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Buy a big car because the down payment is minimum and the neighbor has a big car – The paradigm of new vaccination policy

Posted by AlexanderMathew on 05 Apr 2010 at 16:20 GMT

This article provides some evidence about how countries arrive at decisions regarding introduction of new vaccines in their national programs, specifically Hib vaccine. And that raises pertinent questions about whether these decisions are made in the proper context of each country. Even though immunizations have been a great success, and have prevented millions of deaths, there are questions being asked about the relevance of some of the newer vaccines. These questions are not just being asked in poorer countries, but in the very rich countries too. Even among the rich countries, before a new vaccine is introduced, apart from the safety and effectiveness of the vaccine, the next relevant questions like disease burden and cost-effectiveness are assessed and calculated before a decision to introduce a new vaccine is made. Doubts about the relevance and need for the newer vaccines have been expressed by not just anti-vaccine activists, but by responsible medical professionals. There is a justifiable doubt among many professionals whether the newer vaccines are being introduced not just based on the medical needs and financial capabilities of poor countries.

In 1998, the WHO advised all countries to consider their Hib disease burden before introducing the Hib Vaccine. But in 2006 the WHO changed its advice to all countries to include Hib vaccine in the routine immunization program regardless of the national burden. This is a surprising change in the policy of the WHO and does not seem logical by any public-health standards. Not surprisingly, but perhaps ironically, this study shows that the change in the WHO recommendations does not seem to have made any difference in the policy of countries in introducing Hib vaccine in their national program.

This study shows that the help from the GAVI initiative and the policy of neighboring countries have a big impact on the decision of countries to introduce Hib vaccine, while the cost of the vaccine has a smaller impact. So it is interesting to see that the national burden of the disease and the cost-benefit analysis of the use of the vaccine are not much relevant in these national policy decisions. And that appears to be a lop-sided way to make such decisions. As Dr.Puliyel has written in his comments, the actual burden of Hib disease in India is much smaller than the one highlighted to introduce the Hib vaccine to India. And wider studies about the incidence of Hib disease in India which showed a lower incidence than predicted were ignored before recommendations were made to introduce Hib vaccine to India. This is similar to the history of the introduction of Hepatitis B Vaccine (HBV) in India. Before the introduction of HBV in India, there were some small studies and predictions showing the incidence to be very high which justified the universal introduction of HBV vaccine to India. But later detailed studies have shown the incidence of Hepatitis B in India was much lower than the earlier predictions. To ignore the burden of a disease in a country before introducing a new vaccine for that disease is a waste of money as all countries, especially the poorer ones have only very limited resources. To spend money on some problem which does not exist is illogical. Optimum use of limited resources should be the thrust of any public-health related expenditure. Such thoughts do not seem to play any part in decisions regarding introduction of newer vaccines to poor countries...

The initial help by the GAVI initiative gives a false sense of security as the introductory price of the vaccine is small and it encourages the use of such vaccines for universal use in countries which could not otherwise have done it on their own. But after the initial help from the GAVI initiative, and once the funding from them dries up, many poor countries will find it difficult to continue the program. Or it may be continued at enormous cost, at the risk of not doing other more cost-effective health measures. The introduction of newer and costly vaccines in poor countries without studying the disease burden and cost-benefit analysis is akin to a poor fellow buying a new big car because the down payment is minimum and his neighbor has a big car. The question whether it is needed is never asked, let alone answered.

Dr.Alexander Mathew, M.B.B.S., F.A.A.P
Kochi, Kerala. India

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No competing interests declared.