Wrong cure

By Sumana Narayanan
Published: Tuesday 30 September 2008

-- (Credit: DEBOJYOTI KUNDU) Who will benefit from globally promoted pneumonia vaccine?

the pneumonia vaccine that the Global Alliance for Vaccines and Immunization, a public-private coalition, and who are promoting in developing countries is expensive, inefficient and causes serious side-effects, contends a letter published in a public health journal.

In a letter to the Bulletin of the World Health Organization published online, paediatricians Jacob Puliyel and Sona Chowdhary of St. Stephen's Hospital, Delhi, said the vaccine was not effective against the common form of pneumonia in India, clinical pneumonia. Seven-valent pneumococcal conjugate vaccine or pcv 7 combats seven strains of pneumonia-causing bacteria and is known to work for uncommon radiological pneumonia. Clinical pneumonia cannot be diagnosed through X-rays but symptoms such as cough, while radiological pneumonia shows on X-rays.

"Radiological pneumonia is so rare that 1,000 children must be vaccinated to prevent 3.6 cases of pneumonia," said Puliyel. His letter is a comment on a paper published earlier in the same journal by experts from who and the un's Children's Fund (unicef).

The authors of the original paper in their rejoinder to Puliyel's letter agree that the vaccine is not effective against clinical pneumonia but continue to project it as a way of reducing deaths due to pneumonia in children. who's position paper on pneumonia, however, states that the vaccine covers 80 per cent of the strains occurring in the us, but covers less than 50 per cent of the strains in India and other developing nations.

Asthma instead
pcv 7 can cause asthma. Data from clinical trials in Colombia, Chile, Gambia, Brazil, South Africa, Bangladesh, Indonesia and the Philippines shows that for every 3.6 cases of pneumonia which are prevented, 1.3 children will get asthma. Asthma is a lifelong condition unlike pneumonia.

"The data on pneumonia in India is inadequate. We need more information before introducing this vaccine (in universal immunization programmes)," says Ajay Gambhir, member of the National Technical Advisory Group on Immunization set up by the health and family welfare ministry.

The paper published in the who bulletin extrapolates the Indian scenario from a study in Bangladesh on the effectiveness of another vaccine--Hib conjugate vaccine, which is for meningitis but also combats pneumonia--in preventing radiological pneumonia.

Cost factor
The cost of the vaccine is also high. A child needs three doses of pcv 7, with each dose costing nearly Rs 4,000. So to prevent about four cases of pneumonia, the government will be spending Rs 1.2 crore. The who-recommended treatment of pneumonia using antibiotic Septran costs Rs 10. The Global Alliance for Vaccines and Immunization was offering a reduced price of Rs 50 per child as an introductory offer on the pneumonia vaccine, said Puliyel. Even at this price, the cost of saving four lives would be Rs 50,000, he added.

who considers pneumonia vaccines to be a priority for inclusion in governments' immunization programmes. Pneumonia kills 1.6 million people every year, of which over half are children less than five years old. In its position paper on pcv, who states, "Despite the absence of some serotypes that are important causes of pneumococcal disease in developing countries, pcv 7 can prevent substantial mortality and morbidity in these countries."

Gambhir, however, said, India should wait till a pcv which covers Indian strains is developed. "I wouldn't introduce pcv 7. The problem is that even if we vaccinate children, new strains will appear and so we need continuous monitoring. Currently, India does not have a monitoring mechanism in place," he added.

An official from the health and family welfare ministry also said the government was not considering adding pcv 7 to the universal immunization programme at present. "We are struggling with the hepatitis B vaccine introduction, so we are not looking at pcv right now," he said.

Manufacturer Wyeth Pharmaceuticals has already introduced the vaccine in the private market. Vaccines for hepatitis and meningitis (Hib) also entered the private market before becoming part of the government's immunization programme. "Perhaps in another four years pcv will be in the programme if there is at least 70 per cent coverage of strains in India," said R K Agarwal, president, Indian Association of Paediatricians.

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