I read the dialogue on these issues with interest(1,2). Dr. Jacob John suggests that we must give 15 doses of OPV per child, besides a whole host of other vaccines. I am the District Immunization Officer in the district of Damoh in Madhya Pradesh. At present only 75% of the population in the state is covered with 3 doses of OPV and 55% with three doses of DPT. I am aware that a very tiny portion of our population in India receive as many as 7 doses of OPV and if the lAP recommends it, this same population will come for 15 doses. But will that move us any closer to prevention of polio when 25% have not even had 3 doses of polio vaccine in the same way when half the population have not received 3 doses of DPT and we have little provision for disposable syringes and needles, should we embark on a costly program with newer vaccines. I feel that the lAP definitely needs to rethink its priorities.
 

Murali Manohar Shrivastava,
District Immunization Officer,
Damoh, Madhya Pradesh,
India.

REFERENCES

1. Puliyel JM. Newer Vaccines: Like Marie Antionette said, "Let the poor eat cake". Indian Pediatr 1998; 35: 1245.

2. John TJ. Reply. Indian Pediatr 1998; 35: 1246- 1249.
 

Dr. Shrivastava, District Immunization Officer of Damoh in Madhya Pradesh, deserves all praise and encouragement for several reasons. First, he has overcome an unseen barrier and has shared with the readers of the Academy's official journal some stark ground realities. Second, he has illustrated the fact that the Academy and its journal, apparently dominated by professionals in academics and in the private (non-governmental) sector, are also very useful for pediatricians in the government sector. Third, he has pointed out that some clarifications are necessary on the specific issue of the number of doses of OPV that we are giving to our children.

Let me quote the exact statement: "Since we did not follow scientific principles, now we are forced to give some 15 doses of OPV per child and also reach 99% coverage." This is a criticism of the government's policy to give 15 doses per capita. It is not lAP's policy to give 15 doses. These days the government is procuring and distributing over 500 million doses of OVP annually for about 125 million under-fives. Thus, the per capita annual consumption of OVP is 4 doses, or a total of 20 doses per child over 5 years of life. Now let us look at the processes of administering OPV to children. In the routine immunization, an infant, under the National Immunization Program, will be given 4 doses (0 dose, and at 6,10 and 14 weeks). In the second year of life another dose to make the total. Five doses of OPV. Then in the pulse immunization program, all children are to be given 2 doses per year, for 5 years, adding to a total of 10 doses. Thus, routine plus pulse doses add upto 15 doses. And the government procures enough vaccine to give 20 doses per child. If individual children are not receiving an average of at least 10 plus doses, I wonder where all the vaccine is actually going. Only the Ministry of Health can solve this puzzle. If, in Madhya Pradesh, only a tiny proportion of children actually receive 7 doses of OPV, perhaps Dr. Shrivastava has inadvertantly put his finger on a problem that has missed our attention in the past. How can India eradicate polio if such is the ground reality in parts of India? In 1999, a third round of pulse immunization is planned, in March, in four states in which the incidence of polio continues to worry us. The readers will have seen reports of the third round and its consequences, by the time this note appears in Indian Pediatrics.

Let me once again draw the attention of the readers to the issues of vaccine for personal protection and vaccine for elimination of the infectious agent from the community. If the scientific principles of these issues could not be fully grasped by international "experts" and ministry officials, I shall not blame readers of Indian Pediatrics for not clearly understanding them.

As I write this reply, the official figures of routine immunization coverages under VIP are in front of me. For Madhya Pradesh, 3 dose coverages for OPT and OPV are 89% to 96% during the last 3 consecutive years. Measles vaccine coverage was 81 % to 95%. According to Dr. Shrivastava the OPT and OPV coverages are 55% and 75%, respectively. Now, I do believe that the data given by Dr. Shrivastava are nearer the truth. The government figures are the signs of "Targetitis" and "Targetoma", and only meant for international "experts".

Wearing the hat of National President, IAP, I believe that there exists a great opportunity and challenge for each District Branch of IAP to begin taking some very important responsibilities in the district itself. If the District Branch could reach out to the District Immunization Officer, together they can decide how IAP can identify the local needs and their solutions. Can we not do an independent assessment of immunization coverages? Can we not see for ourselves if OPT is being recorded as given, when the staff are not provided adequate supplies of 'syringes and needles? Can we not report every case of the vaccine preventable diseases to both the District Officials and to a Central Registry so that suppression of data at the local level can be prevented? I will very much welcome your thoughts and ideas on these matters.

Dr. Shrivastava asks a very important question. If even the VIP has not achieved success, "should we embark on a costly pro- gram with newer vaccines"? The critical word here is: who are "we"? For the District Officer, "we" are the government sector. The answer is "No" to the government. They should first achieve success with VIP, eradicate polio, eliminate measles mortality and neonatal tetanus, before they embark on newer and more costly modalities. All the government officers must realize that it is their own Ministry that enables the entry, marketing and popularization of newer vaccines. "We" the Academy should not shy away from newer vaccines if they are necessary, safe and. effective. IAP constantly rethinks its priorities and positions on newer vaccines. It is the government who does not seem to rethink this is- sue and covers up so many ills under the lame excuse of poverty. The cost of prevention will be more than repaid, several fold higher, and we will be the richer if we take disease prevention honestly and seriously.

T. Jacob John,
Chairman,
Committee on Immunization and
President, Indian Academy of Pediatrics,
2/91 E2 Kamalakshipuram,
Vel/ore, Tamil Nadu 632 002,
India.