Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years--India, 2014 and updates on immunization

A review of safety and immunogenicity of a novel measles, mumps, rubella (MMR) vaccine

Measles, mumps, and rubella (MMR) are highly infectious viral diseases affecting young children and have high secondary attack rates. Present MMR vaccines show consistent seroconversion rates for anti-measles and anti-rubella antibodies with variable responses for anti-mumps antibodies. Most common strains for MMR vaccines, currently available in India, are the Edmonston-Zagreb measles strain, Leningrad Zagreb (L-Z) mumps strain, and the RA 27/3 rubella strain. L-Z strain of mumps virus has been found to be associated with aseptic meningitis by different studies from different parts of the world including India. Recently, a novel freeze-dried MMR vaccine developed by Zydus Lifesciences (Zyvac MMR) contains Edmonston Zagreb measles strain, Hoshino mumps strain, and RA 27/3 rubella strain. The Hoshino strain is WHO approved and was found to induce interferon gamma production. This review article aims to provide a comprehensive appraisal of the data available on the safety and immunogenicity of the novel MMR vaccine.

A Cross-Sectional Observational Study Analyzing the Knowledge, Attitude, and Practice of Young Female Nursing Officers and Female Doctors About the Human Papillomavirus Vaccine

Background Cervical cancer (CC) is the second most common cancer among Indian women and is caused by a human papillomavirus (HPV) infection. To achieve its global commitment to the elimination of CC, India is planning to include the HPV vaccine in its national immunization program. The success of the prevention of CC mostly depends on the level of awareness and knowledge among healthcare providers about different aspects of the disease and the vaccine. We aimed to evaluate the knowledge, attitudes, and practices (KAP) regarding CC, HPV, and the HPV vaccine in first-contact young female doctors and nursing officers. Methodology This cross-sectional study was conducted at the All India Institute of Medical Sciences, Kalyani, between February and June 2024 among young female health workers aged between 20 and 35 years. To evaluate KAP we used a validated, self-administered questionnaire. Results There were a total of 204 participants, whose median age was 26 (interquartile range = 25 to 29) years; among them, 114 (55.9%) were nursing officers and 90 (44.1%) were junior doctors. Good knowledge was found among 85.5% of doctors and 70.2% of nursing officers (p < 0.01). A positive attitude was found in 81.1% of doctors and 67.5% of nursing officers (p < 0.01). The overall good practice score was low (31.3%). A higher level of education was associated with good knowledge (β = -1.16, 95% confidence interval (CI) = -1.76, -0.55, p < 0.01) and positive attitude (β = -0.53, 95% CI = -0.9, 0.16, p = 0.005) toward HPV, CC, and the HPV vaccine. Conclusions Our cohort showed good knowledge and attitude toward CC, HPV, and the HPV vaccine, but poor HPV vaccine uptake and practice. Therefore, health education programs focused on increasing awareness and uplifting confidence are needed to accept and recommend the HPV vaccine in developing countries like India.

Incidence of lymphadenitis following Bacillus Calmette-Guérin (BCG) vaccination in north Indian children

INTRODUCTION

Bacillus Calmette-Guerin (BCG) vaccination is given as a part of the national immunization schedule in India and its most common complication is BCG lymphadenitis. The reported incidence of BCG lymphadenitis ranges from 0.1 to 9.9% in various studies. In our country, though most babies get BCG vaccination during the neonatal period, the incidence of BCG lymphadenitis is not studied well.

AIMS

To study the incidence of lymphadenitis following BCG vaccination at tertiary care hospital in North India.

METHODS

It was a prospective longitudinal observational study. All newborns weighing ≥1.5 kg at birth without any significant illness who received BCG vaccination at our institute were enrolled and followed up for 16 weeks after vaccination. Babies were examined at 6, 10 and 14 weeks for the development of lymphadenopathy. Meta-analysis of studies evaluating incidence of BCG adenitis in children was also performed.

RESULTS

Out of 817 babies vaccinated during the enrolment period, 605 babies could be followed up till 16.2 ± 0.9 weeks post BCG vaccination. One case of BCG lymphadenitis was detected at 14 weeks. Thus, the observed incidence of BCG lymphadenitis was 0.16% (95% CI of 0.004%-0.92%). Meta-analysis of 21 studies showed mean incidence estimate of 0.336% (95% CI: 0.315%-0.358%) using fixed effect model whereas random effect model showed mean incidence of 4.45% (95% CI: 3.02%-6.15%).

CONCLUSION

The lower incidence of lymphadenitis in our study can probably be attributed to a less immunogenic vaccine (Danish 1331), proper technique, experience of the vaccinator and good storage facilities available at our institute.

Public health facility quality and child immunization outcomes in rural India: A decomposition analysis

Universal coverage of routine childhood vaccines remains a challenge in many low- and middle-income countries (LMICs). In India, vaccination campaigns have increased full immunization coverage among 12-23 month old children from an estimated 62% in 2015-2016 to 76% in 2019-2020. Long-term improvements in coverage will likely require systemic changes to both the supply and demand sides of immunization programs. However, the effect of health system inputs on child vaccination outcomes remains poorly quantified in India. We examined the association between the quality of public health facilities and child vaccination outcomes in rural India using data from the nationally representative Integrated Child Health and Immunization Survey (2015-2016) which covered 1,346 public primary health sub-centers and 44,571 households. We constructed two indices of sub-center quality using multiple correspondence analysis: one related to the general health infrastructure quality and the other measuring vaccine service delivery. Using probit regression, we analyzed the relationship between vaccination outcomes in children under 2 years of age and sub-center quality, controlling for household socioeconomic characteristics. Additionally, we conducted Fairlie decomposition analysis by wealth group - bottom wealth quintile relative to the top four wealth quintiles- to examine factors contributing to gaps in immunization between rich and poor households. Infrastructure quality index was positively associated with completion of seven vaccination outcomes: full immunization, DPT-1 (first dose of diphtheria, pertussis, and tetanus), DPT-2, DPT-3, Bacillus Calmette-Guérin (BCG), hepatitis B (birth dose), and on-time vaccination (OTV). Vaccine service delivery index was positively associated with completion of measles vaccination. The distribution of infrastructure quality contributed to increased gaps in full immunization and OTV between rich and poor households, while greater proximity to vaccination site for poorer households reduced these gaps. Improved quality of health facilities, particularly facilities used by low-income households, may improve vaccination outcomes.

The Outbreaks of Acute Encephalitis Syndrome in Uttar Pradesh, India (1978–2020) and Its Effective Management: A Remarkable Public Health Success Story

Introduction

Acute encephalitis syndrome (AES) is a major public health enigma in India and the world. Uttar Pradesh (UP) is witnessing recurrent and extensive seasonal AES outbreaks since 1978. Government of India and UP state government have devised various mitigation measures to reduce AES burden and AES associated mortality, morbidity and disability in Uttar Pradesh. The aim of this study was to describe the public health measures taken in order to control seasonal outbreaks of AES in UP between 1978 and 2020.

Methods

We used literature review as a method of analysis, including the Indian government policy documents. This review utilized search engines such as PubMed, Google Scholar, Research Gate, Cochrane, Medline to retrieve articles and information using strategic keywords related to Acute Encephalitis Syndrome. Data was also collected from progress reports of government schemes and websites of Indian Council of Medical Research (ICMR), National Vector Borne Disease Control Programme (NVBDCP) and Integrated Disease Surveillance Programmes (IDSP).

