Routine childhood vaccination coverage has been slow to rise in India. Nearly 38 per cent of children failed to receive all basic vaccines in the first year of life in 2016. Dr Kishore Kumar looks at the myriad factors limiting vaccination coverage and opportunities to do better.
Human beings have benefited from vaccines for more than two centuries, yet the pathway to effective vaccines has been neither neat nor direct. There has been a remarkable success story of vaccination in terms of saving lives and giving more people a chance of healthy and productive lives. However, the benefits of vaccination are still being missed by many. Despite steady progress, routine childhood vaccination coverage has been slow to rise. An estimated 38 percent of children in India failed to receive all basic vaccines in the first year of life in 2016. The factors limiting vaccination coverage include large mobile and isolated populations that are difficult to reach, and low demand from under-informed and misinformed populations who fear side-effects and are influenced by anti-vaccination messages.
Changing times
When I qualified as a paediatrician, three decades ago, if someone had told me that poliomyelitis (better known as polio) will be eliminated in 30 years, I would not have believed it. We used to see up to 10 newly infected Polio cases a day in the government hospital where I trained and two to three deaths a week attributed to ‘Bulbar Polio’ as we used to call it back then. That apart, there were several cases of ‘Brain Infection’ called meningitis in that hospital, and the test we used to do on those children called lumbar puncture yielded only pus! Instead of the clear fluid (called cerebrospinal fluid or CSF) surrounding the brain, the fluid used to be infected, which in turn damaged the brain of the children, crippling them for life! Back in those days, we had accepted all this as an inevitable reality.
Edward Jenner created the world’s first vaccine for smallpox in the 1790s. Yet at the time of India’s independence in 1947, the country was reporting the largest number of smallpox cases in the world. Tuberculosis (TB) was also perceived as a major cause of morbidity and mortality. In May 1948, the Government of India (GoI) issued a press note stating that TB was reaching “epidemic proportions” and BCG (Bacillus Calmette Guerin) vaccination was introduced on a limited scale and strict supervision to control the disease. Although the efficacy of the vaccine in preventing pulmonary TB was in question, it was the only protective measure available at the time. Similarly, for diseases like small pox, elimination and prevention could happen due to the availability of vaccinations.
Since 1999, we have seen a significant drop in the cases of brain infection in children by a bacteria called Haemophilus Influenzae type b – which has virtually disappeared today, due to mass vaccination. The virtual elimination of polio is another modern-day wonder, due to the team efforts of various organisations, including WHO, UNICEF, Bill & Melinda Gates Foundation, and Rotary International, to name a few. The world will soon be declared polio free. Just like it is free of small pox.
Current challenges
Today India is becoming a leading producer and exporter of vaccines, yet it is home to one-third of the world’s unimmunised children. There were several causes for this vaccine deficit:
- Insufficient government investment (which has now improved)
- Focus on polio eradication, often at the expense of other immunisations
- Low demand caused by poor education on the subject
- Several myths about vaccination (which are being busted with recent mass education)
- The influence of anti-vaccine advocates
Another major challenge is the lack of quality supply chains and efficient logistics systems, leading to wastage of vaccines. Reports say that over 25 percent of the vaccines go to waste before reaching doctors and their patients, while some lose their efficacy by the time they are administered. This poses a major challenge for the government and public health agencies, working to expand the immunisation coverage, especially in remote areas of the country where supply chain logistics and infrastructure are in poor shape.
Way forward
Given the low childhood vaccination coverage, India’s Ministry of Health and Family Welfare launched Mission Indradhanush (MI) in 2014, to target underserved, vulnerable, resistant, and inaccessible populations. The programme ran between April 2015 and July 2017, vaccinating around 25.5 million children and 6.9 million pregnant women. This contributed to an increase of 6.7 percent in full immunisation coverage (7.9 percent in rural areas and 3.1 percent in urban areas) after the first two phases. In October 2017, the prime minister of India launched Intensified Mission Indradhanush (IMI)—an ambitious plan to accelerate progress. It aimed to reach 90 percent full immunisation coverage in districts and urban areas with persistently low levels. IMI was built on MI, using additional strategies to reach populations at high risk, by involving sectors other than health.
A developing country like India that boasts of the world’s largest immunisation programme – with annual cohorts of around 26.7 million infants and 30 million pregnant women – needs to do better. As we approach the last year on the Global Vaccine Action Plan (GVAP 2011-2020), a new strategy for immunisation is needed for the entire health and development community – one that reflects the collective inputs of people, communities, governments, civil society, health professionals, academia, development agencies, and the private sector. The new strategy needs to be ready for endorsement at the 73rd World Health Assembly in May 2020.
(The author is Founder Chairman & Neonatologist, Cloudnine Group of Hospitals, Bengaluru, India)
