India has made huge strides as far as public health achievements are concerned, made possible by the use of safe and effective vaccines delivered through quality programmes. For example, small pox was eliminated in 1975, polio in 2014 and maternal and neonatal tetanus (MNT) in August 2015.
While India has shown its ability to undertake massive campaigns to improve vaccination coverage, routine immunisation coverage, which stands at 65 per cent when last measured, remains low. Moreover, the immunisation schedule lacks important vaccines that are already in use in most countries. All that is set to change.
In 2014, the Prime Minister’s Office announced the decision to introduce four new vaccines as part of India’s Universal Immunization Programme (UIP). These are vaccines against rotavirus, rubella and polio (injectable) and an adult vaccine against Japanese encephalitis introduced in districts with high levels of the disease. Earlier in 2011, a vaccine against Haemophilus influenza type B (Hib) was introduced as part of the pentavalent vaccine to contain diphtheria, pertussis, tetanus, hepatitis B and Hib. Thus the government has introduced or committed to introduce more vaccines than it has in the last 30 years of the UIP.
These vaccines could collectively prevent at least one lakh infant deaths, deaths of adults in the working age group and up to 10 lakh cases of hospitalisation each year. India’s UIP will now be able to provide free vaccines against 13 life-threatening diseases to 27 million children annually, the largest birth cohort in the world.
The India Newborn Action Plan (INAP) was launched in September 2014 with the aim of reducing preventable newborn deaths and stillbirths and the goal to attain single digit neonatal mortality and stillbirth rate by 2030. The current rate is 38/1,000 live births. To reach this goal, four additional vaccines are being thought of as priority vaccines for introduction in India.
Priority vaccines The first of them is the Pneumococcal conjugate vaccine. Singularly, bacterial pneumonias kill more children under the age of five than any other disease. India has the world’s highest number of deaths caused by Streptococcus pneumoniae, the bacteria most commonly associated with pneumonias. There are an estimated 5-6 lakh cases of severe episodes of pneumococcal pneumonia and 95,000-1,05,000 deaths in India annually. An effective and safe vaccine for pneumococcus pneumonia is available.
The Human Papillomavirus (HPV) vaccine is next. Cervical cancer is one of the top three cancers affecting women in the world. Worldwide, every fourth new case is an Indian. It is estimated that in India, there are 1.32 lakh new cases every year and about 75,000 deaths reported. Two strains of HPV-16 and -18 are responsible for almost 80 to 85 per cent of cervical cancers. Preventive vaccines are available and are given to adolescents (9-13 years).
The third is the influenza vaccine. Immunising mothers during pregnancy against vaccine-preventable diseases has the potential to improve health outcomes in mothers and their children. This is likely to emerge as a key strategy to address neonatal mortality in particular which accounts for almost half of the under-five mortality. This strategy has been successfully used to eliminate MNT. Clinical trials have shown that influenza vaccination during pregnancy can prevent influenza disease in pregnant women and their newborn children for the first six months of life with no indication of harm to the recipients or their children .
Given the potential impact of maternal influenza immunisation programmes on maternal and child health worldwide, the World Health Organisation Strategic Advisory Group of Experts on Immunization (SAGE) has recommended that pregnant women having influenza vaccine receipt in countries initiating or expanding their influenza vaccine programmes be made a priority. In India, a large number of deaths were reported during the H1N1 outbreak from 2009 onwards. Infection in pregnant women led to deaths in their third trimester. The Maharashtra government has introduced seasonal flu vaccine for high-risk groups including pregnant women. Season flu vaccine, which includes the pandemic H1N1 strain, is a priority vaccine for use in high-risk groups in India including pregnant women.
The last is the cholera vaccine. Though interventions for the prevention and control of cholera (including an oral vaccine produced and licensed in India) are available, cholera remains an important cause of morbidity and mortality. It is estimated that there are about 7-8 lakh cases every year resulting in about 20,000-24,000 deaths. About 400-500 million people are at risk. Outbreaks occur after the monsoon. Though the oral vaccine is available in India, there has been limited use.
Targeting seven diseases
The UIP is now a much strengthened programme, supported by a transparent system of taking decisions to introduce new vaccines, being sensitive to adverse events following immunisation and with the capacity to add additional vaccines. Through Mission Indradhanush [to cover, by 2020, children who are either unvaccinated, or are partially vaccinated against diphtheria, whooping cough, tetanus, polio, tuberculosis, measles and hepatitis B], India aims to be on track to increase routine immunisation coverage to 90 per cent within a few years. The years to come may well be the golden years of immunisation in India.
(Prof. Ramanan Laxminarayan is Distinguished Professor and Dr. Lalit Kant is Senior Adviser, Infectious Diseases, Public Health Foundation of India, New Delhi. The views expressed are personal.)
