Pneumonia is emerging as the leading killer of children under the age of five in India with about 400,000 children dying of it every year. This disease now accounts for nearly a fifth of the infant mortality rate of two million deaths a year, according to the Indian Academy of Pediatrics—this is estimated to be the highest mortality rate in the under-5 age group across the world.
At least a quarter of such deaths can be prevented by vaccination, say paediatricians. They are now asking for the inclusion of the pneumococcal conjugate vaccine in the national immunization schedule (the pneumococcal vaccine for adults is also given to all senior citizens in developed countries, not just to children, and the practice is becoming increasingly common in India too).
Too many preventable deaths
“Half of all severe cases of pneumonia are caused by the pneumococcus bacteria and almost 40% of these deaths are preventable by use of pneumococcal conjugate vaccine in the National Immunization Program,” said Nitin Shah, chairperson, Asian Strategic Alliance for Pneumococcal Disease Prevention (ASAP)-India, at the Mumbai pneumococcal disease conference in October.
Pneumonia is inflammation of the lungs caused by the bacterium Streptococcus pneumoniae. The same bacteria can also infect blood, the middle ear, sinuses or cause meningitis where the covering of the brain and spinal cord is infected. “This group of diseases is collectively called pneumococcal disease and can also lead to brain damage, paralysis, learning disabilities, speech delays and at times death,” says Rohit Agrawal, secretary general, Indian Academy of Pediatrics and co-convener of ASAP-India.
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The old order changes...
At present the immunization schedule for Indian children includes six mandatory vaccines, such as BCG to prevent TB and OPV or IPV (both polio vaccines) given at birth and every 4-6 weeks (a total of six doses: four within the fourth month with a booster given at 18 months to two years, and a second booster between ages 4-5). Pulse Polio immunization is also given in addition to the routine polio drops to prevent poliomyelitis.
The Hepatitis B vaccine is given in three doses—at birth and then at the end of the first and sixth months—to prevent liver infection. DTwP (formerly DPT) or DTaP prevent diphtheria, tetanus and pertussis and is given at six weeks in three doses at intervals of four-six weeks, followed by two boosters between two and five years. The measles vaccine is given at nine months; the MMR vaccine, given at 15 months, is for protection from measles, mumps and rubella.
It is this regimen that paediatricians are keen to update by adding at least three new vaccines—the pneumococcal conjugate vaccine, the Hib vaccine, which prevents H. influenzae type b bacterial meningitis and can be combined with DTwP in the same schedule as a common combination vaccine, and the Hepatitis A vaccine. “Hepatitis A also needs to be added to make up a mandatory list of nine vaccines for Indian children,” says Shyam Kukreja, convenor, ASAP-India. Dr Kukreja says that as the focus of health care moves towards a regimen of prevention rather than cure, there is need to upgrade the immunization schedule. Combination vaccines that mean fewer pricks for a young child are also on the recommended list for paediatricians. “Hepatitis A & B, DTwP+ Hib+Hepatitis B are examples of combination vaccines that reduce the disease burden and offer greater safety,” says Sanjeev Bagai, a senior paediatrician at New Delhi’s Rockland Hospital.
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Cost benefit besides comfort
Medical practitioners also say the cost-benefit analysis in choosing vaccines is an important factor in determining whether the vaccines are voluntary or mandatory. “The new pneumococcal conjugate vaccines designed for nearly 100% protection cost Rs4,000 for a single dose, while the old polysaccharide pneumococcal vaccine, which was given to children above two years, cost Rs1,150 for a single dose,” says Dr Bagai.
In a country like India, where cross-infections abound, he says a comprehensive vaccination programme is crucial. “The parameters a parent must consider before choosing a new vaccine are affordability, the risk versus benefit ratio of the vaccine and its side effects,” says Rajiv Chabbra, consultant paediatric and neonatal intensivist, Artemis Health Institute, Gurgaon.
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Catching up with the world
The benefit of a vaccine programme is centred mainly on the fact that by building prior immunity, the chances of drug-resistant strains of bacteria developing are minimized. For instance, doctors use antibiotics to treat children with pneumonia, but increasing incidence of drug-resistant pneumococcal disease is a major cause of concern. “Even the World Health Organization has been pushing for the use of (the) anti-pneumonia vaccine for the last two-three years,” says Dr Bagai.
The vaccine approach is also gaining ground in the control of certain other diseases such as rotavirus diarrhoea, a common cause of illness in children less than two years. However, the vaccine against this is rather expensive, at Rs1,000 for 2 drops.
Dr Chhabra says: “One of the recent vaccines in the market is to prevent cervical cancer. This vaccine is recommended for adolescent girls before the start of sexual activity in three doses” (the cervical cancer vaccine can be given between 10-45 years of age, but since there is evidence that the disease is sexually communicable, the earlier it’s taken, the better.)
Dr Chabbra feels winter ailments too can be curtailed by using the flu vaccine available from September till March.
“Immunization is the biggest medical achievement of the last century and is by far the most cost effective health care intervention,” says Dr Bagai, who says that new vaccines that protect against streptococcal pneumonia, Hepatitis A, meningitis, flu and chicken pox, which are now listed as voluntary vaccinations, should be given to all children.
These are the new vaccines on the block (for both adults and children) that you should ask your doctor about:
Voluntary vaccines: Hepatitis A, chicken pox, flu, pneumococcal, meningococcal meningitis, typhoid, rotavirus and Japanese encephalitis.
Combination vaccines: These vaccines spare you multiple pricks and can be cheaper, since they may immunize a child against, say, six major illnesses with one shot. “Some combinations under development include MMR (mumps+measles+ rubella)+varicella and DTaP+Hib+IPV+Hepatitis B+Hepatitis A,” says Sanjeev Bagai, senior paediatrician, Rockland Hospital, New Delhi.
— Archana Rai
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How we feel toward a mentally ill person has a lot to do with how closely that person’s symptoms conform to gender stereotypes, new research shows. People don’t have much sympathy for someone with more stereotypical problems, specifically a woman with major depression or an alcoholic man, Galen V. Bodenhausen of Northwestern University, Chicago, explained in an interview. But when a person’s symptoms are out of line with these stereotypes (say, an alcoholic woman or a depressed man), we will view them more positively and want to help them, he said.
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— Staff Writer
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