We appreciate the response of Dr. Srivastava to our editorial on pneumococcal vaccines for India. His conclusion that the decision to introduce pneumococcal vaccines for routine use in India must be carefully examined is consistent with our own call for the government to develop a process and timeline for introducing pneumococcal vaccines. Likewise, we concur with many of his points, including the need to take into account competing priorities and to make special efforts to reach the children at highest risk of pneumonia and pneumococcal disease. These are the children most likely to benefit from all vaccines, including pneumococcal vaccines, and every effort should be made to assure that these children are not denied these life-saving interventions. Perhaps the Indian approach to introduction of pneumococcal vaccines could be designed to roll out the vaccine in the most affected areas first?

We also agree with Dr. Srivastava that limited health spending should not require the introduction of pneumococcal vaccine to occur at the expense of support for other cost effective and life saving interventions. However, if the evidence suggests, as we believe it will, that pneumococcal vaccines would improve child survival in India, we hope that he and other members of the Academy would urge the government to increase its spending on health to accommodate pneumococcal vaccination and other life-saving interventions. We note that recent government allocations for health in the national budget (2.9% in 2004) indicate that there is substantial room for growth in the national budget (i.e., 97.1% of the budget is spent on "non-health" priorities), and that this level is lower than the allocations in some neighboring south Asian countries (~8%) and in many industrialized, countries (>15%). With government spending at those levels, Indian children could be assured access to a full range of life-saving interventions including pneumococcal immunizations.

It is clear that Dr. Srivastava has the best interests of Indian children in mind when raising these issues and that, like our editorial urges, he is hoping to promote an evidence-based discussion and decision with regard to the vaccine. To this end, we respectfully hope that he will join us in urging for this discussion to proceed without delay because the price of indecision and inaction is the missed opportunity to prevent pneumonia cases and deaths.