Indian association questions plan for hepatitis B immunisation
New Delhi
Ganapati Mudur
Circulated by the Indian Medical Association in public interest.
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This is about an article appearing in this weeks British Medical Journal about Hepatitis B vaccination in India. It is being circulated in the public interest.
The article reports the findings of the Indian Medical Association, Sub-Committee on Immunization headed by Professor SK Mittal
It suggests that the need for vaccination has been grossly exaggerated. Instead of the figure of 180,000 deaths annually, it says deaths from hepatocellular carcinoma due to the infection is only 5000/year. To put this in context, tuberculosis is known to cause 400,000 deaths annually in India. The report says that there is little justification for the vaccine to be included in the UIP (Universal Immunisation Programme) at a cost of over Rs 500 crores each year. There is little information from the pilot study on hepatitis B immunization done by the government. As of now the only beneficiary seems to be vaccine manufacturers.
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The article reports the findings of the Indian Medical Association, Sub-Committee on Immunization headed by Professor SK Mittal
It suggests that the need for vaccination has been grossly exaggerated. Instead of the figure of 180,000 deaths annually, it says deaths from hepatocellular carcinoma due to the infection is only 5000/year. To put this in context, tuberculosis is known to cause 400,000 deaths annually in India. The report says that there is little justification for the vaccine to be included in the UIP (Universal Immunisation Programme) at a cost of over Rs 500 crores each year. There is little information from the pilot study on hepatitis B immunization done by the government. As of now the only beneficiary seems to be vaccine manufacturers.
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The Indian Medical Association has criticised a government proposal to expand universal immunisation against the hepatitis B virus throughout India, saying that it would be "wasteful spending" on a low priority health problem.
In a report sent to the health ministry, the association said that a systematic review of
studies indicates that the rate of chronic carriage of hepatitis B in India is 1.6% and not 4% as projected. It has also cautioned that the proposal to immunise infants at 6, 10, and 14 weeks would not significantly change rates of chronic carriers because most cases result from vertical transmission (directly from mother to baby during and after pregnancy).
The report, made public by the association last week, has evoked sharp reactions from some doctors who have said that the lower estimate of rates of chronic carriers should not deter universal immunisation. "When an effective, inexpensive vaccine is available, it would be unethical to deny it to the population," said Subrat Acharya, a gastroenterologist at the All India Institute of Medical Sciences in New Delhi.
After a pilot project to immunise infants against hepatitis B in 15 cities and 32 districts, the health ministry has proposed to scale up the programme nationwide at an estimated annual cost of 5bn rupees (£58m; €86m; $110m).
The lower estimate of chronic carrier rate translates into only 16 million cases instead of 40 million, the association said in its report, which follows a 10 month long consultative process. It has also cited national cancer registry data that show that the number of deaths from liver cancer from hepatitis B is only 5000 instead of previous estimates of more than 180 000.
"The decision to introduce the hepatitis B vaccine into universal immunisation appears to have been taken without thought to either the disease burden or the efficacy of the 6, 10 and 14 week schedule," said Jacob Puliyel, a paediatrician at the St Stephen's Hospital in New Delhi and author of the report released by the association.
"Nowhere in the world is there any study that has demonstrated the efficacy of the 6, 10, and 14 week schedule to reduce chronic carrier rates," Dr Puliyel said. "The results of India's pilot project also remained unevaluated."
The association has said that studies from India show that vertical transmission contributes to a significant proportion of chronic carriers in the community and favours introducing hepatitis B vaccination at birth.
"The health ministry knows it can't reach all children at birth, so it's designed this
alternative schedule," Dr Puliyel said. However, several doctors have expressed surprise at the association's report and have said that its recommendations spring from "mistaken notions of the true disease burden from hepatitis B."
"Neither the association nor paediatricians are in any position to appreciate the true
disease burden caused by this virus," said Vivek Saraswat, a gastroenterologist at the Sanjay Gandhi Postgraduate Institute of Medical Sciences in Lucknow.
Doctors have argued that the primary source of hepatitis B infection in children is
horizontal transfer in and before early school. "We have no explanation yet for the mode of transmission, but it could be injuries," Dr Sarawat said.
But even doctors who favour universal immunisation concede that large community
studies will be needed to resolve the true prevalence of hepatitis B in India. "There will
always be sceptics," Dr Acharya said. "But instead of arguing against universal
immunisation, they should try to suggest ways to reduce the cost of immunisation."
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MINISTER OF STATE OF THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI DALIT EZHILMALAI)
(a) No authentic data is available of the number of the deaths caused by Hepatitis-B infection alone. However, according to available data, the number of cases of viral Hepatitis (all types) during 1995 to 1997 (provisional) is as follows:-
Year No. of Persons infected No. of persons died
1995 98943 943
1996 11795 4 801
1997 89038 962
(b) and (c) Hepatitis B vaccination has not been included under the National Immunization Programme as the estimated cost will be around Rs. 525 crores per annum and the measure if initiated will have to be continued indefinitely to cover all children born in the country with 3 doses. Availability of funds to sustain this over such a long period cannot be assured.
(a) No authentic data is available of the number of the deaths caused by Hepatitis-B infection alone. However, according to available data, the number of cases of viral Hepatitis (all types) during 1995 to 1997 (provisional) is as follows:-
Year No. of Persons infected No. of persons died
1995 98943 943
1996 11795 4 801
1997 89038 962
(b) and (c) Hepatitis B vaccination has not been included under the National Immunization Programme as the estimated cost will be around Rs. 525 crores per annum and the measure if initiated will have to be continued indefinitely to cover all children born in the country with 3 doses. Availability of funds to sustain this over such a long period cannot be assured.
Other links to educate you further
- http://www.imanational.com/Hepatitis/PositionPaper.htm
- http://www.imanational.com/Hepatitis/DiscussionHepatitis.htm
- http://www.imanational.com/Hepatitis/BackGroundInfo.htm
- http://www.imanational.com/Hepatitis/ImaDiscussion.htm
After all, they (the pro-vaccine lobbyists) say to themselves, you can't make an omelette without
breaking eggs. But the eggs being broken are small, helpless, and innocent babies, while the omelette is being enjoyed by the pediatricians and vaccine manufacturers. - Harris L. Coulter, PhD
breaking eggs. But the eggs being broken are small, helpless, and innocent babies, while the omelette is being enjoyed by the pediatricians and vaccine manufacturers. - Harris L. Coulter, PhD
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