Letters to the Editor

Indian Pediatrics 2002; 39:503-504

Hepatitis B Immunization Schedule Recommended by IAP

On IAP Hepatitis B Immunization Schedule, Dr. Dutta had stated, "The Indian Academy of Pediatrics (IAP) Committee on Immunization has recently updated the recommendations for Immunization schedule. Some members have desired details regarding the authenticity of Hepatitis B Immunization schedule. The following is a brief description of the rationale for recommending the current Hepatitis B Immunization schedule"(1). Obviously this refers to the IAP Guide Book on Immunization published by IAP(2).

I do not recollect any confusion being created so quickly regarding any vaccine, as has been in the case of Hepatitis B vaccine. In the Guide Book on page 29 it is stated: Using the principles described, the IAP recommends the commencement of HB immunization at birth. Two alternative schedules are available:

(a) For Infants. The recommended schedules are: (i) Birth, 6 and 14 weeks, (ii) 6, 10 and 14 weeks (Combined DTPwc/Hepatitis B vaccine can be preferred)". Dr. A.K. Dutta is one of the editors of this Guide Book. On page 1337 of the November 2001 issue of the Indian Pediatrics(1) Dr. Dutta had mentioned in Table II, four doses schedule at birth, 6, 10 and 14 weeks.

Three and four doses at days 0, 10 and 21(3), at months 0,1, 2 and 12; 0, 1 and 6; or 0, 1, and 12 have been studied(4). These studies have shown that seroprotection is better when interval between the second and the third doses is longer. If three doses of hepatitis B vaccine are given at short intervals, then a fourth dose is required. This is what WHO has suggested recently(5) as mentioned in Table II by Dr. Dutta(2).

Many studies have shown that time between doses 2 and 3 did affect titer levels, when second and third doses are given too close to the first dose, then these doses do not act to boost the immune response as when doses are administered later(4,6).

The study by Gomber et al.(7) has been quoted frequently to incorporate Hepatitis B vaccine in EPI, i.e., given at 6, 10, and 14 weeks. In fact this study should be a strong reason not to incorporate hepatitis B vaccine in EPI schedule. The authors had compared their results with the results obtained by Safari(8), who had followed the classic 0, 1, and 6 months schedule. The GMT obtained by Gomber et al.(7) were 224 mIu/ml as compared to 4023 mIu/ml obtained by Safari. Gomber et al.(7) had further stated: "The significance of post vaccination titers in providing long term protection is unclear but some of the workers suggest that infants who achieve higher Anti HBs titers were likely to be protected better in later years than infants with low titers(9,10)".

Many among us still remember that we had been administered repeated booster doses of small pox vaccine during our school days, and tetanus toxoid is being administered in later life even after 7 doses of tetanus toxoid administered during childhood and adolescence, stressing the need for long term protection.

It should be presumed that the members of the Committee on Immunization of the IAP had studied all pros and cons of the three doses schedule for infants as stated in the Guide Book, and will not suggest ‘soon’ (i) a fourth dose after 1 year of the three one monthly doses, or (ii) a four one monthly doses schedule as is likely to be recommended by WHO.

1. Dutta AK. IAP Hepatitis B Immunization schedule. Indian Pediatr 2001; 38: 1335-1338.

2. Parthasarthy A, Dutta AK, Bhave SY. IAP Guide Book on Immunization. Mumbai, Indian Academy of Pediatrics, 2001.

3. Marchou B, Excler JL, Bourderioux C, Salaun J, Picot N. Yvonnet B, et al. A-3 Week Hepatitis B vaccination schedule provides rapid and persistent protective immunity: A multicenter, randomized trial comparing accelerated classic vaccination schedules. J Infect Dis 1995; 172: 258-260.

4. Jilg W, Schmidt M, Deinhardt F. Vaccination against Hepatitis B: Comparison of three different vaccination schedules. J Infect Dis 1989; 160: 766-769.

5. Introduction of Hepatitis B Vaccine into Childhood Immunization Program. Manage-ment Guidelines, Including Information for Health Workers and Parents, Department of Vaccine and Biological, World Health Organ-ization, Geneva, Final Draft for Comments, February 2001. Website: www.vaccines.who. int/vaccines-documents/

6. Halder SC, Alcada de Monzon M, Lugo DR, Perez M. Effect of timing of hepatitis B vaccine doses on response to vaccine in Yucpa Indian. Vaccine 1989; 7: 106-110.

7. Gomber S, Sharma R, Ramchandran VG, Talwar V, Singh B. Immunogenicity of Hepatitis B Vaccine Incorporated into the Expanded Program of Immunization Schedule. Indian Pediatr 2000; 37: 411-413.

8. Safari A. Hepatitis B vaccination- Now and in future. In: Hepatitis B in India: Problems and Prevention. Eds Sarin SK, Singhal AK. New Delhi, CBS Publishers, 1996; pp 132-151.

9. Coberly JS, Townsend T, Repke J, Fields H, Margolis H, Halsey NA. Sub-optimal response following intradermal hepatitis B vaccine in infants. Vaccine 1994; 12: 984-987.

10. Stevens CE, Toy PT, Taylor PE, Lee T, Yip H. Prospects for control of hepatitis B virus infection: Implications for childhood vaccina-tion and longterm protection. Pediatrics 1992; 90: 170-173.