‘Ever-expanding’ Immunization Program

Recently it was reported that the Central Government has decided to introduce pneumococcal conjugate vaccine (PCV) under the Universal Immunization Program (UIP)¹.

The report mentioned that 50% of the pneumonia-related deaths in children below 5 years of age are due to pneumococcal pneumonia. It also said that Hib pneumonia responsible for 25% of pneumonia-related deaths is already addressed by pentavalent vaccine under UIP.

Expanded Programme of Immunization (EPI) was launched in 1978 with BCG, OPV, DPT and typhoid-paratyphoid vaccines. Typhoid-paratyphoid vaccine was dropped from EPI in 1981. The EPI was rechristened with some major change in focus by the launch of Universal Immunization Programme (UIP) on November 19, 1985. The measles vaccine was added to the existing schedule².

No new antigen was added to the programme for the next 16 years. During this period, globally and in India, a number of new vaccines became licensed and available in the market. The first new antigen added since the beginning of UIP was hepatitis B vaccine which became the 7^th antigen to be introduced in the UIP across the country in 2011 ².

Later, Haemophilus influenza type b (Hib), Rotavirus, Japanese Encephalitis, and Pentavalent vaccines were added to the program bringing the total no. of vaccines to 11^3,4.

The recently included PCV needs a deeper look into the clinical experience with this vaccine. In a trial of 14-valent pneumococcal vaccine, immune response to the pediatric serotypes was reported to be poor until the age of 4.5 years⁵.

In another study, effectiveness of heptavalent pneumococcal vaccine was seen to be greatest in first year of life. However, lack of demonstrated benefit in children >2 years of age was a concern. It could be due to changes in serotype distribution of pneumococci causing disease in older children with age. A decreasing proportion of disease caused by vaccine serotypes could also account for the observed results. Another risk could be that vaccination might increase carriage of non vaccine serotypes. It is also possible that the observed decrease in vaccine effect is due to a decrease in the proportion of pneumococcal pneumonia in older children. The proportion of childhood pneumonia caused by Mycoplasma pneumoniae and Chlamydia pneumoniae increases beyond age 2 years⁶.

Hence, addition of PCV in the UIP has given rise to many questions. In the past, concern has been raised about pressure from the vaccine industry to include new vaccines in UIP even though the clinical and epidemiological justification for their inclusion is controversial⁷.

It has also been suggested that the government does not appear to have access to quality data and high quality expert advice⁸. Even those with expertise on the matter do not tread an independent path, fearing the wrath of their international donors. Immunisation matters are left to manufacturers and international organisations, to “guide” and decide what is to be introduced in our market. Hence, broadly speaking, two nexuses are operating at present — one between international health agencies and the government, and another between vaccine companies and academic associations⁹.

This issue definitely merits a critical analysis of the public health policies in our Country.

References:

1. Times of India. Sunday, April 16, 2017
2. Lahariya C A brief history of vaccines & vaccination in India. Indian J Med Res 2014; 139: 491-511
3. Press Information Bureau, Government of India, Ministry of Health and Family Welfare
   15-March-2013. Available from: http : // www.nic.in / newsite /PrintRelease.aspx ? relid = 93717. Accessed on 24-04-2017
4. National Health Mission, Dept. of Health and Family Welfare, Govt. of Himachal Pradesh. Available from http://www.nrhmhp.gov.in/content/immunisation. Accessed on 24-04-2017
5. Douglas RM, Paton JC,  Duncan SJ, Hansman Antibody Response to Pneumococcal Vaccination in Children Younger than Five Years of Age. J Infect Dis 1983; 148 (1): 131-137(Abstract)
6. Black SB et al Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis J, 2002;21:810–15
7. Puliyel JM, Madhavi Y.Vaccines: policy for public good or private profit? Indian J Med Research. 2008;127: 1-3
8. Bansal CP. IAP’s perspectives on current vaccination scenario in india. Indian pediatrics 2013;50:911-12
9. Vipin M Vashishta; The nexus and the ills afflicting the vaccination practices Indian J Med Res. 2008; 127: 502-3

Dr Vijay Sohoni , January 2018