Mehta, Maliha Ahmad, Dr. Aastha Kant and Dr. Anita Shet are public health researchers at the Johns Hopkins Maternal and Child Health Centre India, International Vaccine Access Centre, Johns Hopkins Blomberg School of Public Health, Baltimore, USA. Meghendra Banerjee, Sreeparna Ghosh Mukherjee, Ipsita Bhattacharjee and Rajib Debangshi are senior program managers and program implantation experts at the Child in Need Institute, Kolkata, India.

Kayur Mehta¹, Maliha Ahmad¹, Meghendra Banerjee², Sreeparna Ghosh Mukherjee², Aastha Kant¹, Ipsita Bhattacharjee², Rajib Debangshi², Anita Shet¹

¹ Johns Hopkins Maternal and Child Health Center India, Baltimore, MD, USA.

² Child in Need Institute (CINI), Pailan, West Bengal, India

Life paused on 24^th March 2020 as India’s national lockdown in response to the pandemic was announced. But there was no stopping Ishaan Mallick – he came into the world with a defiant cry that rang joyfully through his home in Kolkata’s urban slum. The next 16 months passed by in a blink of an eye, but at 16 months of age, Ishaan had yet to be immunized. With no birth certificate or hospital records, he could not receive his vaccines at the nearby Urban Primary Health Center (UPHC).

Ishaan’s situation was unfortunately no unique circumstance in India – a nation home to approximately 2.7 million zero-dose children as of 2021¹. Globally, the COVID-19 pandemic fueled zero-dose numbers as routine immunization activities became deprioritized and faced backsliding coverage, with the number of zero-dose children jumping by 6 million in 2021 from 2019’s baseline². The state of West Bengal witnessed a massive surge in the number of infections and deaths during the second surge of the pandemic. Essential medical services and routine immunization activities were severely affected as many frontline health workers like Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) were reassigned to pandemic-related activities to combat pandemic-induced challenges. Many communities across rural and urban regions were left vulnerable, with limited advocacy and connection to health systems.

But there is power within communities and among partnerships. The NGO, Child in Need Institute (CINI) teamed up with the Johns Hopkins Maternal and Child Health Centre India (MCHI) and embarked on one of the largest routine immunization support programs in West Bengal. CINI identified and trained a cadre of community mobilizers who were local residents of their respective blocks. Enthused with the zeal to protect their children, the community mobilizers learned the basics of immunization and outreach. Working in close convergence with government frontline health workers (FLWs) and receiving inputs from local government functionaries, community mobilizers would chalk out micro-plans to regularize routine immunization in their respective areas, which involved mapping hard-to-reach areas, securing resources, and maintaining monitoring registers. Priority areas included ASHA vacant regions, vaccine resistant pockets, tribal and migrant populations, and hard to reach areas like street settlements, slums, and remote hilly regions. Community mobilizers would pay friendly visits to the homes of children and pregnant women review their immunization status, remind and encourage them to attend their local immunization session. In addition to house visits, mothers’ meetings and mobile campaigns were carried out in which community mobilizers conversed with caregivers, addressed myths and misconceptions, and provided broader counseling about various health and nutrition problems. A set of communication materials including banners, audio jingles, and flipbooks were also developed to spread awareness of childhood vaccine-preventable diseases and the importance of vaccination.

Between July 2021 and April 2022, a total of 75 community mobilizers were trained and deployed, reaching 5,601 children under 5 years of age. Among those, 4,348 (86%) were successfully mobilized to receive their vaccinations. Approximately 20% of the children visited by community mobilizers were from high-risk areas, and among those, 79% attended their routine immunization session – a tremendous success story.

When asked about the various factors that influenced them to attend the routine immunization sessions, communities cited regular home contacts, front line worker cooperation, family counseling, and mothers’ meetings as the top reasons.

“CINI’s Roshni didi and Sunita di spoke with a lot of warmth – just like a family member, she would always discuss my child’s health holistically”

•  Community mother, Jalpaiguri

These endeavors did not come without challenges. Determining the true number of vaccine eligible pregnant women and children was a real challenge without consistent records, especially in wake of the pandemic. Hostile behavior from resistant household members, task sharing with other pandemic-related activities, and personal illness and loss were challenges faced by community mobilizers during the pandemic.

The success of these activities reiterates the public health adage that putting people’s health in their own hands will lead to the best outcomes. These activities, developed by the people, for the people and of the people have set a glorious template for the public health community to follow during challenging times and future pandemics.

Fortunately, Ishaan was not left out from fulfilling his right to vaccination. In December 2021, he was identified by a CINI community mobilizer who discussed with his mother and helped register him, and Ishaan received his first ever vaccinations two weeks later. He was just one of the many zero-dose children brought back to the health system through community engagement and advocacy.

References

1. Dadari I, Belt RV, Iyengar A, Ray A, Hossain I, Ali D, et al. Achieving the IA2030 Coverage and Equity Goals through a Renewed Focus on Urban Immunization. Vaccines [Internet]. 2023 Apr 6;11(4):809. Available from: http://dx.doi.org/10.3390/vaccines11040809.
2. WHO/UNICEF estimates of national immunization coverage 2021. Available at https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/global-monitoring/immunization-coverage/who-unicef-estimates-of-national-immunization-coverage. Accessed 18 July 2023.