Universal Immunisation Programme

This refers to a very thought-provoking article by Jayakrishnan (1). I fully agree with the statement, “Immunisation matters are left to manufacturers and international organisations, to “guide” and decide what is to be introduced in our market.” (1).

There is an acute need to protect adolescents and young adults from the economically poor sections against pertussis and diphtheria. In 2008, the Indian Academy of Pediatrics Committee on Immunisation (IAPCOI), in the consensus recommendations on immunisation, stated: “There is no reason to believe that the disease burden of pertussis is low in adolescents in India. A safe and efficacious vaccine is available. The IAPCOI , therefore, recommends offering Tdap vaccine instead of Td/TT vaccine in all children/adolescents who can afford to use the vaccine” (2). Tdap contains acellular pertussis antigen, and is very expensive (MRP Rs 699) while Td costs Rs 10.08 only. In 2006, the author and a colleague had suggested the use of a reduced quantity of the whole cell pertussis component” (3).

Adolescents and young adults belonging to the weaker economic groups are more prone to infections, but they would not be able to afford such a costly vaccine. On November 5, 2008, this author had written to the Serum Institute of India, a leading vaccine manufacturer, with copies to the convener, IAPCOI and other functionaries of the IAP, “to take the initiative and come out with a combination vaccine of tetanus with reduced quantity of diphtheria and whole cell pertussis components. This is needed for the masses that also need protection against pertussis but cannot afford the current Tdap vaccine.” There was no response from any one.

However, the drug manufacturers alone are not at fault. Under the existing system, tetanus toxoid with reduced quantities of diphtheria antigen and whole cell pertussis antigen is considered as a new molecule, and needs to be studied afresh for safety and efficacy before even applying for a licence. All this would require heavy investment, while the permitted price cannot exceed that of the DTP vaccine. This “will discourage any manufacturer to go for a vaccine which may be the need of the hour but is bound to act as a loss incurring venture. The solution to bail out industry should come from the authorities and the medical profession.” (4) Regarding the administration of hepatitis B vaccine, I quote from a 2007 publication of Jan Swasthya Abhiyan which maintains “Considering the low prevalence of hepatitis B, and the resource constraints, this vaccine should be limited to babies born to hepatitis B+ mothers. For this purpose, all pregnant women should undergo testing for Hepatitis B as part of other tests for anaemia and blood grouping. This does not require any additional effort or equipment and the test kit can be bought in bulk by the government for, say Rs 15-20.” (5).

In 2000, I had stated, “Checking of HBs Ag status is not a very expensive or difficult procedure. If it is checked for the prospective marriage partners, the problem of horizontal and later vertical transmission of the virus to the new born can be eradicated” (6).

I had emphasised the importance of blood testing by stating: “If a person is already infected, administration of the vaccine (by routine schedule) will not alter the course of the disease. The infected person may act as a source of infection, while having the false assurance that he or she has been immunised against hepatitis B disease” (6). This point was raised since, sometimes, hepatitis B vaccination is carried out as a campaign, providing vaccine free or at subsidised cost.

I fully agree with Dr Jayakrishnan’s views that the national vaccination policy should be disease-oriented. In addition, it needs to be stressed that tuberculosis, measles, polio, diphtheria, tetanus, pertussis, and typhoid should be given priority before including hepatitis B, haemophilus b influenzae, pneumucoccal and varicella diseases in the National Immunisation Programme.