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Indian Pediatr 2013;50: 867-874
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Influenza Vaccination in India: Position
Paper of Indian Academy of Pediatrics, 2013
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VM Vashishtha, A Kalra and P Choudhury
From Advisory Committee on Vaccines and
Immunization Practices, Indian Academy of Pediatrics.
Correspondence to: Dr Vipin M
Vashishtha, Convener, IAP Advisory Committee on Vaccines and
Immunization Practices (ACVIP), Mangla Hospital and Research
Center, Shakti Chowk, Bijnor, Uttar Pradesh, 246701, India.
Email:
[email protected]
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Burden of Influenza is significantly higher in developing countries as
compared to developed countries, but the data on the disease burden is
less well defined in most of the developing countries including India,
and consequently, constraints evolving strategies for prioritization of
measures to prevent and control it. The ‘swine flu’ or ‘A(H1N1)’
pandemic is on the wane but the virus continues to circulate causing
sporadic outbreaks even in 2013. The A(H1N1)pdm09 has replaced the
previous circulating seasonal A (H1N1) virus and acquired the status of
a seasonal virus. Limited influenza activity is usually seen throughout
the year in India with a clear peaking during the rainy season. The
rainy season in the country lasts from June to August in all the regions
except Tamil Nadu where it occurs from October to December. IAP
recommends the ideal time for offering influenza vaccines is just before
the onset of rainy season. The efficacy/effectiveness data of trivalent
inactivated influenza vaccines are also presented in different age
groups and different categories of individuals. The IAP maintains its
earlier recommendations of using the current trivalent inactivated
influenza vaccine in all children with risk factors but not as a
universal measure. IAP has now prioritized different target groups for
influenza vaccination based on contribution of the group to the overall
influenza burden, disease severity, and vaccine effectiveness in
different age groups and categories. The current trivalent inactivated
influenza vaccines incorporate the 2009 pandemic strain also, hence
avert the need of a separate ‘A (H1N1)’ vaccine. IAP stresses the need
of more refined surveillance; large scale studies on effectiveness of
seasonal influenza vaccines in Indian children, and more effective,
properly matched, higher-valent influenza vaccines.
Keywords: Influenza vaccines, Swine flu, Indian Academy of
Pediatrics, Recommendations.
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There are three types of Influenza viruses A, B
and C. The subtypes of type A Influenza virus is
determined by haemagglutinin and neuraminidase.
Both A and B viruses are responsible for
seasonal influenza epidemics, and out-of season
sporadic cases and outbreaks [1]. The Influenza
type A causes moderate to severe illness in all
age groups in humans and other animals whereas
type B primarily affects children and causes
usually a milder illness. The illness by type C
Influenza virus is rarely reported in humans
[2].
Burden of Disease
Seasonal influenza
Global: Influenza
occurs globally with an annual attack rate
estimated at 5%–10% in adults and 20%–30% in
children [1]. Children aged <5 years, and
particularly those <2 years of age, have a high
burden of influenza. According to a recent
estimate, in 2008 there were 90 million (95%, CI
49-162 million) new cases of seasonal influenza,
20 million (95%, CI 13-32 million) cases of
influenza-associated acute lower respiratory
infections (ALRI), and 1-2 million cases of
influenza associated severe ALRI, including 28
000-111 500 deaths [3].
Developing countries:
The incidence of influenza episodes and
associated ALRI is significantly higher in
developing countries as compared to developed
countries [3]. A systematic review of seasonal
influenza epidemiology in sub-Saharan Africa
showed that on average, influenza accounted for
about 10% (range 1%-25%) of all outpatient
visits and for about 6.5% (range 0.6%-15.6%) of
hospital admissions for acute respiratory
infections in children [4]. Recent studies from
many developing countries of Asia have shown the
importance of burden of influenza-related
illness in the region [5-13].
India: Adequate
data on the prevalence and burden of influenza
in India is lacking. According to published data
in India, it contributes to around 5-10% of all
acute respiratory infections (ARI). The reported
incidence of influenza URI was found to be 10/
100 child years and that of ALRI to be only
0.4/100 child years [2]. According to an Indian
review, influenza virus was responsible for
about 1.5% to 14.5% of all ARIs episodes [14]. A
community-based study from north India estimated
incidence of influenza episodes among children
with ARI around 180 and 178 per 1000 children
per year, amongst children below 1 and 2 years,
respectively. Similarly, the incidence of
influenza-associated ALRI was calculated as 33
and 44 per 1000 children per year [3,15].