Results

The incidence of AES cases in UP have declined from 18.2 per million population during 2005-2009 to 15 per million population during 2015-2019 [CI 12.6–20.6, P-value < 0.001] and case fatality rate (CFR) reduced from 33% during 1980-1984 to 12.6% during 2015-2019 [CI 17.4–30.98, P-value < 0.001]. AES incidence was 9 (2019) and 7 (2020) cases per million populations respectively and CFR was 5.8% (2019) and 5% (2020). This decline was likely due to active surveillance programs identifying aetiological agents and risk factors of AES cases. The identified etiologies of AES include Japanese encephalitis virus (5–20%), Enterovirus (0.1–33%), Orientia tsutsugamushi (45–60%) and other viral (0.2–4.2%), bacterial (0–5%) and Rickettsial (0.5–2%) causes. The aggressive immunization programs against Japanese encephalitis with vaccination coverage of 72.3% in UP helped in declining of JE cases in the region. The presumptive treatment of febrile cases with empirical Doxycycline and Azithromycin (EDA) caused decline in Scrub Typhus-AES cases. Decrease in incidence of vector borne diseases (Malaria, Dengue, Japanese Encephalitis and Kala Azar) i.e., 39.6/100,000 population in 2010 to 18/100,000 population in 2017 is highlighting the impact of vector control interventions. Strengthening healthcare infrastructure in BRD medical college and establishment of Encephalitis Treatment Centre (ETC) at peripheral health centres and emergency ambulance services (Dial 108) reduced the referral time and helped in early treatment and management of AES cases. The AES admissions increased at ETC centres to 60% and overall case fatality rate of AES declined to 3%. Under clean India mission and Jal Jeevan mission, proportion of population with clean drinking water increased from 74.3% in 1992 to 98.7% in 2020. The proportion of household having toilet facilities increased from 22.9% in 1992 to 67.4% in 2020. Provisions for better nutritional status under state and national nutrition mission helped in reducing the burden of stunting (52%) and wasting (53.4%) among under five children in 1992 to 38.8% (stunting) and 36.8% (wasting) in year 2018. These factors have all likely contributed to steady AES decline observed in UP.

Conclusion

There is a recent steady decline in AES incidence and CFR since implementation of intensive AES surveillance system and JE immunization campaigns which is highlighting the success of interventions made by central and state government to control seasonal AES outbreaks in UP. Currently, AES incidence is 9 cases per million population (in year 2019) and mortality is 5.8%.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2020-21) and Update on Immunization for Children Aged 0 Through 18 Years

Justification

In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations.

Process

Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting in March, 2020 followed by online meetings (September-October, 2020), to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached.

Objectives

To review and revise the IAP recommendations for 2020–21 and issue recommendations on existing and new vaccines.

Recommendations

The major changes include recommendation of a booster dose of injectable polio vaccine (IPV) at 4–6 years for children who have received the initial IPV doses as per the ACVIP/IAP schedule, re-emphasis on the importance of IPV in the primary immunization schedule, preferred timing of second dose of varicella vaccine at 3–6 months after the first dose, and uniform dosing recommendation of 0.5 mL (15 µg HA) for inactivated influenza vaccines.

Evolutionary analysis of rotavirus G1P[8] strains from Chennai, South India

Rotaviruses by virtue of its segmented genome generate numerous genotypes. G1P[8] is the most common genotype reported globally. We intend to identify the evolutionary differences among G1P[8] strains from the study with vaccine strains. Stool samples collected from children <5 years were screened for rotavirus antigen by enzyme linked immunosorbent assay. The samples that tested positive for rotavirus were subjected to VP7 and VP4 semi-nested RT-PCR. Sanger sequencing was performed in randomly chosen VP7 and VP4 rotavirus strains. Phylogenetic analysis showed less homology between study strains and vaccine strains and they were placed in different lineages. The VP7 and VP4 proteins of rotavirus were analyzed by two different platforms to identify the amino acid substitutions in the epitope regions. Nine amino acid substitutions with respect to Rotarix®, RotaTeq® and Rotasiil®-V66A, A/T68S, Q72R, N94S, D100E, T113I, S123N, M217T, and I281T were observed in VP7. There were five amino acid substitutions-S145G, N/D195G, N113D, N/I78T, E150D in VP4 (VP8 portion) with respect to Rotarix® and RotaTeq® vaccine strains. M217T substitution in VP7 (epitope 7-2) and N113D, D195G substitution in VP4 (epitope 8-3, 8-1) confer changes in polarity/electrical charge with respect to vaccine strains, thus indicating the need for continued surveillance.

Safety and immunogenicity of a multidose vial formulation of 13-valent pneumococcal conjugate vaccine administered with routine pediatric vaccines in healthy infants in India: A phase 4, randomized, open-label study

PURPOSE

This phase 4, randomized, open-label, multicenter study in healthy Indian infants and toddlers evaluated the safety, tolerability, and immunogenicity of the 13-valent pneumococcal conjugate vaccine (PCV13) formulated in a multidose vial (MDV) or single prefilled syringe (PFS).

METHODS

Healthy Indian infants (6 weeks of age) were randomized 1:1 to receive either PCV13-MDV or PCV13-PFS concomitant with routine pediatric vaccines. Subjects received a single dose of either PCV13-MDV or PCV13-PFS as a 4-dose schedule (infant series: 1 dose at 6, 10, and 14 weeks of age; toddler dose: 12 months of age). Safety was assessed, including local reactions, systemic events, and adverse events (AEs). Immunogenicity 1 month after both the infant series and toddler dose was measured by concentrations of serotype-specific immunoglobulin G (IgG) antibodies and opsonophagocytic activity titers.

RESULTS

Rates and severities of local reactions and systemic events up to 7 days after each dose of either PCV13-MDV or PCV13-PFS were generally similar, with the majority being of mild or moderate severity. PCV13-MDV had a safety profile comparable with PCV13-PFS; both groups experienced a similar frequency of AEs. PCV13-MDV elicited immune responses comparable with those induced by PCV13-PFS. Clear boosting of immune responses after the PCV13-MDV toddler dose was observed; ≥96% of subjects showed serotype-specific IgG concentrations at or above the defined thresholds 1 month after the PCV13-MDV toddler dose.

CONCLUSIONS

PCV13-MDV was safe, well tolerated, and immunogenic in healthy Indian infants and toddlers when coadministered with routine pediatric vaccinations. Safety and immunogenicity of PCV13-MDV was comparable with PCV13-PFS.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov: NCT03548337.

Varicella Infection in an Immunized Pediatric Living Donor Liver-Transplant Recipient

Varicella-zoster virus (VZV) is a DNA virus belonging to the Herpesviridae family. Primary infection causes chickenpox followed by latency in the sensory ganglia, which can sometimes reactivate leading to herpes zoster. Chicken pox is generally a mild disease of childhood with a secondary attack rate of >85%, but disseminated VZV infection with visceral involvement and fatal outcome may occur in immunocompromised individuals. Indian Academy of Pediatrics recommends two doses of live-attenuated varicella vaccine in healthy unexposed children at 15-18 months and then at 4-6 years of age. The effectiveness of a single dose of vaccine is around 85% and with a two-dose schedule is as high as 92%. Despite the vaccine-induced protection, community-acquired VZV infections still remain a problem in immunocompromised population. We hereby report a case of a previously immunized pediatric liver-transplant recipient who acquired VZV infection. This case report clearly highlights the importance of strict environmental infection control practices, early suspicion, diagnosis, and management in such cases.

