Public health programmes focus interventions at the level of population. Such programmes are organized for the benefit of whole or some specific section of population. Such programmes also carry a risk of harm which could be due to some adverse reaction of the intervention, failure to provide the desired benefit or some flaw in the policy or intervention.
Polio eradication is WHO's global programme, for benefit of world's population. IAP had voluntarily joined this national project. Inspite of extending the deadline for polio eradication many times polio eradication in India and some other countries has not occurred. Many children are known to have developed polio even after taking many doses of OPV, and many children have developed polio because of OPV, known as VAPP.
The agencies responsible for such programmes have an obligation to determine in advance what the relative benefits and harms are envisaged by the proposed intervention. Monitoring should be an ongoing process during the implementation of the programme to evaluate if the programme is providing high benefits and low harms. In case the programme is providing less benefits or more harm, there should be an honest re-evaluation of the programme; and if necessary to take feasible remedial steps or even suspend or end the programme.
Following five issues needed urgent attention:
- Vaccine failure. If a child develops paralytic polio after taking four or more doses of OPV, it means vaccine has failed to provide protection. According to official data during 1998 and 2003, 33 to 60% of polio cases were fully vaccinated.
- High incidence of VAPP. Projected number of VAPP cases for India was 60-75 per year. According to official figures number of VAPP cases varies from 124 to 206 per year.
- Non-availability of IPV. OPV is contraindicated for the children who are immunocompromised due to disease or drugs or have immunocompromised close contacts. IPV is not available in India. This amounts to an act of omission on the part of government of India which puts some people to higher risk of developing VAPP.
- Under reporting of polio incidence. I had raised this issue at the eighth meeting of the National Certification committee for Polio Eradication which was held in New Delhi from 9 th to 11 th May, 2003 that many polio cases are being wrongly discarded as non-polio cases. It was published in Vaccine (Vaccine 2004; 22:3829-3830.)
- Role of non-participants. Wild polioviruses can replicate and multiply in the gut of non-immune children and when shed in feces can spread infection in the community. Vaccinated children who fail to develop antibodies also participate in wild poliovirus circulation in similar manner. But only non-participants in pulse polio immunization are being blamed for failure of the polio eradication. If given the facts that many children have developed polio after taking many doses of OPV, and many children have developed polio because of OPV, and IPV is not being made available even for immunocompromised children, no caring society will approve such a programme. IAP has fully supported this programme. Indian Academy of Pediatrics should have taken the initiatives to ensure that because of polio eradication programme no available harm occurs to any child.
IAP did no studies to find the reasons for vaccine failure, suggested no steps to reduce the incidence of VAPP, rather instructed the members not to tell about the phenomenon of VAPP to parents and made no attempts to make IPV available in India. On the other hand blame for failure of the programme is being put on those few children who had not participated in pulse polio immunization.
