Golden jubilee perspective
Indian Pediatr 2013;50: 111-118
50 years of Immunization in India: Progress
VM Vashishtha and P Kumar
From Mangla Hospital & Research Center, Bijnor, Uttar
Pradesh; and *Kumar Child Clinic, Dwarka, New Delhi; India.
Correspondence to: Dr Vipin M Vashishtha, Director
and Consultant pediatrician, Mangla Hospital and Research Center, Shakti
Chowk, Bijnor, Uttar Pradesh, 246 701, India.
Immunization is one of the most cost effective public health
interventions and largely responsible for reduction of under-5 mortality
rate. However, vaccine preventable diseases (VPDs) are still responsible
for over 5 lakh deaths annually in India. This underlines the need of
further improvement. Today, India is a leading producer and exporter of
vaccines, still the country is home to one-third of the world’s
unimmunized children. There are a number of reasons why India lags
behind its many less developed neighbors in vaccination rates. They
include huge population with relatively high growth rate, geographical
diversity and some hard to reach populations, lack of awareness
regarding vaccination, inadequate delivery of health services,
inadequate supervision and monitoring, lack of micro-planning and
general lack of inter-sectoral coordination, and weak VPD surveillance
system. In this article, we discuss some of the remedial measures to
remove obstacles and improve immunization status of the country.
Heightened political and bureaucratic will, increasing demand for
vaccination by using effective Information, education and communication
(IEC), creating more ‘delivery points’ for routine immunization, proper
monitoring of the program, and changing overall objective of the program
from merely targeting coverage to more meaningful monitoring of the ‘VPD
reduction’ and ‘demand creation’ referred as the ‘output’ of entire
vaccination program. Successful AFP surveillance network should serve as
platform for an efficient integrated disease surveillance system. AEFI
and postmarketing surveillance systems should be urgently upgraded, and
there is need of strengthening the regulatory capacity of the country.
Restructuring of EPI with induction of some new vaccines, clear-cut
guidelines on the policy of introduction of newer vaccines, and
establishing a separate, independent department of public health are few
other areas that need urgent attention.
Key words: Immunization, Vaccine preventable
diseases, VPD surveillance.
Immunization is one of the most cost effective
public health interventions since it provides direct and effective
protection against preventable morbidity and mortality. It has been a
major contributor in the decline of under-5 mortality rate from ~ 233 to
~63 (per 1000) in last five decades in India . However, vaccine
preventable diseases (VPDs) are still responsible for over 5 lakh deaths
annually in India. This underlines the need for further improvement.
India, along with many developing countries, is lagging behind in
sufficient coverage of Routine Immunization (RI). According to World
Health Organization (WHO)/UNICEF estimates, DTP3 coverage in the
South-East Asia and Africa regions of WHO for 2010 remained relatively
low at 77% . In India, the coverage was even lower at 61% . Thus,
the SEA Regional Director declared 2012 as the Year for Intensifying RI
in the Region . This was endorsed by Government of India (GoI) and
2012 was declared as the Year of Intensification of RI in India also
This perspective summarizes the history, achieve-ments,
roadblocks and future of immunization in India.
The Story So Far
India and China were two countries where "some form
of inoculation" was practiced even before 16th
century . However, modern immunization developed in India in 19th
century, parallel to the Western world. Initial years saw considerable
investment in research and development (R&D) in vaccines and about
fifteen vaccine institutes were established beginning in the 1890s.
World’s first plague vaccine by Haffkine (in 1897) and Manson’s
development of an indigenous cholera vaccine were the most notable
achievements of these institutes. However, the benefits of this early
institutionalization did not last long. By the time Indians inherited
the leadership of the above institutions (from Britishers), research and
technological innovation was sidelined as demands for routine vaccine
production took priority .
By early 1970s, many childhood diseases had almost
disappeared from developed countries. These diseases, however, continued
to take many lives in poorer countries. In fact, in 1974, fewer than 5%
of children, worldwide were immunized by age 1 against diphtheria,
polio, tuberculosis, pertussis, measles, and tetanus . That is why
WHO launched the Expanded Programme on Immunization (EPI) in 1974 to
bring vaccination against these six diseases to many underserved areas.
