Indian Pediatrics 2002; 39:327-330  

National Technical Advisory Group on Immunization: A major step forward for child health

The health care professionals in India, especially those involved in child health and preventive medicine, must feel very pleased as the Government of India has established a National Technical Advisory Group on Immunization (NTAGI). This is the fulfill-ment of the long-standing desire of several experts on immunization in the country and of the formal recommendation of the Indian Academy of Pediatrics, made in 1999 (1). The recommendation, submitted to the Depart-ment of Family Welfare, Ministry of Health and Family Welfare, Government of India, was as follows.

"The Academy strongly recommends to the Government of India to constitute an Advisory Committee on Immunization Policies, with representation from the Ministry of Health and Family Welfare, Indian Academy of Pediatrics, Indian Medical Association, Indian Council of Medical Research, National Institute of Biologicals, National Vaccine Testing Facility and independent experts"(1).

In addition to the IAP recommendation, it appears that the World Bank also had encouraged the Government to constitute such an advisory committee for improving the national performance in immunization. The Ministry deserves our appreciation, good wishes and the promise that we, as the Academy, will continue to support it in all programs for child health. The Government can count on the Academy for partnership, and for technical and academic inputs and leadership, in our national immunization efforts, which have not only not achieved their full potential, but has foundered in some major States in the country.

The Ministry issued the Office Order, constituting the NTAGI, in August of 2001. The Secretary to the Government, Department of Family Welfare, is the chairman of this committee, and the Assistant Commissioner, Immunization Program is its Member Secretary. It has representation from a wide spectrum of important constituencies. For example, several national organizations involved in health care policy and research, such as the Indian Council of Medical Research and the National Institute of Health and Family Welfare, and Professional Organizations such as the IAP, Indian Medical Association and the Indian Association of Preventive and Social Medicine have the opportunity and responsibility to be represented on this committee. In addition to wide representation from many Central Government Departments, such as the Child Health and Reproductive and Child Health Programmes of the Department of Family Welfare itself, Department of Women and Child Development, Department of Biotechnology, Planning Commission, Public Health Division of the Department of Health, Drugs Controller General of India etc., five State Governments (Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu and Uttar Pradesh) have also been invited to be represented on the committee. Five ‘experts’ have also been nominated, in their per sonal capacity; they are Dr. K.B. Banerjee, Dr. Ranjit Rai Choudhury, Dr. Shanti Ghosh, Dr. T. Jacob John and Dr. Jotna Sokhey. Although not formal members, representatives of UNICEF, the World Health Organisation, and the World Bank will have a presence in the committee as special invitees.

The overall purpose of NTAGI is to advise the Government on policies, practices and implementation of the national immunization program. The NTAGI held its first meeting on 19 December 2001. Being a relatively large committee, we have decided to form a few subgroups or subcommittees to draft re-commendations on various matters and bring them to the NTAGI for discussion and adoption.

When the Government of India established its Expanded Program on Immunization, in 1977-78, all it had to do was to adopt the policy and programme framework and guidelines from the WHO EPI, which had been established in 1974, and had already been adopted in many developing countries. The UNICEF realized that EPI was an excellent and practical avenue through which child survival and health could be improved. In partnership with all State Governments, the UN agencies, and several agencies that provided fund support, we had achieved the WHO target of 80 per cent coverage with antigens against 6 diseases, by the year 1990. While many States went on, subsequently, to improve immunization coverage even further, to 90 per cent or more, some States slipped and have not yet recovered from slippage to unacceptably low levels. In such States, the local, district and State branches of IAP have the opportunity and a responsibility to work together with the immunization program managers at the local, district and State levels.

In 1985, the EPI was modified as the Universal Immunization Program (UIP), which was introduced at first in a few districts and gradually expanded to all districts by 1990. The major changes under UIP were to include measles vaccine, which had not been included in the national EPI, and to abolish the 80 per cent target in favour of offering full immunization to all children. Since that time, some new vaccines have been licensed for manufacturing or marketing in India, but their need for inclusion in the UIP remains in the domain of discussions. The choice of vaccines to be included must be based on the burden and seriousness of diseases to be prevented, the safety and efficacy of the vaccines and the economic affordability in the context of the national economy. These considerations do require technical inputs and expertise, epidemiological and vaccine studies in some cases, and the demonstration of feasibility for inclusion in the routine immunization schedule and the acceptance of the people at large. Any bureaucratic machinery inadequately covers these areas, and the general trend is to have an advisory committee at the national level. The Committee on Immunization of the IAP will not serve this national role, as its mandate is only to its membership. The NTAGI is a step forward in the right direction. The IAP has to keep this new factor in the equation as it deliberates on vaccines and immunization issues.

