Polio Immunization Research Articles

Evaluation of intensive pulse polio immunization in Solapur District

Background: Mass immunization campaigns are now an established fact for the eradication of poliomyelitis. Intensified pulse polio immunization (IPPI) campaigns using only a booth-based approach have not been sufficient to interrupt wild poliovirus transmission in different areas, where it is most persistent with low immunization coverage. Since 1995, PPI is conducted in India and IPPI was introduced in 1998. When we are progressing toward polio eradication and ever-increasing efforts are being done to administer polio drops to every eligible child, it has been observed subjectively that an element of fatigue is creeping in the health system and community. Aim and Objective: The objective of the study is to assess the operational aspects and knowledge of staff regarding PPI program. Material and Methods: Study design – A community-based cross-sectional study. Setting – Six taluks of Solapur district – Mangalwedha, Sangola, Barshi, Mohol, Pandharpur, and Madha. Study period – October 24–30, 2010, and November 21–27, 2010, i.e., 2 weeks. Sample studied – 174 booths, 359 parents, 1289 houses, and 3162 children under 5 years of age. Result: Out of 174 booths, 94.83% booths were easily accessible and IEC material displayed prominently on 85.06% booths.. Regarding source of information of IPPI, 38.16% parents got information from health workers followed by poster. Placement of teams at transit sites, teams were adequate at 80.77% sites, shifting timing appropriate at 88.46%, deployed member present at site in only 76.92% booths and supervisor cross checking the work of teams at only 50% booths. More than 85% of total booth workers were trained. On post booth day activity, in migrant's population 11.97% children were unimmunized whereas in settled population it was 2.32%. Percentage of unimmunized children in migratory population was more than settled population which is statistically highly significant. Conclusion: Special attention is required toward immunization of migratory populations, including slums with migration, nomads, sugar cane cutters, brick kiln workers, also construction site workers and also on transit sites including bus stand, railway stations, mela sites, and weekly bazaars. The role of local media and mass communication programs should be worked out and organized in a more systemic manner. Use of mass media must be done to motivate people for immunization. Supervisor work needs to improve. Community participation should be view as one of the key component for the success of the program. More voluntary agencies, persons, local leaders, and nongovernmental organizations should be motivated to come forward and work for this noble cause.

Impact of engaging security personnel on access and polio immunization outcomes in security-inaccessible areas in Borno state, Nigeria

BackgroundNigeria was polio free for almost 2 years but, with the recent liberation of areas under the captivity of insurgents, there has been a resurgence of polio cases. For several years, these inaccessible areas did not have access to vaccination due to activities of Bokoharam, resulting in a concentration of a cohort of unvaccinated children that served as a polio sanctuary. This article describes the processes of engagement of security personnel to access security-compromised areas and the impact on immunization outcomes.MethodsWe assessed routine program data from January 2016 to July 2016 in security-inaccessible areas and we evaluated the effectiveness of engaging security personnel to improve access to settlements in security-compromised Local Government Areas (LGAs) of Borno state. We thereafter evaluated the effects of this engagement on postcampaign evaluation indicators.ResultsFrom 15 LGAs accessible to vaccination teams in January 2016, there was a 47% increase in July 2016. The number of wards increased from 131 in January to 162 in July 2016, while the settlement numbers increased from 6050 in January to 6548 in July 2016. The average percentage of missed children decreased from 8% in January to 3% in July 2016, while the number of LGAs with ≥ 80% coverage increased from 85% in January to 100% in July 2016.ConclusionThe engagement of security personnel in immunization activities led to an improved access and improvement in postcampaign evaluation indicators in security-compromised areas of a Nigerian state. This approach promises to be an impactful innovation in reaching settlements in security-compromised areas.

Correlation between Non-Polio Acute Flaccid Paralysis Rates with Pulse Polio Frequency in India.

