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Letters to the Editor

Indian Pediatrics 2002; 39: 108-111  

Reply


The issues raised by Prof. Parvat V. Havaldar and Dr. Shreekant Chorghade are very practical and have a bearing in our day-to-day immunization practices. As the views expressed by both the authors are more or less similar, I on behalf of the IAP Committee on Immunization would like to address the issues simultaneously.

1. Measles and MMR Immunization

Since US references are quoted in both the communications, it will be worthwhile quot-ing relevant information from the Red Book 2000 of American Academy of Pediatrics(1), since updated in 2001.

First and foremost it should be clearly understood that no monovalent Measles vaccine formulation is available in the US and Measles immunization is a part of MMR vaccine administration.

On scheduling immunization, the Red Book 2000(1), observes: "The Immunization schedule used in the United States may not be appropriated for developing countries because of different risks, age specific immune res-ponses, and vaccine availability. The schedule recommended by the Expanded Program on Immunization of the World Health Organiza-tion should be consulted (http://www.who. org). Modifications may be made by the Ministries of Health in individual countries, based on local consideration".

Indian has incorporated one dose of monovalent Measles vaccination after 9 months of age in its National Immunization Schedule and IAP has endorsed it for the reasons rightly stated by Dr. Havaldar; in India, we cannot afford to wait till one year of age as suggested by Dr. Chorghade for the 1st dose of Measles vaccine. Therefore, IAP has recommended in its ‘IAP Policies, Guidelines and Recommendations - April 2001’(2) to administer one dose of MMR vaccine at 12-15 months of age preceded by one dose of Measles vaccine at 9+ months and has also stated the need for evaluation of a second dose of MMR and its timing since one dose of MMR does not offer sufficient protection against Mumps, though it may do so for Rubella. Therefore, the second option mentioned by Dr. Havaldar is acceptable to IAP and hence its plea and recommendation to the Government of India to include MMR vaccine in the National Immunization schedule.

Now to answer the individual questions of Dr. Chorghade:

1. In India, Measles vaccine cannot be started after 1st birthday.

2. Monovalent Measles vaccine at 9+ months followed by MMR vaccine at 12-15 months of age is practiced by many pediatricians in India.

3. Yes. If the individual has not received MMR vaccine before, 2 doses of MMR vaccine at 4 weeks interval should be given before their travel abroad.

4. IAP has devised an Adolescent Immuni-zation Time Table in which it re-commends two doses of MMR starting from 11-12 years of age at 4 weeks interval if not immunized earlier and only one dose, if already immunized at 12-18 months of age (Table I).

Varicella and Hepatitis A vaccine are additional vaccines. These vaccines are recommended depending upon the epidemiology of these diseases especially in the adolescent age group where fatal complications are likely to occur. If a child has already suffered from Chickenpox the vaccine need not be given.

5. The schedule recommended by AAP for MMR Vaccination (till December 2001) is as follows:

1st dose at 12-15 months

2nd dose at 4-6 years

Catch up at 11-12 years, if previously recommended doses were missed or given earlier than the minimum recommended age (This will be treated as 2nd dose).

IAP Time Table 2001(2) recommends, monovalent Measles vaccine at 9+ months followed by a single dose of MMR at 12-15 months. Whether a 2nd dose of MMR vaccine at 4-6 years or 11-12 years, may be needed, has to be evaluated on the basis of occurrence of Mumps cases following a single dose of MMR vaccination in children.

Table I__Adolescent Immunization Time-Table
Vaccine
Age
1. Tetanus toxoid Booster at 10 and 16 years
2. Rubella As part of MMR vaccine or monovalent 1 dose to girls at 12-13 years of age, if not given earlier
3. MMR 1 dose at 12-13 years of age, if not given earlier
4. Hepatitis B 3 doses at 0,1 and 6 months, if not given earlier
5. Typhoid TA, Vi or Oral Typhoid vaccine every 3 years
6. Varicella* 1 dose upto 12-13 years, and 2 doses after 13 years of age, if not given earlier
7. Hepatitis A* 2 doses at 0 and 6 months, if not given earlier.

2. Immunization Schedule for HIV Infected Children

Dr. Havaldar’s observations on HIV/AIDS prevalence in India and his concern about inadvertently administering Oral Polio Vaccine to all children inclusive of possible HIV infected children are well taken. The current recommendation of various vaccines to HIV/AIDS afflicted children as recom-mended by WHO, AAP, ACIP and IAP are given in Table II.

3. Varicella Vaccine

On Dr. Havaldar’s observation that ‘Varicella Vaccine’ is a definite contra-indication for HIV infected persons and pediatricians must be alerted on this issue’, I would like to draw his attention to the 2001 AAP/ACIP recommendations, which has WHO approval also:

1. Routine screening for HIV is not indicated before routine Varicella immunization.

2. Children known to be infected with HIV may be at increased risk to morbidity from Varicella and Herpes Zoster compared with healthy children.

3. Limited data on immunization of HIV infected children in CDC Class 1 with a CD4+ T-lymphocyte percentage of 25 or greater, indicate that the vaccine is safe, immunogenic and effective.

4. Therefore, after weighing potential risks and benefits, Varicella vaccine should be considered for HIV infected children in CDC Class 1 with a CD4+ T-Lymphocyte percentage of 25 or greater.

5. Eligible children, should receive 2 doses of Varicella vaccine with a 3 month interval between doses and return for evaluation if they experience Varicella like rash.

Issues in immunization, relevant to the epidemiological situation in our country have been dealt with in the ‘IAP Policies, Guide-lines and Recommendations on Immunization 2001’ and valid comments from experts and readers are most welcome for future consideration.

Table II__Recommendations for Immunization in HIV Infected Children
Vaccine Known asymptomatic Known symptomatic
WHO ACIP/AAP WHO ACIP/AAP
BCG Yes* No No No
DPT/DtPa Yes Yes Yes Yes
OPV Yes No No No
Measles/MMR Yes Yes Yes Yes
IPV - Yes - Yes
Hepatitis B Yes Yes Yes Yes
Hib - Yes - Yes
Pneumococcal - Yes - Yes
Influenza - Yes - Yes
Varicella - Consider - Consider
Hepatitis A - Yes - Yes
*For regions where risk of TB is high
A. Parthasarathy, 
Chairman
,
 IAP Committee on Immunization, ‘Brindavan’,
 166, Park Road, Western Extension,
 Anna Nagar, Chennai 600 101, Tamil Nadu, India.
 E-mail: apartha2000@yahoo.com
 References


1. American Academy of Pediatrics, Scheduling Immunization, Varicella Zoster Infections. In: 2000 Red Book: Report of the Committee on Infectious Diseases: 25th edn. Ed. Pickering LK, Elk Grove Village, American Academy of Pediatrics; 2000; pp 21-26, 636.

2. Indian Academy of Pediatrics IAP Immunization Time Table, immunization in special circumstances, IAP policies, Guidelines and recommendations. Eds. Parthasarathy A, Dutta AK, Bhave S. Guide Book 2001: Report of the IAP Committee on Immunizations. II Ed. Indian Academy Pediatrics, Kailash Darshan, Kennedy Bridge, Mumbai; 2001; pp 47, 48, 50.

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