Vacccine in India

8/3/2019 Vacccine in India

1/9

At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2011.0405

, 30, no.6 (2011):1096-1103Health AffairsBe DoneAnd ShouldImmunized, And What Can

India's Vaccine Deficit: Why More Than Half Of Indian Children Are Not FullyRamanan Laxminarayan and Nirmal Kumar Ganguly

Cite this article as:

http://content.healthaffairs.org/content/30/6/1096.full.html

available at:The online version of this article, along with updated information and services, is

For Reprints, Links & Permissions:http://healthaffairs.org/1340_reprints.php

http://content.healthaffairs.org/subscriptions/etoc.dtlE-mail Alerts :

http://content.healthaffairs.org/subscriptions/online.shtmlTo Subscribe:

written permission from the Publisher. All rights reserved.mechanical, including photocopying or by information storage or retrieval systems, without prior

may be reproduced, displayed, or transmitted in any form or by any means, electronic orAffairsHealthFoundation. As provided by United States copyright law (Title 17, U.S. Code), no part of

by Project HOPE - The People-to-People Health2011Bethesda, MD 20814-6133. Copyright is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600,Health Affairs

Not for commercial use or unauthorized distribution

at India: HEALTH AFFAIRS Sponsoredon August 16, 2011Health Affairsbycontent.healthaffairs.orgDownloaded from
http://www.healthaffairs.org/http://content.healthaffairs.org/content/30/6/1096.full.htmlhttp://content.healthaffairs.org/content/30/6/1096.full.htmlhttp://healthaffairs.org/1340_reprints.phphttp://healthaffairs.org/1340_reprints.phphttp://content.healthaffairs.org/subscriptions/etoc.dtlhttp://content.healthaffairs.org/subscriptions/etoc.dtlhttp://content.healthaffairs.org/subscriptions/online.shtmlhttp://content.healthaffairs.org/http://content.healthaffairs.org/http://content.healthaffairs.org/http://content.healthaffairs.org/subscriptions/online.shtmlhttp://content.healthaffairs.org/subscriptions/etoc.dtlhttp://healthaffairs.org/1340_reprints.phphttp://content.healthaffairs.org/content/30/6/1096.full.htmlhttp://www.healthaffairs.org/


2/9

By Ramanan Laxminarayan and Nirmal Kumar Ganguly

Indias Vaccine Deficit: Why MoreThan Half Of Indian Children Are

Not Fully Immunized, And WhatCanAnd ShouldBe Done

ABSTRACT Although India is a leading producer and exporter of vaccines,

the country is home to one-third of the worlds unimmunized children.

Fewer than 44 percent of Indias young children receive the full schedule

of immunizations. Indias vaccine deficit has several causes: little

investment by the government; a focus on polio eradication at the

expense of other immunizations; and low demand as a consequence of a

poorly educated population and the presence of anti-vaccine advocates. In

this article we describe Indias vaccine deficit and recommend that the

government move quickly to increase spending on, and otherwise

strengthen, national immunization programs.

India has experienced impressive im-provements in its economic status andpopulation health during the past two

decades. However, it lags behind othercountries of similar per capita gross do-

mestic product in child survival. The mortalityrate for children age five and younger currentlystands at sixty-six per thousand live births, com-pared to thirty-four per thousand live births inthe Philippinesa country with roughly thesame per capita gross domestic product. Be-tween 1990 and 2001, the probability of dyingbefore age five fell more than twice as rapidly inBangladesh and Indonesia as it did in India.1

Although child survival rates have improvedsince 2001,2 India will not achieve its own goal of

reducing the number of infant deaths by halfbefore 2012. And at the current rate of decline,itwillnotmeet the goalthat was set inthe UnitedNations Millennium Declaration3 of cutting themortality rate for children under age five by two-thirds between 1990 and 2015.

There are twenty-seven million new births inIndia each yearthe largest birth cohort in theworld. However, fewer than 44 percent of thesechildren receive the full schedule of immuniza-tions (Exhibit1).2 Thislevelis only slightly betterthan it was in 1998, when the proportion was

42 percent (Exhibit 2). In contrast, in Bangla-desh, on the northeast border of India, 82 per-cent of children are fully immunized by age two.

In adjacent Nepal, 80 percent of children arefully immunized by age one. The 9.6 million un-immunized children in India today account formore than one-third of the 27 million unimmu-nized children around the world. Indias spend-ingon routine immunizations remains low at US$113 million per year in 201011, down from$137 million in 200910.