Swine flu or A (H1N1)
H1N1 pandemic in 2009-10:
The pandemic of H1N1 in 2009 had several
characteristics that differentiated it from
seasonal flu. Globally, the illness rates were
highest in children and young adults (20-40% of
the population), the hospitalization rates were
highest in children below one year of age, and
the ‘case fatality rates’ (CFR) varied
tremendously and were estimated to be between
0.0004- 1.5%. The risk factors for severe
disease and death were pregnancy, morbid
obesity, asthma, children below 2; however,
25%-30% of those who died had no underlying risk
factor [2, 16, 17]. During the 2009 pandemic,
pregnant women were documented as an important
risk group for severe disease across the globe
[16,17].
According to the data from
Government of India, 22.8% of the samples out of
the total samples from 202,790 persons who had
been tested have been found positive for A
(H1N1) [18]. In the majority, the illness was
self-limited with recovery within a week. Among
those tested, 94% cases recovered and 2,728
deaths were reported till December 2010 [18].
Maximum cases were reported during the months of
August and September. Though the attack rate was
highest in the age groups of 20-39 years and
10-19 years, the highest case-fatality was seen
in the age group 20-39 years, followed by young
children less than 5 years old [18]. According
to a recent study (2007-2010) conducted in and
around Delhi, the percent positivity of
Influenza A(H1N1)pdm09 influenza virus was
highest in >5–18 years age groups [19].
‘Seasonal’ versus ‘pandemic
flu’: ‘Seasonal flu’ usually has severe
disease in children below 2 years, individuals
above 65 years, and in persons with chronic
medical conditions whereas ‘pandemic flu’ more
severely affected children and caused deaths in
young adults having no risk factors [16, 17].
Sparing of elderly and very rapid
transmissibility and high attack rates were
other differentiating features. Overall, the
severity and mortality of ‘pandemic flu’ was
higher than seasonal flu (CFR of 0.89% vs
0.13%) [2, 16].
A (H1N1) influenza outbreaks
during 2013 in India: The pandemic
virus continues to circulate and cause waves of
infections leading to hospitalization and
complications in different parts of India
despite the fact that the pandemic stage of the
H1N1 virus had ended in August 2010. Once a
pandemic has occurred, it is expected to have
sporadic outbreaks of smaller magnitude in
subsequent few years. Northern India had an
unusual heightened activity of A (H1N1)
influenza in first quarter of 2013 that led to
261 deaths till February 28, 2013 [20].
Dynamics of Seasonal Influenza Virus
Circulation In India
Seasonality: In
temperate regions, outbreaks consistently occur
during the late autumn and winter months; in
November–March in the Northern Hemisphere; and
in May–September in the Southern Hemisphere
[21]. In India, limited influenza activity is
usually seen throughout the year with a clear
peaking during the rainy season all over the
country. However, northern India has a secondary
albeit a smaller peak in cooler winter months
with pattern similar to temperate regions
[13,19]. The rainy season in the country lasts
from June to August in all the regions except
Tamil Nadu where it occurs from October to
December.
Genetic surveillance of
Influenza virus circulation, 2009-13:
In India, there is change in the genetic makeup
of circulating influenza viruses since 2009.
According to Global Influenza Surveillance and
Response System (GISRS) 2009-13 [22], from
second half of 2009, A(H1N1)pdm09 was the most
predominant influenza virus till first quarter
of 2011. Second half of 2011 showed lower
activity of this strain while A (H3N2) and B
group viruses predominated in this half.
However, from the beginning of 2012, the
pandemic strain, A(H1N1)pdm09 reappeared and
co-circulated with group B and A(H3N2) viruses.
A recent study clearly revealed that clade VII
has been identified as recent circulating clade
in India as well as globally [23].
Group B influenza virus,
mainly the undetermined lineage along with both
Victoria and Yamagata lineages (to some extent)
had circulated almost in equal quantity. There
were two clear-cut peaks available, one during
rainy season (June to September) and another
during winter months. The national laboratories
from Kasauli, Mumbai, and Pune regularly
collaborate with GISRS. So, in 2012 and in first
few months of 2013, A (H1N1) pdm09 and type B
(mainly undetermined) were the main flu virus
strains responsible for influenza outbreaks.
However, it is difficult to predict the future
circulation of different types/subtypes of
influenza viruses in the country. Furthermore,
the yearly type/subtype distribution varied
significantly from region to region, and from
site to site.
