The introduction and scaling up of vaccinations is part of a global strategy to ensure that no child dies without a fair chance at life, writes Dr AP Dubey
India has registered significant gains in childhood health. Infant mortality is down to 39 per 1,000, and neonatal mortality too is on the decline. However, controlling and eradicating childhood infectious diseases like pneumonia, diarrhea and tuberculosis remain a challenge.
In comparison to neighbouring Sri lanka, which has been able to bring its infant mortality rate to single digits, India — by far a much larger country with nuanced complexities — continues to struggle with the burden of infectious childhood diseases. It is also a fact that every third child in the country remains partially or not immunised.
India records 500,000 child deaths annually due to vaccine-preventable diseases. Five per cent of children in urban areas and eight per cent in rural areas are still unimmunised. Since 2014, Mission Indradhanush has covered 201 districts with poor immunisation coverage and has registered some success with children who get left out or drop out of their immunisation schedule.
The main reason for the remaining large number of children dropping out after receiving one or more doses or not receiving any vaccine doses is lack of awareness in the community. Added to this are myths and unfounded fear about vaccines.
The evidence has been around for a long time now. Children who do not receive all vaccines and those who are left unimmunised are most susceptible to childhood diseases and disability. These children run a three to six times higher risk of death compared to fully immunised children.
Children in India are already at a disadvantage as they are faced with the twin burden of high levels of malnutrition and infant mortality. The attempt to reach 90 per cent coverage is ambitious, but it is a job that needs to be done. Only full participation from communities can make this happen.
Since 1985, the Government of India’s Universal Immunization Programme (UIP) has incorporated several vaccines to prevent diseases like diphtheria, pertussis (whooping cough), tetanus, poliomyelitis, tuberculosis and measles. Hepatitis B was introduced in a phased manner in the country starting 1998.
Today, the total number of vaccines in the UIP stands at nine. After the phased rollout of the Hepatitis B vaccine, the Government of India announced in 2014 that four more vaccines would be added to the UIP — rotavirus, rubella, the injectable polio vaccine (IPV) and Japanese encephalitis (in encephalitis-endemic regions).
The Government is now working to have the pneumococcal vaccine introduced in the UIP. The introduction of the rotavirus vaccine, and hopefully the pneumococcal vaccine, will greatly help India bring down the number of under-five deaths from these two major vaccine-preventable diseases.
Through the UIP over a period of time, the Government has been able to increase the immunisation coverage. With global research progress, newer vaccines have been available in the private market in India, and some State Governments have incorporated them into their immunisation schedules. For instance, the Delhi Government introduced some new vaccines like MMR in 2002 and typhoid in 2010.
The decision to make newer, more expensive vaccines part of the UIP have also scripted India’s most recent global health successes: The eradication of polio and elimination of neonatal tetanus. Being a signatory to the WHO for polio eradication, the efforts that were rolled out across the country to increase polio immunisation coverage paved the way for India to be successfully declared polio-free.
The victory against polio was a definitive achievement for the country, and the switches to IPV and from trivalent to bivalent is in keeping with the global strategy towards the polio endgame. In addition, with 90 per cent immunisation coverage of tetanus to mothers during antenatal period and a growing number of institutional deliveries, India is within the range of eliminating neonatal tetanus.
It is also important to mention the work around four critical areas that are part of the UIP — new vaccines, safety, research and monitoring. Dedicated work and proper implementation have also helped build a strong regulatory framework around the safety of vaccines.
The Department of Biotechnology has been actively engaged in the research for newer vaccines. The Drugs Controller General of India has specific criteria for the introduction and licensing of new vaccines. It has constituted a Subject Expert Committee which reviews all aspects of research, safety monitoring and licensing of new vaccines before its market authorisation.
Subsequently, it keeps an eye on post-marketing vaccine surveillance, specifically on safety. With this framework in place, there is complete vigilance during clinical trials, market authorisation and safety reporting.
Along with strengthening regulation, the Government is also vigilant about Adverse Events Following Immunization (AEFI). As immunisation coverage expands, the safety records of vaccines are monitored by the National and State AEFI committees. Established guidelines and reporting formats are already in place for any adverse event. All States in the country have their State and district AEFI committees, which are tasked with collecting detailed information and properly investigating for causality assessment. These reports lead to remedial measures to be taken, which help build the confidence of communities, who may be unsure what to do following an incident.
Immunisation is important for a better future for the children of this country. The introduction and scaling up of vaccinations is part of a global strategy to ensure that no child dies without a fair chance at life. There are guidelines and checks and balances at every step to ensure that immunisation sessions are accessible at even the remotest areas. There is a need for the community to match these efforts — to ensure that they get their children immunised — right from the first birth doses. A key target for any parent in India should be to ensure that their children are fully immunised.
The writer is Director-Professor of Paediatrics, Maulana Azad Medical College, New Delhi