In 1978 the Indian government launched itsExpanded Programme for Immunization. In1985 the program was relaunched as the Univer-sal Immunization Program, with the goal of ex-tending six basic vaccines to all infants and the

tetanus vaccine to pregnant women. The immu-nization schedule was changed to include mea-sles, and the typhoid vaccine was dropped. In2006 hepatitis B and Japanese encephalitis vac-cines were introduced in selected parts of thecountry. The National Technical Advisory Groupon Immunization, which was established by theMinistry of Health in 2002, is the primary tech-nical advisory group on vaccines to the nationalgovernment.4

Although the current immunization programtargets twenty-seven million infants and preg-

doi: 10.1377/hlthaff.2011.0405HEALTH AFFAIRS 30,NO. 6 (2011): 109611032011 Project HOPEThe People-to-People HealthFoundation, Inc.

Ramanan Laxminarayan([email protected]) is vicepresident of policy andresearch at the Public HealthFoundation of India; is avisiting scholar and lecturer atPrinceton University; anddirector of the Center for

Disease Dynamics, Economics,and Policy, in Washington,D.C., and New Delhi, India.

Nirmal Kumar Ganguly is theDistinguished BiotechnologyFellow and Advisor at theTranslational Health Scienceand Technology Institute, andis president of the JawaharlalInstitute of Post GraduateMedical Education andResearch, in New Delhi, India.

1096 H e a lt h A f f a i r s J u n e 2 0 1 1 3 0 : 6

Str engthening Pr ogr ams

http://content.healthaffairs.org/http://content.healthaffairs.org/http://content.healthaffairs.org/http://content.healthaffairs.org/


3/9

nant women every year and is one of the largestimmunization programs in the world, immuni-zation rates through the national program areuneven across twenty-eight states in India. Theproportion of children under age five who are

vaccinated exceeds 70 percent in only elevenstates; it drops below 53 percent in eight statesthat are also the most populous.

Burden Of Vaccine-PreventableDisease

As shown in Exhibit 1, the burden of childhoodinfectious diseases is substantial in India.

Rotavirus A recent estimate gave a range of122,000153,000 for rotavirus-related deaths inIndia annually.5 There were an estimated457,000884,000 rotavirus-related hospitaliza-tions and two million outpatient visits necessi-tated by rotavirus infection for children underage five.

Polio The great challenge in global eradica-tion of polio has until recently been India, wheretransmission of the disease has persisted in thestates of Uttar Pradesh and Bihar, despite high

vaccination rates with multiple doses of vaccine.In addition to routine oral polio vaccine deliv-ered through the immunization program, dur-ing 199596 the Pulse Polio Immunization pro-gram delivered supplementary doses of oralpolio vaccine during what were termed NationalImmunization Days to cover all children underage three. The target age group was increasedduring 199697 to all children younger than

age five. The National Rural Health Mission isa national program to increase public spendingon rural health in states with weak health infra-structure, and the national polio program ac-counts for 14 percent of their funds comparedwith the 3 percent spent on routine immuni-zations.6

There has been a considerable decline in poliocases detected in India recently due to introduc-tion of the so-called monovalent vaccine. This

vaccine includes one antigen, or substancecapable of producing an antibody or other im-mune response for type 1 poliovirus, which ac-

counts for more than 95 percent of the cases inIndia. The monovalent vaccine builds immunitymorerapidly than the so-called trivalent vaccine,which also has antigens against the other typesof wild poliovirus that are not circulating cur-rently in India. In 2004 there were 559 reportedcases of polio, but from September 2010 toMarch 2011 only three cases were reported. Inthe first three months of 2011 there was just onecase,in Howra district,nearthe city of Kolkata in

West Bengal. However, even with these impres-sive declines,it is unlikely that thepolio program

can be scaled back anytime soon unless globaleradication is achieved.