One issue was already presented, namely the inclusion of newer vaccines in the national immunization program. Most newer vaccines tend to be more expensive than the old vaccines already on the UIP schedule. Does the Government have to give such vaccines free of charge to all children, irrespective of their family income? If the Government’s role is in making such vaccines available to the economically weaker families, while allowing the richer families to obtain them on payment, then, the cost to the exchequer will be more easily manageable than if all children had to be provided free service. This is a potential and major policy shift, which the NTAGI may consider at some point in the near future. The IAP, as if it were anticipating such a scenario, had included some newer vaccines in their recommended list, and provided guidelines for the use of other licensed vaccines that were not included in the list.

Any system, including the UIP, is composed of inputs, output and evaluation. The usual mindset for assessing the success of an immunization program is to measure the vaccine coverage among the eligible childhood population. That is only a measure of the efficiency of the input arm of the system. The real output, or outcome, is the degree of reduction of the target diseases. As long as we do not measure the outcome, systematically and in an ongoing manner, the system is incomplete. A functional disease surveillance system is essential if the UIP is to be seen as a successful investment of ‘human power’ and resources(2). Fortunately, we do have a practical and low cost model of surveillance, which is currently being established in Kerala State, systematically, and district by district. As of the time of writing this editorial, the Kerala State Branch of IAP is considering the possibility and potential of its formal backing and support of this innovative State program for child health and for prevention of communicable diseases in general. Once this becomes fruitful, then we would have developed yet another model, for the other States to emulate.

With epidemiologic data on real time basis we will have the opportunity to examine if any modifications are necessary in our scheduling of routinely given vaccines. To cite one example, if the frequency of measles in children once vaccinated in infancy warrants, the UIP policy may have to be altered to a two-dose schedule of measles vaccine. This kind of information, especially with the age pattern of such break through disease, can be generated only by ongoing disease surveillance.

Another area in which some new thinking needs to be developed is regarding the roles and responsibilities and their sharing, among the Central and State Governments and the agencies of the Local Self Government (otherwise known as the Panchayati Raj), in the national immunization program. The inclusion of representatives from five States on the NTAGI augurs well for such an initiative. After all, is not Health a State subject? Ultimately it is for the communities themselves to demand immunization service and avail of its full benefits. Community participation, as envisaged in the ideal of ‘primary health care’, can be made real only through the involvement of the elected representatives of the community. Progress in this direction of decentralization will enable us to convert the current understanding and attitude of the national immunization program as a vertical scheme of the Central Government, into a new understanding of immunization as an integral and integrated part of primary health care, owned by people themselves. The twin sister of this transformation will be the creation of demand for vaccines by the people, which will ensure the quality and the success of a sustainable immunization program.

The recent establishment of the NTAGI by the Ministry of Health and Family Welfare is a major step forward in the field of child health in general and the national immuni-zation program in particular. In a country in which we have not been able to prevent communicable diseases perpetuated through the neglect of environmental sanitation, such as water and food borne and vector borne infectious diseases, we have an immediate moral responsibility to prevent at least the vaccine preventable diseases, for the sake of the fulfillment of the rights of every child to health and quality of life.

A sustained and successful immunization program, consciously covering the ethical demands of equity and quality, requires considerable dialogue and visionary thinking and bold implementation. Breathing life into such a mission is the opportunity presented before us in the formation of the National Advisory Group. Let us proclaim that immunization is the birth right of every child.

T. Jacob John
(Advisor, Kerala State Institute of Virology
and Infectious Diseases),
439 Civil Supplies Godown Lane,
Kamalakshipuram, Vellore, TN, 632 002.
[email protected]

1. Committee on Immunization. Update on the Recommendations of the Academy to other Agencies on Immunization. Indian Pediatr 1999; 36: 785-787.

2. John TJ, Samuel R, Balraj V, John R. Disease surveillance at district level: a model for developing countries. Lancet 1998; 352: 58-61.