A phase 4 study of the safety of the 13-valent pneumococcal conjugate vaccine in children 6 to 17 years of age in India

PURPOSE

The 13-valent pneumococcal conjugate vaccine (PCV13) was recently approved in India for the prevention of pneumococcal disease in children aged 6 to 17 years based on global data as well as immunogenicity and safety findings from a phase 3 study. The current phase 4 study in India further evaluated the safety profile of PCV13 in this age group to support the positive benefit-risk profile of PCV13.

METHODS

Healthy male and female children aged 6 to 17 years in India were administered a single intramuscular injection of PCV13. Through 7 days after PCV13 administration, local reactions and systemic events were recorded daily by caregivers in an electronic diary. Adverse events (AEs) were collected from the provision of informed consent through 28-42 days postvaccination.

RESULTS

One hundred subjects enrolled in and completed the study. After PCV13 vaccination, 73.9% and 57.8% of subjects reported local reactions and systemic events, respectively. The majority of reactogenicity events were mild to moderate in severity, with injection site pain and fatigue the most frequently reported local reaction and systemic event, respectively. Six subjects reported 7 AEs, all of which were considered unrelated to PCV13. One subject reported a serious AE (acute hepatitis), which was considered unrelated to PCV13 and ultimately resolved. No subjects withdrew because of AEs, and there were no deaths.

CONCLUSION

PCV13 vaccination was well tolerated with an acceptable safety profile in healthy subjects aged 6 to 17 years in India. This work further supports the safety profile of PCV13 for prevention of pneumococcal disease in this age group in India.

Improving vaccination coverage and timeliness through periodic intensification of routine immunization: evidence from Mission Indradhanush

Only an estimated 62% of Indian children under the age of 2 years are fully immunized. We examined the association between India's Mission Indradhanush (MI)-a periodic intensification of the routine immunization program-which was implemented in phases across districts between March 2015 and July 2017, and routine vaccination coverage and timeliness among children. We used data from a 2015 to 2016 national survey of children (n = 29,532) and employed difference-in-difference regressions to examine binary indicators of receipt of 11 vaccines and whether vaccines were received at recommended ages. The full immunization rate was 27% higher among children under 2 years old residing in MI phase 1 and 2 districts (intervention group) as compared with those residing elsewhere (control group). The rate of receiving all vaccines at recommended ages was 8% higher in the intervention group. Receiving doses of oral polio vaccine (OPV) birth dose, OPV dose 1 (OPV1), OPV2, OPV3, bacillus Calmette-Guérin, and hepatitis B birth dose vaccines were 9%, 9%, 11%, 16%, 5%, and 19% higher in the intervention group than the control group, respectively. More research is required on the cost-effectiveness of investing in MI-type programs as compared with routine immunization.

Mass gatherings: a review of the scope for meningococcal vaccination in the Indian context

The risk of meningococcal transmission is increased with crowding and prolonged close proximity between people. There have been numerous invasive meningococcal disease (IMD) outbreaks associated with mass gatherings and other overcrowded situations, including cramped accommodation, such as student and military housing, and refugee camps. In these conditions, IMD outbreaks predominantly affect adolescents and young adults. In this narrative review, we examine the situation in India, where the burden of IMD-related complications is significant but the reported background incidence of IMD is low. However, active surveillance for meningococcal disease is suboptimal and laboratory confirmation of meningococcal strain is near absent, especially in non-outbreak periods. IMD risk factors are prevalent, including frequent mass gatherings and overcrowding combined with a demographically young population. Since overcrowded situations are generally unavoidable, the way forward relies on preventive measures. More widespread meningococcal vaccination and strengthened disease surveillance are likely to be key to this approach.

Impact of Obesity and Being Overweight on the Immunogenicity to Live Attenuated Hepatitis A Vaccine in Children and Young Adults

Prior results investigating a correlation between obesity and hepatitis A virus (HAV) vaccine response have been inconclusive, with limited data involving live attenuated HAV vaccines. The aim of this study is to evaluate the effect of overweight and obesity on the response to live attenuated HAV vaccine in children and young adults. This prospective cohort study was conducted in Thailand with subjects ranging in age from seven to twenty-five years. The subjects were administered 0.5 mL of MEVAC™-A and tested for anti-HAV antibodies before and at 8–9 weeks after vaccination. Baseline seronegative subjects (anti-HAV antibodies < 20 mIU/mL) were divided into non-obese (underweight/normal weight) and obese (overweight/obesity/severe obesity) groups. A total of 212 (117 non-obese and 95 obese) subjects completed the study (mean age (SD) = 13.95 (3.90) years). The seroprotection rates were 100%. Postvaccination geometric mean titers (95% CI) were 429.51 (401.97, 458.94) and 467.45 (424.47, 514.79) mIU/mL in the non-obese and obese groups, respectively. Females (p = 0.013) and subjects with truncal obesity (p = 0.002) had significantly higher titers than other participants. Live attenuated HAV vaccine is safe and has comparably high immunogenicity in both underweight/normal weight and overweight/obese persons.

Clinical Characteristics of Children With Celiac Disease Not Responding to Hepatitis B Vaccination in India

The immunological response to hepatitis B virus (HBV) vaccine may be suboptimal in children with celiac disease (CD), but the reasons for this are not well defined.

Objectives

This study was undertaken to assess the immune response to HBV vaccine in CD children and to explore the possible factors affecting the immune response.

Methods

The study population consisted of 3 groups-50 newly diagnosed CD children (group 1), 50 previously diagnosed CD children who were on gluten free diet (GFD) >3 months (group 2), and 100 age and gender matched healthy controls (group 3). The patient characteristics were recorded, and the blood samples were analyzed for HBsAg and anti-HBs titers. The nonresponders were given a booster dose of HBV vaccine and reevaluated after 6 weeks.

Results

Positive anti-HBs response was found in 46% in newly diagnosed CD children, 60% in CD children on GFD, and 83% in healthy controls (P < 0.001). The immune response to HBV vaccine in CD children was inferior to that in healthy children (53% vs 83%, P < 0.001). The immune response was found to be significantly affected by age at diagnosis, delay in diagnosis, type of presentation, and compliance to GFD. 44 out of 45 (97.77%) nonresponders from CD group seroconverted after a single booster dose.

Conclusion

Early diagnosis and good compliance to GFD may improve the immune response to HBV vaccine in CD children. Single additional booster dose is sufficient to attain optimal immune response.

The need & the issues related to new-generation typhoid conjugate vaccines in India

The low- and middle-income countries bear the highest burden of typhoid fever in the world. India, along with other South Asian countries, has a significant incidence of typhoid fever among young children though there is a paucity of published data on community burden. In spite of the availability of Vi-polysaccharide (Vi-PS) and conjugated Vi-PS vaccines, these are not adequately utilized in India and in the neighbouring countries. To address many shortcomings of the unconjugated Vi-PS vaccines, typhoid conjugate vaccines (TCVs) are developed by conjugating Vi-PS with different carrier proteins. Three such vaccines using tetanus toxoid as a carrier protein are already licensed in India. Several other Vi-PS conjugates are currently in various stages of development. The current review provides an update on the existing and upcoming new TCVs along with a detailed discussion on the various issues involved with their clinical use and limitations.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2020-21) and Update on Immunization for Children Aged 0 Through 18 Years

JUSTIFICATION

In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations.

