Letters to the Editor

Indian Pediatrics 2002; 39:1067-1068

Is Hib Vaccination Required at All in India?

Researchers from Christian Medical College, Vellore and Aventis Pasteur International, France have reported a study(1) that found that the Aventis Pasteur vaccine ActHibTM combined in the same syringe, with DPT manufactured by BE Hyderabad works as well as the quadruple vaccine TetrAct HibTM manufactured by Aventis Pasteur.

The authors mention in their discussion possibly as the raison d’etre of their study, that the FDA has "instructed medical practitioners not to co-administer H. influenzae B (Hib) vaccine in the same syringe as DTwP vaccine containing acellular pertussis". There is an obvious oxymoron here - DTwP refers to whole cell pertussis vaccine and one cannot have acellular-DTwP. More importantly, the reference they quote(2) does not in any way relate to what the authors call extemporaneous "non official" combination vaccinations. What was actually reported in the article, was that the FDA found the quadruple vaccine of Marieux Connaught - TriHIBit did not protect against Hib.

The quadruple vaccine of Aventis, TetraAct HibTM costs Rs 923 per child (three doses) and the DPT of BE costs Rs 6.45 for three doses. The use of locally made DPT mixed with Act HibTM makes for considerable cost savings besides avoiding the discomfort of three extra injections. It is our contention that even bigger saving can be made by not using Hib at all.

The authors quote a paper by Jacob John et al(3) to suggest that Hib is the commonest cause of bacterial meningitis in infants and children in India. This paper actually says that microbiologists in India were obtaining ‘less than the expected frequency of H.influenzae B isolates’ and suggests that this may be due to the use of unsuitable media for culture. The paper states that it pertains to pre IBIS decade from 1966-1995.

The Invasive Bacterial Infection Surveillance (IBIS) used the most sensitive bacteriological techniques. They conducted their surveillance in six large teaching hospitals with combined bed strength of 8187 beds, in the metropolitan cities of Delhi, Lucknow, Madras, Nagpur, Trivandrum and Vellore(4). After 48 months of active surveillance in all these hospitals, there were only 58 isolates of Hib among 3441 cases of meningitis, pneumonia and sepsis. It is apparent that Hib is not as big a problem in India as it is in the west. We wonder why this IBIS data, in which Christian Medical College Vellore also participated and which is available since 1998, was not quoted in the paper.

An article published in Vaccine has shown that children in India seem to develop natural immunity to Hib during infancy(5). Studies from Turkey have also demonstrated that children there develop natural immunity to Hib in the first year of life even without the use of vaccines(6). The need for this vaccine in India must therefore be established and this has not been done convincingly in the references quoted by the authors.

In this context a report(7) by the charity "Save the Children" on vaccine promotion in developing countries, is of relevance. In this report published in the British Medical Journal, the charity found that newer vaccines were being promoted in poor countries - "vaccines that they could not afford and perhaps do not need". The British Medical Journal has also published a letter(8), on how this pertains specifically to India.

Indian Pediatrics does well to make authors declare their commercial interests in research published. Caveat emptor – Let the buyer beware! In the impugned article, to which the letter is a response, the influence of the vaccine manufacturer is obvious.

References

1. Cherian T, Thomas N, Raghpaty P, Durot I, Dutta A. Safety and immunogenicity of Haemophilus influenzae Type B vaccine given in combination with DTwP at 6,10,14 weeks of age. Indian Pediatr 2002; 39: 427-436.

2. Adult A. Combination DPT/Hib vaccine fails FDA test. Lancet 1997; 349: 1752.

3. John TJ, Cherian T, Raghpathy P. Haemophilus influenzae disease in children in India: a hospital perspective. Pediatr Infect Dis J 1998; 17: 5169-5171.

4. Steinhoff MC. IBIS Invasive Haemophilus influenzae disease in India: a preliminary report of prospective multihospital surveillance. Pediatr Inf Dis J 1998; 17: 5172-5175.

5. Puliyel JM, Aggarwal KS, Abass FA. Natural immunity fo Haemophilus influenzae b in infancy in Indian children. Vaccine 2001; 19: 4592-4594.

6. Tastan Y, Alikasifoglu M, Ilter O, Erginoz E, Arvas A, Yuksel D, et al. Natural immunity to Haemophilus influenzae Type b among healthy children in Istanbul, Turkey. Indian Pediatr 2000; 37: 414-417.

7. Fleck F. Children’s Charity criticizes global immunization initiative. Br Med J 2000; 324: 129.

8. Ojha RK, Abraham J, Khosla M, Puliyel JM. Vaccine promotion is circumventing market forces. Br Med J 2002; 324: 975.