Polio Endgame In India: Can Social Determinants Be the 'game Changer'?

Background:  A major challenge to the success of the Global Polio Eradication Initiative (GPEI) is reintroduction of wild poliovirus from endemic countries, including India. Social determinants of program implementation have not received adequate attention.

Setting:  Few western districts of Uttar Pradesh (UP), have emerged as endemic reservoirs. The ‘sink-source’ hypothesis has been offered as an explanation for endemicity without any elaborations on context or composition. 

Population:  Social determinants have been explored through a comparative analysis of clusters of districts in Uttar Pradesh – three highly-endemic western UP districts [ Badaun,  Jyotiba Phule Nagar and Moradabad]; four western UP districts bordering the three highly-endemic districts [Aligarh, Bareilly, Muzafarnagar and Rampur]; and five eastern UP districts -- Azamgarh, Ballia, Basti, Gorakhpur and Sultanpur. Parameters analyzed included poverty, population density, literacy, urbanization, religion, availability of primary healthcare institutions and services, cold chain equipment, polio immunization rounds and routine immunization coverage. 

Project Description:  None Applicable

Results/Lessons Learned:  A clear social gradient emerges across the three sets of districts. Contrary to expected trends socio-demographic, poverty and infrastructure indictors are better in western UP while immunization delivery and communitization processes were better in eastern UP. High urbanization rates, proportion of Muslim populations and poor indicators among marginalized Muslim communities in peri-urban locales were higher in western UP. While the program’s focus is largely on microbiological issues, the obstacles to polio elimination may lie in the endemicity of social and/or cultural resistance in some pockets (borne out by our earlier research), leading to clustering of unimmunized children despite good coverage of pulse rounds at macro level. This may sustain low levels of wild poliovirus transmission, and there can be exceptions to the robustness of the pulse approach. Focusing on social determinants is critical and may well be a ‘game changer’