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The point of it


From chickenpox to flu, there is a vaccine to protect your child from an array of diseases. But do they really need them? And do they make for sound public health measures?

Sanghamitra's 18-month-old son has had so many vaccine shots that she has lost count. "I try to keep track with the help of his vaccination card. I think he has had about 13 to 14 injections so far, about one shot every month. They are worth it for his long term health, " she says. Sanghamitra has given him all the vaccines the doctor suggested, even those that she was told are optional.

Many parents in her circle did not go for these vaccines mostly because they feared the side-effects or were reluctant to subject their babies to so many jabs. It is a tough call for most parents - immunisation can mean two or three vaccines against major diseases or a dozen vaccines against an array illnesses.

There is growing uneasiness about how necessary these optional vaccines really are. There are more than 16 vaccine-preventable diseases now and the list is growing with several more in the pipeline.

Not all vaccines are in the immunisation programme of all countries. For instance, the Hepatitis B vaccine is not part of routine immunisation in the UK and the typhoid vaccine is not given in the US and many other developing countries. The Hepatitis A vaccine, given routinely to kids in the US, is only a travel vaccine in the UK and not given in Germany. Chicken pox vaccine is also not given routinely in the UK while it is in the US. Yellow fever vaccine is mandatory in Brazil but not in India as there is no incidence of the disease here. Each country decides what vaccine to use after determining the disease burden, a cost-benefit analysis, safety of the vaccine and so on.

In India, under the national immunisation programme (NIP), within one year, a baby receives nine jabs and two more by the age of two to protect against seven diseases, including the oral polio vaccine (OPV). In comparison, the immunisation programme in UK includes vaccines against 10 diseases which involve 12 jabs or injections for the baby within the first 13 months.

The problem arises when even the health benefit of vaccines is disputed. There have been controversies about vaccine safety and side effects such as autism - and other scary stories. However, several studies have shown that there is no evidence to back these fears.

While the Indian government recommends only six injectible vaccines and the OPV, the Indian Academy of Pediatrics (IAP), an association claiming membership of over 20, 000 practitioners across the country, recommends seven other vaccines - HiB, rotavirus, pneumococcal, Hepatitis A, MMR (measles, mumps, rubella), varicella and HPV vaccines (see box). All these vaccines are optional - administered only if the parents want them, and they are quite expensive too. The cost-benefit calculation and insufficient disease burden argument makes these vaccines ineligible for inclusion in the publicly-funded NIP. There are no such restrictions when it comes to people paying from their own pockets. They are available to anyone who wants them and can pay.

So, how useful or necessary are the vaccines in the Indian market? Are they to be given because they are available? IAP recommends almost all vaccines available in the market. Critics of the IAP's immunisation schedule point out that it is decided by a committee comprising just private practitioners and a few academicians, all paediatricians. "To be the basis of a national recommendation it is vital that the 'expert committee' be comprehensive including epidemiologists, public health or community health experts, health economists, experts in vaccinology or immunology and so on, " states Dr Sanjiv Lewin, professor of paediatrics at St John's Medical College.

It is indeed such a group of experts who usually decide on the immunisation schedule of a country whether it is the UK, Australia, the US or even India which has its National Technical Advisory Group on Immunisation (NTAGI). Take the case of the NTAGI recommendation on rubella vaccine. It is meant to prevent rubella infection in pregnancy which could cause congenital rubella syndrome (CRS) resulting in eye abnormalities, mental retardation or even congenital heart disease in the baby. Yet, NTAGI does not recommend rubella vaccine for babies because the immunisation programme has to cover 80 per cent of babies to be vaccinated for the vaccine to work. Otherwise, the infection could break out when the kids are older resulting in a paradoxical increase in CRS. Since immunisation coverage in India is just over 60 per cent, NTAGI recommends rubella vaccine for 10-15 year-old girls under the NIP to protect future pregnancies. And since mumps is not a significant problem in India, NTAGI includes only the measles vaccines for NIP and not the MMR vaccine. However, IAP recommends the MMR vaccine for babies. It might protect the baby, but is not a sound public health measure.

"Almost all the vaccines recommended by IAP might make sense for an individual as they reduce your risk of getting the disease to some extent, they are quite safe and if you think that risk reduction is worth the price, you can go for it, " says a community health expert.

Anxious parents often end up giving their children all the vaccines. And yet, not all vaccinations are desirable. Most importantly, parents often don't have the means to make an informed choice.

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