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As it is found in the study done by Lahariya et al, the coverage of Hepatitis B vaccination is poor in India. Additionally some basic issues related to HB vaccine need to be clarified before uptake improves.
Doctors and the public perceive that hepatitis B is not a major threat in India. Prevalence of Hepatitis B in Indian population varies from 2-4% in non-tribal and 15.9% in tribal populations (1). Meta-analysis of small studies in India estimates carrier rate at 1.7%. According to ORGI 1991, jaundice was associated with 1% of all cause deaths and deaths due to chronic liver cancer was 0.76% including death from both Hepatitis B & C. Therefore, Hepatitis B & C is a relatively low priority disease for mass vaccination.
The carrier rate in a country is not important in itself, because with some strains, there is a higher chance of becoming an asymptomatic carrier and the infected come to no harm. The vast majority of chronic carriers are completely asymptomatic all their lives (2). A detailed review on the different strains in different countries was done by Norder et al (3). Strains C and D have a greater chance than strain A and B for vertical transmission, increased duration of HBe positive status and increased progression to liver fibrosis and HCC. Modelling without reference to the local strain is an exercise in futility. The cost benefit assessment of Hepatitis B (4) uses the Hepatitis B disease progression rates from Taiwan and comes up with predictions that are not valid for India.
The draft National Policy on immunisation recommended a pragmatic HBV vaccination schedule starting at birth for institutional deliveries and at 6 weeks for the rest. Janani Suraksha Yojana under NRHM has led to a huge increase in institutional deliveries within just four years, the number of beneficiaries rising from 7.39 lakhs per year in 2005-06 to about 1 crore in 2009-10 (5). Yet the majority of births do not take place in institutions and hospitals where Hepatitis B vaccine is stored and given to newborns. Most children receive the vaccine starting only at 6 weeks.
In fact an extensive search of world literature has not shown even one study where immunization starting at 6 weeks in the community has brought down carrier rate of Hepatitis B (6). Also, one third of adult asymptomatic carriers are found to be due to vertical transmission (7). It is time to consider birth dose of Hepatitis B vaccination in UIP with more seriousness. Otherwise it appears we are giving the vaccine merely to comply with a WHO dictate to introduce the vaccine, not to reduce the problem of hepatitis B carrier state.
The question of selective immunization is not impractical (8). Universal testing of HBsAg status of pregnant primiparous mother any time during the 9 months of their pregnancy can be carried out and it can be ensured that babies of the 2% HBsAg carrier mothers get vaccinated at birth. Subsequent pregnancy needs no testing. Selective vaccination of high risk groups (medical, paramedical staff, blood donors, sex workers, soldiers) and selective vaccination of children born to Hepatitis B carrier mothers would be more cost effective. The first dose must be given at birth, as evidence shows that it is most effective in stopping Hepatitis B transmission from mother to child (2).
Thus we should first of all understand whether universal hepatitis B vaccination is really needed in India based on actual facts as mentioned above. If it is needed this data and science needs to be presented. Just providing managerial tips may not be enough to improve vaccine coverage.
Bibliography:
1. Batham A, Narula D, Toteja T, Sreenivas V, Puliyel JM. Sytematic review and meta-analysis of prevalence of hepatitis B in India. Indian Pediatr. 2007 Sep;44(9):663–74.
2. ICMR - Minutes Expert Group Hepatitis B and Hib vaccines. http://www.icmr.nic.in/minutes/Minutes%20Expert%20Group%20%20Hepatitis%2...
3. Norder H, Couroucé A-M, Coursaget P, Echevarria JM, Lee S-D, Mushahwar IK, et al. Genetic diversity of hepatitis B virus strains derived worldwide: genotypes, subgenotypes, and HBsAg subtypes. Intervirology. 2004;47(6):289–309.
4. Aggarwal R, Ghoshal UC, Naik SR. Assessment of cost-effectiveness of universal hepatitis B immunization in a low-income country with intermediate endemicity using a Markov model. J. Hepatol. 2003 Feb;38(2):215–22.
5. 9457038092AnnualReporthealth.pdf [Internet]. [cited 2013 Jun 9]. Available from: http://mohfw.nic.in/WriteReadData/l892s/9457038092AnnualReporthealth.pdf
6. Puliyel JM, Rastogi P, Mathew JL. Hepatitis B in India: Systematic review & report of the “IMA sub-committee on immunization.”Indian J. Med. Res. 2008 May;127(5):494–7
7. Nayak NC, Panda SK, Zuckerman AJ, Bhan MK, Guha DK. Dynamics and impact of perinatal transmission of hepatitis B virus in North India. J. Med. Virol. 1987 Feb;21(2):137–45.
8. Sahni M, Jindal K, Abraham N, Aruldas K, Puliyel JM. Hepatitis B immunization: cost calculation in a community-based study in India. Indian J Gastroenterol. 2004 Feb;23(1):16–8
Competing interests:
No competing interests
19 June 2013
ARCHANA VERMA
Pediatrician
Max Healthcare, Saket, New Delhi
26/4, 2nd floor, Old Rajinder Nagar, New Delhi, India. PIN: 110060
Re: Poor uptake of hepatitis B vaccine in India has several causes, study finds
As it is found in the study done by Lahariya et al, the coverage of Hepatitis B vaccination is poor in India. Additionally some basic issues related to HB vaccine need to be clarified before uptake improves.
