Ending polio in Afghanistan: Big plan, small details

How do vaccinators ensure that every child is reached?

Reza with his two young daughters, Setayesh and Saharnaz. © Tuuli Hongisto/WHO Afghanistan
Reza with his two young daughters, Setayesh and Saharnaz. © Tuuli Hongisto/WHO Afghanistan

Every child needs to be vaccinated to protect them from poliovirus. To achieve this, detailed plans are prepared for vaccination teams. The aim is to find each child under 5 years of age – in Afghanistan, that is around 10 million altogether – and to reach them with vaccines.

A heavy steel gate opens on a quiet suburban street in central Herat. The city lies in a fertile river valley in Western Afghanistan, an area rich with thousands of years of history. Over past centuries, different invaders from Genghis Khan’s army to the troops of the Timurid empire, the Mughals and the Safavids have opened the gates to rule the city once known as the Pearl of Khorasan.

Now, a peaceful group can be seen walking down the streets of Herat. Equipped with blue vaccine carrier boxes and drops of polio vaccine, the teams knock on one door after another to vaccinate any children they find inside. The aim is to eradicate polio in Afghanistan.

Four-year old girl Setayesh peeks from behind the gate and steps out on the street, followed by her father Reza Nazeri, who is carrying sleepy two-year-old little sister Saharnaz.

Reza encourages the girls to open their mouths to receive two drops of polio vaccine, and a drop of vitamin A. The children look at the vaccinators with suspicion, but follow.

The vaccinators thank them and continue down the street.

Locating all children

In March, vaccinators in Herat gave oral polio drops to over 150 000 children.

In a country with one of the highest rates of population growth in the world and frequent population movement, it is no easy feat to tell how many children live in each province, district, village, block, house or tent.

How do vaccinators know where the children in each area are located then? Through a simple but elegant guide known as a ‘microplan’. This is what the vaccinator follows: Where do I start my day, how many children live on that street, which is the next house to visit?

Vaccinators use their microplans to work out which households they will be visiting during the campaign. © Tuuli Hongisto/WHO Afghanistan
Vaccinators use their microplans to work out which households they will be visiting during the campaign. © Tuuli Hongisto/WHO Afghanistan

No coincidence: Who goes where

A few kilometres from Setayeshs’ and Saharnazs’ home, Dr Khushal Khan Zaman is sifting through printed plans on his desk at the World Health Organization office.

Dr Khushal explains that once a year, health workers physically count the houses in their area. Then they check that the plans from the previous year still match the numbers.

Campaign supervisors know the approximate number of children in each house from the last campaign. But the data is complemented by their personal knowledge. As locals, they often know of any changes in the composition of their community – where new children have been born, or the location of nomadic groups who have settled in the area.

This helps keep the plans accurate. For instance, if a nomadic group has stayed in an area for a longer time, their tents may be added to the house-to-house microplans. For shorter stays, a separate checklist is used instead to monitor nomadic population movement. This improves the programme’s ability to trace and reach every child with vaccines, even if they are on the move.

Once the plans have been updated, teams of vaccinators are assigned to visit specific homes on a particular day during the upcoming campaign.

The final plan indicates not only the numbers of houses and children, but also details on how many related items are needed for each team: vaccine vials, vaccine carriers, ice packs (to keep the vaccines at optimum temperature), chalk, tally sheets, pens, leaflets, finger markers, plastic bags and scissors.

This is a contrast to a few years ago, when the plans listed only the name of the area with the estimated number of children to be vaccinated. The newer plans include even the smallest houses, and information on the closest mosque and local elders.

“It needs to be clear to everyone, which team is responsible for which area. We mark where the teams start and which direction they take using arrows,” Dr Khushal explains.

And it is no coincidence who goes where. To ensure that parents allow their children to be vaccinated, vaccinators may be allocated parts of their community that they know well, to increase trust when they deliver the vaccine.

Little children like Setayesh and Saharnaz might not understand yet why the vaccine is important, but their father does. When vaccinators knock, it is not chance that brings them, but care and commitment.

Setayesh is vaccinated against polio. © Tuuli Hongisto/WHO Afghanistan
Setayesh is vaccinated against polio. © Tuuli Hongisto/WHO Afghanistan

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