18 Mar 2010
Civil Society Activism Hinders Vaccine-introduction in India: Vote for autocracy?
By Jacob Puliyel MD MPhil, Delhi, India, et al
Accelerating Policy Decisions to Adopt Haemophilus influenzae Type b Vaccine: A Global, Multivariable Analysis
Shearer and colleagues use sophisticated modeling techniques to try and explain why some countries take longer to adopt Haemophilus influenza type b (Hib) vaccine in their national immunization programs (1). A primary premise they make is that the vaccine is beneficial to society. Published evidence of strain shifts and side effects however contradict this assumption.
Data from Canada and elsewhere suggests that Hib vaccine has nearly eliminated Haemophilus influenza type b but there has been a proportional increase in non-Hib strains including non-serotypable strains causing invasive H influenza disease in the post Hib vaccine era (2-10). Studies from Finland have shown an increase in type 1 diabetes after introduction of the vaccine. The increase in incidence was 58/100000 (p=0.029) (11,12) where the pre-Hib vaccine incidence of Hib in Europe was 12 to 54/ 100000 (13)
We note that research by Shearer and colleagues did not model the results of local studies – only their existence (1). The authors state that knowing a study exists is not equivalent to knowing the implication of their findings or their dissemination to decision makers. Such patronization of decision makers does not serve the cause of objective discourse. In India as also in other countries, evidence of natural immunity to Hib, developed in infancy because of infection with other bacteria (with cross-reactive antigens) (14-17) have been quoted as the rationale negating need to vaccinate with Hib. The low incidence of Hib disease has had a direct bearing on the non-introduction of the vaccine in India.
A large multi-center study in India, funded by GAVI (18) found that the incidence of all-cause pneumonia deaths was fifty times less than what was projected previously (19, 20). The incidence of pneumonia was so low that even with 10% mortality the deaths would not match the figures projected to make the vaccine appear cost-effective. This study argues against the need for both the Hib vaccine and the pneumococcal vaccine in India. Rather conveniently the data from this study was not included in the National Technical Advisory Group on Immunization (NTAGI) report recommending Hib (21). The data from the study was obtained under the Right to Information Act. The omission of this data from the recommendation of the NTAGI (to decision makers) became the focus of a public interest petition in the Delhi High Court and it has resulted in reevaluation of the NTAGI report by the Government of India (22). This suggests that attempts ‘not to disseminate findings to decision maker’ may not always serve the purpose.
Another premise the authors start with (1), is that ‘democracy’ results in early introduction of vaccines. A previous study (23) and their own results (not included in the abstract) (1) have actually proved the opposite - that autocracy favors vaccine introduction. The experience from India also suggests that a well informed and active civil-society movement sometimes stands in the way of the introduction of vaccines. It is not such bad news either.
One is left to speculate what lessons the GAVI will take from this finding. One hopes accelerated introduction of the other vaccines like human papillomavirus, pneumococcal and rotavirus vaccines will not be accompanied by an assault on democratic rights, institutions and systems like the Right to Information Act in India.
Prashant Tyagi MBBS
Department of Pediatrics
St Stephens Hospital
Delhi 110054 India
Mira Shiva MD
Initiative for Health , Equity and Society/Third World Network
All India Drug Action Network
A-60, Hauz Khas
New Delhi - 110 016
Tel: 91-11-26512385, Mob:91 9810582028
Jacob Puliyel MD MPhil
Department of Pediatrics
St Stephens Hospital
Delhi 110054 India
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No competing interests declared.