The last case of polio from India was reported in 2011. That year, the non-polio acute flaccid paralysis (NPAFP) rate in India was 13.35/100,000, where the expected rate is 1–2/100,000. A previous study of data from 2000 to 2010 has detailed the NPAFP rate in a state correlated with the pulse polio rounds conducted there, and the strongest correlation with the NPAFP rate was found when the number of doses from the previous 4 years were used. However, a simple association being found with regression analysis does not prove a causal relationship. After publication of those findings, as the threat of polio had lessened, the number of rounds of OPV administration was brought down. The present study has been done to look at data till the end of 2017, to see if the incidence of NPAFP declined with this reduction in polio immunization rounds. We used polio surveillance data acquired by the Government of India from 2000–2017. Correlation of the NAFP rate to the number of polio rounds in the state was examined, and the cumulative effect of polio doses administered in previous years was sought. NPAFP rate correlated with the OPV pulse polio rounds in that year (R = 0.46; p < 0.001), and the NPAFP rate started to decrease from 2012 when the number of pulse polio rounds had decreased. NPAFP rates in the states of Uttar Pradesh (UP) and Bihar were the highest in the country. Looking at the high-NPAFP states of UP and Bihar, we found that the correlation coefficient was strongest when doses used over 5 years was considered (R = 0.76; p < 0.001). The response to the reduction in OPV rounds (de-challenging) adds credence to the assumption that OPV was responsible for the change in the NPAFP rate. Now that India has been polio-free for over 6 years, we propose that we may be able to reduce NPAFP by further reducing pulse polio rounds.

Epidemiological serosurvey of poliovirus in Guangdong, China: A cross-sectional study

ABSTRACTA cross-sectional study for poliovirus seroprevalence in Guangdong was carried out in 2014, just before a change in polio vaccine commenced in 2015. The aim of the study was to test whether polio immunity level was high enough to satisfy the polio vaccine switch. A total of 6339 people were tested for poliovirus neutralization antibodies (NA). Overall NA seropositivity for PV1, PV2 and PV3 were 95.2%, 94.9% and 88.7%, and the respective geometric mean titer (GMT) were 82.9, 55.8, and 26.3, respectively. There were statistically significant differences in the positive rates and GMT of the 3 serotypes and PV3 had relatively lower positive rates and GMT. The highest seropositivity and GMT were observed in the 1–9 year-old age group. The positive rates of NA and GMT for PV1, PV2 and PV3 in the western region of Guangdong were lower than those of other three regions. The results of this study showed that the population of Guangdong province had a high polio immunity level, a stable base for a polio vaccine switch.

50 Years Ago in the Journal of Pediatrics: Oral Polio Immunization of the Newborn Infant; A Possible Method for Overcoming Interference by Ingested Antibodies

50 Years Ago in the Journal of Pediatrics: Oral Polio Immunization of the Newborn Infant; A Possible Method for Overcoming Interference by Ingested Antibodies

AWARENESS OF GENERAL PUBLIC TOWARDS POLIO IMMUNIZATION IN RURAL PUNJAB PAKISTAN

Background: Poliomyelitis is the acute viral infections of children under the age of five years. Pakistan is among the three countries, along with Nigeria and Afghanistan that are endemic to polio. In 2012, government of Pakistan approved a National Emergency Action Plan (NEAP) for polio eradication. Parents are reluctant towards immunization due to some religious beliefs. In current study we are accessing the attitude and behavior of general population towards polio vaccination. Methods: Cross-sectional study conducted during 2017 in 4 district of Punjab (Faisalabad, Sheikhpura, Kasur and Lahore) Pakistan. The pretested, piloted and validated instrument with a 20 items structured questionnaire was used for this research. The response rate was 84% during the course of Study. Results: In study population 79% of the respondents were well aware of the term Polio. The positive response towards polio immunization was analyzed for only 62% of the parents. 70.46% of the parents strongly agreed with the medical therapeutics for the prevention and treatment of the disease whereas 29.54% of the respondents were found to believe that polio might be caused due to the evil effects Conclusion: Study concluded that the general public is well informed about polio vaccination and giving vaccine to their children on regular basis.

6.5-O8High coverage of the polio immunization program in refugees resettling in Denmark

6.5-O8High coverage of the polio immunization program in refugees resettling in Denmark

A descriptive characterization of acute flaccid paralysis in Nigeria, 2015

Introduction: World Health Organization defines Acute Flaccid Paralysis (AFP) as a syndrome characterized by sudden and rapid weakness of the extremities. The outbreak of wild polio virus in Borno State in August, 2016, necessitated intensive responses in the northern parts of Nigeria with several Polio Immunization Plus Days activities. This study aimed at descriptively characterization of AFP in Nigeria, with a view of identifying the population at risk of AFP, to assess the health seeking behavior of patients with AFP and to determine the pattern of paralysis.

