Vaccination Inequities in India: Current Status and the Way Forward

The term vaccination inequity generally reflects disparities in coverage within a community. It has been described as “avoidable differences immunization between population groups,” arising “because barriers to among disadvantaged groups are not addressed through policies, structures, governance or program implementation.”1World Health Organization Regional Office for EuropeEuropean vaccine action plan 2015–2020. World Europe, Copenhagen, DenmarkPublished 2014http://www.euro.who.int/en/health-topics/disease-prevention/vaccines-and-immunization/publications/2014/european-vaccine-action-plan-20152020-2014Date accessed: October 16, 2020Google Scholar,2Sodha SV Dietz V Strengthening routine systems improve global coverage.Br Med Bull. 2015; 113: 5-14https://doi.org/10.1093/bmb/ldv001Crossref PubMed Scopus (38) Google Scholar Thus, exists when some infants, children, adults do receive vaccination, despite being eligible. This could broadly be related insufficient pull (i.e., demand) by eligible individuals inadequate push supply) the healthcare system. Insufficient vaccines made available and accessible system, but fail get vaccinated. may education, sociodemographic biases, community empowerment, lack of access, disinterest. Inadequate results from system issues affecting availability, affordability, delivery. supplement issue reports inequities factors different countries regions around world. However, can much broader issue, especially because dictionary definition is linked fairness justice.3Inequity. Merriam-Webster.https://www.merriam-webster.com/dictionary/inequity. Accessed 2, 2020.Google Scholar, 4Inequity. Cambridge dictionary.https://dictionary.cambridge.org/dictionary/english/inequity. 5Inequity. Collins.https://www.collinsdictionary.com/dictionary/english/inequity. 6Inequity. Oxford Lexico.https://www.lexico.com/definition/inequity. 7Inequity. Dictionary.com.https://www.dictionary.com/browse/inequity. In that context, should focus on unfairness/injustice(s) associated with (beyond aforementioned factors). commentary explores policies practices newer India. Government India launched Expanded Program Immunization (EPI) 1978. was changed Universal 1985, providing against 6 diseases free charge all infants across country. schedule aligned strategy prevalent most developing countries. A limited number additional were private sector providers return out-of-pocket payment. situation dramatically early 1990s, witnessed wave economic reforms liberalization. led greater purchasing power institutions, including Trade membership, also eased importation many hitherto unavailable products, vaccines. combination an attractive market international manufacturers. Developed make public health decisions basis infectious disease epidemiology, burden, risks consequences (such complications, sequelae) society, significance vis-à-vis other pressing issues. short, need drives development, deployment, decisions, attempting find solutions meet need. India, reverse often true. solution (generally imported vaccine) licensed sale open market, then identified justify its use. artificially created supported manufacturers, who use 2 broad approaches.8Mathew JL Pneumococcal countries: where does science end commerce begin?.Vaccine. 