India, on its part, launched its first vaccine
exactly 50 years back: BCG in 1962  as a part of National
Tuberculosis Program. EPI was launched in India in 1978. Initially, it
included BCG, DPT (3 doses) and typhoid vaccine; OPV was added the next
year. In addition to 3 primary doses of DPT and OPV, 2 boosters at 1.5
years and 5 years were also given to cover children upto 5 years of age.
Achieving self-sufficiency in production of vaccines was also a part of
program. In 1985, the program was converted into Universal Immunization
Program (UIP) with a lofty goal to cover ‘all’ eligible children in the
country, immunization of ‘all’ pregnant women with TT and to improve
quality of services. Although the first booster of DPT was retained in
UIP, the second booster at 5 years was reduced to DT (pertussis
component was omitted). In the same year, measles vaccine was added at 9
months of age, but typhoid vaccine was dropped from the program . In
next 2 decades, there were lots of administrative changes in UIP: It was
given status of National Technology Mission in 1986 to give a sense of
urgency and commitment in achieving the goals; then it was made part of
Child Survival and State Motherhood (CSSM) programme in 1992 and
Reproductive and Child Health (RCH) programme in 1997 .
However, the focus remained on 4 vaccines (BCG, DPT, OPV and Measles)
and 6 diseases only. It was only after 2006 that new vaccines like
hepatitis B, second dose of measles and Japanese Encephalitis vaccines
were introduced . Hepatitis B vaccine was initially introduced in 10
states and then extended to whole country . The Japanese
encephalitis vaccine has been introduced in 111 districts in 15 States
having a high disease burden . In December 2011, pentavalent vaccine
(containing vaccine against diphtheria, pertussis, tetanus (DPT),
Hepatitis B and Haemophilus influenzae type B (HiB)) was
introduced in two states with high coverage of RI: Tamil Nadu and Kerala
. Recently, the Government has decided to introduce it in 6 more
states: Gujarat, Karnataka, Haryana, Goa, J&K and Pondicherry .
In 1988, the GoI committed the nation to the goal of
global polio eradication, along with all 192 member nations of the WHO
(14). Pulse Polio Programme (PPP) was started initially in Delhi in 1994
and was extended to the whole country in 1995. In 1994 and 1995,
children up to 3 yrs of age were covered. From 1996-97 onwards, all
children up to 5 years of age are being covered under this program.
House to house component was added in 2000-01 as a part of
intensification of Pulse Polio Programme. The National Polio
Surveillance Project (NPSP) was launched in 1997 to provide technical
and logistic assistance to the GoI and work closely with state
governments and a broad array of partner agencies to achieve the goal of
polio eradication in India . The efforts yielded good results:
Number of polio cases reduced from about 35000 in 1994 to just 741 cases
in 2009. Use of monovalent OPV, and later bivalent OPV (1and 3)  in
the pulse polio rounds has paid rich dividends. The last case of polio
due to wild virus was reported on 13th
January, 2011 from West Bengal. India has been polio free for more than
a year and was removed from the endemic countries list on February 25,
2012 by the WHO .
Recently, 11 centers across the country have been
identified for laboratory supported surveillance for vaccine preventable
diseases with special reference to potential vaccines in collaboration
with the Indian Council of Medical Research (ICMR) . In another
recent initiative, name and telephone based tracking of pregnant mothers
and children through a web enabled system has been introduced. The
initiative intends to make sure that all pregnant mothers and children
receive full continuum of care including complete vaccination .
India has also joined the global post-marketing surveillance network for
reporting adverse event following immunization (AEFI) associated with
new vaccines and Maharashtra is the participating state .
Efforts are also on to improve health infrastructure
in the country: key to optimize the implementation of UIP. National
Rural Health Mission (NRHM) was launched in 2005 to re-vitalize the
primary health care systems for the benefit of the people living in
rural areas, particularly in difficult, inaccessible and remote parts of
the country. Since the launch of NRHM in 2005, more than 15 billion
dollars have been provided to the States in addition to their budgets,
for strengthening health systems and infrastructure with key focus on
reproductive and child health, including immunization .