Doctors and the public perceive that hepatitis B is not a major threat in India. Prevalence of Hepatitis B in Indian population varies from 2-4% in non-tribal and 15.9% in tribal populations (1). Meta-analysis of small studies in India estimates carrier rate at 1.7%. According to ORGI 1991, jaundice was associated with 1% of all cause deaths and deaths due to chronic liver cancer was 0.76% including death from both Hepatitis B & C. Therefore, Hepatitis B & C is a relatively low priority disease for mass vaccination.
The carrier rate in a country is not important in itself, because with some strains, there is a higher chance of becoming an asymptomatic carrier and the infected come to no harm. The vast majority of chronic carriers are completely asymptomatic all their lives (2). A detailed review on the different strains in different countries was done by Norder et al (3). Strains C and D have a greater chance than strain A and B for vertical transmission, increased duration of HBe positive status and increased progression to liver fibrosis and HCC. Modelling without reference to the local strain is an exercise in futility. The cost benefit assessment of Hepatitis B (4) uses the Hepatitis B disease progression rates from Taiwan and comes up with predictions that are not valid for India.
The draft National Policy on immunisation recommended a pragmatic HBV vaccination schedule starting at birth for institutional deliveries and at 6 weeks for the rest. Janani Suraksha Yojana under NRHM has led to a huge increase in institutional deliveries within just four years, the number of beneficiaries rising from 7.39 lakhs per year in 2005-06 to about 1 crore in 2009-10 (5). Yet the majority of births do not take place in institutions and hospitals where Hepatitis B vaccine is stored and given to newborns. Most children receive the vaccine starting only at 6 weeks.
In fact an extensive search of world literature has not shown even one study where immunization starting at 6 weeks in the community has brought down carrier rate of Hepatitis B (6). Also, one third of adult asymptomatic carriers are found to be due to vertical transmission (7). It is time to consider birth dose of Hepatitis B vaccination in UIP with more seriousness. Otherwise it appears we are giving the vaccine merely to comply with a WHO dictate to introduce the vaccine, not to reduce the problem of hepatitis B carrier state.
The question of selective immunization is not impractical (8). Universal testing of HBsAg status of pregnant primiparous mother any time during the 9 months of their pregnancy can be carried out and it can be ensured that babies of the 2% HBsAg carrier mothers get vaccinated at birth. Subsequent pregnancy needs no testing. Selective vaccination of high risk groups (medical, paramedical staff, blood donors, sex workers, soldiers) and selective vaccination of children born to Hepatitis B carrier mothers would be more cost effective. The first dose must be given at birth, as evidence shows that it is most effective in stopping Hepatitis B transmission from mother to child (2).
Thus we should first of all understand whether universal hepatitis B vaccination is really needed in India based on actual facts as mentioned above. If it is needed this data and science needs to be presented. Just providing managerial tips may not be enough to improve vaccine coverage.
Bibliography:
1. Batham A, Narula D, Toteja T, Sreenivas V, Puliyel JM. Sytematic review and meta-analysis of prevalence of hepatitis B in India. Indian Pediatr. 2007 Sep;44(9):663–74.
2. ICMR - Minutes Expert Group Hepatitis B and Hib vaccines. http://www.icmr.nic.in/minutes/Minutes%20Expert%20Group%20%20Hepatitis%2...
3. Norder H, Couroucé A-M, Coursaget P, Echevarria JM, Lee S-D, Mushahwar IK, et al. Genetic diversity of hepatitis B virus strains derived worldwide: genotypes, subgenotypes, and HBsAg subtypes. Intervirology. 2004;47(6):289–309.
4. Aggarwal R, Ghoshal UC, Naik SR. Assessment of cost-effectiveness of universal hepatitis B immunization in a low-income country with intermediate endemicity using a Markov model. J. Hepatol. 2003 Feb;38(2):215–22.
5. 9457038092AnnualReporthealth.pdf [Internet]. [cited 2013 Jun 9]. Available from: http://mohfw.nic.in/WriteReadData/l892s/9457038092AnnualReporthealth.pdf
6. Puliyel JM, Rastogi P, Mathew JL. Hepatitis B in India: Systematic review & report of the “IMA sub-committee on immunization.”Indian J. Med. Res. 2008 May;127(5):494–7
7. Nayak NC, Panda SK, Zuckerman AJ, Bhan MK, Guha DK. Dynamics and impact of perinatal transmission of hepatitis B virus in North India. J. Med. Virol. 1987 Feb;21(2):137–45.
8. Sahni M, Jindal K, Abraham N, Aruldas K, Puliyel JM. Hepatitis B immunization: cost calculation in a community-based study in India. Indian J Gastroenterol. 2004 Feb;23(1):16–8
Competing interests: No competing interests