PROCESS

Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting in March, 2020 followed by online meetings (September-October, 2020), to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached.

OBJECTIVES

To review and revise the IAP recommendations for 2020-21 and issue recommendations on existing and new vaccines.

RECOMMENDATIONS

The major changes include recommendation of a booster dose of injectable polio vaccine (IPV) at 4-6 years for children who have received the initial IPV doses as per the ACVIP/IAP schedule, re-emphasis on the importance of IPV in the primary immunization schedule, preferred timing of second dose of varicella vaccine at 3-6 months after the first dose, and uniform dosing recommendation of 0.5 mL (15 µg HA) for inactivated influenza vaccines.

Structural equation modeling to detect correlates of childhood vaccination: A moderated mediation analysis

Objectives

This study used a health belief theory derived framework and structural equation model to examine moderators, mediators, and direct and indirect predictors of childhood vaccination.

Methods

A secondary analysis was conducted using data collected from a cross-sectional survey of a random sample of 1599 parents living in urban and rural areas of Mysore district, India. Applying two-stage probability proportionate-to-size sampling, adolescent girls attending 7^th through 10^th grades in 23 schools were selected to take home a questionnaire to be answered by their parents to primarily assess HPV vaccine intentions. Parents were also asked whether their children had received one dose of Bacillus Calmette–Guérin; three doses of Diphtheria, Pertussis, Tetanus; three doses of oral Polio vaccine; and one dose of Measles vaccine. In addition, parents were asked about their attitudes towards childhood vaccination.

Results

Out of the 1599 parents, 52.2% reported that their children had received all the routine vaccines (fully vaccinated); 42.7% reported their children had missed at least one routine vaccine, and 5.2% reported that their children had missed all routine vaccinations. Perceptions about the benefits/facilitators to childhood vaccination significantly predicted the full vaccination rate (standardized regression coefficient (β) = 0.29) directly and mediated the effect of parental education (β = 0.11) and employment (β = -0.06) on the rate of full vaccination. Parental education was significantly associated indirectly with higher rates of full vaccination (β = 0.11). Parental employment was significantly associated indirectly with decreasing rates of full vaccination (β = -0.05). Area of residence moderated the role of religion (β = 0.24) and the ‘number of children’ in a family (β = 0.33) on parental perceptions about barriers to childhood vaccination. The model to data fit was acceptable (Root Mean Square Error of Approximation = 0.02, 95% CI 0.018 to 0.023; Comparative Fit Index = 0.92; Tucker–Lewis Index = 0.91).

Conclusions

Full vaccination rate was relatively low among children in Mysore, especially among parents who were unsure about the benefits of routine vaccination and those with low educational levels. Interventions increasing awareness of the benefits of childhood vaccination that target rural parents with lower levels of education may help increase the rate of full childhood vaccination in India.

Human papillomavirus vaccination: Good clinical practice recommendations from the Federation of Obstetric and Gynecological Societies of India

Human papillomavirus (HPV) vaccination offers an excellent prospect for the primary prevention of cervical cancer. The bivalent and quadrivalent vaccines are both available in India. The nonavalent vaccine is licensed but not yet available. However, there still remain controversies regarding the vaccination of older women, immunocompromised females and other special groups. To provide recommendations for HPV vaccination in India. The Federation of Obstetric and Gynecological Societies of India (FOGSI) convened an expert group on cervical cancer prevention to formulate good clinical practice recommendations (GCPR) with respect to vaccine efficacy and safety, target groups, optimal timing and dosing schedules. HPV vaccines are licensed for females aged 9-45 years in India and have been seen to be safe and effective. FOGSI recommends HPV vaccination of all girls <15 years of age as the best target group, in whom two-doses at an interval of 6 months, extendable to 18 months, are recommended. Three-doses are recommended in girls >15 years of age, immunocompromised persons and sexual assault survivors. Older women and women with abnormal screening results may be vaccinated with an understanding that vaccination does not protect against already acquired infections and screening has to continue. Single-dose vaccination results are promising. Increased awareness is required to reduce vaccine hesitancy. HPV vaccination should be the priority to achieve the elimination of cervical cancer. The introduction of affordable HPV vaccines and reduced dose schedules will improve coverage.

A Comprehensive Review of Meningococcal Disease Burden in India

INTRODUCTION

Meningococcal disease caused by Neisseria meningitidis has a high case fatality rate. Of 12 distinct serogroups, A, B, C, W-135 (W) and Y cause the majority of infections. The meningococcal disease burden and epidemiology in India are not reliably known. Hence, we performed a narrative review with a systematically conducted search to summarize information on meningococcal disease burden and epidemiology and vaccination recommendations for meningococcal disease in India.

METHODS

A search of Medline and Embase databases was undertaken to identify relevant publications published in the last 25 years.

RESULTS

Results from 32 original publications, 11 of which were case reports, suggest a significant burden of meningococcal disease and related complications. Meningococcal disease is increasingly reported among adolescents and adults, and large outbreaks have been reported in this population. Meningococcal disease in India is caused almost exclusively by serogroup A; serogroups B, C, W and Y have also been documented. Meningococcal disease burden data remain unreliable because of limited disease surveillance, insufficient laboratory capacity, misdiagnosis and prevalence of extensive antibiotic use in India. Lack of access to healthcare also increases under-reporting, thus bringing the reliability of the data into question. Conjugate meningococcal vaccines are being used for disease prevention by national governments and immunization programs globally. In India, meningococcal vaccination is recommended only for certain high-risk groups, during outbreaks and for international travelers such as Hajj pilgrims and students pursuing studies abroad.

CONCLUSION

Meningococcal disease is prevalent in India but remains grossly underestimated and under-reported. Available literature largely presents outbreak data related to serogroup A disease; however, non-A serogroup disease cases have been reported. Reliable epidemiologic data are urgently needed to inform the true burden of endemic disease. Further research into the significance of meningococcal disease burden can be used to improve public health policy in India. Fig. 1 Plain language summary.

Explaining socioeconomic inequalities in immunisation coverage in India: new insights from the fourth National Family Health Survey (2015-16)

BACKGROUND

Childhood vaccinations are a vital preventive measure to reduce disease incidence and deaths among children. As a result, immunisation coverage against measles was a key indicator for monitoring the fourth Millennium Development Goal (MDG), aimed at reducing child mortality. India was among the list of countries that missed the target of this MDG. Immunisation targets continue to be included in the post-2015 Sustainable Development Goals (SDG), and are a monitoring tool for the Indian health care system. The SDGs also strongly emphasise reducing inequalities; even where immunisation coverage improves, there is a further imperative to safeguard against inequalities in immunisation outcomes. This study aims to document whether socioeconomic inequalities in immunisation coverage exist among children aged 12-59 months in India.

METHODS

Data for this observational study came from the fourth round of the National Family Health Survey (2015-16). We used the concentration index to assess inequalities in whether children were fully, partially or never immunised. Where children were partially immunised, we also examined immunisation intensity. Decomposition analysis was applied to examine the underlying factors associated with inequality across these categories of childhood immunisation.