Availability of new safe and effective vaccines
against major killers like diarrhea and pneumonia necessitated serious
deliberations on further strengthening of National Immunization
Programme. The Ministry of Health and Family Welfare formulated
National Vaccine Policy in April 2011 to provide broad policy
guidelines and framework to guide the creation of evidence base to
justify need of research and development, production, procurement and
quality assessment of vaccines under UIP .
Current Status of RI in India
After putting up a good show in its first decade
(1985-95) with coverage of RI reaching 70-85%, there has been
deterioration in the performance of UIP . The coverage of different
vaccines has fallen by 15 to 20%. Surveys carried out during National
Family Health Survey (NFHS) I, II and III and by independent agencies
such as UNICEF, have revealed that the coverage levels may be lower by
as much as 15-40% compared to reported levels of coverage in the UIP
[17,18]. Indeed, there are a few states in India that have efficiently
running UIP and several that do not.
According to the most recent Coverage Evaluation
Survey (CES), a nationwide survey covering all States and Union
Territories of India, conducted during November 2009 to January 2010 by
UNICEF, the national fully immunized (FI) coverage against the six
vaccines included in UIP in the age-group of 12-23 month old children is
61% whereas it was 54.1% and 47.3% as reported by District Level
Household and Facility Survey (DLHS-3) (2007-08) and NFHS-III (2005-06),
respectively [18-20]. Regarding coverage of individual antigens in the
similar age group, the CES 2009 reported BCG, OPV and DTP3 doses
coverage, and measles first dose coverage as 86.9%, 70.4%, 71.5%, and
74.1%, respectively . The corresponding figures cited by DLHS-3 and
NFHS-3 were 86.7%, 66%, 63.5%, and 69.5%, and 78.1%, 78.2%, 55.3%, and
58.8%, respectively [18, 20]. As far as newer antigens are concerned,
the 3 doses of Hepatitis B vaccine coverage among children 12-23 months
in 16 States/UT where it is part of UIP evaluated to be 58.9% by CES
2009 . However, birth dose administration is still a challenge in
all these states. About 7.6% of children between the ages of 12-23
months have not received any vaccine .
There is a large inter-state variation in the
coverage of RI. As per CES 2009, there are 4 states (Goa, Sikkim, Punjab
and Kerala) >80% of children between 12-23 months of age are fully
immunized. This percentage is < 50% for another 5 states (Bihar, Madhya
Pradesh, UP, Nagaland and Arunachal Pradesh) . Six states with high
population contribute to 80% of 8.1 million unimmunized children in the
country, 52% of the total unimmunized children reside in Uttar Pradesh
and Bihar alone .
Where are we Lacking?
The barriers to achieve 100% immunization coverage
There are a number of reasons why India lags behind
its per capita GDP counterparts in vaccination rates (compare to
Bangladesh, where 82% of children are fully vaccinated by age two).
Huge population with relatively high growth rate is a barrier
in itself. Approximately 27 million children are born in India each year
– the largest birth cohort in the world – but less than 44% receive a
full schedule of vaccinations . To reach each and every one of such
a huge cohort every year is obviously a daunting task. Geographical
diversity (snow bound/ hilly areas, deserts, tropical forest areas,
remote island territories), cultural diversity (with various religions,
languages, traditions, beliefs and customs) and Political instability
("coalition" governments, "politically sensitive areas" like Naxal/terrorist-affected
areas) are some problems that are rather unique to India and make the
task more complex. Reaching out to mobile/migrant population (that is a
significant proportion of population in some states) is another
challenge. Special efforts are needed to identify and reach some pockets
of low immunization that are still there in many states.