2009; 27: 4247-4251https://doi.org/10.1016/j.vaccine.2009.04.031Crossref (15) One academic channel, organizing sponsoring educational activities (e.g., Continuing Professional Development programs, lavish conferences) motivating key opinion leaders (often paid basis) highlight commercial extensive marketing, direct-to-consumer advertising, physicians at prices lower than retail. These measures create clamor introduction vaccines, even without scientific justification.9Mathew Global access vaccines: commerce: never twain shall meet.BMJ. 2008; 336: 974https://doi.org/10.1136/bmj.39563.553715.BECrossref Assessment burden epidemiological characterization hampered nonexistent surveillance/reporting systems. such situations, indirect estimates, extrapolations settings, guesswork, inaccurate calculations used quantify Notable examples 10-fold inflation poliomyelitis cases (compared data),10Sathyamala C Mittal O Dasgupta R Priya Polio eradication initiative India: deconstructing GPEI.Int J Serv. 2005; 35: 361-383https://doi.org/10.2190/K882-9792-3QYX-JKTDCrossref (37) estimation hepatitis B prevalence,11Thyagarajan SP Jayaram S Mohanavalli Prevalence HBV general India.in: Sarin SK Singal AK Hepatitis Problems Prevention. CBS Publishers Distributors, New Delhi, India1996: 5-16Google various modeling estimates calculate childhood pneumonia (and proportion pneumococcal disease).12Rudan I Boschi-Pinto Biloglav Z Mulholland K Campbell H Epidemiology etiology pneumonia.Bull Organ. 86: 408-416https://doi.org/10.2471/blt.07.048769Crossref (909) Scholar,13Wahl Knoll MD Shet et al.National, regional, state-level severe morbidity children modelled 2000 2015.Lancet Child Adolesc Health. 2020; 4: 678-687https://doi.org/10.1016/S2352-4642(20)30129-2Abstract Full Text PDF (7) paucity data twin local potential effectiveness suits industry for-profit Data recommendations developed transplanted Guidance provided bodies, WHO United Nations Children's Fund, prestigious universities, research foundations, others, further bolster this approach. Indian stakeholders, policymakers professionals, accept this. Dissenting voices challenging dependence external ignored. leads wherein country like immense intellectual expertise, robust technical know-how, strong indigenous industry, powerful economy (currently ranked fifth worldwide) ends up bowing imperialism disguised assistance/guidance address own problems. Additional pertinent effectiveness, cost alternate strategies, sustainability obviously considered.14Mathew KNOW ESSENTIALS: tool informed absence formal HTA systems.Int Technol Assess Care. 2011; 139-150https://doi.org/10.1017/S0266462311000109Crossref (11) Scholar,15Mathew ESSENTIALS – novel algorithm vaccine-related decision-making countries.Int Infect Dis. 2010; 14: e447https://doi.org/10.1016/j.ijid.2010.02.612Abstract Similarly, short-term long-term program, impact needs, taken into account. Case studies (Appendix File 1,16Lodha Jain Y Anand Kabra Pandav CS review epidemiology.Indian Pediatr. 2001; 38: 349-371https://www.indianpediatrics.net/april2001/april-349-371.htmDate 6, 2020PubMed 17Phadke Kale ethics vaccine.Indian Eth. 2000; 8: 8-10https://ijme.in/articles/epidemiology-and-ethics-in-the-hepatitis-b-vaccine/?galley=pdfDate 18Batham Narula D Toteja T Sreenivas Puliyel JM Sytematic meta-analysis prevalence India.Indian 2007; 44: 663-674https://www.indianpediatrics.net/sep2007/663.pdfDate 19Puliyel Rastogi P Mathew systematic & report ‘IMA sub-committee immunization’.Indian Res. 127: 494-497https://jacob.puliyel.com/download.php?id=159Date 20WHOWeekly record: position WHO, Geneva, SwitzerlandPublished July 9, 2004https://www.who.int/immunization/wer7928HepB_July04_position_paper.pdfDate 21Mittal vaccination: myths controversies.Indian 2003; 70: 499-502https://doi.org/10.1007/BF02723142Crossref 22WHO Country IndiaHepatitis B. IndiaPublished 2016http://origin.searo.who.int/india/topics/hepatitis/factsheet_b__hepatitisday2016.pdfDate 10, online), conjugate 2,23The Fund (UNICEF)Pneumonia: forgotten killer children. (UNICEF)/WHO, York, NY2006https://www.unicef.org/publications/files/Pneumonia_The_Forgotten_Killer_of_Children.pdfDate 24World OrganizationPneumococcal paper.Wkly Epidemiol Rec. 82: 93-104https://www.who.int/wer/2007/wer8212.pdfDate 25Thomas Invasive Bacterial Infection Surveillance (IBIS) GroupInternational Clinical Network (INCLEN)Prospective multicentre hospital surveillance Streptococcus pneumoniae India.Lancet. 