The authors assume that all vaccines are equally useful and cost effective in all countries. This is far from established.
The
1998 position paper of the WHO stated that countries should consider
Hib burden before introducing the vaccine (1). After the Bangladesh and
Indonesia probe studies showed little benefit from Hib vaccine in these
countries (2), inexplicably, the WHO modified its recommendation to say
Hib vaccine must be introduced in all routine immunization programs,
regardless of national burden (3).
Vaccines against pneumonia
(Hib and pneumococcal vaccine) only address two of the many causes of
pneumonia (and causes of deaths from pneumonia). Even vaccines that are
very efficacious against strain-specific-disease may have very little
utility in the community, because the strain-specific-disease is a rare,
compared to all the other causes of pneumonia (- low utility in terms
of absolute risk reduction). For example, the Pneumococcal vaccine
reduces only 3.6 cases of pneumonia per 1000 children vaccinated
according to Madhi et al. The abysmal cost-benefit equation of this
vaccine was discussed by us in the Lancet not long ago - ( $250,00 will
need to be spent to prevent 4 cases of pneumonia. Treatment of 4 cases
of pneumonia with Septan- as recommended by the WHO - would instead cost
$1) (4). And this was before strain shifts made these vaccines even
less useful (5-13).
The uptake of expensive vaccines of doubtful
utility in poor countries thus requires a huge push. International
organizations like the WHO and GAVI have all played their part. A
previous study has shown that countries without democracy take up
vaccines more easily (14). I wonder if one can develop an index of
arm-twistability of these poor countries. Factors like corrupt
dictatorships, greater dependence on foreign aid, absence of an
empowered civil-society movement and lack of expertise within the
country to allow it to make an independent evaluation of the costs and
benefits, will all contribute to this index of arm-twistability.
Excellent correlation to vaccine uptake with this index is likely to be
found. It will allow international agencies to concentrate on these
countries where the response to their overtures is likely to be more
gratifying.
Jacob Puliyel
puliyel@gmail.com
Reference
1.
Anonymous (1998) Global programme for vaccines and immunization (GPV).
the WHO position paper on Haemophilus influenzae type b conjugate
vaccines. Wkly Epidemiol Rec 73: 64–68. Find this article online
2. Puliyel J. GAVI and WHO: Demanding accountability. BMJ 2010;341:c4081 Pg 266.
3.
World Health Organization (2006) WHO Position Paper on Haemophilus
influenzae type b conjugate vaccines. Wkly Epidemiol Rec 81: 445–452.
4. Dabade G, Puliyel J. Global health and the Bill and Melinda Gates Foundation. Lancet 2009;373:2195-6
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Sheldon L. Kaplan, William J. Barson, Philana L. Lin, Stephanie H.
Stovall, John S. Bradley, Tina Q. Tan, Jill A. Hoffman, Laurence B.
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12. [No authors listed]
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14. Jessica C. Shearer, Meghan L. Stack, Marcie R. Richmond Allyson P. Bear, Rana A. Hajjeh, David M. Bishai.
Accelerating Policy Decisions to Adopt Haemophilus influenzae Type b Vaccine: A Global, Multivariable Analysis. http://www.plosmedicine.o...
No competing interests declared.