Coverage Evaluation Survey of UNICEF  found that
reason for partially immunization/ non-immunization was "did not feel
the need", "not knowing about the need" and "not knowing where to go for
vaccination" in 28.2%, 26.3% and 10.8% cases. This means that lack of
awareness is one great barrier to achieve cent percent immunization
coverage. A more recent study in 225 villages of Uttar Pradesh
corroborated the fact that lack of awareness is the one of the main
reason for partial immunization/ non-immunization . Hence, the
demand for vaccines also suffers. Low levels of education negatively
impact health-seeking behavior. In addition, adverse events following
immunization (AEFI) even when these are shown to be unrelated to a
vaccine, have been widely reported in the media and have contributed to
a culture hostile to vaccination in certain communities .
Apart from the above mentioned barriers, there are
some other issues on "supply side" that pose challenges to achieving
high RI rates. They include inadequate delivery of health services
(supply shortages, vacant staff positions, lack of training); lack of
accountability, inadequate supervision and monitoring; lack of
micro-planning at district level; general lack of inter-sectoral
coordination and lack of coordination between state and central
governments resulting in missed opportunities to improve immunization
coverage and quality. Falsification of data and over-reporting of rates
are other big concerns as they give false sense of security and
interfere with proper planning [8,21,24].
The above barriers are further compounded by a weak
VPD surveillance system in the country. There is lack of disease burden
data on many important VPDs in India that results in the perception that
the disease is not important public health problem. Further, there is
utter lack of diagnostic tools for certain VPDs. Lack of baseline
surveillance data also is a bottleneck in monitoring the impact of
Focusing on polio eradication exclusively while
neglecting UIP ("de-linking" of UIP from Polio Eradication Initiative:
PEI) by the policy-makers has also led to deterioration of performance
of UIP [8,24,25]. It has been suggested that house-to-house rounds of
PPP have also made certain sections of society "dependent" on health
workers: UIP has been adversely affected by this also .
At Government level, resource constraints and
competing priorities need careful planning and policy-making. The fund
allocation for RI is still less than desirable. India had spent around
$113 million on vaccine interventions in 2011, down from $137 million in
2009-10 . There is need to step-up spending on vaccination front.
What is Needed?
The road ahead…
Political and Bureaucratic Will
Such an elaborate program obviously can’t succeed
without political and bureaucratic support at all levels. The existing
National level "Inter Agency Coordination Committee" (ICC) needs to
increase its focus on routine immunization. A public-private partnership
between GoI, NTAGI, Indian Academy of Pediatrics (IAP), Indian Medical
Association (IMA), development partners, ICDS, Ministries of Railways,
Education and Defence, and key NGOs involved with immunization and State
representation should be strengthened . The program managers need to
ensure and monitor that funds are appropriately released in a timely way
for operational costs. Ensure an uninterrupted supply of all antigens to
state level through a vaccine stock management system that includes
annual forecasting and wastage rates. Central level should provide
technical support and resources for states to develop evidence based
social mobilization plan. In specific low performing States, a district
/ block based operations research scheme could be considered and scaled
up if successful. All hard-to-reach and urban slum areas should be
reached at least four times per year with RI or catch ups (21).
Effective IEC Activities
Since lack of awareness has been found to be main
barrier, focus should be on increasing demand for vaccination by using
effective IEC and bringing immunization closer to the communities. The
immunization services provided at the fixed sites should be improved.
There should be better monitoring and supervision, and district
authorities should be made accountable for the performance of RI in
their district .
Induct Innovative Methods to Improve RI
The number of immunization ‘delivery points’
especially in rural and remote areas having poor access to health
facility, should be increased. ‘Immunization booths’ should be
constructed at every locality in urban areas particularly in slums, and
local municipality board member should be made accountable for their
performances. Large and varied cadres of volunteers, including, for
example, local registered medical practitioners, quacks, pharmacists,
chemists and retired nurses and other health personnel can be recruited
to offer immunization services. Proper training including maintenance of
cold chain and basic minimum education on vaccines must be imparted to
all of them. Complete immunization should be made mandatory to get
admission in school by appropriate legislation. Incentives in cash and
kind may be offered to those families having fully immunized kids .