RESULTS

We found that in India, only 37% of children are fully immunised, 56% are partially immunised, and 7% have never been immunised. There is a disproportionate concentration of immunised children in higher wealth quintiles, demonstrating a socioeconomic gradient in immunisation. The data also confirm this pattern of socioeconomic inequality across regions. Factors such as mother's literacy, institutional delivery, place of residence, geographical location, and socioeconomic status explain the disparities in immunisation coverage.

CONCLUSIONS

In India, there are considerable inequalities in immunisation coverage among children. It is essential to ensure an improvement in immunisation coverage and to understand underlying factors that affect poor uptake and disparities in immunisation coverage in India in order to improve child health and survival and meet the SDGs.

Review of long term immunogenicity and tolerability of live hepatitis A vaccine

Hepatitis A represents one of the major public health problems worldwide including India. Vaccination is the most effective way to prevent hepatitis A infection. Two types of hepatitis A vaccines-live attenuated (H2 strain) and inactivated (killed) are available for use in clinical practice in India with former having advantage of a single-dose compared to two-dose killed vaccine. One of the important characteristic of an ideal vaccine includes its ability to provide life-long protection. In this article we reviewed the available long-term (≥10 years follow-up) published data on live attenuated hepatitis A (H2 strain) vaccine. The data from country of origin of the vaccine (China) and India establish the long-term immunogenicity, protection, and tolerability. Based on the results of several clinical trials showing long-term protection, single dose of live attenuated hepatitis vaccine can be widely used to protect high-risk population against hepatitis A virus infection and related complications.

Burden and Molecular Epidemiology of Rotavirus Causing Diarrhea among Under-Five Children: A Hospital-based Study from Eastern India

Background

Rotavirus (RVA) causes severe gastroenteritis in under-five children, and there are many diverse strains of the virus that are localized to different parts of the world.

Objectives

To study the burden and molecular epidemiology of RVA causing gastroenteritis among children from Eastern India.

Materials and Methods

This hospital-based cross-sectional study included children under-five with gastroenteritis. Demographic and clinical parameters were recorded in a predesigned pro forma. Stool samples collected from these children were initially screened for RVA VP6 antigen by enzyme immunoassay (EIA). Each EIA-positive sample was then subjected to RNA extraction, followed by reverse transcription, and heminested multiplex polymerase chain reaction for genotyping of RVA strains.

Results

Of 320 included children, RVA was detected in 30.62% (98/320) cases by EIA. The highest incidence for RVA-positive cases (34.61%) was observed among children in the age group of 24-36 months, followed by 0-12 months (33.04%). Of the 97 completely typed samples, single genotype was detected in 85 (87.62%) samples with either G (VP7) or P (VP4) types. However, mixed genotypes were detected in 12 (11.21%) samples. G3P[8] (44.09%) was the most common genotype, followed by G1P[8] (32.65%), G2[P4] (5.10%), G1[P6] (3.06%), and G9[P4] (1.02%).

Conclusions

The present study found RVA positivity in 30.62% of children with gastroenteritis, with the highest burden among 24-36 months old. The predominant genotypes were G1, G3, and P[8]. Further large-scale/multicentric studies should be conducted to document the diversity of circulating RVA genotypes in this region for giving inputs for vaccination strategy.

Current status of human papillomavirus vaccination in India's cervical cancer prevention efforts

Efforts are being made to scale up human papillomavirus (HPV) vaccination for adolescent girls in India. Bivalent and quadrivalent HPV vaccines were licensed in the country in 2008, and a nonavalent vaccine was licensed in 2018. Demonstration projects initiated in Andhra Pradesh and Gujarat in 2009 introduced HPV vaccination in public health services in India. Following a few deaths in these projects, although subsequently deemed unrelated to vaccination, HPV vaccination in research projects was suspended. This suspension by default resulted in some participants in a trial evaluating two versus three doses receiving only one dose. Since 2016, the successful introduction of HPV vaccination in immunisation programmes in Punjab and Sikkim (with high coverage and safety), government-sponsored opportunistic vaccination in Delhi, prospects of a single dose providing protection, and future availability of an affordable Indian vaccine shows promise for future widespread implementation and evaluation of HPV vaccination in India.

Paediatric chronic myeloid leukaemia: Is it really a different disease?

Paediatric chronic myeloid leukaemia (CML) has biological and clinical differences from adult CML. Management of paediatric CML presents unique challenges in growing children, and there are no specific guidelines for paediatric CML. This review focusses on the clinical characteristics, diagnostic issues and management of paediatric CML. Major studies that provide the basis of managing paediatric CML are summerized here. Studies conducted on adult CML patients were used to guide the management of places where studies were lacking in paediatric CML. Recently, dasatinib and nilotinib have been approved for treatment of paediatric CML, and their role has been discussed in the current management perspective. Allogeneic transplant, fertility and vaccination in paediatric CML, have also been discussed.

Age-stratified anti-HAV positivity in Pune, India after two decades: Has voluntary vaccination impacted overall exposure to HAV?

The degree of transmission of hepatitis A virus (HAV) is inversely proportional to the socioeconomic status of a community. Serosurveys conducted at Pune, India during 1982-98 documented significant reduction in HAV exposure of paediatric, higher socioeconomic status (HSS) population. Anti-HAV positivity (ELISA) in age-stratified Pune population representing HSS and lower middle socioeconomic status (LMSS) (n = 1065) and infants till the age of 15 months (n = 690) was determined in 2017. Anti-HAV positivity in the LMSS population decreased significantly in 2017 while an increase was seen in the HSS category. The surprising rise in anti-HAV positivity in the HSS population reflected vaccine- and infection-induced antibodies while only infection-induced antibodies were present in the LMSS category. Lowest antibody prevalence in infants was at 12 months, the recommended age for hepatitis A vaccination. Improved hygiene and selective immunization practices impacted HAV exposure of the LMSS population. The data emphasize the need for hepatitis A vaccination irrespective of socioeconomic status.

Vaccination coverage and factors associated with routine childhood vaccination uptake in rural Vellore, southern India, 2017

BACKGROUND

Vellore district in southern India was selected for intensified immunization efforts through India's Mission Indradhanush campaign based on 74% coverage in the National Family Health Survey in 2015. As rural households rely almost entirely on the Universal Immunization Program (UIP), we assessed routine immunization coverage and factors associated with vaccination status of children in rural Vellore.

METHODS

We conducted a cross-sectional household survey among parents or primary caretakers of children aged 12-23 months during August-September 2017 using two-stage, EPI cluster sampling. We verified vaccination histories from vaccination cards and collected data on sociodemographic and non-socio-demographic characteristics by using mobile data capture. Associations with vaccination status were examined with univariate and multivariate logistic regression models.

RESULTS

A total of 643 children were included. Coverage of BCG, third dose pentavalent/DPT, measles/MR vaccines and full vaccination (BCG, three doses of polio and pentavalent/DPT and measles/MR vaccines) among children with vaccination cards (n = 606) was 94%, 96%, 93% and 84%, respectively. Of children with vaccination cards, 70.8% had received all recommended doses according to the UIP schedule. No socio-demographic differences were identified, but parents' familiarity with the schedule (Adjusted Prevalence Odds Ratio (aPOR): 2.06, 95%CI = 1.26-3.38) and receiving information on recommended vaccinations during antenatal visits (aPOR: 2.16, 95% CI = 1.13-4.12) were significantly associated with full vaccination status of the children.

