POST 01424E: INTRODUCE NEW VACCINES BUT WHAT ABOUT ACCESSIBILITY TO OLDER ESSENTIAL VACCINES?

Dear Sir, It was nice to get responses from those who are to take decisions regarding the vaccine policy of India . I still fear that we at the decision level need to work more to make vaccines accessible like posting more health workers, making their service conditions better and so on. In India half of the sub centres do not have staff; then who is going to vaccinate? Further, one fourth of them are located at a distance of more than 10 km from the nearest habitation. Who would go (all this distance) to get vaccinated? These are the issues that need solution. Also diseases like Rabies kill more than 20,000 patients every year in India , most of them school-going kids, but we do not have free antirabies vaccine/serum available in the hospitals, for want of money. How to save these children is a question? There have been many studies by the national institute of epidemiology Chennai and other public health institutes on why people do not get their children vaccinated, and we need to thoroughly go through the reasons and ensure a Functional Vaccine Delivery Mechanism (FVDM) as such , so that even if we wish to introduce a new vaccine it is well utilized. Another problem is that the states like Himachal, that had very high coverage have actually gone down after the introduction of a new vaccine Hepatitis-B. So introducing newer vaccines where coverage is good is not a universal recipe to follow. The biggest fallacy is that we do cost effective estimates keeping in view the 80% utilization of the vaccine but we do not reach a half mark in actual practice because we donot have a FVDM. FVDM may need functional sub-centre with full staff, cold chain and less distance of the sub centre besides a mechanism to keep mothers reminded of the next due date. Thanks and regards, Dr Omesh Bharti. M.B.B.S.,D.H.M.,M.A.E.(Epidemiology) Directorate of Health Services, Himachal Pradesh, Shimla, +91 9418120302 [email protected], [email protected] ________

Sir, Older essential vaccines should be given a thrust through strengthening of primary health care. You stated that money is not a problem - May I suggest that we put our money on mere essentials like filling vacant posts of health workers. Secondly introduction of second dose of measles in RI has been tagged with a 85% RI coverage. We could have had similar criteria for other newer vaccines for infants. Once an effective vaccine delivery mechnism is in place to ensure access to at least three fourths of the population, we can introduce new ones too and further reduce m/m. Dr RK Sood

In respect of post 01424E comments of Lora are definitely welcome and it should not be 'either/or' however I feel that these are too much focussed on introduction of a new vaccine. Issue here is whether there is a threshold of 40%, 50% or 60% for coverage of traditional vaccine or absolutely none before a country thinks of introducing a new vaccine. For India with too much of diversity picture needs to be seen statewise and states where there is good coverage of existing vaccines must go for new vaccines of course maintaining good coverage of existing vaccines say at least 80%. It is absolutely useless to think of introducing a new vaccine if existing vaccine coverage is very low say 20% to 40% or even 50%. I seek opinion of experts on this threshold of coverage of existing vaccines. With warm regards Dr Naresh Goel Assistant Commissioner(UIP) Ministry of Health and Family Welfare Government of India

In regards to Post 01424E, it should be not be an 'either/or' but rather how to "introduce new vaccines while ensuring and sustaining availability and financing of older essential vaccines as well as the new vaccines". For many countries, the challenge is twofold: - to increase or sustain financing for current vaccines within their health budgets and - to advocate and ensure long-term financing for the more expensive, newer vaccines (and program operational and cold chain costs), particularly as GAVI funds phase out. Considerations need to include burden of disease, cost saving and benefit analysis, storage capacity and needs, strength of the current system for ensuring high routine coverage every year, program and operational needs, and sustained financing for vaccines, transport, cold chain, fuel, etc. This was recently discussed at the East and Southern Africa Regional EPI Managers' Meeting in Mombasa, Kenya in March. The attached presentation may be a useful reference for adaptation by countries on how to communicate and advocate for new vaccines. Thanks and best regards, Lora ________ ##text##