Proper Monitoring of the Program
Although vaccination is a medical intervention, the
vaccination program, UIP, is not simply a medical modality – it is a
management-dominant modality. The managerial, administrative and
governance-related inadequacies need to be addressed on a priority basis
. The need to monitor the progress of control of diseases under UIP
has not been realized; one element of the poor performance of UIP is
precisely this lack of monitoring .
The fact that some states have been performing very
well shows that we have the potential to achieve excellence. The success
factors (in well-performing states) and failure factors (in
poorly-performing states) must be identified and addressed with passion
to reach our goal at the earliest .
Structured work allocation and accountability needs
to be set and monitored: from health worker level till the highest
level. For example, a health worker should be allocated 100-150 babies
and he/ she should be responsible for immunization (may be along with
delivery of other health services) of those children. Each rung of the
health-care machinery should be answerable/ accountable to the immediate
superior rung in the hierarchy . Ideally immunization sessions should
be supervised by a medical officer as done in Tamil Nadu, the only state
of the country having this arrangement.
Running such an elaborate program without any
objective record keeping and retrieval system is rather non-tenable in
current era. As of now, parents have the immunization card that is
filled by the health care worker. There is no record at the health
center. If the card is lost, there is no way of verifying what vaccines
have been taken/ not taken, if taken then from where and which batch
number: there is no record!
To target only the coverage reached with different
vaccines may be misleading and may fall short of achieving full
objectives. The more important item to be monitored is the ‘impact’ or
‘output’ of entire vaccination program. ‘Output’ consists of disease
reduction and demand creation. Outcome measurement by disease
surveillance is essential to evaluate the success of UIP and to assess
input efficiency. Every "case" detected under UIP is evidence of the
success of the monitoring process as well as evidence for suboptimal
output of UIP or suboptimal efficacy or schedule of a particular vaccine
that call urgent remedial measures . This will allow program
managers to move beyond the monitoring of immunization coverage and
understand the broader impact of immunization on disease reduction .
Thus, the UIP system must be district-based in terms
of inputs, output and monitoring/evaluation. In 2002, WHO, UNICEF, and
other partners introduced the concept of "Reaching Every District,"
which was the first step toward achieving more equitable coverage. This
approach has started yielding good results whereever it was introduced
. To go even further, the experience of successful polio vaccination
campaigns that have aimed to reach every child, even those outside of
typical government outreach, can be leveraged, and the "Reach Every
District" strategic approach can be recast as "Reaching Every Community"
Develop Effective Surveillance Systems
UIP can seize the opportunity and establish a
surveillance system for all important childhood infectious diseases. As
has been demonstrated by the AFP surveillance network in India,
efficient surveillance systems can be established, even in resource-poor
settings, at quite low cost relative to the cost of the intervention
itself. Where appropriate, this network should serve as the platform
both for an integrated disease surveillance system that provides
epidemiological data on other communicable diseases, and for detection
and response to emerging infectious disease threats. Funding for disease
surveillance is usually disease specific and time limited. In the
presence of weak national systems, parallel systems tend to be
established in order to generate data suited to the needs of specific
programs . Integrated Disease Surveillance Project (IDSP)- a state
based decentralized surveillance program in the country launched by
Ministry of Health and Family Welfare, GoI in November 2004, and IDsurv–a
web-based infectious disease surveillance program developed by IAP–are
laudable efforts in this regard [27, 28]. However, more comprehensive,
coordinated efforts in the line of Active Bacterial Core surveillance-a
population-based surveillance system run by Centers for Disease Control
and Prevention (CDC), Atlanta in US would actually serve the purpose in
the long run .
Adverse Effects Detection, Reporting and Redressal
There is need of having a functional real-time AEFI
and post-marketing surveillance system in the country . This will
not only help in generating national data, but also useful to allow (and
settle) compensation claims for vaccination-related injuries and serious
adverse events. It will also provide sound basis for decisions to
modify/ abandon certain vaccine preparation based on reactogenicity
profile, should the need arise .
