India’s immunization efforts face challenges, jeopardizing lives and straining healthcare costs. But solutions exist. As International Immunization Week begins, Dr. Chandrakant Lahariya, a physician and global health expert, reveals poor quality data is jeopardizing the achievement of our immunization goals. Several marginalized populations are deprived of life-saving vaccines because of administrative bottlenecks. He says better data collection, transparency in data sharing, localized strategies, and combating myths will help improve immunization coverage. At the same time, with rising comorbidities, it’s time to focus on adult immunization. With stints at the World Health Organization and UNICEF and a key role in India’s COVID-19 fight, he brings unique insight into overcoming these obstacles.
Excerpts from the interview:
Interviewer: India’s immunization program started way back in 1978. It expanded to become universal in 1985. Yet, even now, we struggle to achieve full immunization for all children. Can you explain the main problems at the community level?
Dr Chandrakant Lahariya: Firstly, even with our efforts, it’s hard to ensure vaccines reach every single child. India is a huge country with over 6.5 lakh villages. Getting every vaccine to every corner reliably is complex. That’s a supply issue.
But even where vaccines are available, sometimes there’s a demand issue. Vaccination is voluntary, right? People might not want their kids vaccinated or might not understand why it’s so important. This leads to hesitancy and what we call “zero-dose children” – those who don’t get any of the routine vaccinations. We have improved our reach and increased the number of vaccines, but still lagging behind countries like Bangladesh or Sri Lanka, which have over 95% coverage. Within India, southern states generally do better, while lots of kids go unvaccinated in Uttar Pradesh, Madhya Pradesh, Bihar, and Rajasthan. There’s a lot of inequality to address.
“Within India, southern states generally do better, while lots of kids go unvaccinated in Uttar Pradesh, Madhya Pradesh, Bihar, Rajasthan. There’s a lot of inequality to address.”
Interviewer: What exactly is causing the lack of demand for vaccination? Is it confined to certain sections or populations?
Dr. Chandrakant Lahariya: Every state needs to pinpoint the specific populations being missed and understand why they’re not being reached. Take migrant populations – they’re often underserved. Families move for work, and they may not know where to get vaccinations in the new location. Plus, the local health system might not be aware of new arrivals to offer services. This is common in border areas where migration for work is frequent, and people may not even have their child’s immunization records with them.
Also, our system has gaps. Remote hilly areas and tribal communities may remain untouched. Worse, sometimes vaccinations appear complete on paper, but there’s no real effort on the ground. We need tailored, local strategies to truly boost our immunization coverage.
“Migrant families are missing out on vital vaccines. No data = no access. India needs local solutions to fix immunization gaps.”
Interviewer:You emphasize the need for localized solutions. Do we have enough data necessary for policymakers to design truly effective, targeted immunization campaigns? If not, what are the biggest gaps in our data collection efforts?
Dr. Chandrakant Lahariya: You’re right. Localized solutions need localized data, and that’s where we face a major problem. India lacks access to good quality, granular data at the local level. Without this, how can policymakers know which populations are being missed and why?
Other countries proactively collect and share this kind of data, empowering researchers and public health experts to identify needs and propose effective interventions. Sadly, in India, either the data we collect is unreliable, or even when good data exists, the government is reluctant to share it. This hinders the wider community of researchers, epidemiologists, and pediatricians who could analyze the data and suggest innovative, targeted solutions.
Interviewer: Has the integration of technology not improved the quality of data being collected?
Dr. Chandrakant Lahariya: On paper, technology should improve things, right? Talk of smart devices, and apps improving data collection– we saw it with Co-WIN. But creating that kind of tech juggernaut for every vaccination program is just not feasible. And even with Co-WIN, the wider public didn’t get access to the data. Only the government had it. This lack of transparency is the norm with apps and tech.
Now, Co-win has been repurposed as U-WIN as this big tech solution to track immunization numbers, but we still lack real-time data. Lakhs of vaccination doses are given in the remotest parts of India. We still collect data on paper in remote areas, and then type it in in the system. That’s hardly an optimal use of technology. Worse yet, the data often misrepresents facts. It’ll say 100% immunization when we’re at maybe 50-70%. The real tragedy is that those missing numbers are the poor, the marginalized. Bad data perpetuates health inequity – I’d say it directly contributes to it.
“We still collect data on paper in remote areas, then type it in in the system. That’s hardly an optimal use of technology.”