Vaccination Against Influenza
Influenza Vaccines
Most of the current seasonal
influenza vaccines include 2 influenza A strains
and 1 influenza B strain. Globally, trivalent
inactivated vaccines (TIV) and live attenuated
influenza vaccines (LAIV) are available [1].
However, in India, LAIV is not available and a
monovalent vaccine containing single pandemic
strain, A(H1N1)pdm09 is also available. All
currently available trivalent vaccines now have
the influenza strain that is antigenically
similar to 2009 pandemic swine flu strain i.e.
A(H1N1)pdm09. Hence, there is no need to go for
separate ‘swine flu’ vaccine.
The antigenic composition of
the influenza vaccines is revised twice annually
and adjusted to the antigenic characteristics of
circulating influenza viruses obtained within
the WHO’s GISRS to ensure optimal vaccine
efficacy against prevailing strains in both the
northern and southern hemispheres [1]. The most
recent WHO recommendations are available at
http://www.who.int/influenza/vaccines/virus/recommendations/en/index.html.
I. Trivalent inactivated
influenza vaccines (TIVs): The
trivalent influenza vaccines are produced from
virus growth in embryonated hen’s eggs and are
of three types: whole virus, split product,
subunit surface – antigen formulations [1]. In
most countries, whole virus vaccines have been
replaced by less reactogenic split virus
vaccines and subunit vaccines. Trivalent
influenza vaccines are the only influenza
vaccines licensed for vaccination of children <2
years of age, persons aged
³50
years, and for pregnant women. Current trivalent
influenza vaccines are not licensed for children
<6 months of age [1].
II. Live attenuated influenza
vaccine (LAIV): Live
attenuated influenza vaccine provides broader
and higher levels of protection than trivalent
inactivated vaccines in healthy children aged
2-5 years of age. A Cochrane review of RCTs
evaluating live vaccines in healthy children
aged >2 years found an overall efficacy against
laboratory confirmed influenza of 82% (95%, CI
71% -89%) and an effectiveness against
influenza-like illness (ILI) of 33% (95%, CI
28%-38%). Inactivated vaccines had a lower
efficacy of 59% (95%, CI 41%-71%) but similar
effectiveness at 36% (95%, CI 24%-46%) [24]. A
quadrivalent live attenuated vaccine for
intranasal application containing 2 influenza A
strains and 2 influenza B strains was licensed
in the USA in 2012 [1]. Live attenuated vaccine
is not recommended below 2 years of age, in high
risk individuals and in pregnant women.
Non-pregnant individuals aged 2–49 years may
receive either TIV or LAIV in accordance with
national policy.
III. Adjuvanted trivalent
influenza vaccines (aTIVs): In order
to enhance immunogenicity, some current
formulations of trivalent vaccines include
adjuvants such as oil-in-water adjuvants or
virosomes [25]. Adjuvanted vaccine shows
enhanced priming and boosting, as well as
efficacy in infants, although need for two doses
remains [25]. It also demonstrates an increased
‘breadth’ of response. Currently data on
adjuvanted vaccines are limited.
IV. Quadrivalent influenza
vaccines: The development of
quadrivalent influenza vaccine formulation for
seasonal influenza vaccine is of interest in
providing comprehensive protection against
influenza B viruses. Global influenza
surveillance system has also recommended that
there should be further research on the fourth
strain (another influenza B virus of different
linage). It was noted that for 4 of the previous
8 seasons, use of quadrivalent influenza vaccine
instead of trivalent would have had
substantially improved match of global
circulating strains and there is definite
potential public health benefit for quadrivalent
vaccine [26].
Dosage Schedule
Trivalent influenza vaccine
is administered intramuscularly, injected into
the deltoid muscle (for vaccinees aged >1 year)
or the antero-lateral aspect of the thigh (for
vaccinees aged 6–12 months). Children aged 6-35
months should receive a pediatric dose, and
previously unvaccinated children aged <9 years
should receive 2 injections administered at
least 4 weeks apart. A single dose of the
vaccine is appropriate for school children aged
>9 years and healthy adults [1,2].
Live attenuated vaccine is
given as nasal spray, 1 dose only, but children
aged 2-8 years who have not received seasonal
influenza vaccine during the previous influenza
season should receive 2 doses, at least 4 weeks
apart. Annual vaccination (or re-vaccination, if
the vaccine strains are identical) is
recommended, particularly for high-risk groups
[1].
