This refers to the Editorial by Levine and Cherian(1). Authors suggest that India could add H. influenzae type b and the pneumococcal vaccines to its universal childhood immunization program and that the Government should formulate a time-table for the introduction of pneumococcal vaccine. I feel these recommendations require serious examination.

Authors admit "there are no efficacy data from India", "data on serotypes or serogroups causing severe pneumococcal disease in India are limited", "careful population-based studies to estimate the incidence of invasive pneumococcal disease (IPD) from India are lacking". They also make a dubious statement: "perhaps more importantly, pneumonia remains the leading killer of children in India".

Taking a wider view of the problems of children in India, one must note that over 27 million babies are born each year. Majority of these are among the underprivileged segments of the population in rural areas and urban slums. Among these, the incidence of low birth weight babies as well as neonatal mortality is very high. Malnutrition is rampant and complete routine immunization coverage very low. In a country with limited resources, priorities in health care must be fixed and appropriately addressed. In the context of immunizations, these include DPT, BCG, polio, measles and hepatitis B. The government has taken several initiatives to maximize routine immunizations in poorly performing States. India is still fighting to eliminate poliomyelitis, which target was to have been reached by the year 2000. Colossal amounts of funds and manpower have been invested (and continue to be put in), which could have been used elsewhere. One must consider any introduction of other life saving vaccines in the current scenario.

Even if India were to obtain pneumococcal vaccine at a heavily subsidized cost (the manufacturer would make huge profits nevertheless!), its inclusion in "routine immunization" program would entail massive administrative inputs in view of the sheer numbers involved. In the present state of health delivery system in many States, the vaccine would be unlikely to reach those presumably having a higher incidence of severe pneumococcal disease (such as malnourished infants in underprivileged population).

Pediatricians are enamoured of newer vaccines. The conjugate pneumococcal vaccine is being aggressively promoted and individual pediatricians are prescribing it for those who can afford. We must, however, carefully examine various issues and analyse all aspects of the problem when making recommendations to the Government.

R.N. Srivastava,
IAP President 1996,
487, Mandakini Enclave,
New Delhi 110 019, India.
E-mail: [email protected]