Revaccination after Autologous Hematopoietic Stem Cell Transplantation Is Safe and Effective in Patients with Multiple Myeloma Receiving Lenalidomide Maintenance

Guidelines recommend vaccination starting 12 months after autologous hematopoietic stem cell transplant (aHCT), but there is varying practice for patients on maintenance therapy, with some centers not immunizing at all. Because of decreased vaccine rates among the general population causing loss of herd immunity, we aimed to establish the safety and efficacy of revaccinating multiple myeloma patients on lenalidomide maintenance (LM). Of the 122 patients who were vaccinated after aHCT between 2010 and 2014 at Memorial Sloan Kettering Cancer Center, 91 (75%) were on LM. Vaccine responses were defined by increases between pre- and postvaccination titers. Reponses varied by vaccine type with 76% responding to pertussis, 70% diphtheria, 60% tetanus, 71% Haemophilus influenzae, and 58% pneumococcal. All patients retained minimal levels of polio immunity, but 27% responded with increased titers. Fewer patients received hepatitis A and B, but of those who did, 30% responded to hepatitis A and 40% to hepatitis B. No differences were seen in rates of response for those on LM at time of vaccination compared with those who were not. There were no vaccine-related adverse effects. Reimmunization with inactivated vaccines in patients on LM is therefore both safe and effective, offering this population immunity to vaccine-preventable diseases.

Assessing the impact of the Lebanese National Polio Immunization Campaign using a population-based computational model

BackgroundAfter the re-introduction of poliovirus to Syria in 2013, Lebanon was considered at high transmission risk due to its proximity to Syria and the high number of Syrian refugees. However, after a large-scale national immunization initiative, Lebanon was able to prevent a potential outbreak of polio among nationals and refugees. In this work, we used a computational individual-simulation model to assess the risk of poliovirus threat to Lebanon prior and after the immunization campaign and to quantitatively assess the healthcare impact of the campaign and the required standards that need to be maintained nationally to prevent a future outbreak.MethodsAcute poliomyelitis surveillance in Lebanon was along with the design and coverage rate of the recent national polio immunization campaign were reviewed from the records of the Lebanese Ministry of Public Health. Lebanese population demographics including Syrian and Palestinian refugees were reviewed to design individual-based models that predicts the consequences of polio spread to Lebanon and evaluate the outcome of immunization campaigns. The model takes into account geographic, demographic and health-related features.ResultsOur simulations confirmed the high risk of polio outbreaks in Lebanon within 10 days of case introduction prior to the immunization campaign, and showed that the current immunization campaign significantly reduced the speed of the infection in the event poliomyelitis cases enter the country. A minimum of 90% national immunization coverage was found to be required to prevent exponential propagation of potential transmission.ConclusionsBoth surveillance and immunization efforts should be maintained at high standards in Lebanon and other countries in the area to detect and limit any potential outbreak. The use of computational population simulation models can provide a quantitative approach to assess the impact of immunization campaigns and the burden of infectious diseases even in the context of population migration.

Polio immunity and the impact of mass immunization campaigns in the Democratic Republic of the Congo.

BackgroundIn order to prevent outbreaks from wild and vaccine-derived poliovirus, maintenance of population immunity in non-endemic countries is critical.MethodsWe estimated population seroprevalence using dried blood spots collected from 4893 children 6–59 months olds in the 2013–2014 Demographic and Health Survey in the Democratic Republic of the Congo (DRC).ResultsPopulation immunity was 81%, 90%, and 70% for poliovirus types 1, 2, and 3, respectively. Among 6–59-month-old children, 78% reported at least one dose of polio in routine immunization, while only 15% had three doses documented on vaccination cards. All children in the study had been eligible for at least two trivalent oral polio vaccine campaigns at the time of enrollment; additional immunization campaigns seroconverted 5.0%, 14%, and 5.5% of non-immune children per-campaign for types 1, 2, and 3, respectively, averaged over relevant campaigns for each serotype.ConclusionsOverall polio immunity was high at the time of the study, though pockets of low immunity cannot be ruled out. The DRC still relies on supplementary immunization campaigns, and this report stresses the importance of the quality and coverage of those campaigns over their quantity, as well as the importance of routine immunization.

