Vaccines save lives and are one of the most cost-effective interventions in a country's public health system. Globally, the WHO estimates that immunization prevents 2 to 3 million deaths. But apart from preventing sickness and death associated with communicable and infectious diseases such as diarrhea, measles, pneumonia, and polio, in children and adults, a robust immunization program is also key to improving economic outcomes by reducing healthcare expenses that push millions into poverty each year. Thus, the world over, time and again, both from a child and maternal health point of view and equity and economic development perspective - vaccines have proven to be a worthy life-saving and well-being enhancing investment.
Early to recognize this virtuous cycle between vaccines, individual’s health, and national prosperity, India had set up a Universal Immunization Programme (UIP) in place in the 1970s. One of the world’s largest immunization programs, UIP was mandated to provide vaccines to infants, children, and pregnant women. Several milestones have been achieved over the last four decades.
New life-saving vaccines (Inactivated Polio, Rotavirus, Measles-Rubella, Pneumococcal Conjugate Tetanus, and adult diphtheria) have been added to the routine immunization schedule; Polio was eradicated in 2014; indigenous vaccine production capacity has been added; cold chains were established, and monitoring and evaluation systems have been implemented across the country. The Government of India has also rolled out an Electronic Vaccine Intelligence Network (eVIN) system that digitizes the entire vaccine stock management, logistics, and temperature tracking at all vaccine storage levels – from national to the sub-district. Further, just over the last five years, the government has also put a new impetus behind expanding and accelerating routine coverage to improve outcomes and strengthen vaccine program delivery. As a result of these immunization system strengthening efforts, coverage rates have substantially picked up over the years. Till about 2005-06, coverage rates hovered between the range of 35.4% to 44% but by 2015- 16, NFHS data showed coverage increased to 62% in 2015-16. After the launch of Mission Indradhanush (2015) and Intensified Mission Indradhanush (IMI) (2017) - which aimed at achieving immunization coverage to more than 90% by December 2018 and to full immunization after that - further gains have been made. In February of 2020, government estimates showed an average increase of 18.5% in full immunization coverage than that in the National Family Health Survey (NFHS-4) carried out in 2015-16.
Most recently, evidence from phase 1 of NFHS-5 shows that full immunization among children aged 12-23 months – a key Sustainable Development Goal (SDG) indicator - has recorded substantial improvement across Indian States/UTs/districts. There has also been significant improvement in reporting of immunization coverage from vaccination cards. Across states, 70% to 96% of children age 12-23 months are reported to be fully vaccinated based on information from vaccination cards only. Further, data has shown that the possession of vaccination cards by mothers of young children (below three years) has substantially increased after implementing 'Mission Indradhanush'.
In almost three-fourths of the districts, 70% or more children aged 12-23 are fully vaccinated against childhood diseases.
These improved outcomes have come on the back of focussed efforts to conduct several rounds of immunization activity over several working days, increasing immunization sessions with flexible timing, mobile sessions, and government departments' extensive mobilization. Nearly eleven states distributed additional funding for IMI rounds. Further, coverage rates are also up because IMI has focused on reaching previously underserved and missed populations in urban and rural areas.
Going forward, these gains must be built upon, and coverage percentages must be continuously tracked with the view to accelerate and widen reach. It is essential to do so for two reasons.
One, coverage percentages are critical measures to assess the success of programs – in that it tells how many individuals within the population have been covered. Two, coverage rates are essential from the strategic perspective because increased coverage means "herd" immunity. This 'indirect' benefit kicks in when a sufficient percentage of a population has become immune to an infection (either through vaccination or previous infection), significantly reducing the likelihood of disease for individuals who lack immunity.
Achieving herd – immunity, however, poses a considerable challenge. Immunization programs have to overcome widespread vaccine hesitancy (low trust in taking vaccines), which poses a significant global public health challenge and one that India, too, needs to tackle head-on. Indeed, owing to misinformation on vaccine potential side–effects, community-specific social norms, and general lack of awareness of the benefits of vaccines rooted in scientific evidence, individuals and communities have sometimes refused to take the vaccines in the past. Studies have shown that in-slum areas, nearly 83% people were vaccine-hesitant. Low socioeconomic status, reluctance to vaccinate, and lack of awareness were the significant reasons people highlighted. Another 2018 study by the Ministry of Health and Family Welfare study found that up to 11 % of parents were reluctant to vaccinate their children against infectious diseases. These trends must be arrested by amplifying communication drives focusing on driving behaviour change towards higher acceptance and building trust via healthcare workers who are well informed and can share the benefits of taking vaccines.
To date, India has made steady progress in driving immunization outcomes. The recent results from NFHS – 5 data have also validated that a series of efforts over the last decade have begun to yield substantial dividends. But more needs to be done, and gains need to be built upon.
New data and evidence can now be leveraged to inform policy further so that additional resources can be targeted towards addressing gaps, closing last mile challenges in reaching vulnerable and left out populations, and amplifying awareness building, communication and behaviour change efforts to tackle vaccine hesitancy aggressively.
Going forward, India's biggest priority is to reach "zero-dose" children, who are still not receiving even the first dose of DTP-containing vaccine. Working closely with WHO and international alliances such as GAVI to identify under-immunised children for essential childhood vaccination will be critical. We also need to identify and begin to apply a behavioural lens to the vaccination challenge. Indeed, while availability and affordability of vaccines secures the supply side, a focus on the demand side is needed to create a pull for vaccine and overcome vaccine hesitancy. The Corona pandemic is a challenge – but it also gives us an opportunity to convey that vaccines can and do save lives, and that we should leave no stone unturned to expand coverage and close gaps in immunization. Finally, immunization is key pillar of Universal Health Coverage.
(Dr Naveen Thacker is the Executive Director of International Paediatric Association, which examines India’s immunisation program.)
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