Pneumonia Pneumonia remains the leadingkiller of children in India; it accounted for371,605 deaths in children under age five in2008.7,8 However, assessing the burden ofpneumococcal disease through routine surveil-lance remains a technical challenge in resource-poor settings. Invasive disease surveillance,which focuses on cases of pneumonia, bactere-mia, and meningitis, is useful in mapping thedifferent strains of pneumococci, but the vastmajority of infections are noninvasive and only

cause middle-ear infections that are not re-

E xh i bi t 1

Rates Of Vaccination And Burden Of Vaccine-Preventable Disease In India, 200408

Disease

Vaccinationrate (%)(200506)

Deathsin India(200408)

Cases reportedby India(2008)

Diphtheria (DPT1/DPT3) 76 (55.3) 2,000 6,081Tetanus (DPT1/DPT3) 76 (55.3) 13,000 3,714

Pertussis (DPT1/DPT3) 76 (55.3) 86,000 44,180Poliomyelitis 88.8 0 559Measles 58.8 81,275 48,181Hepatitis B 50 37,000 a

Rotavirus a 122,000153,000 a

Pneumonia a 371,605 a

SOURCES Data for burden of deaths from diphtheria (DPT1/DPT3), poliomyelitis, and hepatitis B arefrom 2004 estimate of deaths in Southeast Asia: World Health Organization. The global burden ofdisease: 2004 update. Geneva: WHO; 2008. Data for burden of deaths from tetanus (DPT1/DPT3)pertussis, and measles are from the 2008 World Health Organization (WHO) estimate; see Note 7 intext. Vaccination rates calculated from National Family Health Survey, 200506. aNot available.

E xh i bi t 2

Immunization Trends In Nine Indian States And The Country As A Whole, 1998 2006

Percent

SOURCES Note 2 in text. National Family Health Survey, India. Results of the National Family HealthSurvey 19981999. Mumbai: NFHS; 1999 [cited 2011 Apr 18]. Available from: http://hetv.org/india/nfhs/index.html.

J un e 2 01 1 3 0 :6 H e a l t h A f f a i r s 1097at India: HEALTH AFFAIRS Sponsored

on August 16, 2011Health Affairsbycontent.healthaffairs.orgDownloaded from
http://content.healthaffairs.org/http://content.healthaffairs.org/http://content.healthaffairs.org/


4/9

ported. Data from randomized control trials ofthe pneumococcal conjugate vaccine suggestthat roughly a third of severe pneumonia casesglobally are caused by pneumococci. A globalstudy that assessed the burden of pneumoniacaused by a particular strain of bacteria, Strepto-coccus pneumoniae, estimated that pneumococ-cal infections were responsible for 142,000

deaths in India in 2000roughly a third of allpneumonia deaths in that countrywhich rep-resents 17 percent of the global deaths frompneumococci;9 72,000 deaths were attributableto Haemophilus influenzae type b (Hib).8 Indiaaccounts for a fifth of the 370,000 deaths inchildren under age five caused by this virusworldwide. Although vaccines for this diseasehave been used extensively for at least twenty

years and have eliminated the disease in bothdeveloping and developed countries, they arenot distributed in India.

Measles According to recent estimates, the

81,275 annual deaths from measles in India ac-count for three-quarters of the global deathsfrom this disease. It is estimated that two-thirdsof the children who die of measles and the otherpreventable childhood diseases would have sur-

vived if they had been immunized.10

Moreover, 94 percent of these deaths in Indiaare concentrated in just ten states: UttarPradesh, Bihar, Rajasthan, Madhya Pradesh,Jharkhand, Assam, West Bengal, AndhraPradesh, Orissa, and Gujarat. The overall rateof vaccination for measles in India among chil-dren remains low, at 66 percent. The National

Technical Advisory Group on Immunizationsadvises a catch-up campaign for children ages912 months in states with a vaccination ratebelow 80 percent, and a routine second dosein states with higher vaccination rates.

Expanding Routine ImmunizationInrecentyearsthere have been some successesinincreasing rates of immunization in India. Forexample, programs that use community healthworkers have been shown to improve immuni-zation rates overall in India to a greater extent

than other interventions, although more evi-dence is needed to make the connection con-clusive.11

The unfortunate fact, however, is that Indiaspends woefully little on routine immunization.Only 2.1 percent of the national governmentshealth budget is allocated to routine immuniza-tiona small amount given the countrys largepopulation and number of births.12 The addi-tional cost per capita each year to reach 90 per-cent of Indian children with the six basic vac-cines already included in the national

immunization programdiphtheria, tetanus,pertussis, tuberculosis, polio, and measleswould be less than three rupees, or eight cents,in the poorest states and even less in the otherstates.3 Or equivalently, thevaccine cost per fullyimmunized child would be roughly eighty cents.

In addition, there is a long list of other chal-lenges to Indias immunization program. Theseinclude a shortage of trained personnel to man-

age the program at both the national and statelevels; the need to undertake innovations in vac-cines, disease surveillance, vaccine procure-ment, and effective vaccine management; theabsence of good data on disease burden to in-form vaccination priorities; the lack of baselinesurveillance data for monitoring the effects of

vaccination; and the absence of a system of rou-tine reporting and surveillance.

Challenges to improving coverage also lie onthe demand sidethat is, the degree to whichindividuals do their part to be vaccinated. Pooreducation levels, which are consistently corre-

lated with the likelihood that individuals willnot complete vaccination schedules, pose a ma-

jor barrier to expanding vaccination rates in ru-ral areas.13 Adverse events following immuniza-tion, even when these are shown to be unrelatedto a vaccine, have been widely reported in theIndian news media and have contributed to aculture hostile to vaccination in certain Indiancommunities.14 Better communication about thebenefits of vaccines and the potential but typi-cally harmless side effects, such as sore arms andlow-grade fevers, could greatly boost confidencein vaccines and the immunization program.

A related issue is the quality of the vaccinesadministered in India. Low-quality vaccine mayexplain the poor past performance of the PulsePolioprogram,referencedabove.15 Furthermore,most of the Universal Immunization Program

vaccines procured for routine immunizationsin India come from manufacturers that are notprequalified by the World Health Organization.Poor vaccine quality could lead to greater inci-dence of immunization-related adverse eventsand lower public trust in immunizationprograms.

The unfortunate factis that India spendswoefully little onroutine immunization.





5/9

Incentives could help to improve vaccinationrates if their sustainability could be ensured. Arecent randomized controlled trial provided evi-dence of the effect of modest, nonfinancial in-centives on vaccination rates in children ages

13. The trial found that villagers provided withlentils and metal plates, in exchangefor complet-ing their immunization schedules, had higherrates of vaccination (38.3 percent) than peoplein villages that used other approaches such ashaving reliable immunization camps, which aretemporaryimmunization facilities set up to issuemass vaccinations to children (16.6 percent). Bycontrast, control villages with no interventionsregistered only a 6.2 percent vaccination rate.16

In addition to finding the best ways to boost vaccination rates, more attention needs to bepaid to the effect of vaccination campaigns on

routine healthsystem functions. It haslong beensurmised that having intensive campaigns to im-munize for one condition could lead to broaderimmunization access overall. However, a studyof the effect of the polio campaign did not findevidence of synergy between the campaign andnonpolio routine immunization rates.17 In fact,there has been concern that emphasis on thepolioprogram has detracted from routine immu-nization, rather than increasing it.

New Antigens

In many developing countries, the immuniza-tion schedule goes beyond the basic six vaccines.Newer or underusedvaccines can protect againstother diseases that pose a danger in India, in-cluding hepatitis B, a common cause of livercancer; Hib; pneumococcus, a major cause ofpneumonia; and rotavirus, which causes life-threatening diarrheal disease. Countrieswith in-comes lower than Indias have already begun toadminister these vaccines.18According to recentestimates, these vaccines could be added to In-dias immunization program at an additional

cost of around twenty-one rupees or fifty centsper person nationally each year.3

In 2009 the National Technical AdvisoryGroup on Immunization recommended using apentavalent vaccinea combination of five vac-cines in one injectionconsisting of diphtheria,tetanus, pertussis, hepatitis B, and Hib antigens.Subsequently, the GAVI Alliance authorized

$165 million to help introduce a combinationvaccine in ten states in India.19

Initially, there were concerns that the cost ofthe pentavalent vaccine would be covered foronly two years, after which India would haveto pay for the vaccine out of its own budget.20

The national government plans to roll out thepentavalent vaccine on a trial basis in 2011 in twostates, Kerala and Tamil Nadu, which alreadyhave high rates of routine immunization.21 Therollout willhelpgenerate operational knowledgeon the use of these new antigens, but the avertedburdenmight notbe indicative of potentialin the

rest of the country because Tamil Nadu andKerala may have a lower rate of Hib infectionthan poorer states with weaker health care infra-structure and less access to antibiotics.