FACTORS ASSOCIATED WITH LOW ACHIEVEMENT IN POLIO IMMUNIZATION

Background of the research: The Ministry of Health Republic of Indonesia has been implementing Polio Immunization (PIN) 2016 simultaneously in Indonesia since 8 to 15 March 2016. Overall, the result of implementation PIN polio at Dharmasraya regency in 2016 has reached about 93.15%. While the lowest scored was reached by Tiumang PHC 75.76%. The purpose of this research is to determine the factors associating on the low of reaching polio immunization in March 2016 at community health centers (Puskesmas) Tiumang Dharmasraya 2016. Methods: using descriptive analytic with Cross-Sectional Study research design. The number of samples is 94 people with accidental sampling technique. Where the research was conducted in Puskemas Tiumang, Dharmasraya. Data were collected using a questionnaire then processed by SPSS software. The result of the study is presented in the form of distribution frequency and chi-square test. Result: The study showed that almost half of 42 respondent were knowledgeable (44.7%), negative (45.7%), and the lowest (3.2%) in no act category. Furthermore, almost half is supported by negative family (30.9%). The result of the statistical test found that (p-value=0.093), there is no significant relationship between knowledge and polio immunization. Moreover, there is no significant relationship between attitudes toward immunization values (p-value=0.082), there is no significant relationship between the cadres roles and polio immunization (p-value=0.591). However, only family support that can reach the significant relationship toward immunization (p-values= 0.005). Discussions: it is hoped that mothers concern about their children‟s health to be kept and those who have not been motivated yet to visit with their children getting immunization polio.Key Word: Knowledge, Behavior, Achieviement, Polio

Stakeholder perceptions of communication about vaccination in two regions of Cameroon: A qualitative case study.

BackgroundUnderstanding stakeholders’ (parents’, communities’ and health workers’) perspectives of communication about childhood vaccination, including their preferences for its format, delivery and content, is an important step towards designing better communication strategies and ensuring more informed parents. Our objectives were to explore stakeholders’ views, experiences and preferences for childhood vaccination communication in Cameroon.MethodsIn 2014, in the Central and North West Regions of Cameron, we gathered qualitative data for our case study using the following methods: semi structured interviews; observations and informal conversations during routine immunization clinics and three rounds of the National Polio Immunization Campaign; document analysis of reports and mass media communications about vaccination; and a survey of parents. We conducted a thematic analysis of the qualitative data to identify themes relating to views, experiences and perceptions of vaccination information and its delivery. Survey data were analysed using simple descriptive statistics.ResultsAll of the parents interviewed felt that vaccinating their child was important, and trusted the information provided by health workers. However, many parents wanted more information. Parents did not always feel that they could ask questions during vaccination appointments. All participants felt that health workers and vaccination clinics were important sources of information. Social mobilisation activities such as door-to-door visits and announcements during religious services were important and accepted ways of communicating information, especially during vaccination campaigns. Information communicated through mass media and text messages was also seen as important. In general, stakeholders believed that more consistent messaging about routine vaccination through community channels would be helpful to remind parents of the importance of routine vaccination during ongoing rounds of vaccination campaigns against polio.ConclusionsThis study confirms that parents regard information about childhood vaccination as important, but that health services need to be organized in ways that prioritize and facilitate communication, particularly about routine vaccination.

Intradermal Administration of Fractional Doses of Inactivated Poliovirus Vaccine: A Dose-Sparing Option for Polio Immunization.

A fractional dose of inactivated poliovirus vaccine (fIPV) administered by the intradermal route delivers one fifth of the full vaccine dose administered by the intramuscular route and offers a potential dose-sparing strategy to stretch the limited global IPV supply while further improving population immunity. Multiple studies have assessed immunogenicity of intradermal fIPV compared with the full intramuscular dose and demonstrated encouraging results. Novel intradermal devices, including intradermal adapters and disposable-syringe jet injectors, have also been developed and evaluated as alternatives to traditional Bacillus Calmette–Guérin needles and syringes for the administration of fIPV. Initial experience in India, Pakistan, and Sri Lanka suggests that it is operationally feasible to implement fIPV vaccination on a large scale. Given the available scientific data and operational feasibility shown in early-adopter countries, countries are encouraged to consider introducing a fIPV strategy into their routine immunization and supplementary immunization activities.