Efficacy
Efficacy and effectiveness of
Trivalent Influenza vaccines: In general, HI
antibody titers of 1:40 or greater have been
shown to provide 50% efficacy of protection in
healthy adults [1]. However, a cutoff of 1:110
for antibody titers may be preferable to predict
the conventional 50% clinical protection rate in
children, and a titer of 1:330 would predict an
80% protective level, which would seem to be
more desirable from a public health perspective
[27].
The reported
efficacy/effectiveness of influenza vaccines
varies substantially with factors such as the
case definition (e.g.
laboratory-confirmed influenza disease or the
less specific influenza-like illness), the
‘match’ between the vaccine strains and
prevailing influenza strains, vaccine
preparation, dose, prior antigenic experience,
and age or underlying disease conditions of an
individual [1]. WebTable I
summarizes the efficacy/effectiveness of
trivalent influenza vaccines in different age
groups and categories along with grading of
evidence. However, most of these conclusions and
summaries are based on studies done in temperate
climate countries. There is no data on
efficacy/effectiveness of influenza vaccines
from India.
Duration of serum antibody
response to seasonal influenza vaccines:
Following vaccination, anti-HA antibody titers
peak 2-4 weeks post-vaccination in primed
individuals but may peak 4 weeks or later in
unprimed individuals or older adults. Serum
antibody titers may fall by 50% or more by 6
months after vaccination, with the degree of
reduction being proportional to the peak titers
achieved. Vaccine-induced serum antibody titers
then remain stable for two to three years.
Evidence from clinical trials suggests that
protection against viruses that are similar
antigenically to those contained in the vaccine
extends for at least 6–8 months [28].
Efficacy and effectiveness of
monovalent A (H1N1) pdm vaccines: There is
no study on performance of A (H1N1)pdm i.e.
pandemic 2009 vaccines from India. A
case-control study of Arepanrix (AS03) in Canada
showed very high effectiveness [29]. In Germany,
a study of single-dose Pandemrix in individuals
14 and above was limited due to vaccines
becoming available very late, coinciding with
peak activity [30]. Another study in seven
European countries of multiple vaccines also had
a narrow window between circulation of cases and
availability of vaccine. Analysis did not
distinguish between the different vaccine-types
used. The vaccine efficacy increased as delay
between vaccination and symptom onset increased
[31]. In US, a study of inactivated and live
vaccines in 4 communities found that the number
of cases dropped coincidentally with the
availability of vaccines [32]. The inactivated
vaccine effectiveness point estimate was 88.6%
among individuals 10-49 years, lower in those 6
months-9 years and over 50 years. Live vaccine
had an increased effectiveness in children 6
months-9 years [32].
Safety of Trivalent Influenza
and Monovalent A (H1N1) vaccines: Transient
local reactions at the injection site occur
frequently (>1/100), and fever, malaise, myalgia,
and other systemic adverse events may affect
persons without previous exposure to the
influenza vaccine antigens, trivalent influenza
vaccines are generally considered safe [1]. No
vaccines against seasonal influenza contain the
AS03-adjuvant which has been associated with
rare cases of narcolepsy/cataplexy following
large-scale use of an AS03-adjuvanted pandemic
H1N1 vaccine, primarily in the Nordic countries
[33] and in England [34].
During some influenza
seasons, seasonal trivalent as well as
monovalent Influenza A (H1N1) pdm 2009 vaccines
have been associated with a slight increase in
the risk of Guillain-Barré syndrome [35, 36]. A
brand of seasonal trivalent vaccine from M/s CSL
2010 batch was associated with febrile seizures
in children <5 years of age in Australia [26].
In US also, a higher risk for febrile seizures
was found from Fluzone, another brand of M/s CSL
during December 2010-January 2011. Analysis of
these observations concluded that risk was only
present among 6-23 month olds when trivalent
vaccine was given along with PCV13 [26]. Apart
from these few product-specific issues, there
are no generic safety issues for influenza
vaccines in young children.