A recent study estimated that a rotavirus vac-cination program using a 50 percent effective

vaccineat theGAVI Alliance price of fifteen centsa dose would prevent 44,000 deaths and$206 million in treatment costs each year.22

The estimated cost-effectiveness of vaccinationwas $21.41 per disability-adjusted life-yearaverted, or $662.94 per life saved. Even at a priceof $14 per two-course dose, a universal rotavirus

vaccination program would be cost-effective at$200 per disability-adjusted life-year averted.

Although the rotavirus vaccine has been dis-cussed by the technical advisory group, therehas been no proposal to date to introduce this

vaccine into Indias immunization program.The Indian government has been reluctant to

pay for the newer vaccines, including thepneumococcal conjugate vaccine, demandingthat they be supplied for about a quarter of theircurrent price. However, Indias own pharma-ceutical and biologics industry should be ableto produce newer vaccines at international qual-

ity levels and competitive prices, although pricesare unlikely to come down to those of vaccinesused in routine immunization.

Other priorities include implementation of acombination measles-rubella vaccine, targeteduse of an inactivated polio vaccine, and possiblya pneumococcal and rotavirus vaccine.

Vaccine Manufacture In IndiaIndia is a leading producer and exporter of vac-cines, including complex vaccineslikethe penta-

More attention needsto be paid to theeffect of vaccinationcampaigns on routine

health systemfunctions.

J un e 2 01 1 3 0 :6 H e a lt h A f f a i r s 1099at India: HEALTH AFFAIRS Sponsored



6/9

valent rotavirus vaccine. Although vaccines usedin India are primarily provided through thegovernment, a third of the population buys vac-cines from theprivate market. There arethirteenmajor vaccine manufacturers in India, and theIndian vaccine market is about $260 million inannual sales.23 Roughly 43 percent of the globalUniversal Immunization Program vaccine sup-ply (more than 70 percent in the case of single

vaccine) comes from India. Exhibit 3 shows do-mestic production capacity for new vaccines.24

Public facilities for vaccine production dateback to the days of British rule in India, when

vaccines were needed to protect soldiers.23 TheUniversal Immunization Program had procured

vaccines from both the public and the privatesectors, but in January 2008, the Drugs Control-ler General (India), which is the national drugand vaccines regulatory authority similar to theUS Food and Drug Administration, withdrewproduction licenses from all public-sector unitsfor failure to comply with good manufacturingpractices. There is an effort under way to restart

vaccine production in the public sector by im-proving quality and compliance with thesestandards.

ConclusionsIndia currently stands poised to make sizablepublic investments in health and to take onthe growing burden of noncommunicable dis-eases through the National Rural Health Mis-sion. The government has announced thatpublic

spending on health will increase from 0.9 per-centto 23 percent of gross domestic product. Inthis environment, reducing the high burden of

vaccine-preventable diseasesshould be an imme-diate priority.

Increasing allocation of resources to the coun-trys immunization program is an immediatesolution and is well worth thecost. The challengeis in increasing allocations for routine immuni-zation while not letting up on the polio eradica-tionprogram.However,government revenuesinIndia are growing rapidly and should be able to

E xh i bit 3

Domestic Production And Development Of New Vaccines In India, 200809

Company Presentation Installed capacity

Hepatitis B

Serum Institute of India Ltd., Pune a 1,000Panacea Biotec, New Delhi Multidose 540Panacea Biotec, New Delhi Single dose 120

Bharat Biotech Int. Ltd., Hyderabad

a 1,000HBI, Udhagamandalam, Hyderabad a 200Shanta Biotechnic Pvt. Ltd., Hyderabad a 2,000

Haemophilus influenzae type b

Bio-Med Pvt. Ltd., Ghaziabad Monovalent 40Panacea Biotec, New Delhi a 150Shanta Biotechnic Pvt. Ltd., Hyderabad a b

Panacea Biotec, New Delhi Tetravalent (DPT-Haemophilus influenzae type b ) 4,500Shanta Biotechnic Pvt. Ltd., Hyderabad a 3,000Panacea Biotec, New Delhi Pentavalent (DPT-hepatitis B-Haemophilus

influenzae type b)1,000

Shanta Biotechnic Pvt. Ltd., Hyderabad a b

Pneumococcal conjugate vaccine

Serum Institute of India Ltd., Pune; Pancea Biotec, New Delhi 811 valent Preclinical development

Shanta Biotechnic Pvt. Ltd., Hyderabad

a

Research and developmentJapanese encephalitis

Shanta Biotechnic Pvt. Ltd., Hyderabad a 2,000Biological E Ltd., Hyderabad a Expected launch in 2012Indian Immunologicals Ltd., Hyderabad a Research and development

Rotavirus

Bharat Biotech Int. Ltd., Hyderabad a b

Shanta Biotechnic Pvt. Ltd., Hyderabad a b

Serum Institute of India Ltd., Pune a b

SOURCE Central Bureau of Health Intelligence, MoHFW. National Health Profile (NHP) of India2009 [Internet]. New Delhi: The Bureau; 2009 [cited 2011 May 17]. Availablefrom: http://cbhidghs.nic.in/writereaddata/linkimages/11%20Health%20Infrastructure8356493923.pdf. NOTES DPT is diphtheria, pertussis, and tetanus. Installedcapacity is expressed as quantity in hundred thousands of doses. aSpecifics of dosage are not available. bNot under production yet.





7/9

support this expanded commitment. Increasingthe current allocation for routine immunizationby $221 million per year could greatly improve

vaccination rates. This figure is based on an esti-mated thirteen million children who remain un-immunized and a cost of seventeen dollars perfully immunized child, as well as increasing the

technical staff in charge of the national immu-nizationprogram from thecurrent level of three.The increased spending on routine immuniza-tion would represent 3.6 percent of Indiashealth budget of roughly $6 billion in 2011,and half that proportion if India were to followthrough on increasing overall public healthspending to even 2 percent of gross domesticproduct.

Moreover, India could improve delivery strat-egies for these vaccinesfor example, by offer-ing a second opportunity for measles immuniza-tion, as recommended by the World Health

Organization and UNICEF.25 The second-oppor-tunitymeaslescampaign,whichwouldcostIndialess than two rupees (about five cents) per per-son per year, has helped many African countriesmuch poorer than India reduce their measlesdeaths sharply in the past decade.

With regard to vaccine manufacturing, the In-dian government should invest in its public fa-cilities to bring them up to the standards of goodmanufacturing practices, which are followed byinternational pharmaceutical and biotech firms

to ensure that products meet specific require-ments for identity, strength, quality, and purity.Given the great national interest in vaccines,achievement of such standards could go a longway toward allaying concerns that vaccinationprograms primarily drive private-sector profitsrather than serving a public good.

Adhering to the World Health Organization

prequalification standards would enable moredomestic manufacturers to find internationalmarkets. These standards, coupled with a moreefficient procurement system that factors in thetimelines of the vaccine manufacturing process,will greatly reduce the risk for vaccine manufac-turers.

The National Technical Advisory Group on Im-munization described earlier should be strength-ened in two ways. First, it is important that thisbody hold regular meetings and widely circulateits recommendations. Indias secretary of healthcurrently chairs the group. Although this pro-

vides a connection to the government, maintain-ingthegroupasanindependentexpertbodythatoffers advice to government could be a more

valuable function.The time is right to roll out additional vac-

cines,such asHaemophilusinfluenzae typeb,hep-atitis B, and rotavirus, especially in states thathave demonstrated high levels of routine immu-nization. The National Technical AdvisoryGroup on Immunization has already recom-mended these antigens. It is also time to counterthe anti-vaccine advocates who consider any ex-panded program a ploy by vaccine manufac-

turers to profit at the expense of the Indian pub-lic. Investments in disease surveillance couldhelp evaluate the burden of disease that couldbe averted by adding new antigens in the immu-nization schedule.

The ultimate goal, of course, must be reducingIndias disturbingly high child mortality rate.Redressing the vaccine deficit, through the stepsoutlined above, is an essential step along Indiasroad to development.

The authors are grateful to SwetaAdhikari, Yolisa Nalule, and Sanjukta SenGupta for technical and editorialassistance and useful comments. Anyerrors that remain are the responsibilityof the authors.

The ultimate goalmust be reducingIndias disturbinglyhigh child mortality

rate.

J un e 2 0 11 3 0 :6 H e a l t h A f f a i r s 1101at India: HEALTH AFFAIRS Sponsored



8/9

NOTES

1 Lopez A. Annex 2a. In: The globalburden of disease and risk factors.

Washington (DC), New York (NY): World Bank and Oxford UniversityPress; 2006.