“The real tragedy is that those missing numbers are the poor, the marginalized. Bad data perpetuates health inequity.”
Interviewer: International organizations like the WHO track immunization data globally. Shouldn’t they have stricter protocols for data quality before accepting and publishing country-level statistics?
Dr. Chandrakant Lahariya: Globally, there’s a push to improve data of health programs. But ultimately, collecting credible health data is a sovereign country’s prerogative. International organizations or agencies can only offer suggestions; they can’t force countries to follow specific procedures.
Interviewer: India’s immunization program has had several successes. We’ve eradicated polio and smallpox and achieved maternal and neonatal tetanus elimination in 2015. These victories demonstrate the power of vaccines! Now, let’s turn our attention to ongoing programs for other diseases.
Dr. Chandrakant Lahariya: Vaccines are a powerful, cost-effective weapon against disease. It’s a proven fact – as immunization coverage rises, disease prevalence plummets. Diphtheria, for example, is largely controlled thanks to vaccines. (Although it’s worth noting, India contributed significantly to global diphtheria cases between 2001 and 2015.) The same goes for whooping cough and many others.
However, we can’t be complacent. COVID disrupted routine immunizations, and by late 2022, we saw a worrying rise in measles cases. This again highlights the clear link: higher vaccination coverage directly translates to lower disease prevalence.
Now, there’s an important point to consider. While our policies currently focus on childhood immunization, we need to expand our focus. Developing policies to increase adult immunization coverage is crucial for long-term public health.
“COVID disrupted routine immunizations, and by late 2022, we saw a worrying rise in measles cases.”
Interviewer: Given the rising burden of NCDs and concerns about compromised immunity, what vaccines should be made available in the next 5-10 years to avoid a major public health crisis?
Dr. Chandrakant Lahariya: There are about 145 diseases for which vaccines are under development. But Vaccines follow a complex journey, from development to delivery. There’s no guarantee they’ll provide a solution for every disease. Vaccines significantly reduce healthcare costs, but the fight continues for diseases like TB or HIV, where we still lack effective vaccines. There’s also the case of dengue, where a vaccine exists but isn’t yet approved for use in India.
We can’t solely rely on vaccines still in the development stage… Plus, the need for vaccines shifts with changing disease trends. COVID-19 vaccines became crucial, but the focus has now changed.
“There are about 145 diseases for which vaccines are under development. But Vaccines follow a complex journey, from development to delivery.”
What we need is to maximize the use of existing, safe vaccines to reach more adults, particularly those who are immunocompromised or have comorbidities. Pneumococcal vaccines, effective against pneumonia, meningitis, and sepsis, are a prime example. While used for children, they’re also vital for protecting vulnerable adults. The same applies to typhoid, chickenpox, and annual flu vaccinations. Additionally, Zostavax reduces the risk of shingles for those over 50, and meningococcal vaccines protect adults.
However, we need to move away from a solely broad public health strategy. Tailored approaches focusing on individual needs are necessary to identify high-risk populations and create communication strategies increasing awareness and acceptance of these vaccines within these specific groups. For example, live attenuated vaccines are not administered in immunocompromised individuals.
“What we need is to maximize the use of existing, safe vaccines to reach more adults, particularly those who are immunocompromised or have comorbidities to reduce out-of-pocket expenditure on diseases”
Interviewer: Can you clarify the optimal age for HPV vaccination, especially given India’s tragic cervical cancer burden? Are there benefits for older women getting vaccinated later? Also, please address the vaccine’s safety profile.
Dr. Chandrakant Lahariya: The HPV vaccine is recommended for a broad age range, typically from 9 years old up to 45 years of age. The ideal scenario is to receive the vaccine before becoming sexually active. Its effectiveness is highest when administered between 9 and 14 years old. In this age group, two doses are typically sufficient. Between 15 and 45 years of age, three doses are recommended. It’s a safe and well-established vaccine used in over 120 countries worldwide. Importantly, it protects against not only cervical cancer but also other HPV-related cancers and even genital warts in men. While there’s always a possibility of individual reactions or minor side effects, the significant benefits of the vaccine far outweigh these minimal risks.
“The HPV vaccine is recommended for a broad age range, typically from 9 years old up to 45 years of age. The ideal scenario is to receive the vaccine before becoming sexually active.”
Listen to the full interview here:
