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Immunization Dialogue Indian Pediatrics 1999; 36:318-320 |
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Contraindicationss of OPV |
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Administration of Trivalent Oral Polio Vaccine should be delayed in children suffering from acute febrile illness, diarrhea and dysentery, debilitating aimlment abdominal pain and in patients untergoing steroid therapy. It should be avoided in patients with leukemia, lymphoma, malignancy and dysgammaglobinemias. It should not be administered to a child with immunodeficiency and also to a child who is in close contact of a person with immunodeficiency. Such children should be administered Inactivated Polio Vaccine (IPV). Although, Inactivated Polio Vaccine may not provide 'herd immunity', but, should the 'at risk' child not be provided 'safe personal immunity'? Now AIDS has taken firm roots in our country. Many children with the condition even unknown to the parents may be inadvertently given OPV and could later develop neuroparalysis. I seek views on the following two issues: (i) IPV was available in India in mid-eighties. Why are we not reintroducing the improved type of the vaccine which is available? It might be expensive, but, we are already administering Hepatitis Band Hib vaccines which are also expensive. Are we waiting for some catastrophe?; and (ii) The public in general has been conveyed the message that OPV is absolutely safe vaccine and there is no contraindication to its administration. Can we be accused of withholding vital information' from the parents?
Yash Paul, Bani Park, Jaipur 302016, India. There is a lot of merit in Dr. Yash Paul's loud thinking on the two polio vaccines. However, the issues are inherently somewhat complex, to which additional and unfortunate complications have been contributed by some major players, for reasons that are not entirely science-based. Like in many other situations, decisions and choices on issues of immunizations ,and polio eradication efforts are not quite as transparent and straight forward as they should have been. Yet, all of us, members of lAP, our government, international and bilateral aid organizations and the relevant United Nations agencies desire the eradication of poliomyelitis as soon as possible and certainly no later than the year 2000. Yes, in our enthusiasm to eradicate poliomyelitis, perhaps it is better to overlook certain issues of disagreement than to treat them as bones of contention, for several reasons. For one thing, poliomyelitis due to wild polioviruses can be eradicated by using OPV exclusively, and the government of India has made a conscious decision to do so, fully supported, or rather, fully directed, by the WorId Health Organization. Any dissension at this time is unwise and unwarranted, particularly so as we do not want to give any excuse for anyone to blame any delay in the achievement of polio eradication on such frivolous grounds as even a debate in a scientific journal. Even those who believe that it would have been much simpler to eradicate polio using 3 or 4 doses of the enhanced potency inactivated polio vaccine (IPV) in combined form with DPT, than with targeting virtually 100% of children to take 13 to 15 doses of OPV, should hold their horses and fully endorse and support the efforts to get rid of wild polioviruses as soon as possible. Secondly, since the IPV manufacturing unit was closed down, there is no point in debating this issue on theoretical grounds as there is no source for sufficient supplies of lPV. Contrary to Yash Paul's view that IPV may not provide 'herd immunity' (herd effect is the better term), it is OPV that has poor herd effect for which reason we have to give 13-15 doses to all children to achieve the break in wild poliovirus transmission, not due to herd effect but by over immunizing 100% of susceptible children. Most probably, we could have eradicated polio by herd effect, had we chosen to use IPV, but again, there is no point in lamenting what would not have been acceptable to the major players. We should not cry over spilled milk, but get on with the job of eradicating polio by using the chosen tool most effectively. Therefore we must overlook the defects of OPV and get rid of wild polioviruses using it; the sooner we achieve it the sooner we can discontinue using OPV altogether. Yash Paul is right in demanding that IPV be made available for individual use in children in whom OPV is contraindicated. I do not believe that fever, diarrhea, dysentery, abdominal pain, etc. are specific contraindications for OPV but they are reasons to postpone immunization with any vaccine only if such delay is not detrimental. If a child falls ill with any of them during the course of rabies immunization after bite from a rabid animal, I would continue the doses as per schedule. Recently this question arose in a child who developed chickenpox rash during post exposure rabies immunization and the course went uninterrupted: Immunosuppression due to disease or drugs is an important issue with regard to the question of OPV versus IPV. My colleagues give IPV in the context of bone marrow transplantation. It is my understanding that IPV is licensed in India for such purposes, but what is not licensed is the IPV combined with DPT, otherwise called DPTP. Regarding the message that OPV is absolutely safe, we do know that it is not. However, I will not suggest that the public be alarmed by the very small risk of vaccine associated polio, a price we have accepted to pay for the control and eradication of wild polio viruses. On the other hand I do believe that it is unethical on the part of the government not 10 compensate children and their families when a child develops this adverse reaction. With improved surveillance of all cases of acute flaccid paralysis, I am sure the government is aware of cases of vaccine associated polio cases.
T. Jacob John, and President, Indian Academy of Pediatrics Thekkekara, 2/91 E-2, Kamalakshipuram, Vellore, Tamil Nadu - 632 002, India.
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