2 National Family Health Survey.Child health. Chap. 9 in: Results ofthe National Family Health Survey

20052006. Mumbai: NFHS; 2006[cited 2011 May 26]. Available from:http://hetv.org/india/nfhs/nfhs3/NFHS-3-Chapter-09-Child-Health.pdf

3 Jha P, Laxminarayan R. Choosinghealth: an entitlement for all Indi-ans. Toronto: Center for GlobalHealth Research, University ofToronto; 2009.

4 John TJ. Indias National Technical Advisory Group on Immunisation. Vaccine. 2010;28(Suppl 1):A8890.

5 Tate JE, Chitambar S, Esposito DH,Sarkar R, Gladstone B, Ramani S,et al. Disease and economic burdenof rotavirus diarrhoea in India.

Vaccine. 2009;27(Suppl 5):F1824.6 Deolalikar AB, Jamison DT, Jha P,

Laxminarayan R. Financing healthimprovements in India. Health Aff(Millwood). 2008;27(4):97890.

7 Black RE, Cousens S, Johnson HL,Lawn JE, Rudan I, Bassani DG, et al.Global, regional, and national causesof child mortality in 2008: a sys-tematic analysis. Lancet. 2010;375(9730):196987.

8 Watt JP, Wolfson LJ, OBrien KL,Henkle E, Deloria-Knoll M, McCallN, et al. Burden of disease caused by Haemophilus influenzae type b inchildren younger than 5 years: global

estimates. Lancet. 2009;374(9693):90311.

9 OBrien KL, Wolfson LJ, Watt JP,Henkle E, Deloria-Knoll M, McCallN, et al. Burden of disease caused byStreptococcus pneumoniae in children

younger than 5 years: global esti-mates. Lancet. 2009;374(9693):893902.

10 Kumar R, Jha P, Bassani D, DhingraN, Corsi D, Kaur N. Parental recall

and the effect of basic immunisationon overall child mortality: a popu-lation-based study in Chandigarh,India. Toronto: University ofToronto; 2009.

11 Patel AR, Nowalk MP. Expandingimmunization coverage in rural In-dia: a review of evidence for the role

of community health workers. Vac-cine. 2010;28(3):60413.

12 Ministry of Health and Family Welfare. Routine immunization: re-leases to state H&FW society routineimmunization for the financial year201011 [Internet]. New Delhi: TheMinistry; 2011 [cited 2011 May 17].

Available from: http://mohfw.nic.in/searchdetails.php?lang=1&lid=376&skey=immunization

13 Elliott C, Farmer K. Immunizationstatus of children under 7 years inthe Vikas Nagar area, North India.Child Care Health Dev. 2006;32(4):41521.

14 Adverse Drug Reaction centers thatalso deal with adverse events relatedto immunizations were set up by theDrugs Controller General of Indiaand the Indian Council for MedicalResearch in the 1980s but weresubsequently discontinued. Theseefforts have been renewed throughthe National PharmacovigilanceProgram of India.

15 Aylward RB, Maher C. Interruptingpoliovirus transmissionnew solu-tions to an old problem. Biologicals.2006;34(2):1339.

16 Banerjee AV, Duflo E, Glennerster R,Kothari D. Improving immunisationcoverage in rural India: clustered

randomised controlled evaluation ofimmunisation campaigns with andwithout incentives. BMJ. 2010;340:c2220.

17 Bonu S, Rani M, Baker TD. The im-pact of the national polio immuni-zation campaign on levels andequityin immunization coverage: evidencefrom rural North India. Soc Sci Med.2003;57(10):180719.

18 GAVI Alliance. Executive director/

CEO report to the GAVI Alliance andfund board meeting [Internet].Geneva: GAVI; 2008 [cited 2011 May6]. Available from: http://www.gavialliance.org/resources/1_CEO_report_June_2008.pdf

19 GAVI Alliance [Internet]. Geneva:GAVI. Press release, 18 million In-

dian children to receive life-savingfive-in-one vaccine; 2009 Aug 11[cited 2011 Apr 18]. Available from:http://www.gavialliance.org/media_centre/press_releases/2009_08_11_india_pentavalent.php

20 Vashishta VM. Introduction of Hibcontaining pentavalent vaccine innational immunization program ofIndia: the concerns and the reality.Indian Pediatr. 2009;46(9):7812.

