Sunday, 16 June 2013

Dr. Yashwant Amdekar - Vaccination...

The following is a short note by Dr. Yashwant Amdekar on Vaccination needs for children forwarded to Dr. Sailakshmi of Ekam Foundation.

1. Vaccines that should be given to all children -  EPI vaccines must be given to all children and are available free of charge through government and municipal outlets. These include BCG, DPT, OPV, Measles – primary and booster doses. It is important not to miss booster dose of DPT and OPV at 18 months. If child misses the opportunity, vaccine can be given any time thereafter. In case of missed dose, previous dose need not be repeated even if there is a long gap. HBV (hepatitis B) and HiB (bacterial hemophilus influenza vaccine) is being introduced in phases by the government and if available free or affordable, must be taken.

2. MMR vaccine is ideal only when its coverage in the community is large and in which case, second dose of MMR would be necessary anytime at next planned visit but not before 2 months. IAP recommends it at 5 years. If MMR vaccine coverage in the community is poor, it is better not to give MMR as there is a chance of developing natural immunity due to pool of infection continuing in the community. In fact such an exposure to these infections in childhood will prevent occurrence of such disease in later life. Mumps and Rubella are likely to be harmful in later life as against in early childhood. So, either consider two doses of  MMR or no dose.

3. Rubella vaccine may be ideal if woman has not had Rubella during childhood and is ideally given before pregnancy. However it is not easy to know whether woman has had such an infection early in life. In such a case, it may be ideal to offer Rubella vaccine so as to prevent Rubella syndrome in foetal life. Alternatively MMR vaccine can be given as it is easily available and may offer some more protection against Mumps and Measles besides Rubella. There is no harm of vaccine given to a woman if she has had such an infection in the past.                                                                                                                 

HPV vaccine has some scientific benefits. Firstly as cause of cervical cancer is known to be due to human papilloma virus (16 and 18 serotypes) infection, vaccine is more specific against cervical cancer. Secondly, such an infection is almost universal though only small number of infected women would go on to develop cervical cancer. But in absence of regular screening program in our country (in fact, such screening is not much prevalent even in western countries), diagnosis of cervical cancer is possible only in late stage that is nearly fatal. Worst part of this disease is the fact that it hits women in their 30’s and 40’s and loss of mother at this age is disastrous to the family. From all these points of view, HPV vaccine may be considered if affordable but it cannot be recommended to be included in government program because there are more pressing problems than HPV.

4. I would add about IPV. With near eradication of wild polio infection in India (early January 2014, India will be polio-free), we are all elated. However success is still far away as there have been epidemics of polio in countries who were polio-free for many years and this was due to either importation of wild polio virus from countries who still continue to harbor such an infection or also caused by OPV that is capable of developing vaccine derived polio virus besides vaccine associated polio virus. Unfortunately such virus though not wild, is capable of causing same degree of harm as that of wild virus. In fact, if we don’t take proper care, polio caused by vaccine virus is likely to occur at any age including adults and by then if most adults have lost immunity against polio, such a disease may also be fatal and result in epidemics. So IPV is the need of the hour and government is likely to bring IPV in routine immunization schedule for all children in addition to OPV that may have to be continued for some more years. But under cover of IPV, OPV will not cause any harm and over years OPV may have to discontinued.

Finally I feel if anyone can afford just one extra vaccine beyond EPI vaccines, it must be IPV. Far more important is to improve coverage of EPI vaccines in the country which stands at dismal 50% only in spite of vaccine available free to the community. We need at least > 90% coverage to be effective in preventing pool of infection so that even unvaccinated children would be safe as they would not have any exposure to vaccine preventable infection.

So pass on two important messages. First - every child must take EPI vaccines including booster dose of DPT and OPV. Second – if possible give IPV at least one dose that can prime better immune response to OPV and may avoid vaccine induced disease.   

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