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Tool Helps Vaccinate India's Urban Poor

A Patna medical worker vaccinates a child
A Patna medical worker vaccinates a child in one of 650 Anganwadi Centers throughout the city now offering vaccinations monthly. Photo by Tove Ryman

Published: August 31, 2009

Imagine going from a vaccination program with 10 sites in centrally located hospitals, to 650 non-hospital locations in a year's time!

That's what local health staff in Patna, the capital of the Indian state Bihar, did using Geographic Information Systems (GIS) technology.

Patna, Bihar, one of the fastest-growing urban areas in the world, is the fifth fastest-growing city in India. With about two million residents, Patna trails many cities worldwide in rates of childhood vaccinations, and is in one of two Indian states with endemic polio transmissions. Overall, India accounts for 40 percent of the world's children not fully vaccinated (3 doses of diphtheria-pertussis-tetanus (DPT3) in the world. The country's reported DPT3 coverage was 62 percent in 2008, translating to 9.5 million children not fully immunized against DPT.

In July 2008, CDC worked with UNICEF and the India Ministry of Health to support Patna's vaccination program's expansion. This expansion allowed the program to provide monthly vaccinations at the city's numerous "Anganwadi Centers" – integrated child development facilities situated in low-income areas.

CDC staff Tove Ryman and Randall Young crossing one of many rivers in Bihar state
CDC staff Tove Ryman and Randall Young crossing one of many rivers in Bihar state to observe how effective GIS technology is in vaccination logistics.

GPS piloted for vaccination

"This was a pilot project borne out of observations that there are a lot of urban areas in India that don't have good vaccination programs," says CDC's project officer Tove Ryman, MPH, public health advisor in CDC's Strengthening Immunization Systems Branch, Global Immunization Division, NCIRD. "We see this as a pilot project to see if GIS mapping is usable technology and methods that can be applied to other cities in India."

CDC equipped planners with a handful of GPS units, affordably priced at $125 a piece, that enabled them to capture the geographic coordinates of the sites. From there, digital and paper maps were created for planning how to get vaccine and medical staff to the centers most efficiently considering the physical distances between staff, the centers and the location of the vaccine, currently stored centrally in area hospitals.

Throughout the pilot, each vaccination site was linked to a hub hospital, which in turn functioned as the center point for personnel, logistics and financial management. The vaccinators were auxiliary nurse midwives, posted in nearby rural health centers. Both GIS technology and local knowledge of closest routes linking these sites was used for this planning. Vaccinators' place of residence and their regular posting location were also taken into consideration while determining the allotment of vaccination clusters to the nurses. According to Narottam Pradhan, MD, senior routine immunization consultant for UNICEF based in Patna, the urban GIS technology has made a difference in increasing the rates of immunization coverage.

Children in India
CDC hopes GIS technology can help improve vaccination rates for India children. India accounts for 40 percent of all children not fully vaccinated against DPT worldwide. Photo by Tove Ryman

Immunizations up two-fold

"Preliminary data of the first three months suggests immunization coverage has gone up two-fold and further improvement is expected," he says, adding that the GIS tool was crucial in managing the logistics and the personnel.

Ryman and Randall Young, a geographer in ATSDR's Division of Health Studies, spent part of June in Patna. Their arrival in Patna occurred three months into the pilot's data-collection phase. They were then able to use this data to better understand the on-the-ground deployment issues, so as to strengthen the program in Patna and apply lessons learned in the next pilot effort.

"It was very exciting to see all the additional vaccination sites now available and to experience what kind of demand there was from mothers to have their children vaccinated," Ryman says.

Digital maps
Digital maps, such as this one, were critical for health workers as they increased the number of vaccination sites from 10 to 650 in Patna.

Young observes that there is excitement about the potential of GIS technology, but also hesitation about changing the current system that people are comfortable using. "It's new technology… I think it's going to take some time to get the local health staff to adopt it fully."

The trip was Young's first to India. He trained a local staff member to use GIS maps, and provided several digital maps for the staff there to use.

"When you go from 10 to 650 service points, I don't see how you can do it without a digital map. I think it's an invaluable tool on the logistics side and has potential in terms of monitoring as well," he says.

Pradhan adds that the GIS technology makes it possible to "determine areas where vaccination services have not yet been planned so that, in the future, new sites can be determined and immunization sessions planned for these areas."

GPS unit
Affordable GPS units helped planners locate the Anganwadi Centers on digital and paper maps, and coordinate getting vaccine and medical staff to those locations efficiently.

Young works in ATSDR's Geospatial Research Analysis & Services Program. The program includes 20 geographers, making it the largest GIS group at CDC. The group frequently consults with other parts of the agency in developing applications for GIS mapping technology. Currently, GIS tools are used on many public health efforts, including to monitor the progress of the H1N1 virus and to locate US areas near active hazardous waste sites. Young also utilizes GIS tools to quantify the geographic barriers to women in using mammography clinics.

"This tool is promising. In urban areas where outreach activities have not yet been initiated the GIS-aided planning tool could be of immense versatile use – particularly with the onset of NUHM (National Urban Health Mission in India), a tool such as the GIS would be helpful in mapping slums and underserved areas and help in planning for the location of Urban Health posts and determining the service areas of urban community link workers," Pradhan says.

CDC staff will continue to monitor progress with the pilot in Patna, and stand ready to provide additional assistance if the local staff request it.

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