1999; 353: 1216-1221https://doi.org/10.1016/S0140-6736(98)07228-6Abstract (136) 26JL 45: 160-161https://www.indianpediatrics.net/feb2008/160.pdfDate 27Mathew Singhi dilemma continues.Indian 2014; 140: 165-166https://www.ijmr.org.in/showBackIssue.asp?issn=0971-5916;year=2014;volume=140;issue=2;month=AugustDate 28Indian Academy Pediatrics Committee (IAPCOI)Consensus immunization, 2008.Indian 635-648https://www.indianpediatrics.net/aug2008/635.pdfDate 29Adegbola RA Childhood priority strategic interest Bill Melinda Gates Foundation.Clin 2012; 54: S89-S92https://doi.org/10.1093/cid/cir1051Crossref (35) 30Levine OS O'Brien KL Deloria-Knoll M al.The Pneumonia Etiology Research Project: 21st century study.Clin S93-S101https://doi.org/10.1093/cid/cir1052Crossref (138) 31Mathew Ray al.Etiology acquired prospective, cohort study.J Glob 5050418https://doi.org/10.7189/jogh.05.020418Crossref (49) 32Mathew pneumonia: what we know, know!: based 5th Dr. IC Verma Excellence Oration Award.Indian 2018; 85: 25-34https://doi.org/10.1007/s12098-017-2486-yCrossref (5) 33Pneumonia (PERCH) Study GroupCauses requiring admission HIV infection Africa Asia: PERCH multi-country case-control study.Lancet. 2019; 394: 757-779https://doi.org/10.1016/S0140-6736(19)30721-4Abstract (283) 34Ministry Family WelfareNational operational guidelines. Introduction (PCV). Ministry Welfare, 2017https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/Operational_Guidelines_for_PCV_introduction.pdfDate 35International Institute Population Sciences (IIPS), ICFNational survey (NFHS-4), 2015–16: International Sciences, Mumbai, December 2017https://ruralindiaonline.org/library/resource/national-family-health-survey-nfhs-4-2015-16-india/Date 36Farooqui Jit Heymann DL Zodpey Burden pneumonia, deaths states: modelling estimates.PLoS One. 10e0129191https://doi.org/10.1371/journal.pone.0129191Crossref 37Evaluating (Inspire). U.S. National Library Medicine. https://clinicaltrials.gov/ct2/show/NCT03900520. Updated April 8, 2019. 38Liu L Chu Oza all-cause cause-specific under-5 mortality 2000–15: analysis implications Sustainable Goals.Lancet 7: e721-e734https://doi.org/10.1016/S2214-109X(19)30080-4Abstract online; Table 1), inactivated polio 3,39Puliyel Gupta MA future programmes: planning 125: 1-4https://www.ijmr.org.in/showBackIssue.asp?issn=0971-5916;year=2007;volume=125;issue=1;month=JanuaryDate 40Mathew after: IPV have role.Indian 68: S15-S22PubMed 41Mittal Vaccine paralytic poliomyelitis.Indian 573-577https://doi.org/10.1007/BF02723161Crossref (6) 42Mittal way forward.Indian 74: 153-160https://doi.org/10.1007/s12098-007-0009-yCrossref (18) 43John TJ bringing health.Indian 126: 91-93https://www.ijmr.org.in/showBackIssue.asp?issn=0971-5916;year=2007;volume=126;issue=2;month=AugustDate 44John Will poliovirus (IPV) complete eradication.Indian 122: 365-367https://ijmr.icmr.org.in/ijmr/archive/CurrentTopicView.aspx?year=Indian%20J%20Med%20Res%20122,%20November%202005,%20pp%20365-367%20(Editorial1)$EditorialDate 45Krishnan Jadhav John Efficacy India.Bull 1983; 61: 689-692https://apps.who.int/iris/bitstream/handle/10665/264914/PMC2536153.pdf?sequence=1&isAllowed=yDate 46Simoes EA Padmini Steinhoff MC Antibody response two doses enhanced potency.Am Dis Child. 1985; 139: 977-980https://doi.org/10.1001/archpedi.1985.02140120023021PubMed 47Simoes antibody seronegative potency.J Biol Stand. 1986; 127-131https://doi.org/10.1016/0092-1157(86)90031-4Crossref (13) 48Samuel BU Cherian Sridharan G Mukundan Immune intradermally injected vaccine.Lancet. 1991; 338: 343-344https://doi.org/10.1016/0140-6736(91)90480-dAbstract (39) 49Selvakumar Intestinal immunity induced vaccine.Vaccine. 