Lack of Public Data, Rising Costs and Availability of Drugs Ail India’s Immunization Project
While India has been able to marginally reduce the infants infected from Diphtheria, Tetanus and Measles, the cases of Tuberculosis, Pneumonia, Pertussis and Diarrhoea have only magnified.
Representative image (Reuters)
Forty years after immunization was introduced for the first time in India, Prime Minister Narendra Modi addressed representatives from 54 countries at the Partnership for Maternal, Newborn and Child Health (PMNCH) and cited the renamed Mission Indradhanush—it aims to immunize all children under the age of 2 years, as well as all pregnant women—as being “close” to his heart.
But four years after its inception, the project is crippled by the paucity of funds, hidden behind the opacity of inadequate data and doesn’t even include all the vaccines that are globally recommended.
Immunization was expanded to Universal Immunization Programme in 1985 and renamed as Mission Indradhanush on December 25, 2014 by the Centre. Its aim was to fully immunize infants till two-years-old and pregnant women with all available vaccines till 2020. In October 2017, the project was further strengthened with the launch of the Intensified Mission Indradhanush with an additional aim of addressing low-performing areas.
Increasing Burden of Vaccine-Preventable Diseases
As per the Performance of Key HMIS Indicators report accessed by News18.com, the coverage of fully immunized infants has reduced from 17,409,713 in 2017-18 to 15,931,967 in 2018-19. This is a decrease from around 65.2% to 59.67% if we go by the estimated annual cohort of 26.7 million as mentioned in the journal contributed by Vandana Gurnani (Joint Secretary, MoHFW) and colleagues.
As per the same report, while India has been able to marginally reduce the infants infected from Diphtheria, Tetanus and Measles, the cases of Tuberculosis, Pneumonia, Pertussis and Diarrhoea have only magnified.
Earlier, the Intensified Mission Indradhanush had proposed the target of 90% coverage to December 2018. Speaking to News18, Dr Pradeep Haldar, Deputy Commissioner (Immunization Division), MoHFW, claimed that the target has been met. Yet, lack of data makes it difficult to cross check such claims.
As per India State Level Disease Burden Initiative (ISLDBI) report 2017, almost a third (32.7%) of the total disability-adjusted life years (DALYs)—effectively the years lost due to ill-health, disability of early death—for the country in 2016 was from communicable, maternal, neonatal and nutritional diseases (CMNNDs). These diseases are effectively preventable and yet account for 80.8% of deaths of children below 14 years, the report said. CMNNDs like Diarrhoea, lower respiratory infections, tuberculosis and meningitis are among the top 30 causes of the DALYs. UNICEF’s child mortality (under 5 years) report concurs, adding that in 2017, 9.2% of children died of Diarrhoea, 2% of measles, 2.4% of meningitis, 14.3% of pneumonia and 0.5% of tetanus. The WHO Global Health Observatory 2017 report on child mortality (till 4 years) estimated that of every 1,000 children, 0.9 have died of meningitis/encephalitis. When it comes to the rotavirus vaccines that prevent diarrhoea, the vaccines were only introduced a year-and-a-half ago, and are currently only available for 11 states. According to Dr Haldar, "the nation-wide accessibility of the vaccine will be made available in the next six months."
Moreover, in spite of the several reports and the recommendations by both the WHO and the National Technical Advisory Group on Immunisation (NTAGI), the National Immunisation Schedule (NIS)—the blueprint for India’s immunization activities—doesn’t make vaccines for the Pneumococcal Conjugate, Rota virus and Japanese Encephalitis (JE) available for all the states.
Justifying JE’s limited coverage, Dr Haldar said, “There is no human-to-human transfer in Japanese Encephalitis. Thus, the vaccines are available only at 230 districts where the infectant has been indigenously traced. Another 37 districts have been identified.”
In 2017, more than 5,400 cases of Acute Encephalitis Syndrome (AES) and Japanese Encephalitis (JE) disease were reported in Uttar Pradesh, which lead to 748 deaths. This data was presented by the Uttar Pradesh health minister Sidharth Nath Singh to the state assembly in a written answer to a question in August 2018.
Feel the Pinch
The last reported case of Polio was witnessed in 2014. Since then, the government has claimed that Polio has been eliminated in the country. Yet, eliminating Polio hasn’t solved the purpose.
