A drop in the bucket: Rotary volunteer Prassad Sundaram immunizes a young child in India. Credit: Rotary Bangalore

It was a dispiriting summer for Rotary club volunteers in the southern Indian states of Karnataka and Andhra Pradesh, where a recent polio outbreak has saddled the organization with the challenge of intensifying an already considerable grassroots immunization campaign.

India is one of only seven countries in the world where polio is still endemic—and perhaps the most troublesome. Last year, the nation recorded nearly 1,600 cases—a sixfold increase over the previous two years, representing 85% of cases worldwide. Concentrated immunization efforts in the northern states of Uttar Pradesh and Bihar have reduced India's total cases this year to 115, with record-setting lows for the season of high transmission.

But Karnataka and neighboring Andhra Pradesh, which had been polio-free since 2000, recorded 16 cases between July and early September.

In Bangalore, where 2,000 members from 37 Rotary clubs participate in polio eradication efforts, news of the virus's resurgence has prompted a reassessment of the tactics that had taken more than a decade to refine.

“I'm worried; I'm very worried, because even one case means we have a desperate situation,” says Prassad Sundaram, assistant district director of the Bangalore Rotary. One recent planning session was marked by finger-pointing, Sundaram adds, with Rotarians asking, “How could this happen? Who let whom down?”

The Global Polio Eradication Initiative, a partnership between the World Health Organization (WHO), Rotary International and the US Centers for Disease Control and Prevention, this year refocused its strategy, with the goal of worldwide eradication by 2005. The initiative is moving US$35 million and 297 million additional doses of oral polio vaccine (OPV) to all polio-endemic countries and to another seven countries at risk from the virus.

But whether that money will trickle down to the local level—where volunteers drop OPV into the mouths of the 170 million Indian children under the age of five—remains unclear.

Rotary clubs in India still receive Rs 4,000 (approximately US$87) from their national council to coordinate the two national immunization days (NIDs) scheduled for early next year. Sundaram says his club raises and spends more than Rs 50,000 per NID. They are now scrambling for additional funds to rent billboards across Bangalore—at a cost of Rs 1.5 million—to urge parents to immunize their children.

During the NIDs, volunteers mark immunized children on the cuticles, then comb the city and outlying villages for untagged children. They chalk the doors of the thousands of houses they have visited. Full immunization requires five OPV doses during a child's first 1.5 years, supplemented during NIDs with at least 10 doses through age five.

Given India's birth cohort of nearly 28 million children per year, any lapses in routine immunization can cause significant setbacks, says Louise Baker of the WHO's Southeast Asia office in New Delhi. With some two million children born between immunization days, disenfranchised or geographically isolated areas can quickly become hotbeds of transmission.

According to P. Narayana, vice chairman for Rotary India's national PolioPlus committee, a study commissioned after the virus's resurgence found that less than 70% of the children—considerably less than the 98% the organizers believed they had reached—in some southern districts had been immunized during the past year

“People have become apathetic,” says Narayana. “Some here got the impression that [the NIDs are] good enough, but the newborn children are not adequately protected.”