CONCLUSIONS

We found higher UIP antigen coverage and proportion of fully vaccinated children than previously reported from rural Vellore. However, adherence to the recommended schedule was still not optimal. Our study highlights the potential of improving parental awareness of vaccination schedule and targeting health education interventions at pregnant women during antenatal visits to sustain and improve routine immunization coverage.

Gynecological Cancers-the Changing Paradigm

Outstanding research in the last few decades led to newer insights into the management of gynecological cancers. In the preventive arena, the efficacy and safety of HPV vaccination are well accepted and is now in addition to bi- and quadrivalent vaccines; there is a nonavalent vaccine against nine oncogenic HPV strains. Recent studies also looked into the dosaging schedules and age of vaccination against HPV to improve the vaccine efficacy and coverage. HPV testing is now approved as a primary screening test for cervical cancer in women aged more than 30 years with better sensitivity than the traditional cytology. Opportunistic salpingectomy for ovarian cancer prevention and neoadjuvant chemotherapy for advanced ovarian cancers are accepted practices. The role of personalized medicine in ovarian cancer and comprehensive genomic analysis of endometrial cancers are also covered in this review.

An integrative behavior theory derived model to assess factors affecting HPV vaccine acceptance using structural equation modeling

The study examined factors that affect parental intention-to-vaccinate adolescent daughters with HPV vaccine in Mysore district, India. A cross-sectional study was conducted among 1609 parents of adolescent girls attending schools in Mysore District between February 2010 and October 2011. A validated questionnaire was used to assess parental attitudes, beliefs related with HPV infection, cervical cancer, HPV vaccine and vaccination in general. Structural equation modeling was used to estimate parameters and assess whether a model based on the integrative behavior theory would fit the current data. More than two-thirds (78.0%) of parents would accept vaccinating their daughters with HPV vaccine. Intention to HPV vaccination significantly increased with increase in the perception of parents about the benefits (standardized regression coefficient (β) = 0.39) or sources of information about HPV vaccine (β = 0.24), but intention decreased significantly with an increase in the perception about barriers to HPV vaccination β = -0.44). The effect of beliefs about severity of HPV infection or cervical cancer (β = 0.20), and beliefs about benefits (β = 0.20) or barriers (β = -0.25) to vaccination in general on intention to HPV vaccination were significantly mediated by parental attitudes and source of information about the vaccine. Geographical location significantly moderated the awareness about HPV on beliefs about severity of HPV infection or cervical cancer (β = 0.33), and the effect of religion on norms related to HPV vaccination (β = 0.19). Fit of the model to the data was acceptable. This study identified modifiable parental attitudes about HPV vaccine and beliefs related with HPV infection, cervical cancer and vaccination, which predicted parental intention-to-vaccinate their daughters with HPV vaccine in India. Health education interventions tailored to counter parental negative attitudes and beliefs about HPV vaccine and vaccination in general would be important for the community to promote HPV vaccination.

Human Papillomavirus Vaccine Acceptability among Parents of Adolescent Girls in a Rural Area, Mysore, India

STUDY OBJECTIVE

The purpose of this study was to examine factors predicting human papillomavirus (HPV) vaccine acceptability among parents of adolescent girls in a rural area in Mysore district, India.

DESIGN

Cross-sectional.

SETTING

Mysore, India.

PARTICIPANTS

Parents of school-going adolescent girls.

INTERVENTIONS

Parents completed a validated self-administered questionnaire.

MAIN OUTCOME MEASURES

Parental willingness to vaccinate their daughters with HPV vaccine.

RESULTS

Of the 831 parents who participated in this study, 664 (79.9%) were willing to vaccinate their daughter with HPV vaccine sometime soon if they were invited to receive it. Higher odds of parental willingness to vaccinate their daughters with HPV vaccine was observed among those who believed that HPV vaccine is safe (adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.01-4.45); their daughter might become sexually active (aOR, 1.84; 95% CI, 1.08-3.13); they have support of other family members to vaccinate their daughter (aOR, 2.86; 95% CI, 1.47-5.57); and that HPV infection causes severe health problems (aOR, 1.64; 95% CI, 1.04-2.57). In contrast, parents who believed that there is low risk that their daughter will get cervical cancer (aOR, 0.52; 95% CI, 0.29-0.95); that the family will disapprove of getting their daughter vaccinated (aOR, 0.45; 95% CI, 0.22-0.76); that the injection might cause pain (aOR, 0.53; 95% CI, 0.31-0.89), and were older-age parents (aOR, 0.96; 95% CI, 0.93-0.99) had lower odds of willingness to vaccinate daughters with HPV vaccine.

CONCLUSION

Acceptance of HPV vaccination for daughters was high among rural parents in Mysore, India. However, health education to reduce the belief that injection is painful and that daughters are at low risk to get cervical cancer is important to further improve parental HPV vaccine acceptability in Mysore. Public health education should target older-aged parents and extended family members.

Urban-Rural Inequities in the Parental Attitudes and Beliefs Towards Human Papillomavirus Infection, Cervical Cancer, and Human Papillomavirus Vaccine in Mysore, India

STUDY OBJECTIVE

The aim of this study was to compare the parental attitudes and beliefs about human papillomavirus (HPV), cervical cancer, and HPV vaccine between urban and rural areas, India.

DESIGN

Cross-sectional.

SETTING

Mysore, India.

PARTICIPANTS

Parents of school-going adolescent girls.

INTERVENTIONS

Parents completed a self-administered questionnaire.

MAIN OUTCOME MEASURES

Attitudes and beliefs about HPV, cervical cancer, and HPV vaccine.

RESULTS

A total of 1609 parents from urban (n = 778) and rural (n = 831) areas participated in this study. Most of the parents had never heard about HPV (73.6%), did not know that their daughters could get an HPV infection (62.7%) or cervical cancer (64.1%) in the future, and believed that HPV vaccine was not effective (67.1%). Parents living in the urban area were more likely to believe that HPV infection (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.43-5.06) and cervical cancer (aOR, 2.68; 95% CI, 1.83-3.91) could cause serious health problems than those living in the rural area. The odds of agreeing that HPV vaccination will make girls sexually active was lower among urban than rural parents (aOR, 0.55; 95% CI, 0.33-0.94). There was no significant difference among parents in the urban and rural areas in their beliefs about susceptibility of their daughter to HPV infection or cervical cancer, and beliefs about the safety and ability of HPV vaccine to protect against cervical cancer.

CONCLUSION

Rural parents might be reluctant to recommend behaviors that can help prevent HPV infection and cervical cancer such as HPV vaccination for their daughters.

Investigation of an outbreak of varicella in Chandigarh, North India, using a real-time polymerase chain reaction approach

Outbreaks of varicella are reported when susceptible population accumulates. This study reports a chickenpox outbreak in Burail in August 2014, wherein 20 laboratory-confirmed cases were identified by the detection of varicella zoster virus (VZV) DNA and VZV IgM antibodies. The viral load between vesicular swabs and serum samples from 8 patients with active lesions was found to have good correlation and further also related with disease severity. Real-time polymerase chain reaction can be useful for early diagnosis of an outbreak and vesicular swab can be used as a less invasive sample for assessing the disease severity.

