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Letters to the Editor Indian Pediatrics 2002; 39: 106-107 |
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Emerging Issues in Immunization |
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1. Measles Vaccination It is interesting to note that in 1997 there was an outbreak of acute encephalopathy without rash in northern India with high mortality. After extensive investigation now it is attributed to measles virus presenting unusually in a vaccination era(1). Alarms have been raised about the possibility of future catastrophe by malignant nature of a possible "mutant measles virus" (News, BMJ 2001; 322: 693). The Director General of Indian Council of Medical Research says since 1998 three outbreaks of highly fatal illness have occurred involving the brain or kidney attributable to measles virus from different parts of India, the major target being adult population. Dr. T. Jacob John leading Indian virologist and immunization expert comments on this that it is not a one-time event but an early warning. I have seen many cases of illnesses clinically resembling measles sometimes in the epidemic form in vaccinated population in the last 18 years of pediatric teaching and child care. I am sure senior pediatricians will endorse my experience with their own. EPI has the recommendation of one dose of measles vaccine after the age of 9 months and MMR has not been included in EPI. Childhood immunization recommendations of USA (1998) recommend two mandatory doses of MMR vaccination at the age of 12-15 months and 4-6 years with an additional optional catch up vaccine at 11-12 years(2). They further qualify measles vaccine as "countable dose" the definition of which is(3): (i) Administered with live virus vaccine; (ii) Administered at or after age of 12 months; (iii) Administered at least 1 month after first countable dose (to qualify as second countable dose); (iv) Administered more than 3 months after any prior dose of inactivated measles virus vaccine: (v) Given at proper intervals from any proximate administration of immune globulin (IG), whole blood or blood products containing antibody, unless adequate antibody response to the dose is confirmed through subsequent serolgoical testing. If we consider above recommendations almost all children in India are practically not vaccinated for measles. We can not afford to give the first dose of measles vaccine after 12 months as significant proportion of children under 12 months are affected by measles. In light of above, we should seriously consider advising a second dose of measles vaccine after 1 year of age or incorporate MMR vaccine in the EPI. The second option appears to be more practical since the cost of MMR vaccine is not very high and a large proportion of children will be protected from mumps epidemics and its complication with the hidden benefit of rubella vaccine.
In 1997 about 48,000 children were estimated to be living with HIV/AIDS in India(4). The figures related to HIV/AIDS in India are always underestimate and increasing rapidly at an exponential pace. As per the recent information, India suffers most of the disease burden next only to Africa(5). In future there will be lakhs of children with HIV/AIDS in India. These children need special recommendation for immunization as is being done in developed countries(2). Two major catastrophes can occur in India in these children with the present recommendations. Some HIV infected children receiving OPV under EPI and Pulse Polio Program may suffer extensive paralytic polio or death, which may have an adverse effect on the program. The other issue is of chicken pox vaccine, which has been aggressively marketed by multinationals and enthu-siastically taken up by many pediatricians. Varicella vaccine is a definite contra-indication for HIV infected persons and pediatricians must be alerted on this issue. I hope that the Expert Committee on Immunization of IAP will address these and many more emerging issues in the immediate future for the optimal child health care policies of this country. Parvat V. Havaldar, Professor and Head, Department of Pediatrics, Karnataka Institute of Medical Sciences, Hubli 580 022, India. E-mail: [email protected] |
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