Dear Dr Bharti I totally agree with your comments. What is the need of the hour is to think of new vaccines but simultaneously not to loose focus on the existing vaccines. Children dying due to diseases for which vaccines are available is nothing less than a crime. We all need to do our bit and reach all children with all available vaccines. Money is not the issue particularly for cheaper older essential vaccines. However lack of staff or uncommitted staff sometimes is the issue. Recent immunization surveys do show some improvement in coverage but a lot is desired to be done. I feel lack of people is causing lack of supervision in the field and all sessions as desired are not being held. Through this forum I appeal to all to strengthen the immunization programme of India so that more and more children are immunized against all VPDs. With warm regards Dr Naresh Goel Assistant Commissioner(UIP) Ministry of Health and Family Welfare Government of India

Dear Dr Omesh Bharti,I do really see your point and to me the message is that we should not only "look before we leap" but also should avoid "biting more than we can chew" at any particular time.However, I think the word "bent' is a bit too strong.Any resposible governeemt or EPI manager should consider many things before introducing a new vaccine likewhat is the burden of the disease(s) being addressed by the new vaccine(s)?how much savings will I be making by saving one child from the particular disease?what is my current performance in reaching my target children?do I have the stoarge (cold and dry) capacity to accommodate new vaccines at ALL levels?where will the funding come from?I agree that we should avoid introducing new vaccines because "other people are doing it"But at the same time, we should realise our obligation to ensure the survival of our children especially when the technology is available- otherwise when we leave the immunization scene- there will be no one to replace us.Let us advise our Goverments that leaving 50% of children under one year of age unprotrcted from vaccine-preventable diseases because we are not reaching them with vaccines we call "traditional" but you appropriately described as "older essential" vaccines is like toying with our future. Let us pause for a moment and consider the absolute numbers : in a country with a population of under one year old of about 10 million- leaving about 5 milllion unvaccinated is a big deal.The challenge for all of us is to continue to finds ways to advocate for more ownership and visibilty of child survival programs like immunization.Let us emphasize that immunization is one of the most cost-effective strategies to reduce poverty and support nation buildingWithout this, those of us working in areas with poor immunization coverage would be putting ourselves on the "endangered species" list. Femi. OyewoleWHO Inter-Country Support TeamOuagadougou, Burkina Faso World Health Organization

Dear Dr Bharti,Agreed that India has a immunization coverage around 50% and we are talking of introduction of newer vaccines. As India contributes heavily to infectious diseases burden. Hence newer vaccines against infectious diseases like Japanese encephalitis, Rota virus diarrhoea, Cervical Cancer by HPV will certainly off load the disease burden, save lives & diability limitation, ameliorate social imbalance etc. When newer vaccines are introduced disease burden, morbidity, mortality is taken into account. Safety data is always analysed by various agencies like WHO, DCGI, ICMR etc. What type of or level of prevention the new vacine can provide is assessed. Cost effectiveness of introducing vaccine in both public & private sector is analysed, programmatic cost of vaccine introduction, affordability, accessbility, feasibility of introduction will be asssessed through operational research. These all can be done in states which are haveing moderately performing immunization system e.g. western, southern Indian states. A formative research can answer for introduction of newer vaccines.Reference:1) Disease burden in India: Estimations and causal analysis*From WHO INDIA, Commission on Macroeconomics and Health2) Shaping a Strategy to Introduce HPV Vaccines in India, www.rho.org/files/PATH_FRTS_India.pdf As far as about enhancing accessibility of older vaccines: training, implementation of WHO's RED strategy, PATH's Immunization Tickler Bag, Supportive supervision experience from Child Vaccine Project, effective utilization of MCHN / Village Health, Nutrition & Sanitation Days under NRHM, alternate vaccine delivery under RCH-II, factual data of vaccine utilization, coverage and demand, subcentre or even village wise micro - plans and finally commited Health worker & truthful supervision, regular monthly sub centre wise honest evaluation by sector medical officers will definitely achieve immunization accessibility & coverage.Hope this is usefulWith RegardsDr Manoj Dr Manoj B Patki, MDAssociate ProfessorDepartment of Community Medicine,Mamata Medical College,Khammam, A.P. - 507002Tel: (91-8742) 223075 Ext.28 / 29Fax: (91-8742) 235160Resi: (91-8742) 254066Mob: (+91)9848254290, (+91)94918092073Email:[email protected]: www.mamata.org