Birth complications control between midwives among women in Cross River States-Nigeria

Objectives: This study sought to assess birth complications control between midwives among women in cross river states-Nigeria. To achieve this purpose, one null hypothesis was formulated to guide the study. Method: The study adopted was survey design. The sample consisted of 360 post-natal women selected from a population of 78,814 through the polio immunization registers of selected health centers. Accidental sampling technique was used to select the respondents. The instrument used for collecting data for the study was a 36-item questionnaire. Independent t-test and contingency chi-square were used in testing the null hypotheses. Results: The result showed that women delivered by traditional midwives have more negative control of delivery pain caused by birth complication than their counterparts who are delivered by western trained midwives; On the basis of finding it implies that western midwives are different from their counterparts. All what the traditional midwives need is workshops, seminars, conferences during ante-natal period to acquaint the traditional midwives with delivery related activities and procedures. It was also recommended that the traditional midwives should be given adequate training so that they can face the society and avoid further complications. Conclusion: Government should also continue to train more midwives to avoid the patronage of traditional birth attendance because hospital is the best place for delivery.

Acute flaccid paralysis surveillance in bosnia and herzegovina: Recent isolation of two sabin like type 2 poliovirus.

The WHO Regional Commission for the Certification of Poliomyelitis Eradication has recently indicated Bosnia and Herzegovina (B&H) as a high risk country for transmission, following importation, of wild poliovirus (WPV) or circulating vaccine-derived poliovirus (cVDPV). We analyzed data on Acute Flaccid Paralysis (AFP) surveillance between 2007 to 2016, and the trend of polio immunization coverage in B&H. The majority of AFP cases was recorded in 2016 suggesting an enhancement of the AFP surveillance activities. However, the decline in the immunization coverage, around 74%, and the isolation of two Sabin-like poliovirus type 2 strains, one of them close to a VDPV, require a particular attention in the area. Although B&H has successfully maintained its polio-free status since 2002 several challenges need to be addressed.

Determinants of successful vitamin A supplementation coverage among children aged 6-59 months in thirteen sub-Saharan African countries.

Vitamin A supplementation (VAS) for children aged 6-59 months occurs regularly in most sub-Saharan African countries. The present study aimed to explore child, household and delivery platform factors associated with VAS coverage and identify barriers to compliance in thirteen African countries. We pooled data (n ~60 000) from forty-four household coverage surveys and used bivariate and multivariable regression analyses to assess the effects of supplementation strategy, rural v. urban residence, child sex, child age, caregiver education and campaign awareness on child VAS status. Setting/Subjects Primary caregivers of children aged 6-59 months in thirteen countries. Door-to-door distribution resulted in higher VAS coverage than fixed-site plus outreach approaches (91 v. 63 %) and was a significant predictor of supplementation in the adjusted model (OR=19·0; 95 % CI 17·2, 21·1; P<0·001). Having been informed about the campaign was the main predictor of VAS in the door-to-door (OR=6·8; 95 % CI 5·8, 7·9; P<0·001) and fixed-site plus outreach (OR=72·5; 95 % CI 66·6, 78·8; P<0·001) groups. Door-to-door provision of VAS may achieve higher coverage than fixed-site models in the African context. However, the phase-out of door-to-door polio immunization campaigns in most sub-Saharan African countries threatens the main distribution vehicle for VAS. Our findings suggest well-informed communities are key to attaining higher coverage using fixed-site delivery alternatives.

Community engagement and integrated health and polio immunisation campaigns in conflict-affected areas of Pakistan: a cluster randomised controlled trial.