Regulatory and Ethical Issues
There is an urgent need of strengthening the
regulatory capacity of the country and to have a reliable, properly
functioning national regulatory authority. Currently, the Indian NRA,
i.e. the Drug Controller General of India is overburdened with
performing many diverse tasks including marketing authorization and
licensing activities related to drugs, cosmetics, vaccines, etc. We need
to have a vaccine specific NRA to oversee different issues related to
vaccines such as licensing, post-marketing surveillance including AEFI
surveillance, lot (batch) release process, laboratory support for
vaccine testing, regulatory inspections of Good Manufacturing Practices
(GMP), authorization and approval of clinical trials, etc. Hence, the
NRA ought to be a more competent, effective, independent and transparent
body. There should be a single window system to avoid regulatory delays,
and strict guidelines for approval and cancellation of license must be
formulated and practiced. We need clear national guidelines on the
ethical conduct of clinical trials. Ethical concerns, skepticism, and
low vaccination rates persist despite India’s emergence as a global
manufacturing leader in vaccines. Similar, improvement in the
functioning of NTAGI is also desired.
Support to Indigenous Vaccine Industry
Most low-cost traditional vaccines are now produced
by vaccine manufacturers in developing countries. Currently about 43% of
the global UIP vaccines come from India, and the Serum Institute is the
world’s leading producer of measles vaccines . Though, the current
national vaccine policy seems supportive of Indian vaccine industry with
liberal support from government-owned institutions like department of
biotechnology (DBT), National Institute of Immunology (NII), department
of science, etc still there is need to further empower Indian vaccine
sector to meet the indigenous demand of vaccines. The time has come to
develop more effective public private partnership (PPP) and share
responsibility of meeting demand of local vaccine need. Of late, there
is ‘orphanization of primary (EPI) vaccines’ with declining interest and
production of these vaccines. The private sector is more interested in
developing newer expensive vaccines where all the innovation, R& D is
diverted. There is need of innovation in public sector units (PSUs)
producing EPI vaccines.
Restructuring of EPI
We need to evolve with times. For the children of the
country to reap benefits of advances in immunology and related sciences,
new epidemiological data on major killers and emerging infections, it is
essential that we relook and update our archaic UIP. Following issues
need urgent attention:
6, 10, 14 week vs 2, 4, 6 month schedule:
The latter schedule, besides being superior immunologically also has the
advantage of facilitating visits at the crucial ages of 4 and 6 months
when infants are being weaned (from breast feeding) and hence vulnerable
to development of malnutrition in the absence of proper nutritional
advice. It will also help to reduce the large gap and hence drop-out
rate (between the 3rd DPT at
14 weeks and measles vaccine at 9 months) and thereby ensure
implementation of more comprehensive child health practices like growth
monitoring, nutritional advice, etc. . Thus, it needs serious
Polio ‘End game’ and ‘Post-eradication vaccine
policy’: India has successfully eliminated wild poliovirus and no
wild case of polio is reported since January 13, 2011 . Globally,
there are urgent plans to withdraw tOPV and switch to bOPV under cover
of IPV , yet no such urgency is being displayed by the GoI. There
are no consultations taking place in this regard. There are many issues
that need to be sorted out on future widespread use of IPV, both at
strategic and technical front.
Hib vaccine: Following recommendations of IAP
 and NTAGI , GoI has already introduced Hib vaccine in two
southern states . It should be extended to all over the country, as
the move has the potential to save over 70,000 child deaths and
significantly more cases of illness and disability every year in India
Typhoid vaccine: Typhoid fever has possibly
highest prevalence as compared to any other VPD in India. Recently, a Ty
21 polysaccharide vaccine has shown good efficacy and even effectiveness
in one large scale Indian trial; its inclusion in the UIP must be
childhood booster of DTP: The pertussis
component was dropped from the national schedule when EPI was adopted as
UIP in India and it continues to be the same. This was without any sound
scientific basis. It is absolutely necessary that this is restored in
the schedule immediately . TdaP vaccine at 10 years of age might have
to be added sometime later, as "epidemiological shift" is known to occur
once we reach good coverage at lower age .
