The Hindu (Thiruvananthapuram)
Make EPI an ‘Essential Programme on Immunisation’
The year 2024 marks a signicant milestone for immunisation programmes, both globally and in India. It commemorates 50 years since the launch of the Expanded Programme on Immunization (EPI) by the World Health Organization (WHO) in 1974. The EPI was introduced as the eradication of smallpox virus was on the horizon, and a need to leverage the then immunisation infrastructure and a trained workforce was recognised to expand the benet of available vaccines. Following the announcement, nearly every country across the world initiated its national immunisation programme. India launched the EPI in 1978, which was later renamed as the Universal Immunization Programme (UIP) in 1985. In India, this year is also two decades since the country conducted the last nationwide independent eld evaluation of the UIP, in collaboration with international experts. This is an opportune moment to assess the progress made and envision the future.
Globally, and in India, there has been signicant progress in terms of the impact of immunisation and vaccines. While in 1974, there were vaccines to prevent six diseases, ve decades later, there are vaccines against 13 diseases which are universally recommended; and vaccines against 17 additional diseases are recommended for a context-specic situation. There is research in progress to develop vaccines against nearly 125 pathogens — many would prevent diseases prevalent in low- and middle-income countries.
A success story
The children with three doses of DPT, a tracer indicator of coverage, has been rising over these years. In the early 1970s, around 5% of children in low- and middle-income countries had received three doses of DPT, which increased to 84% in 2022 at the global level. Smallpox has been eradicated, polio eliminated from all but two countries and many vaccine preventable diseases have nearly disappeared. In India, the coverage has increased every passing year and in 2019-21, 76% of children received the recommended vaccines.
Since the launch of EPI, studies have shown that vaccines have saved millions of lives and prevented billions of hospital visits and hospitalisations. Economic analyses have estimated that vaccines are highly cost-eective interventions, with every single dollar (or rupee) of expenditure on vaccination programmes ensuring a seven to 11-fold return.
In nearly all low- and middle-income countries, including India, the immunisation programme remains a success among all government initiatives, nearly always with far greater coverage than any other health programme. Moreover, in mixed health systems with both the public and private sector delivering services, immunisation often remains the only health intervention with greater utilisation from a medical doctor, has 15 years of work experience with the World Health Organization in its India O ice, Regional o ice for Africa, Brazzaville, and Headquarters in Geneva a medical doctor, is a former Joint Secretary, Reproductive and Child Health, Ministry of Health and Family Welfare, Government of India, and also a global health expert. He is the CEO of Wadhwani Initiative for Sustainable Healthcare (WISH), India the government sector. For instance, in India, the share of the private sector in overall health services is nearly two thirds; however, nearly 85% to 90% of all vaccines are delivered from government facilities. Experts often argue that the immunisation coverage is a tracer indicator of the possible highest coverage any government intervention can achieve in a given setting.
Yet, it is not without challenges. In early 2023, the UNICEF’s ‘The State of the World’s Children’ report revealed a concerning trend: for the rst time in more than a decade, the childhood immunisation coverage had declined in 2021. In 2022, globally, an estimated 14.3 million children were zero dose (did not receive any recommended vaccine) while another 6.2 million children were partially immunised. Over the years, the vaccination coverage in India has increased, both nationally and State-wise. However, there are persisting inequities in coverage by geography, socio-economic strata and other parameters, which demand urgent interventions.
From childhood focus to life course
It is interesting that when it comes to vaccination, people often (and wrongly) believe that the vaccines are only for children only. The truth is that in nearly 225 years since the availability of the rst vaccine against smallpox in 1798, vaccines have always been available for individuals of all age groups, including adults.
The rst anti rabies vaccine, cholera, and typhoid vaccines developed between 1880s to mid 1890s were primarily for adults. The rst vaccine ever developed in any part of the world against plague (in 1897) was from India and meant for individuals across all age groups. The BCG vaccine (against tuberculosis) was rst introduced in a nationwide campaign in 1951 and was also administered to the adult population. In uenza vaccines have always been administered to adults and children alike. This history clearly illustrates that vaccines have always been intended for individuals of all age groups.
However, considering that children are most vulnerable from vaccine-preventable diseases, they have rightly been prioritised for vaccination. A few decades ago, the supply of vaccines was limited, and the nancial resources and trained workforce that governments had were scarce. Thus, vaccines were aimed to be delivered to the population groups which would benet from them the most — children.
However, in the last ve decades, things have changed for the better. With increased vaccine coverage, children are better protected. However, diseases that are preventable with vaccines are increasingly becoming common in the adult population.
Therefore, it becomes imperative that government policies now focus on the vaccination of adults and the elderly, as well, as is happening in many countries. For better coverage of adult vaccines, we can learn from the past and ve decades of the EPI.
First, there are some initial policy and technical discussions regarding expanding immunisation coverage in additional populations. The recent announcement on HPV vaccines for teenage girls is a good start.
However, the Indian government needs to consider providing recommended vaccines for a wider section of adults and elderly population. Considering that vaccines are highly cost eective, once recommended by the National Technical Advisory Group on Immunization (NTAGI), vaccines for all age groups should be made available as free at the government facilities.
Second, the NTAGI in India, which provides recommendations on the use of vaccines should start providing recommendations on the use of vaccines in adults and the elderly. We need to remember that once a vaccine is recommended by the government body, the coverage is likely to be far greater than if the vaccines are not recommended by the government.
Third, the prevailing myths and misconceptions about vaccines must be proactively addressed to tackle vaccine hesitancy. The government must consider the help of professional communication agencies to dispel myths (and in a layperson’s language and with the use of social media). This also requires citizens to learn and educate themselves about these vaccines from reliable sources.
Fourth, various professional associations of doctors — community medicine experts, family physicians and paediatricians should work to increase awareness about vaccines among adults and the elderly. Physicians treating patients with any disease should use the opportunity to make them aware of vaccines.
Fifth, medical colleges and research institutions should generate evidence on the burden of diseases in the adult population in India.
There are studies which have noted that the introduction of new vaccines in national programmes contributes to increased coverage of all existing vaccines. Therefore, it is likely that expanding coverage of vaccines for adults and the elderly may result in improved coverage with childhood vaccines and reduced vaccine inequities. India’s EPI has made major progress and it is arguably a time for another independent national level review of the UIP in India, engaging key partners and international experts.
In late 2023, India launched a pilot initiative of adult BCG vaccination as part of eorts to ‘end TB’ from India. The COVID-19 vaccination of the adult population has made the public sensitized to the need for and the benets of adult vaccination. This is a right opportunity to start a new journey of adult vaccination in India. In the 50 years of the EPI, it is time for another expansion of the programme with focus on zero dose children, addressing inequities in vaccine coverage and oering vaccines to adults and the elderly. It is time to make EPI an ‘Essential Program on Immunization’.
In the 50 years of the Expanded Programme on Immunization, it is time for another expansion