21 Kounteya S. Gates offers govt$110 mn for 5-in-one shot rollout.Times of India. 2011 Mar 23.

22 Esposito DH, Tate JE, Kang G,Parashar UD. Projected impact andcost-effectiveness of a rotavirus vac-cination program in India, 2008.Clin Infect Dis. 2011;52(2):1717.

23 Gogtay NJ, Dhingra MS, Yadav A,Chandwani H. Vaccine policy, regu-lations, andsafetyin India. IntJ RiskSafety Med. 2009;21:2330.

24 Central Bureau of Health Intelli-gence,Ministry of Healthand Family

Welfare. Health infrastructure. Chap.6 in: National health profile (NHP)of India2009 [Internet]. NewDelhi: The Ministry; 2009 [cited2011 May 26]. Available from:http://cbhidghs.nic.in/writereaddata/linkimages/11%20Health%20Infrastructure8356493923.pdf

25 World Health Organization, WorldHealth Assembly. Reducing globalmeasles mortality [Internet].Geneva: WHO; 2003 [cited 2011 Apr18]. [WHA Resolution 56.20].

Available from: https://extranet.who.int/aim_elearning/en/measles/resources/pdf/WHA_reducing_measles_mortality.pdf





9/9

ABOUT THE AUTHORS: RAMANAN LAXMINARAYAN &

NIRMAL KUMAR GANGULY

RamananLaxminarayan isvice president ofpolicy and researchat the Public HealthFoundation of India.

Ramanan Laxminarayan andNirmal Kumar Ganguly provide

Health Affairs readers with adisturbing review of vaccinecoverage in Indiaa country with a

third of the worlds unvaccinatedchildren.

Having such low coverage isinconsistent with a country thatwants to put a man on the moon inten years, says Laxminarayan.Expanding immunization rates asa key intervention to avert needlessdeaths of young children should bean urgent priority.

Laxminarayan is vice president ofpolicy and research at the PublicHealth Foundation of India, a

public-private partnership designedto strengthen training, research,and policy development in publichealth. He is also a visiting scholarand lecturer at PrincetonUniversity. He is director of theCenter for Disease Dynamics,Economics, and Policy, withheadquarters in Washington andNew Delhi. The center was foundedwith the objective of using research

to support better decision makingin health policy.

Laxminarayans research dealswith the integration of

epidemiological models ofinfectious diseases and drugresistance into the economicanalysis of public health problems.He has served on a number ofadvisory committees at the WorldHealth Organization, the USCenters for Disease Control andPrevention, and the Institute ofMedicine. In 200304 he served onthe National Academy of Sciences/

Institute of Medicine Committee onthe Economics of AntimalarialDrugs. He subsequently helpedcreate the Affordable MedicinesFacility for Malaria, a novelfinancing mechanism forantimalarials. Laxminarayan earnedhis master of public health degreeand his doctorate in economicsfrom the University of Washingtonin Seattle.

Nirmal KumarGangulyispresident of theJawaharlal Instituteof Post GraduateMedical Educationand Research.

Ganguly is the DistinguishedBiotechnology Fellow and Advisor

at the Translational Health Scienceand Technology Institute in New

Delhi and president of theJawaharlal Institute of PostGraduate Medical Education andResearch. He is a fellow of theImperial College Faculty ofMedicine in London, the RoyalCollege of Pathologists in London,the International Academy ofCardiovascular Sciences in Canada,the Third World Academy ofSciences in Italy, the InternationalMedical Sciences Academy in NewDelhi, the National Academy of

Medical Sciences in New Delhi, theIndian National Science Academyin New Delhi, the National

Academy of Science in Allahabad,and the Indian Academy ofSciences in Bangalore.

In January 2008 Ganguly washonored with the prestigiousPadma Bhushan award by thepresident of India for his work inmedicine. Ganguly earned hisbachelor of medicine, bachelor ofsurgery degree from the Universityof Calcutta; his doctor of medicinedegree from the Post GraduateInstitute of Medical Education andResearch, Chandigarh; andhonorary doctor of science degreesfrom Bundelkhand University,Jhansi; Chhatrapati Shahu JiMaharaj University, Kanpur; andthe University of Calcutta, Kolkata.

J un e 2 01 1 3 0: 6 H e a lt h A f f a i r s 1103on August 16, 2011Health Affairsbycontent.healthaffairs.orgDownloaded from

Documents

Vacccine in India