Vaccinating kids against two killer diseases crucial

In June, a team of medical researchers led by researchers from the Johns Hopkins Bloomberg School of Public Health published a 15-year trend analysis in the Lancet to show how child mortality from Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) bacterial infections in high-burden countries fell by 51% and 90% respectively between 2000 and 2015. Due to timely introduction of vaccines and improvement in general health parameters, the bulk of the global burden of these two killer diseases are confined to a handful of countries.

India accounts for the maximum number of deaths in the world for both. Approximately 50% of all pneumococcal deaths in 2015 occurred in four countries in Africa and Asia, with India heading the chart. An estimated 68,700 Indian children died in 2015, followed by Nigeria (49,000), Congo (14,500) and Pakistan (14,400). Similarly, with an estimated 15,600 Hib deaths, India led the global Hib toll, too, in 2015, followed by Nigeria, China and South Sudan.

Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (pneumococcus) are bacteria that can cause meningitis, pneumonia, sepsis and other serious complications, especially in children. They have been major causes of child mortality in developing countries. Estimates for the year 2000 showed about 2.1 million severe infections and 2,99,000 child deaths from Hib; and 6.6 million severe infections and 600,000 child deaths from pneumococcus worldwide — not including the cases of opportunistic infection in children with HIV.

In the last two decades, childhood deaths from these two leading causes declined sharply as vaccines were introduced in high-burden countries. The shots virtually eliminated Hib as a significant public health threat in areas of high and sustained coverage. However, children in several developing countries with high disease burdens have only started to receive Hib vaccine in the past decade. A vaccine against pneumococcus, known as the pneumococcal conjugate vaccine (PCV), began to be used in many low-income countries, where much of the disease burden is found, in 2009.

India started late. While both vaccines were available in the private sector for a long time, the Union Health Ministry introduced the Hib vaccine only in 2011. The estimated national coverage remained relatively low. The other one, PCV, was introduced only in 2017 and that, too, only in five states. Inadequate funding was the major bottleneck as India’s health budget didn’t grow much in the last decade.

Over the years, introduction of new vaccines in India was supported by the Gavi, The Vaccine Alliance –- a network of private and public entities –- that supports introduction of vaccines around the world.

Gavi hand-holding was available for the introduction of inactivated polio vaccine, measles-rubella, pentavalent vaccine (containing Hib), pneumococcal and rotavirus. For pentavalent vaccine, the Gavi support ended in 2016, following which the health ministry manages the programme with its internal funding. Similarly, for pneumococcal and rotavirus vaccines, the hand-holding will end in 2020 and 2022, respectively.

How much money will the health ministry require to continue with the pneumococcal programme and extend it to the rest of the country once Gavi departs? A month before the Lancet study, three US-based public health researchers carried out an analysis to calculate the amount and, in the process, flagged several areas of concern.

Given the high disease-burden and death toll, the National Technical Advisory Group on Immunisation in 2016 recommended introducing the PCV in the Universal Immunisation Programme (UIP), which targets a cohort of 27 million newborns across the country with six vaccines and another two vaccines (against rotavirus and Japanese encephalitis) in a few states. The government had initially rolled out PCV in three states — Bihar, Uttar Pradesh and Himachal — in 2017. Rajasthan and Madhya Pradesh were later added to the list.

The progress remains slow in part due to the relatively high cost of PCV compared with other vaccines already provided under the UIP. Though the Gavi support will continue until 2021, the health ministry needs to find adequate resources to continue with the vaccination.

In their study, published last month in BMJ Global Health, the trio from University of Strathclyde, Glasgow, Johns Hopkins University, Maryland, and Princeton University, New Jersey, found that introducing PCV into the UIP would protect thousands of households from the risk of expenditure on treatment and hospitalisation for pneumococcal diseases, but it would incur an annual cost of nearly $240 million or approximately Rs 1,632 crore — more than double the Rs 700 crore India spent on immunisation in 2014-15.

Such an investment would avert 34,800 deaths annually, assuming vaccine coverage levels and distribution at 77% — similar to the coverage of diphtheria, pertussis (whooping cough), tetanus vaccination. The greatest reduction in disease incidence and mortality is predicted to occur in the first few years after the introduction of the vaccine. If the coverage level is expanded to 90%, the total annual cost is estimated to rise to Rs 2,230 crore. In addition, there would be a saving on the out-of-pocket expenditure, but the maximum gain would be for people in the lowest socio-economic category.

“The estimated average annual decline in child deaths from pneumococcus jumped from 3% during 2000-2010 to 8% after 2010 when many high-burden countries began widespread immunisations with PCV. The pneumoccocal disease burden is now limited to a small number of countries (including India) that have not introduced the vaccine or have not yet fully scaled the vaccines. Further progress against these diseases will depend on efforts in these countries,” says Brian Wahl, a scientist in the Bloomberg School’s Department of International Health, who led the Lancet study team. “These bacteria still cause far too many child deaths.”

The question is, does the health ministry hold the same view, and if it does, what it is doing to mop up the resources needed? There is little clarity at the moment.