1987; 5: 141-144https://doi.org/10.1016/0264-410x(87)90062-4Crossref (17) 50John golden jubilee 2004; 119: 1-17PubMed 51Mittal Pediatrics.Indian 2006; 43: 1097-1101https://www.indianpediatrics.net/dec2006/1095.pdfDate 52John TJ. Lessons campaign.https://www.india-seminar.com/2012/631/631_t_jacob_john.htm. 14, 53John perspective vaccine-associated poliomyelitis.Bull 53-58https://apps.who.int/iris/bitstream/handle/10665/72353/bulletin_2004_82%281%29_53-58.pdf?sequence=1&isAllowed=yDate 54John Dharmapalan An ethical appraisal choice Ethics. 26-29https://doi.org/10.20529/IJME.2018.074Crossref (2) 55Kohler KA Banerjee Hlady WG Andrus JK Sutter RW Vaccine-associated during 1999: decreased risk massive oral vaccine.Bull 2002; 80: 210-216PubMed 56Shah NK Thacker N Vashishtha Kalra Ugra strategies under IAP Action Plan 2006.Indian 1057-1063PubMed 57Vashishtha VM al.Polio Eradication Committee, PediatricsRecommendations 2nd Consultative Meeting (IAP) improvement immunization.Indian 367-378https://www.indianpediatrics.net/may2008/367.pdfDate 58Mathew (VAPP) jeopardizing goal regional polio.Int 10: S221-S222Google Figure 1) presented illustration. similar pattern apparent (non-EPI) those A, human papillomavirus, rotavirus, influenza, varicella, acellular pertussis vaccine, typhoid vaccine.Table 1Profile States Where PCV Was Launched First PhaseVariableIndiaUttar PradeshBiharMadhya PradeshRajasthanHimachal PradeshUnder 5 rateaPer 1,000 live births.49.778.158.164.650.737.6 RankbRanking order worst best 36 states union territories ARI, acute respiratory infection; PCV, vaccine.132618Child births.9.415.610.514.29.73.5 vaccine.162928Infant births.40.763.548.151.241.334.3 vaccine.143714Neonatal births.29.545.136.736.929.825.5 vaccine.143813Percentage ARI preceding weeks2.74.72.52.12.11.6 vaccine.112202024Percentage whom treatment sought78.176.568.072.387.889.0 vaccine.2216203033Percentage full vaccination62.051.161.753.654.869.5 vaccine.71481023a Per births.b Ranking India.ARI, vaccine. Open table new tab had (development production) decades.59Lahariya brief history 491-511https://www.ijmr.org.in/showBackIssue.asp?issn=0971-5916;year=2014;volume=139;issue=4;month=AprilDate fact, significant EPI globally produced addition, biotechnology able produce very quickly. Unfortunately, technological expertise harnessed completely self-sufficient respect requirements. Some years back, manufacturing plants shutdown. vacuum policy allow multinational manufacturers sell designed entirely set them. particularly relevant large annual birth exceeding 27 million and, hence, demand manufacture, marketing tailored country's needs (in terms targeted serotypes included).26JL Scholar,60Mittal revisited… yet again.Indian 390-395https://www.indianpediatrics.net/may2008/390.pdfDate assured several doses, years, leveraged negotiate acceptable foreign manufacturers.26JL There no single agency tasked monitoring communicable epidemiology (akin Centers Disease Control Prevention); however, recently Communicable Delhi redesignated Centre Control.61National Control. https://ncdc.gov.in/index.php. 13, component, regarding prevention diseases, it functions more advanced microbiology laboratory diagnostic facilities rather proactively defining institution repurposed collate sentinel sites country, sustain upgrade built eradication, monitor adverse events, scientifically guide toward rational decisions. (IAP)—the national society child professionals—is major voice advocating Advisory Vaccines Practices (formerly Immunization) august body periodically consensus statements, papers, favoring documents common features. First, they always issued after appearance domestic market.28Indian 62Balasubramanian Shah Pemde HK al.Indian (ACVIP) recommended (2018–19) update aged 0 18 years.Indian 55: 1066-1074https://doi.org/10.1007/s13312-018-1444-8Crossref (40) 63Vashishtha Choudhury years–India, 2014 updates 51: 785-800https://doi.org/10.1007/s13312-014-0504-yCrossref (83) 64Vashishtha