The critical issue in India, where the pentavalent vaccine is being rolled out, is raising the coverage levels of immunisation
“Immunisation is not an election issue. It should be.” Seth Berkley, CEO, GAVI Alliance, is not known for mincing his words. Throw in the immense experience he brings in from the area of vaccination, and he is easily the most articulate global proponent of immunisation. In India recently to meet with the heads of government and to bring together leaders of society to pitch into the vaccine effort, Dr. Berkley spoke with The Hindu on a range of issues germane to universal immunisation, India’s recent polio success, and the plan of action for the future.
The GAVI Alliance is an international organisation that works at saving children’s lives and protecting people’s health by increasing access to immunisation in poor countries. With funding from governments across the world, it takes forward its agenda of making vaccines available to children, assisting developing nations to gain access to vaccines at affordable rates, with the firm belief that “immunisation is a matter of justice.”
“The critical issue here in India — since we now have permission to roll out the pentavalent (the combo protection against diphtheria-tetanus-pertussis (DTP), hepatitis B, Haemophilius influenzae type b) vaccine throughout the country — is to get coverage levels up.” It is essential to create a demand for vaccines and, at the same time, deal with irresponsible stories that talk of side effects without any validation.
“This is one of the ideas behind creating an Advisory Council for GAVI in India: to get a group of people from all sectors to discuss how we might help in these issues, besides being voices in Indian society to counter any negative voices out there,” Dr. Berkley explains. He is also thrilled that India has recently committed to being a donor to the international vaccine effort; promising GAVI $4 million over the next four years.
India’s anti-polio programme
He doles out much praise for India, clearly astounded by its recent success with eradicating polio. It is believed that India’s achievement of stopping the transmission of the wild polio virus by immunising all children between 0-5 years, provided a big boost for the global effort to defeat polio. “It is incredible! It shows to me what India can do when it focusses. The world thought it was impossible, India did it on a scale that no one can imagine: mobilising front-line workers volunteers, NGOs, local politicians.”
Also, the spin-offs from the polio effort for the country have been momentous. “If you look at a place like Bihar that had incredibly low immunisation rates, we have already seen polio teams turning their attention to routine immunisation, seen coverage going up from the low 30s (percentage) to about the 60s (percentage). In places like that we can take it higher. Ideally, about 90 per cent of the community must be immunised. While in the South we have a coverage rate of about 85-90 per cent, in the North, it hovers around the 30s.” Clearly, a nation cannot remain content with an average immunisation of 60 per cent.
So, the challenges indeed remain huge, despite the massive mobilisation for polio that seems to have paid off. For Dr. Berkley though, his calling and work depends on remaining hopeful, in believing that more children will continue to be covered, and not be felled by vaccine-preventable diseases. In that vein, he says, “Let me start out with the positives. Five years ago, India had more cases of polio than anywhere in the world, but it was able to mobilise and reach every child, in essence. This should have emboldened India in terms of what should be done; it shows what is possible and what can be done today.”
Lessons learnt and vaccinations
Of course, routine immunisation is a little more complicated routine, injections [unlike the oral polio vaccine] need more trained health workers, and people have to come to a facility instead of doing it door-to-door, as with polio. “Remember, that is also the system that is needed to ensure that polio does not get back into the country. As you know, your neighbours have not done as well as you. So, while we have to keep polio coverage levels up, we must be able to use the skills, micro plans, and social mobilisation from that exercise for a range of other vaccinations which will have a dramatic effect on children’s lives.”
He goes on to add, “We recently approved a grant of over $100 million for India, to work on improving the delivery of vaccines, and that is going to focus on some of the least-performing districts, trying to transition some of the polio workers to do a better job on routine vaccination, improve surveillance and get a better understanding of the supply chain.”
The task at hand is urgent and the country cannot allow it to be beset by doubts spiralling into controversies over the safety and efficacy of vaccines. Dr. Berkley says, “In a place like India we fool ourselves, or, we are completely isolated from our population to say these diseases are not real; they don’t occur. When you roll out vaccines, you have a dramatic effect on morbidity and mortality. It is true that in places these diseases have almost disappeared, but people move and organisms move, but until we end up eradicating an organism, it is essential to protect children.”
He adds: “My understanding is that if you look at any of the leaders in India in science, there is no controversy. There is absolutely incontrovertible proof of both the burden of disease and the effect of vaccine. Indeed, there are a few people who continue to bring up these questions. They are isolated, but that is not to say they haven’t been listened to by the media.”
The roll out of the pentavalent vaccine has been hotly debated in India, and there are claims that children have died after being vaccinated, and consequently the demand to shelve the vaccine. Dr. Berkley does not dismiss this outright. Instead, he explains that there is a component in the pentavalent vaccine that can cause fever in children, but that is even true of the older DPT vaccine. “So you cannot say there aren’t any side effects, but they are not significantly worse than they were with the DPT. Usually, the side effects come from the whole cell pertussis component, not from [additional] Hepatitis B or HIB components. One thing you can do is to educate parents that children will sometimes have fever after vaccinations; after all they are learning how to fight off a bad infection.”
Dr. Berkley also thinks one of the key ways to take this fight on is through the National Rural Health Mission, which will build systems to guide such efforts. “I hope that assurance will survive an election. India has not stepped up in terms of financing health as it could have. We are not talking of absolute amounts, because the economy is growing, but the relative amount, because India is low, in comparison with the other countries in the region.” He pauses, and then allows a sentence to hang in the air, as ominous as the future it signifies, “When a child dies of preventable diseases it is a tragedy, but when thousands die because we are not rolling out tools that we have that are inexpensive, and are available ….
(This article has been corrected for a factual error)