Diagnosis and Management of Gaucher Disease in India – Consensus Guidelines of the Gaucher Disease Task Force of the Society for Indian Academy of Medical Genetics and the Indian Academy of Pediatrics

Justification

Gaucher disease (GD) is amongst the most frequently occurring lysosomal storage disorder in all ethnicities. The clinical manifestations and natural history of GD is highly heterogeneous with extreme geographic and ethnic variations. The literature on GD has paucity of information and optimal management guidelines for Indian patients.

Process

Gaucher Disease Task Force was formed under the auspices of the Society for Indian Academy of Medical Genetics. Invited experts from various specialties formulated guidelines for the management of patients with GD. A writing committee was formed and the draft guidelines were circulated by email to all members for comments and inputs. The guidelines were finalized in December 2016 at the annual meeting of the Indian Academy of Medical Genetics.

Objectives

These guidelines are intended to serve as a standard framework for treating physicians and the health care systems for optimal management of Gaucher disease in India and to define unique needs of this patient population.

Recommendations

Manifestations of GD are protean and a high index of suspicion is essential for timely diagnosis. Patients frequently experience diagnostic delays during which severe irreversible complications occur. Leucocyte acid β-glucosidase activity is mandatory for establishing the diagnosis of Gaucher disease; molecular testing can help identify patients at risk of neuronopathic disease. Enzyme replacement therapy for type 1 and type 3 Gaucher disease is the standard of care. Best outcomes are achieved by early initiation of therapy before onset of irreversible complications. However, in setting of progressive neurological symptoms such as seizures and or/neuroregression, ERT is not recommended, as it cannot cross the blood brain barrier. The recommendations herein are for diagnosis, for initiation of therapy, therapeutic goals, monitoring and follow up of patients. We highlight that prevention of recurrence of the disease through genetic counseling and prenatal diagnosis is essential in India, due to uniformly severe phenotypes encountered in our population.

Acute Encephalitis Syndrome in Eastern Uttar Pradesh, India: Changing Etiological Understanding

Seasonal outbreaks of acute encephalitis syndrome (AES) with high case fatality have been occurring in Gorakhpur division in Eastern Uttar Pradesh, India, for more than three decades. Japanese encephalitis virus (JEV) accounted for <10% of AES cases, while the etiology of the remaining cases remained largely unknown. Investigations conducted during the 2014 and 2015 outbreaks indicated Orientia tsutsugamushi (Haruo Hayashi 1920) (Norio Ogata 1929) Tamura et al. 1995 (Rickettsiales: Rickettsiaceae) as the etiology in about 60% of AES cases. Hospital-based surveillance studies indicated that about one-fifth of the patients with acute febrile illness were due to scrub typhus. Further studies are required to identify the etiology of about a third of AES cases that test negative for scrub typhus, JEV, or dengue.

Nasopharyngeal Pneumococcal Colonization and Impact of a Single Dose of 13-Valent Pneumococcal Conjugate Vaccine in Indian Children With HIV and Their Unvaccinated Parents

BACKGROUND

Human immunodeficiency virus (HIV) infection increases risk of invasive disease from Streptococcus pneumoniae. Pneumococcal conjugate vaccines (PCV) prevent invasive disease and acquisition of vaccine type (VT) pneumococcus in the nasopharynx.

OBJECTIVE

To look at the safety and impact of one dose of PCV13 on acquisition of VT pneumococcal carriage in Indian children with HIV.

METHOD

We conducted a cohort study in families of HIV-infected children (CLH) and families of HIV-uninfected children (HUC) in West Bengal. All children received one dose of PCV13. Nasopharyngeal swabs were collected from children and parents at baseline and 2 months after vaccination.

RESULT

One hundred and fifteen CLH and 47 HUC received one dose of PCV13. Fifty-eight percent of CLH were on antiretroviral therapy (ART), and the median nadir CD4 count was 287. There were no significant adverse events in either group. HUC had more VT colonization than CLH-55% versus 23% of all pneumococcal isolates. HIV infection doubled the risk of nonvaccine serotype colonization (P = 0.03). There was no difference in acquisition of VT isolates in CLH (4.4%) and HUC (4.5%) post-PCV13; however, older CLH (>5 years) had decreased clearance of VT strains. ART made no difference in pneumococcal colonization at baseline or after PCV13; however, CLH with higher nadir CD4 counts before starting ART were less likely to have VT colonization post-PCV13 (prevalence ratio, 0.2; 95% confidence interval: 0.1-0.5).

CONCLUSION

While there was no difference in acquisition of VT nasopharyngeal carriage of pneumococcus in CLH and HUC after one dose of PCV13, earlier access to ART may impact response to PCV13 in CLH.

Effect and cost-effectiveness of educating mothers about childhood DPT vaccination on immunisation uptake, knowledge, and perceptions in Uttar Pradesh, India: A randomised controlled trial

BACKGROUND

To assess the effect of health information on immunisation uptake in rural India, we conducted an individually randomised controlled trial of health information messages targeting the mothers of unvaccinated or incompletely vaccinated children through home visits in rural Uttar Pradesh, India.

METHODS AND FINDINGS

The study tested a brief intervention that provided mothers face-to-face with information on the benefits of the tetanus vaccine. Participants were 722 mothers of children aged 0-36 months who had not received 3 doses of diphtheria-pertussis-tetanus (DPT) vaccine (DPT3). Mothers were randomly assigned in a ratio of 1:1:1 to 1 of 3 study arms: mothers in the first treatment group received information framed as a gain (e.g., the child is less likely to get tetanus and more likely to be healthy if vaccinated), mothers in the second treatment group received information framed in terms of a loss (e.g., the child is more likely to get tetanus and suffer ill health if not vaccinated), and the third arm acted as a control group, with no information given to the mother. Surveys were conducted at baseline (September 2015) and after the intervention (April 2016). The primary outcome was the proportion of children who had received DPT3 measured after 7 months of follow-up. The analysis was by intention to treat. A total of 16 (2.2%) participants were lost to follow-up. The coverage of DPT3 was 28% in the control group and 43% in the pooled information groups, giving a risk difference of 15 percentage points (95% CI: 7% to 22%, p < 0.001) and a relative risk of 1.52 (95% CI: 1.2 to 1.9, p < 0.001). The information intervention increased the rate of measles vaccination by 22 percentage points (risk difference: 22%, 95% CI: 14% to 30%, p < 0.001; relative risk: 1.53, 95% CI: 1.29 to 1.80) and the rate of full immunisation by 14 percentage points (risk difference: 14%, 95% CI: 8% to 21%, p < 0.001; relative risk: 1.72, 95% CI: 1.29 to 2.29). It had a large positive effect on knowledge of the causes, symptoms, and prevention of tetanus but no effect on perceptions of vaccine efficacy. There was no difference in the proportion of children with DPT3 between the group that received information framed as a loss and the group that received information framed as a gain (risk difference: 4%, 95% CI: -5% to 13%; p = 0.352; relative risk: 1.11, 95% CI: 0.90 to 1.36). The cost per disability-adjusted life year averted of providing information was US$186, making the intervention highly cost-effective with respect to the WHO-recommended threshold of once the gross domestic product per capita (US$793 in the case of Uttar Pradesh). Key study limitations include the modest sample size for this trial, limiting power to detect small differences in the framing of information, and the potential for contamination among households.

CONCLUSIONS

Providing mothers of unvaccinated/incompletely vaccinated children with information on tetanus and the benefits of DPT vaccination substantially increased immunisation coverage and was highly cost-effective. The framing of the health information message did not appear to matter.