MMR vaccine: Though of late, GoI has undertaken
albeit quite late the initiative of providing 2nd
dose of measles vaccine through RI and campaign mode, it would have been
better had mumps and rubella components are also added.
Introduction of newer vaccines: There are about
23 new/ improved vaccines that are now available or would be available
soon. Although inclusion of a new vaccine in national schedule adds the
cost of vaccine and logistics to the health budget of a country, it also
results in savings by reduction of the disease burden. Thus, the
decision to include a new vaccine in national schedule needs careful
scientific analysis regarding all the issues involved, ranging from
policy issues (whether introduction of the new vaccine is in sync with
immunization policy of the country) to technical and programmatic issues
(whether implementation of the decision is technically feasible) .
New vaccines should not be introduced at the expense of sustaining
existing immunization activities. Instead, the introduction of a new
vaccine should be viewed as an opportunity to strengthen immunization
systems, increase vaccine coverage and reduce inequities of access to
immunization services . Merely making the vaccine available in few
pockets, for certain sections and for limited duration will not have any
impact at national level. The ‘equity’ needs to be ensured so that the
vaccine reaches to the section of the society who needs it the most
Integrated Delivery of Health Interventions
Strengthening of immunization systems in such a way
that they support and integrate with other preventive health services
like providing vitamin A supplementation, deworming, growth monitoring,
distribution of insecticide-treated bed nets, etc. offer the opportunity
to create synergies and facilitate the delivery of services to bolster
comprehensive disease prevention and control. Incorporating immunization
into integrated primary health care programs may also facilitate social
mobilization efforts, help generate community demand for services and
address equity issues . The strategy of child health days, led by
UNICEF, has also helped to promote RI .
Research and Development (R&D)
Investment in research and development is bound to
pay rich dividends. A large number of vaccine products are currently in
the pipeline and are expected to become available in near future.
According to recent unpublished data, more than 80 candidate vaccines
are in the late stages of clinical testing. About 30 of these candidate
vaccines aim to protect against major diseases for which no licensed
vaccines exist, such as malaria and dengue. The benefits of development
of better vaccines for existing VPDs like tuberculosis, typhoid and
influenza, increasing the ambit of VPDs by development of vaccines
against mass killers like HIV, malaria, dengue fever, RSV, enteric
pathogens like E.coli, Klebsiella, etc, development of more
thermostable vaccines (so that need of maintenance of cold chain is
obviated) and development of alternative delivery of vaccines, like
mucosal vaccines/ edible vaccines  cannot be overemphasized.
Apart from all the above mentioned measures, there is
an urgent need of establishing a separate, independent department of
Public Health. All the community health projects should be supervised
and run under this department rather than in the form of different
vertical programs. There must be prioritization of the need of a
particular vaccine based on the disease burden data of that VPD rather
than on the availability of the product in the international market.
There must be clear cut transparent guidelines on the policy of
introduction of newer vaccines. And in the last, efforts should be made
to devise guidelines to regulate hitherto ‘unregulated’ private vaccine
market. There must be a ‘code of conduct’ for marketing vaccines in
Immunization has delivered excellent results in
reducing morbidity and mortality from childhood infections in the last
50 years. Although the success has not been as spectacular as in
developed world, the fact is we have eradicated small pox, and now on
the verge of eradicating polio. There has been substantial reduction in
the incidence of many VPDs. It is widely believed that the progress in
last two decades or so has not been as swift on this front as in other
fields. Nevertheless, there has been some improvement in last few years:
Introduction of newer antigens in UIP (Hepatitis B, 2nd
dose of Measles, Japanese encephalitis and Hib in few states), framing
of National Vaccine Policy, and acknowledging the need to intensify RI
are steps in right direction. We now need to step up our efforts to
strengthen all components of UIP (vaccination schedule, delivery and
monitoring, and VPD/AEFI surveillance), overcome all barriers
(geographical, politico-social and technical) and invest heavily in R&D
to achieve immunization’s full potential and a healthier Nation.
Funding: None; Competing interests:
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