IAP Recommendations on
Influenza Vaccination
IAP has recommended seasonal
influenza vaccine (including the earlier
monovalent A (H1N1) vaccine) only for the
category of ‘high-risk children’. This
category contains the following:
• Chronic cardiac,
pulmonary (excluding asthma), hematologic
and renal (including nephrotic syndrome)
condition, chronic liver diseases, and
diabetes mellitus
• Congenital or acquired
immunodeficiency (including HIV infection)
• Children on long term
salicylates therapy
• Laboratory personnel
and healthcare workers
Vaccination against ‘swine
flu’ (A (H1N1)pdm) during ongoing outbreaks
(2013): There is no need to get unduly
worried about the recent spurts in the activity
of influenza A (H1N1) virus in few northern
states. Though it is expected to have A (H1N1)
infections slightly more severe with higher
mortality than seasonal influenza caused by
other co-circulating strains; still the
situation is not as alarming as it was in
previous few years when the country was in the
grip of the ongoing pandemic. Considering the
fact that the available influenza vaccines are
going to have much better effectiveness against
the circulating A(H1N1)pdm09 strain than other
influenza viruses owing to more ‘complete match’
between the strain circulating in the community
and the strain contained in the vaccines, IAP
justifies its earlier recommendation of using
the influenza vaccine in all children with risk
factors as mentioned above and also wherein the
vaccine is desired/requested by parents [2].
IAP recommendations on
‘target group prioritization’ for seasonal
influenza vaccination:
Though the risk groups for
influenza in low- and middle-income countries
including India are less well defined, still,
based on global estimates for developing and
low-middle income group countries, IAP believes
that influenza vaccination should aim primarily
at protecting vulnerable high-risk groups
against severe influenza-associated disease and
death. However, there is lack of effectiveness
data in few categories of individuals and in
different age groups. The suggested
prioritization (Table I) is based
on following attributes: contribution of risk
group to the overall influenza disease burden in
population, disease severity within individual
risk group, and vaccine effectiveness in
different age groups and categories.
Accordingly, following groups of individuals
should be targeted for seasonal annual
vaccination (in order of priority).
TABLE I Summary of disease burden, efficacy/effectiveness of TIVs, and prioritization of influenza Vaccination in
Different Age Groups and Categories of Target Population
Age group/ |
Burden of |
Fatalities/Severe
|
Effectiveness/efficacy
|
Level of |
Prioritization |
Category |
disease |
disease |
of vaccine |
evidence |
|
0-6 months |
High (+++) |
Very high (++++) |
Not eligible |
NA |
2* |
6-23 months |
High (+++) |
High (+++) |
Not effective/Very low |
Moderate |
3 |
2-5 years |
Substantial (++) |
Moderate (++) |
Moderate |
Limited |
4 |
6-64 years |
Low (+) |
Low (+) |
Moderate to High |
Moderate |
4 |
>65 years |
High (+++) |
Very high (++++) |
Low |
Low |
1 |
Pregnant women |
Substantial (++) |
High (+++) |
Moderate** |
Limited to high** |
2 |
Individuals with asthma |
Not known |
Moderate (++) |
Not effective |
Limited |
3 |
Individuals with HIV/AIDS |
Not known |
High (+++) |
Moderate |
Low |
2 |
Individuals with other underlying
medical conditions |
Not known |
High (+++) |
Low |
Limited |
2 |
Health-care workers |
Substantial (++) |
Moderate (++) |
High |
High |
3 |
*Not eligible to receive currently
licensed influenza vaccines and should
be protected through vaccination of
their mothers during pregnancy;
**Effectiveness varies for maternal and
neonatal protection; Prioritization:
1-Highest; 2-High; 3-Moderate; 4-Low. |
Prioritization of target
groups: (1-Highest priority, 4-Lowest
priority)
1. Elderly individuals
(>65 years) and nursing-home residents (the
elderly or disabled)
2. Individuals with
chronic medical conditions including
individuals with HIV/AIDS, and pregnant
women (especially to protect infants 0-6
months)
3. Other groups: health
care workers including professionals,
individuals with asthma, and children from
ages 6 months to 2 years.
4. Children aged 2-5
years and 6-18 years, and healthy young
adults.
Amongst pediatric population,
apart from the children with chronic medical
conditions (see above), the children below 2
years of age should be considered a target group
for influenza immunization because of a high
burden of severe disease in this group.
Ideal time for influenza
vaccination: The data on seasonality of
influenza in India, illustrate the difficulty in
having uniform vaccination timing for a vast
country like us and have implications when
formulating vaccination policies. The evidence
of antigenic drifts of circulating influenza
viruses in India; together with the temporal
peaks in seasonality of influenza in different
parts of the country illustrate the need for a
staggered approach in vaccination timing. Hence,
the best time for offering vaccine for
individuals residing in southern states would be
just before the onset of rainy season, i.e.
before October while for rest of the country, it
should be before June [37].
‘Northern’ versus ‘Southern’
Hemisphere recommendations: Vaccines elicit
a relatively strain specific humoral response,
have reduced efficacy against antigenically
drifted viruses and are ineffective against
unrelated strains. It is of utmost importance,
therefore, that vaccine should incorporate the
current strain prevalent during that time.