Pediatrics, (acvip)Indian 2013 2013; 50: 1095-1108https://doi.org/10.1007/s13312-013-0292-9Crossref (36) 65Vashishtha Yewale VN Bansal CP Mehta PJ (ACVIP). perspectives measles rubella elimination strategies.Indian 719-722https://doi.org/10.1007/s13312-014-0488-7Crossref 66Vashishtha Influenza paper 2013.Indian 867-874https://doi.org/10.1007/s13312-013-0230-xCrossref (19) 67Vashishtha SG Pertussis (IAP).Indian 1001-1009https://doi.org/10.1007/s13312-013-0274-yCrossref (27) 68Singhal Amdekar YK Pediatrics. Immunization.Indian 390-392https://www.indianpediatrics.net/may2007/390.pdfDate Second, effectiveness.28Indian Scholar,62Balasubramanian instances, statements “there reason believe low adolescents India” vaccine.28Indian problem fit solution, around. Third, framed apparently pediatricians “in office practice” (pseudonym sector) children's families pay them.28Indian Scholar,63Vashishtha Scholar,64Vashishtha Scholar,69Vashishtha IAP-ACVIP recommendations: ‘individual’ ‘office practice’ setting.Indian 56: 510-511https://www.indianpediatrics.net/june2019/510.pdfDate reasonable, if parents engaged fair discussion highlighting (or thereof). But practice, nudged purchase expensive Innovative “optional vaccine,” “desirable “administration one-to-one discussion” coined promote reasons. All require (because higher risk) it, whereas afford it) perhaps least it.70Paul 2018–19 recommendations.Indian 338https://www.indianpediatrics.net/apr2019/338.pdfDate consequence instead proactive (demanding evidence), remains reactive (identifying means market). Of course, will ways, guidance members, protection individual advocacy health. Fourth, approach diverting For example, studying whether current infant still necessitates life dose later infancy (which reduce programmatic cost), using multiple measles–mumps–rubella vaccine.68Singhal measles–rubella providers, is. Therefore, pains suggest mumps great place vaccine.62Balasubramanian emphasis develop schedule, sector. pitched recommends alternative schedule. Naturally, includes EPI. official country-specific guidelines considerations, freely advises about well. principle, citizens freedom choices their Vaccination compulsory sense eliciting punitive forfeiture privileges) happens settings. makes efforts track unvaccinated ensure completion motivation, participation, social mobilization. Mission Indradhanush avatars, Intensified 2.0, steps direction.71Gurnani Haldar Aggarwal MK al.Improving lessons Indradhanush, cross-sectoral strengthening strategy.BMJ. 363: k4782https://doi.org/10.1136/bmj.k4782Crossref (55) By contrast, (more expensive) non-EPI forced onto families, empowering them done overtly well subtly, offering services. supports supplying rates cheaper price (as incentive prescribe prices). Unempowered leave decision personal assisting choices. Many disingenuously argue warrant “What harm do?” Sometimes, declining financial reasons guilt. Such opt 1 whole series. creates partially vaccinated remain susceptible disease. •Communicable main driver practice decisions.•Robust essential before introduced. help establish assess otherwise).•The newly designated nodal establishing guiding stakeholders considerations.•The desire protect willingness (rather waiting become EPI) (to decisions) education campaigns providers. authors acknowledge thank Equity University Michigan School Public support supplement. findings conclusions articles necessarily represent Michigan. received research, authorship, publication. None any associations, over past might pose conflict interest. JLM conceptualized study, searched literature, interpreted data, drafted manuscript, finalized manuscript. SKM reviewed draft manuscript input. IRB/Ethics committee approval sought identifiable subjects accessed, analyzed, presented. No disclosures reported paper. Download .pdf (.39 MB) Help pdf files