Wednesday, April 25, 2012

Indian Doctor Questions Vaccines & Herd Immunity

Vaccine, injection and we???
- Dr Niraj Pandit (He's on Facebook)


First I like to thank you very much for voting on issue which I feel really important. Now you must have question in mind that why I am asking such silly question? Believe me it is not silly but serious!

The question which I have asked is related to our Vaccination Programme. It was written in K Park Text book of Preventive and Social Medicine that Experience with smallpox eradication programme showed the world that immunization was the most powerful and cost effective weapon against vaccine preventable diseases. So in 1974 the WHO has launched its expanded programme on immunization EPI against vaccine six preventable diseases. The government of India launched EPI in 1978 with objectives of reducing the mortality and morbidity resulting from vaccine preventable diseases of childhood and achieve self sufficiency in the production of vaccines1. Same was intensified with Universal Immunization Programme (UIP) with two vital components two dose of TT to pregnant woman and immunization of children with EPI vaccines in first year of life.

Our target was to achieve universal immunization by 1990. Surprising the book author also writing that no country even industrialize world has ever achieved 100% immunization. Therefore ideal acceptable level is 80% or more, which help to protect community from epidemic of such diseases. Also science says that ‘herd immunity’ play role in control. 
These all are known to all of us. You are saying what is new I am telling? Government of India report Health information 2005 says that 99% 0f polio cases declined between 1987 to 2005, similarly 21% diphtheria, 73% pertussis, 78% measles and 92% decline of Neo-natal tetanus cases in India2. The govt wants to focus that these achievement is due to vaccination programme. Do you think so? I am telling that there is very minimal role of vaccination in reducing above disease burden. Supportive evidences are

1. NHFS survey result says that percentage of children 12-24 months who have received all recommended vaccines were 36% in NFHS-I, 42% in NFHS-II and 44% in NFHS-III at India level3. So we never achieved more than 50% vaccination coverage. Even polio coverage was 78% in NFHS-III. Thus overall vaccination coverage is low so that minimum support to role of vaccination in morbidity and mortality reduction.

2. It was pointed out that the percentage of the population living below the poverty line decreased from 55 percent in 1973-74 to 36 percent in 1993-94 (Central Statistical Organization, 1999). Evidence from the 61st round of NSSO data shows that the extent of poverty decreased further from 26.1 percent in 1999-2000 to 22.0 percent in 2004-05 (Ministry of Finance, 2007). Thus there is improvement of living standard in citizen of India. This was more supportive evidence then the vaccination. It is know fact that tuberculosis in western world came under control before discovery of ant-tuberculosis drugs. Similarly if you improve the living standard of citizen of country it will reduce the disease burden of disease like tuberculosis, measles, polio, diphtheria, pertussis and tetanus.

3. Role of herd immunity: if we discuss one by one disease and role of herd immunity it will clarify that there is minimum role of herd immunity. 

a. BCG vaccine, really controversial vaccine as per my personal opinion. The vaccine efficacy is 0 to 80 and that is known since Chingulput trial. Still we recommended in programme due known fact that it is preventing sever type of tuberculosis miliary tuberculosis and tuberculosis meningitis. Ok I am supporting same. But till 2008, we were teaching and following as community physician that you should take BCG vaccine till five years and insist for scar formation after vaccination. But recently I have read guideline “Immunization handbook for Medical officer”4 on page 21 that BCG is given only upto one year because most children acquire natural clinical / subclinical tuberculosis infection by the age of one year and this too protect against sever form of TB. And second point there is no need to revaccinate the child even if no scar. I have tried to get evidence of above policy. One fellow from programme has written that this is based on Indian Association of Pediatrician (IAP) guideline5. I have visited web of IAP for detail guideline. On web ‘IAP guide book on immunization’ is available and in chapter -4 is consist of individual vaccine page 18 they clearly recommended BCG till the age of “Five” years and BCG may be repeated once children less than five and no scar. So what is the Evidence for changing policy??? It is known fact that there is no role of heard immunity in case of BCG.

b. In DPT, in case of Tetanus it is also known fact that there is no role of herd immunity. In DPT vaccine, most side effects are due to pertusis component. To get protection against all three diseases there should be complete schedule of vaccine with booster dose. But NFHS results have observed that only 55% coverage of DPT three doses in country3. 

c. Polio, really hard to understand, in 1995 we have started polio eradication programme with aim to eradicate from India and world by 2000 and still in 2010 we are fighting with few hundred cases. They are located in few districts of UP and Bhihar. It is clearly written in IAP guide book on immunization5 page 20 that this poor efficacy is attributed to high population densities, malnutrition, poor sanitation that increase the risk of infection with other enteroviruses and NOT due to poor vaccine potency due to breaks in cold chain. So it is clear still we are not able to supply basic needs of our population. IAP in their recommendation is suggesting Injectable polio vaccine for good efficacy, so again one more injection??? 

d. Measles vaccine has very good relation with herd immunity and plays important role in prevention of measles disease and controlling of epidemic of it. Full marks to this vaccine in whole programme. 

4. Big issue is injection itself. I have asked community to poll on five injection without reason in one year and majority replied “NO” to poll. If we are not ready to take injection without full knowledge why should we prescribe small fragile new comer in our world (Infant)? Why? We as doctor knew something but what about general community? Second issue injection safety, in one of my study in Gujarat, it was found that 77% of injection were unsafe6. So safety is also issue. Last point is that its painful to take injection, don’t forget this part!

5. Since EPI, we never thought about alternate route of vaccination, why? I know few my learned friends who have not given any vaccine to their children and till date nothing happened. So now my question to community at large
What are your comments? Should we think to refine our policy or forget? 

My points:
1. Vaccine policy changes are really evidence based or not? 
2. BCG policy change, do we need to do RTI?
3. GOI has recently launched Evidence based vaccination policy, will we really want to follow or it will be on paper?
4. WHO vaccine fraud is exposed recently in case of H1N1 read WHO_vaccines. html and wp-dyn/content/ article/2010/ 06/04/AR20100604 03034.html So do we need to rethink about vaccine concept?
5. Alternative vaccination need to think, as Ayurveda has concept of over all increasing immunity against all disease rather single specific protection.
I welcome comment and again putting poll that do you think this information is useful? 
Yes / No / not agree/ partly agree 

Dr. Niraj Pandit

1. K Park; Textbook of Preventive and Social MedicineBhanot Publication; 19th edition page 363
2. Govt. of India 2005, Health Information 2005, Ministry of Health and Family Welfare New Delhi.
3. National Family Health Survey – III, National Fact sheet India, Minitery of Health and Family Welfare, New Delhi
4. Immunization Hand book for Medical officer published by Department of Health and Family Welfare, Ministry of Health and Family welfare, New Delhi 2008 accessed on web on 9/6/2010 
5. IAP guide book on Immunization accessed on web dt 9/6/2010
6. Pandit N B, Choudhary S K, Unsafe injection practices in Gujarat; Singapore Med J 2008; 49 (11)

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