Influenza vaccination is recommended annually to
ensure optimal match between the vaccine and
prevailing influenza strains, and because,
unlike the long-lasting, strain-specific
immunity following natural infection, influenza
vaccines induce protection of relatively short
duration, particularly in the elderly [38]. To
ensure optimal vaccine efficacy against
prevailing strains in both the northern and
southern hemispheres, the antigenic composition
of the vaccines is revised twice annually and
adjusted to the antigenic characteristics of
circulating influenza viruses obtained within
the global influenza surveillance network.
WHO classifies India under
the ‘South Asia’ transmission zone of Influenza
circulation and reviews strain circulation in
the country during both the meetings, i.e.
February (for northern hemisphere) and September
(southern hemisphere). Though India lies within
the northern hemisphere, parts of the country
have a distinct tropical environment being
located close to the equator and behaves much
like southern hemisphere seasonality with almost
year round circulation and monsoon months peak,
still northern India experiences another peak
during winter just like northern hemisphere
pattern [13, 19]. But these patterns and strain
circulation dynamics are not fixed and exclusive
to one particular hemisphere and strains usually
‘spill’ from one to another. Hence, IAP believes
it will not be prudent to stick to strain
formulations recommended for one hemisphere, but
one should use the vaccine that has the ‘most
recent strains’ irrespective of the
hemisphere-specific formulations.
Why Has IAP Not Recommended ‘Universal
Influenza Vaccination?
There are several reasons why
IAP has not offered universal recommendations,
i.e. routine use of available Influenza
vaccines:
The burden is less defined:
Sufficient data to estimate precisely the
contribution of influenza to childhood mortality
in India is not available. Data on morbidity and
mortality of influenza in India is very limited
and current status does not justify the
prioritization of strategies for influenza
prevention and control.
Target groups less well
defined: The attack rates of seasonal
influenza is although greatest in young
children, the highest mortality and morbidity
are observed in the elderly, individuals with
certain underlying chronic health conditions,
pregnant women, and health care workers. In
recent pandemic H1N1 outbreaks, healthy young
adult population was more severely affected. The
risk groups for influenza in India are less well
defined and we do not have data on burden of
influenza in different age groups.
Issues related to vaccine
availability, timing, suitability and
effectiveness: Data are limited on the
effectiveness of trivalent influenza vaccines in
tropical regions including India. There is no
large scale study on effectiveness of influenza
vaccines in Indian children. In tropical
regions, it is not always clear which
formulation is best, and what time of year is
optimal. Would vaccine be available round the
year? Would trivalent vaccines’ effectiveness be
different in tropical countries like India with
year-round circulation, or could existing
effectiveness data be generalized to apply to
tropical settings? Further, there is little
evidence regarding effectiveness of influenza
vaccines in children below 2 years of age even
from industrialized countries [39]. In
conclusion, the reliable evidence on influenza
vaccines is thin. Furthermore, the available
influenza vaccines leave a considerable amount
of circulating influenza virus strains
uncovered, hence IAP believes there is not only
need of large scale studies on effectiveness of
seasonal influenza vaccines in Indian children,
but more effective (adjuvanted), properly
matched (region specific) with broader coverage
(higher valent) influenza vaccines are also
needed before a more liberal recommendation is
contemplated.
Need for a more extensive,
region-specific surveillance: Though India
is regularly participating in global influenza
surveillance through a network of national
laboratories, still there is diversity in
prevailing virus types/sub-types at sub-regional
levels. A significant section of circulating
viruses belongs to undetermined lineages, hence
not represented in available vaccines.
ANNEXURE
Writing committee: Vipin
M. Vashishtha, Ajay Kalra, Panna Choudhury
IAP Advisory Committee on
Vaccines & Immunization Practices, 2013-14:
Office-bearers: CP Bansal (Chairperson),
Rohit Agarwal (Co-chairperson), Vijay Yewale
(Co-chairperson), Vipin M Vashishtha (Convener),
Sailesh Gupta (lAP Coordinator), Members:
Shashi Vani, Anuradha Bose, Ajay Kalra, AK
Patwari, Surjit Singh; Consultants:
Naveen Thacker, NK Arora, Rajesh Kumar, HP
Sachdev, VG Ramachandran, Ajay Gambhir;
Rapporteur: Panna Choudhury.
Funding: None;
Competing interests: None stated.
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