The extremely low rates of routine immunization in large parts of the country remain a matter of serious concern. Inadequate routine administration of polio vaccine in UP, Bihar, West Bengal and some other parts has been chiefly responsible for the delay in polio eradication from India. Sporadic outbreaks of diphtheria and measles have been observed in different parts in the Northern States. We need to examine various issues and impediments involved and consider taking more proactive and persuasive measures.

Despite sound strategies and massive inputs of resources (involving huge finances and manpower) India is not polio free as yet. In Bangladesh and Sri Lanka a very high rate of routine immunization has contributed to eradication of polio (polio was "imported" into the former country from India in 2006, but the spread was rapidly contained). In India the southern states, having close to 90% routine immunization coverage, are virtually polio-free. A few districts in Western UP and Bihar continue to harbor wild poliovirus, from where it is exported to contiguous and remote areas (West Bengal, Mumbai, Andhra Pradesh). The strong resistance of small segments of illiterate and underprivileged population in a few districts (and certain other pockets) to supplementary polio immunization has resulted in persistent endemic transmission of poliovirus in these areas. A substantial number of infants and children continue to be missed during the Pulse Polio campaigns. After considerable delay, India had seemed close to eradication of wild poliovirus with only 66 cases being reported during the year 2005 (an all time low). However, there was a setback in 2006 with 641 cases (81% in UP and 9% in Bihar). This year, by mid-August, 163 cases have been reported (130 from UP and 21 from Bihar). The surveillance data indicate that wild poliovirus transmission is mostly in children below 3 years in the endemic areas, because insufficient number in that age group have been immunized (which could have been possible through adequate routine immunization).

The goal of global eradication of polio seems reachable despite the problems in India and the difficulties of immunizing target populations in remote areas of Pakistan and Afghanistan. In India, the wisdom of incurring large amounts of expenditure and massive deployment of manpower aimed at polio eradication, while many other common and serious diseases remain widely prevalent and require control measures, has rightly been questioned. However, having come so far of getting the world rid of this scourge, the world community and various funding and supportive agencies appear determined to attain that goal. Had there been a high coverage of routine polio vaccination, it is very likely that India would have been polio-free by now. Even after polio eradication is achieved, universal routine coverage with polio vaccine will be necessary to prevent re-introduction of wild poliovirus.

Protection from vaccine preventable diseases is one of the most crucial rights of children. Whereas, the Southern States in India have been successful in providing routine vaccinations and other basic health facilities, the health infrastructure in some Northern States remains extremely poor and the immunization coverage very low. The obvious question arises as to why a very large number of children remain inadequately immunized?

The inadequately immunized children are mostly in rural areas and in urban slums, and semiurban, underprivileged communities. In the former the health delivery facilities are very poor and health care units almost nonfunctional. Remoteness and lack of communications are a factor in some States. Even the available services in urban areas are often not utilized, for various reasons. Immunizations often remain incomplete because the parents do not bring the infant for subsequent doses, because of frequent occurrence of fever and pain following the first dose of DPT vaccine. Little effort is made by the health officials (PHC staff, Anganwadi workers) as well as others (such as school teachers) to ensure full immunizations.

Whereas the parents must have the primary responsibility of getting their child fully immunized (along with ensuring proper health care and nutrition), the child must not be made to suffer if the caregivers are not able to discharge that duty. In a caring and civil society children’s needs and rights must not be neglected and the community should take up the necessary measures to ensure care and justice for all children.

The gravity of the situation calls for a more vigorous approach. Recently, the government has made renewed efforts to provide routine immunizations. The logistic aspects (vaccine availability, use of disposable syringes, monitoring, etc.) are being addressed. The required facilities, particularly in rural areas, are being strengthened. However, no amount of planning and "action from the top" is likely to succeed unless the vaccination procedures are accepted and sought by the community, which, in the present state of socioeconomic development (ignorance and apathy being widely prevalent) seems unlikely. Making routine immunization compulsory would generate a sense of urgency and create demands for the required inputs. In southern States in India and in many developing countries (with economic and educational standards no better than UP or Bihar) routine vaccination coverage is very high since that practice has been established as a norm.

The onus of having the child vaccinated cannot be totally placed on the parents and they cannot be reprimanded for their ignorance and negligence. The proximate community must shoulder that responsibility. In rural areas, the village Panchayat officials may be made accountable and ensure that every child in the village is adequately vaccinated. They need to be informed about the benefits of vaccinations and, along with the health officials, they should tackle misinformation and local problems. The village could be offered some incentive if every child is fully immunized. The Government has made plans to empower the village councils, and encourage overall rural development (infrastructure, electrification, telecommunication, health status, etc.). A recent government document lists various functions of the Village Panchayats(1). The core functions concern drinking water, roads, culverts, bridges, rural electrification, health and sanitation, including hospitals, primary health centres and dispensaries. The Village Panchayat should demand proper facilities for vaccinations and basic health care.

Children in urban slums, those from migrant families employed in construction work, children working at various odd jobs and street children receive very little health care. Illiterate parents do not avail of whatever facilities may be at hand. Mobile Health teams and NGOs providing vaccinations and basic health care facilities could easily reach the urban underprivileged population. Again, the responsibility for that should be assigned to the local elected representatives and community leaders.

Every child in the country should have a Health Card. The card should include the child’s birth registration, a few very basic health information messages and details of immunization records and any major disability and disease. The card should be regarded as a valuable document and appropriately prepared to ensure lasting quality. Besides providing vital information, the card would be of help in provision of health care. The Health Card should be issued at birth, to be updated until the age of 18 years and serve as a lifelong record thereafter. However, such cards can be urgently supplied to all children under the age of 5 years.

While taking cognizance of various new vaccines and their usage, the IAP has helplessly watched the declining rates of routine immunization. We can do little for poor governance, misinformation and a host of other socioeconomic problems. We must, however, fight for the most essential measures to protect children from disease and disability and their overall welfare. IAP should demand that routine immunization be made compulsory for all children.