The death of an eight-year-old girl, Anju, this August after denial of anti-rabies vaccine at Agra’s Sarojini Naidu Medical College (SNMC) is followed by the admission by Health Ministry that fatality rate for rabies in India is 100 per cent. Although the circumstance of Anju’s death is particularly Kafkaesque and macabre — the officer at the Community Health Centre, where she was first taken, refused to allow administration of anti-rabies vaccine because the child had no Aadhaar card — in reality, it only signifies the routine functioning of India’s health bureaucracy. As per the Health Ministry’s own admission, all the 110 reported rabies patients in 2018 died. Buried in the National Health Profile, 2019, casualties such as Anju’s are a statistic on 100 per cent fatality rate for rabies in India.

India needs 3.5 crore doses of anti-rabies vaccine annually and is facing an acute shortage forcing the National Pharmaceutical Pricing Authority to instruct all five manufacturers of anti-rabies vaccines — IIL, Zydus, Cadila, Bharat Biotech, SII and Sun Pharmaceuticals — to address the issue by facilitating availability. What the Health Ministry has not done is to address the core issue of over-dependence on private manufacturers for essential vaccines and the absence of a clear-cut national vaccine policy that renders even the Universal Immunisation Programme (UIP) susceptible to the machinations of the market players.

Disastrous decision

The impact of a disastrous decision in 2008 to shut down the three largest public sector units — Central Research Institute (CRI), Kasauli, Pasteur Institute of India (PII) Coonoor, and BCG Vaccine Laboratory (BCGVL) Guindy — dramatically altered the vaccine availability and pricing in India. These facilities were supplying not just the entire Universal Immunisation Programme (UIP) demand for the anti-tuberculosis BCG vaccine, Tetanus Toxoid and DPT vaccines but also producing yellow fever vaccine, anti-snake venom and anti-rabies vaccine. The promised highly-modernised vaccine park in Chennai to replace these units has still not started delivering at the economies of scale that it was supposed to.

While this led to a steady price increase in the cost of basic vaccines and severely limited access over the years, the government slowly resumed production in some units. The resumption of production in PSU units, even though it has been half-heartedly and without adequate financial support and augmentation, still witnessed an increase in supply and by 2013-14, the BCGVL was supplying over a third of the country’s demand for BCG vaccine while also bringing the price down from ₹3 to ₹2.80.

Government needs to step up

This begs the obvious question about why the government has not spent more on augmentation and modernisation as well as expansion of vaccine PSUs whereas countries such as Brazil meet the entire supply of vaccines for its immunisation programme in publicly-funded vaccine manufacturing units. China similarly has several government-run production institutes.

Indeed, inclusion of a vaccine in the UIP in India is equivalent to accessing the market of over 60 rich countries simultaneously which is the reason for hectic lobbying and promotion of irrational vaccination even against diseases against which Indians develop natural immunity.

Against an initiative of the Delhi Government to promote vaccination of hepatitis A virus (HAV), research among school children by Dr SK Acharya, Yogesh Batra et al of the All India Institute of Medical Sciences (AIIMS) published in the Bulletin of WHO 2002 showed that by the time they are 10-12 years old, children in government schools had roughly 98 per cent anti-HAV antibodies and the incidence of HAV infection had shown no increasing trend to require inclusion of a publicly-funded vaccination programme. Irrational advertising campaigns such as anti-pneumococcal vaccine promotion, etc., need to be perceived in this context.

It is clear that over-dependence on private players is leaving the most vulnerable sections susceptible to easily treatable infections due to scarcity and lack of access on one hand and promotion and introduction of irrational and controversial vaccines on the other.

The government needs to step in and follow the recommendations of different parliamentary panel reports as well as the suggestion made by a committee led by former health secretary Javid Chowdhury, which said: “The committee recommends that the revocation of the suspension of the licence of the units (vaccine units at Kasauli et al ) be made subject to the condition that a new line for production of vaccine/sera will be set up at the three locations within a period of three years…

“The committee recommends that the Ministry considers making them (vaccine units) autonomous by registering them as companies… The committee recommends that the government considers constituting a National Vaccine Security Advisory Board composed of stakeholders such as public health specialists, paediatricians, public health administrators, vaccine techonologists, etc., to advice the government on important issues related to national vaccine security…”

In no civilised society or state would a child be left to die of a totally treatable disease because she did not have an identification card. It is time India addresses real and immediate health concerns of its citizens.

Published on November 15, 2019