SummaryBackgroundPakistan faces huge challenges in eradicating polio due to widespread poliovirus transmission and security challenges. Innovative interventions are urgently needed to strengthen community buy-in, to increase the coverage of oral polio vaccine (OPV) and other routine immunisations, and to enhance immunity through the introduction of inactivated polio vaccine (IPV) in combination with OPV. We aimed to evaluate the acceptability and effect on immunisation coverage of an integrated strategy for community engagement and maternal and child health immunisation campaigns in insecure and conflict-affected polio-endemic districts of Pakistan.MethodsWe did a community-based three-arm cluster randomised trial in healthy children aged 1 month to 5 years that resided within the study sites in three districts of Pakistan at high risk of polio. Clusters were randomly assigned by a computer algorithm using restricted randomisation in blocks of 20 by an external statistician (1:1:1) to receive routine polio programme activities (control, arm A), additional interventions with community outreach and mobilisation using an enhanced communication package and provision of short-term preventive maternal and child health services and routine immunisation (health camps), including OPV (arm B), or all interventions of arm B with additional provision of IPV delivered at the maternal and child health camps (arm C). An independent team conducted surveys at baseline, endline, and after each round of supplementary immunisation activity for acceptability and effect. The primary outcome measures for the study were coverage of OPV, IPV, and routine extended programme on immunisation vaccines and changes in the proportion of unvaccinated and fully vaccinated children. This trial is registered with ClinicalTrials.gov, number NCT01908114.FindingsBetween June 4, 2013, and May 31, 2014, 387 clusters were randomised (131 to arm A, 127 to arm B, and 129 to arm C). At baseline, 28 760 children younger than 5 years were recorded in arm A, 30 098 in arm B, and 29 126 in arm C. 359 clusters remained in the trial until the end (116 in arm A, 120 in arm B, and 123 in arm C; with 23 334 children younger than 5 years in arm A, 26 110 in arm B, and 25 745 in arm C). The estimated OPV coverage was 75% in arm A compared with 82% in arm B (difference vs arm A 6·6%; 95% CI 4·8–8·3) and 84% in arm C (8·5%, 6·8–10·1; overall p<0·0001). The mean proportion of routine vaccine doses received by children younger than 24 months of age was 43% in arm A, 52% in arm B (9%, 7–11) and 54% in arm C (11%, 9–13; overall p<0·0001). No serious adverse events requiring hospitalisation were reported after immunisation.InterpretationDespite the challenges associated with the polio end-game in high-risk, conflict-affected areas of Pakistan, a strategy of community mobilisation and targeted community-based health and immunisation camps during polio immunisation campaigns was successful in increasing vaccine coverage, including polio vaccine coverage.FundingBill & Melinda Gates Foundation.

Knowledge and perceptions of polio and polio immunization in polio high-risk areas of Pakistan.

Pakistan and Afghanistan remain the only countries where polio is endemic, and Pakistan reports the most cases in the world. Although the rate is lower than in previous years, the situation remains alarming. We conducted a mixed methods study in high-risk areas of Pakistan to identify knowledge, attitudes, and practices of target populations about polio vaccine and its eradication, and to estimate coverage of routine immunization and oral polio vaccine. We surveyed 10,685 households in Karachi, 2522 in Pishin, and 2005 in Bajaur. Some knowledge of polio is universal, but important misconceptions persist. The findings of this study carry strategic importance for program direction and implementation.

Assessment of source of information for polio supplementary immunization activities in 2014 and 2015, Somali, Ethiopia.

IntroductionCommunication is key for the successful implementation of polio vaccination campaigns. The purpose of this study is to review and analyse the sources of information utilized by caregivers during polio supplementary immunization activities (SIAs) in Somali, Ethiopia in 2014 and 2015.MethodsData on sources of information about the polio campaign were collected post campaign from caregivers by trained data collectors as part of house to house independent monitoring. The sources of information analysed in this paper include town criers (via megaphones), health workers, religious leaders, kebele leaders (Kebele is the lowest administrative structure in Ethiopia), radio, television, text message and others. The repetition of these sources of information was analysed across years and zones for trends. Polio vaccination campaign coverage was also reviewed by year and zones within the Somali region in parallel with the major sources of information used in the respective year and zones. 57,745 responses were used for this analysis but the responses were received from < or = 57,745 individuals since some of them may provide more than one response. Moreover, because sampling of households is conducted independently during each round of independent monitoring, the same household may have been included more than once in our analysis. The methodology used for independent monitoring does not allow for the calculation of response rates. Monitors go from house to house until information from 20 households is received.ResultsFrom the total 57,745 responses reviewed, over 37% of respondents reported that town criers were their source for information about the 2014 and 2015 polio SIAs. Zonal trends in using town criers as a major source of information in both study years remained consistent except in two zones. 87.5% of zones that reported at least 90% coverage during both study years had utilized town criers as a major source of information while the rest (12.5%) used health workers.ConclusionWe found that town criers were consistently the major source of information about the polio campaigns for Somali region parents and caregivers during polio immunization days held in 2014 and 2015. Health workers and kebele leaders were also important sources of information about the polio campaign for parents.