The WHO’s Polio Eradication and Endgame Strategic Plan 2013-2018 recommends withdrawing the oral live attenuated polio vaccine (OPV) and introducing inactivated polio vaccine (IPV) to “eliminate the rare risks of vaccine-associated paralytic polio and vaccine-derived poliovirus”. These diseases that occur from the weakened vaccine strains turning virulent are capable of causing infectious Polio, and are potential reasons for Acute Flaccid Paralysis (AFP), which affects the nervous system, causing the muscles and reflexes in the body to become weak.
However, the maker and the only supplier of the IPV to the Indian government is Sanofi. According to Unicef document, the rate of IPV produced by Sanofi for India and other countries will increase from the current 0.75 euro (Rs 60.52) to 1.81 euros (Rs 146.07) per dose in 2019, and to 2.18 euros (Rs 175.92) per dose from 2020 through 2022
Since India is now a GAVI (the vaccine alliance) transition country (graduated from a low-income to a middle-income country), it will not be eligible for purchasing IPV at the subsidised price offered to GAVI-eligible countries, explains Dr Jyoti Joshi, Head of South Asia with the Center for Disease Dynamics, Economics & Policy (CDDEP).
Also, pneumococcal conjugate vaccines (PCVs) are limited to only five states. “It is very expensive… To expand it nation-wide, we would need Rs 2,000 crores,” said Dr Haldar.
The patent of PCV is with offshore partners: Pfizer and GlaxoSmithKline.
Leena Menghaney, South Asia-Head with Médecins Sans Frontières (MSF) or Doctors Without Borders told News18.com that the Indian government has granted patent of a public health drug to private companies who are establishing its monopoly.
Taking cognizance, MSF in 2017 dragged the government to the court over the issue.
“The cost of these vaccines could have been affordable had these were manufactured in India,” Menghaney explained, pointing towards the official apathy.
The emerging burden of iron-deficiency anaemia (flagged by the ISLDBI report) and cervical cancer (recommended by NTAGI) have also not been addressed in the NIS. Introduction of the HPV vaccines would depend on the Supreme Court verdict as it is hearing a matter on the illegal trial of the vaccine on girls from poor socio-economic background in Gujarat and Andhra Pradesh.
A 2018 journal contributed by the office-bearers of the Immunization Division (MoHFW) among others estimated that it cost around $32.43 in 2017 to fully immunize an infant.
"With the price burden of IPV and PCV, and the need to make other recommended vaccines available nationally, the cost will go up by double, or even more," Dr Haldar explained.
Centre, on the other hand, however, had reduced the budget for RCH from Rs 11,002.02 crore in 2017-18 to Rs 7745.3 crore in 2018-19. In the 2019-20 interim budget, Rs 6758.51 crore has been allocated for RCH, in which immunization is just a subset.
Lost in Numbers
In the last few years, several numbers have been thrown to the public in various ways. Analyzing few of them reflects that they don’t really relate to each other.
Till 2016, only 65% infants were fully immunized in the first year of their lives—a mere 4% increase from 2009. In the National Family Health Survey 2015-16 (NFHS-4), the number became 62% that saw a sudden spike of 25.29% to 87.29% in the Universal Immunization Programme coverage report 2016-2017.
Yet, PM Modi felt the need to launch the Intensified Mission Indradhanush in 2017 that flushed in an additional fund of Rs 6411.11 lakh for the low-performing states apart from what has been provided for Routine Immunization under part ‘C’ of Programme Implementation Plan.
PM Modi, at PMNCH Forum 2018, also announced that 32.8 million children have been reached over the last three years under Mission Indradhanush—a number too less for three years combined and over 100% for an annual coverage considering the estimated annual cohort.
On the contrary, the coverage of BCG vaccines for Tb has been 116.5% in 2018-19. While for that of mmeasles-rubellahas reduced from 111.5% in 2017-18 to 109.3% in 2018-19. When asked how for a coverage of over 100%, thousands of children under five years of age reported Tb and Measles, Dr Haldar exclaimed at the vagueness of the baseline due to lack of an exact data of infants, especially due to the continued traditional deliveries.
"The NFHS like any other survey reports (AHS, DLHS etc) is conducted in selected households—601,509 in the NFHS-4. Its outcome can be massively different from the actual or administrative reports," remarked Dr Haldar.
Considered as a highly credible report, NFHS forms the basis in framing several policies including planning the immunization project.
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