 "Administering the right dose")
To comfort her hypochondriac father who had been reading about flu epidemics, Ananya Raman decided to take an influenza vaccine while preparing to move to Bangkok two years ago. It had not been easy. Once inside a flourishing private hospital in Kochi, the 34-year-old copywriter recalls running to get a prescription, and later, an experienced nurse slapping the point of the injection hard into her raised arm. Although Raman has had the shot every year since (in Bangkok), her view on its effectiveness remains mixed. "I haven't had the flu so I guess it worked. But then, I don't know anybody else that has had the flu either."
As more vaccines to prevent infectious diseases in adults enter the market and awareness spreads, the administration of such shots has been slowly increasing in India. However, vaccines are largely still thought to be something meant for children. On an average, Mumbai-based doctor Dheeraj Mulchandani's clinic gets five enquiries a month now. While the surge in H1N1 cases in the last four or five years has led to this fear, notes Mahesh Lakhe, infectious diseases specialist, Columbia Asia Hospital, Pune, consciousness is higher in countries like the United States and Australia where there is greater emphasis on public health. Swine flu has reportedly claimed more than 2,100 lives in India.
Raman's reservation about the flu vaccine's efficacy is in line with general experience. Among Mulchandani's clients, for instance, a couple who kept getting repeated flu attacks was advised to take the shots and the frequency of attacks came down drastically. On the other hand, two other recipients in the last year have benefitted very little from the vaccine. Mulchandani's own yearly sinusitis attacks reduced after he started taking the shots five years ago. By accounts from various doctors, the flu vaccine is around 50-70 per cent effective, and, at worst, zero per cent effective at preventing seasonal flu. The infective strain is different each season, so an annual flu shot is prescribed for optimal protection.
Influenza and pneumococcal vaccines are generally recommended for people over the age of 60-65 who are exposed to respiratory problems such as bronchitis, asthma, or who are heavy smokers. In others, they are of little use, maintains Anant Phadke, health activist and member of the Jan Swasthya Abhiyan. For those who are not particularly susceptible to infection, exercise, a healthy diet and safe sex practices help in building immunity. The immunity from many vaccines, however, is short-term, while exposure to the actual virus offers more permanent immunity, as acknowledged by practitioners and medical studies. Since India is yet to be as medicalised like the United States, over-vaccination has not been observed so far, notes Phadke.
In addition to the flu, preventive shots are available for other infections too. If you are a health care worker, it is recommended to go in for the Hepatitis B vaccine since there is a reasonable expectation of being exposed to blood and body fluids. Those who travel frequently and eat outside are advised to consult a physician and be vaccinated against typhoid. Tetanus shots are commonly given to those injured after contact with sharp or rusty objects but one shot usually provides protection for five to ten years and need not be taken multiple times in that period. Besides these, vaccines for HIV, tuberculosis and dengue are in development stages.
There may also be differences in the approach to adult vaccination locally and elsewhere. "In India, your doctor says 'This is good for you' and you agree because you're not a doctor, are you?" says Raman. By contrast, her workplace in Thailand, which arranges for her yearly flu shot sends an attachment outlining risks and benefits. For example, the virus is incubated in chicken eggs, so if you are allergic to eggs, then you might be allergic to the flu shot. There is also a form that asks her about any other allergies, sensitivities and basic medical history. The medical centres in Bangkok are also gentler in dealing with patients, according to her experience.
Cost effectiveness is an important determinant in choosing a vaccine. But about its violation, George Bernard Shaw once noted, "Suppose it were ascertained that every child in the world could be rendered absolutely immune from all disease during its entire life by taking half an ounce of radium to every pint of its milk. The world would be none the healthier, because not even a Crown Prince -no, not even the son of a Chicago Meat King, could afford the treatment. Yet it is doubtful whether doctors would refrain from prescribing it on that ground."
Activist Phadke sounds just as incensed when he speaks about the use of the Human Papilloma Virus (HPV) vaccine in India. The shot, which protects against cervical cancer, is commonly administered as a preventive measure in the United States to girls aged around 11 to 13 years, typically before they become sexual active. Its utility at the onset of sexual relations has not been proved but Phadke finds that Indian doctors "blindly recommend it" to married women in their 30s and 40s. At Rs 3,000 per dose, this makes a recipient poorer by Rs 9,000 after the recommended dosage. "Whoever has the money is asked to take it."
So far, it is the private companies that are spreading awareness in India, and some health activists worry that a conflict of interest could lead to spreading of misinformation. Doctors reckon that there cannot be blanket administration of such preventive vaccines and that mass production for a country like India with a large population would be meaningless. Effectiveness of the shots differs on a case-to-case basis and has to be carefully evaluated by practitioners. But they also point to a need for regulations and monitoring so that vaccines are used for the right indication. "Unless public health emphasises on preventable infectious diseases, we will only be going from one emergency to another," adds fellow infectious diseases expert Om Shrivastav.
Some names have been changed on request