TRIAL REGISTRATION

The trial is registered with ISRCTN, number ISRCTN84560580.

Knowledge, attitudes, and practices of private sector immunization service providers in Gujarat, India

BACKGROUND

India is responsible for 30% of the annual global cohort of unvaccinated children worldwide. Private practitioners provide an estimated 21% of vaccinations in urban centers of India, and are important partners in achieving high vaccination coverage.

METHODS

We used an in-person questionnaire and on-site observation to assess knowledge, attitudes, and practices of private immunization service providers regarding delivery of immunization services in the urban settings of Surat and Baroda, in Gujarat, India. We constructed a comprehensive sampling frame of all private physician providers of immunization services in Surat and Baroda cities, by consulting vaccine distributors, local branches of physician associations, and published lists of private medical practitioners. All providers were contacted and asked to participate in the study if they provided immunization services. Data were collected using an in-person structured questionnaire and directly observing practices; one provider in each practice setting was interviewed.

RESULTS

The response rate was 82% (121/147) in Surat, and 91% (137/151) in Baroda. Of 258 participants 195 (76%) were pediatricians, and 63 (24%) were general practitioners. Practices that were potential missed opportunities for vaccination (MOV) included not strictly following vaccination schedules if there were concerns about ability to pay (45% of practitioners), and not administering more than two injections in the same visit (60%). Only 22% of respondents used a vaccination register to record vaccine doses, and 31% reported vaccine doses administered to the government. Of 237 randomly selected vaccine vials, 18% had expired vaccine vial monitors.

CONCLUSIONS

Quality of immunization services in Gujarat can be strengthened by providing training and support to private immunization service providers to reduce MOVs and improve quality and safety; other more context specific strategies that should be evaluated may involve giving feedback to providers on quality of services delivered and working through professional societies to adopt standards of practice.

A cluster randomized trial to determine the effectiveness of a novel, digital pendant and voice reminder platform on increasing infant immunization adherence in rural Udaipur, India

BACKGROUND

Five hundred thousand children under the age of 5 die from vaccine preventable diseases in India every year. More than just improving coverage, increasing timeliness of immunizations is critical to ensuring infant health in the first year of life. Novel, culturally appropriate community engagement strategies are worth exploring to close the immunization gap. In our study, a digital NFC (Near Field Communication) pendant worn on black thread and voice call reminder system was tested for the effectiveness in improving DTP3 adherence within 2 monthly camps from DTP1 administration.

METHOD

A cluster randomized controlled trial was conducted in which 96 village health camps were randomized to 3 arms: NFC sticker, NFC pendant, and NFC pendant with voice call reminder in local dialect. Randomization was done across 5 blocks in the Udaipur District serviced by Seva Mandir from August 2015 to April 2016.

RESULTS

In terms of our three primary outcomes related to DTP3 adherence, point estimates show conflicting results. Two outcomes presented adherence in the control. DTP3 completion within two camps after DTP1 showed higher adherence in the Control (Sticker) (74.2%) arm compared to the Pendant (67.2%) and Pendant and Voice arms (69.3%). Likewise, the estimate for DTP3 completion within 180 days of birth in the Control (Sticker) (69.4%) arm was higher than estimates in the Pendant (57.4%) and Pendant and Voice arms (58.7%). However, one outcome displayed higher adherence in the intervention. DTP3 completion within two months from the time of registration was higher in the Pendant (37.7%) and Pendant and Voice arms (38.7%) compared to the Control (Sticker) arm (27.4%). In all primary outcomes, differences in adherence were statistically insignificant both before and after controlling for confounding factors. In terms of secondary outcomes, our results suggest that providing a necklace generated significant community discussion (H = 8.8796, df = 2, p = .0118), had strong satisfaction among users (χ2=26.039, df = 4, p < .0001), and resulted in increased visibility within families (grandmothers:χ2=34.023, df = 2, p < .0001, fathers: χ2=34.588, df = 2, p < .0001).

CONCLUSION

Neither the NFC necklace nor the necklace with additional voice call reminders in the local dialect directly resulted in an increase in infant immunization timeliness through DTP3, the primary outcome. Still our process outcomes suggest that our culturally symbolic necklace has potential to be an assistive tool in immunization campaigns. Follow-on work will seek to examine whether positive behavior change towards vaccines can be fostered with earlier engagement of this platform beginning in the prenatal stage, under a continuum of care framework.

Safety and Immunogenicity of 13-Valent Pneumococcal Conjugate Vaccine in Children 6-17 Years of Age in India: An Open-label Trial

In an open-label study in India, 200 healthy participants 6-17 years of age received 13-valent pneumococcal conjugate vaccine (PCV13). PCV13 elicited robust functional antibody immune responses. No adverse events were reported by caregivers at the 1-month follow-up visit. The immunogenicity results together with the known favorable risk-benefit profile of PCV13 support extension of the indication to this age group in India.

A review of immunogenicity and tolerability of live attenuated Hepatitis A vaccine in children

Changing epidemiology of Hepatitis A virus (HAV) has led to an increased susceptibility of adolescents and adults to the infection. Vaccination can remarkably reduce the incidence and associated morbidity of HAV infection. This review is focused on the safety and efficacy of H2 strain derived live attenuated Hepatitis A vaccine. We found the vaccine to be highly immunogenic with minimal or negligible safety issues. Moreover, a single dose of live attenuated vaccine persists a long term immune response and can be a preferred option for developing countries. In 2014, Indian Academy of Paediatrics (IAP) also updated their recommendations for H2 vaccine as a single dose as against the previous 2 dose schedule. A focused approach to include the vaccine in national immunization program should be explored.

Genotype distribution of Group A rotavirus from southern India, 2005-2016

Diarrheal disease due to Group A rotaviruses remain a leading cause of mortality and morbidity in the less developed parts of the world. India has started a phased roll out of rotavirus vaccine in the national immunization program. This analysis summarizes the rotavirus genotype strain distribution pre-vaccine introduction in Vellore, India from December 2005 to June 2016. Rotavirus was responsible for 32% of all diarrheal admission to the hospital. G2P[4] was the predominant strain in the initial years and was gradually replaced by G1P[8]. The emergence of G9P[4] replacing G9P[8], and the detection of G12 strains over several years were documented. There was no clear seasonality of disease. These data form the baseline to monitor genotype distribution post-vaccine introduction in Tamil Nadu.

Immune persistence after pertussis vaccination

Pertussis is one of the most prevalent vaccine-preventable diseases worldwide. The true infection rate is significantly higher than the reported incidence rate. An increased prevalence of pertussis in older populations has been found, mainly caused by waning immunity after vaccination. Vaccine-induced immunity differs due to variation in vaccine content, schedule and coverage. Protection following acellular pertussis vaccines has been suggested to wane faster than whole cell pertussis vaccines. However, long-term immune persistence of whole cell pertussis vaccines may be confounded by a progressive acquisition of natural immunity. The World Health Organization has recommended that a switch from whole cell to acellular pertussis vaccines for primary immunization in infants should only be considered if additional periodic boosters or maternal immunization can be ensured and sustained in the national immunization schedules. In this review, we present data on immune persistence after different pertussis vaccinations and compare the findings from countries with different vaccination strategies. Future aspects in serological studies are briefly discussed.