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Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Indian TV Channels Investigate Hep B Controversy Involving the WHO - A Report ! In the follow up of the controversy raised by Save the Children (Fiona Fleckin BMJ 2002;324:129) suggesting that international organizations were promoting vaccines in poor countries - ' that they could not afford and perhaps do not need', the BMJ had published a letter to suggest that WHO's Children's Vaccine Initiative was misrepresenting data to promote Hep B vaccine in India (2 Circumventing Market Forces (2) Puliel et al.BMJ 2002;324:975.) Data from Taiwan was being used to project that over 200,000 people died from Hep B each year although there were data available from India that the yearly mortality was only 5000 (Dhir V, ICMR)

In the electronic correspondence, Dr Taneja has suggested that the silence of the WHO in not rebutting the accusations in the BMJ was disturbing and may be construed as tacit admission of guilt.

Investigative journalists from the TV channel Aaj Tak (freely translated to 'The News up to Now') investigated the matter of why the WHO recommends the vaccine in India. They showed an interview of Dr. Jacob M. Puliyel St. Stephers Hospital, Delhi) who repeated the discrepancies in the assessments of WHO and ICMR in regard to deaths caused by Hep B in India. Mind you, he was the person who started the whole debate at eBMJ.
WHO insisted that 250,000 people die of Hep B each year. The WHO implied that the ICMR was probably wrong because the ICMR figures depended on counting actual deaths and all deaths may not be reported in India

The reporters also presented data from the cancer registries kept by the ICMR from which it projects that only 5000 people die from Hepatocellular Carcinoma each year. The ICMR said that they may have had 20% in their reporting but the figure of 250,000 of the WHO was way over the top.
Aaj Tak then went on to present data by Prof S.K. Mittal of Maulana Azad Medical College saying how the Hep B programme would eat up most of the money from more important vaccination programmes.

Finally a clip from the Minister of Health suggested that the Govt also felt that the Hep B programme was not affordable.
The controversy is likely to make the Government reconsider the advisability of introducing this vaccine into the universal programme of Immunization
Based on cost benefit analysis it would be very difficult to recommend universal vaccination with Hep B if only 5000 lives will be saved each year given the vaccine costs of 75 million doses of Hep B vaccine needed to immunize the countries birth cohort each year. Star News also carried the same story few days earlier.
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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin,
I realise that still there is a lot of unclear thinking on hepatitis B vaccine and its potential use in our national immunisation program. The line of reasoning that if 250,000 people died for want of HB vaccination, then the vaccine is acceptable, but if only 5000 died, then it is not acceptable is incomplete for two reasons. First, those who believe that prevention of death is the objective of HB vaccination program must state what number of deaths tilt the balance towards acceptance. Then they must provide information indicating that the actual range of number fall short. Similarly, the opposite camp should state their case along the same game rules. In the absence of such process, the numbers game does not take us anywhere. There should be seriousness of purpose with estimating number of deaths. What are the diseases due to HB virus that cause death? Fulminant HBV hepatitis, how many? HBV-induced Cirrhosis deaths, how many? HBV-related hepatocellular carcinoma, how many? Both sides should present thier estimates with methods of estimation.

In India, the governments, both at the centre and in the states, have neglected classical public health, which demands disease surveillance and collation of morbidity and mortality data by diagnosis. Consequently there is dearth of reliable data on almost all infections and diseases. This provides the opportunity for individuals and organisations to argue their case for or against any proposed intervention, and attacking your data with our data provides a plan of armchair game that spills into media. Serious policy issues are not settled in the media, but the ground can be prepared if one has the supporting evidence.

When will HB vaccination programme begin reducing the number of deaths? What is the median age of death caused by any HBV disease? Obviously the benefit is in the future, for expenditure today and into the future. Such expenditure is called investment. If investment (HB vaccination program) is calculated in terms of money, then the benefits must also be calculated in terms of money, with economic adjustments for amortaisation and inflation.

Now, whose responsibility is it to take us through all these, those who want the vaccine or those who do not? It looks to me that people first choose the side and then look for points to argue the case.

There is another side to this issue. Both sides seem to agree that HB vaccine is effective to prevent HB virus infection. There is indigenously made high quality HB vaccine costing about 20-25 rupees per pediatric dose. If we let families who can afford to buy the vaccine and injection services get the benefit, then does the government have any responsibility to the economically weaker families? Here every new vaccine comes as question marks. If a minority of rich families use a vaccine, then the onus is less demanding on the government, but if most rich families use it, then the demand is greater o the government to provide it to the poorer families. In which category will chickenpox vaccine fall? And in which category HB vaccine fall? This is another way serious-minded persons can look at the need for a vaccine in the national program.

Then there is yet another issue, namely, how do we make decisions in the absence of robust data? Here a judgement is needed, by experts. Not just one expert, but by a group or a body of experts. They should not have conflict of financial interests. In our context, both IAP leaders and Indian Association for the Study of Liver Diseases have argued strongly for inclusion of HB vaccine in national program. While dissention is to be welcomed, dissenters should provide rational lines of debate, not just emotional, using print media, news media etc.

Finally, I have been a strong advocate for inclusion of HB vaccine in our national program. My understanding of its purpose is to prevent HB virus infection. We know that there is vertical transmission. The estimated numbers are 166,000 to 333,000 infections annually, leading to 150,000 to 250,000 HB virus carriers being added each year to the carrier pool. Thus, prevention of vertical transmission should become part of our national program. Then there is horizontal transmission, for which the age at risk is from infancy to adult age. The numbers are much larger, since we know roughly the proportion of carriers in the population and if we minus the vertical transmission (which carries highest probability of carrier state) then we get a picture of the magnitude of this mode of transmission. It is huge, I do not have readily calculated numbers, but obviously much more than vertical, just by comparison of carrier rate consequent to vertical versus horizontal. The ultimate consequences are fulminant hepatitis, cirrhosis etc. but all due to infection and its immediate effects or late effects. Preventing these become society's responsibility since intervention is available and feasible, and affordable. The cost of a dose is equal to one meal. If all of us skip three meals each year we can pay for the national immunisation program. I have a small group called SAMAM, skip a meal a month and give the savings to charity. Very occasionally I drink a beer, costing two doses of HB vaccine. My weekly coffees (or teas) equal a few doses of HB vaccine. A nation that does not protect its children, cannot be on its way to development. One other thought. When I became the Purchase Committee Chairman in CMC Hospital, I found that our internal printing press could not compete with outside printers competitively. This anomaly made me study the situation in depth and it struck me that the workers were happy not to work but earn their salary whether or not they made profit. When we gave them contractual orders, they produced good quality items, and the Finance Department complemente me for recouping the salaries of the staff. The lesson: money did not go outside our institution, it simply moved between our own books. If we used indigenously made vaccine, money circulates within India, driving economic development. You can ask any economist if this is true. Now, I have no financial interests in companies, but I do have a tremendous stake in my country progressing economically, health-wise and publlic health-wise.
Hope these lines will help people to understand the complexities of issues and the need for clear thinking and seriousness of purpose.
T Jacob John
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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

There are not too many points to be disagreed with you, Sir!
I more or less endorse your views in this regard.
The problem is public health in India lies in shambles.
We are still not able to decide what our children do need the most!
We still look at the outside world to provide us the estimate of the illnesses faced by our children!
And remedies too!
Ridiculous!
Isn't it?
Vipin

_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin
Thanks for forwarding TJJ views on HB vaccine,which as usual ,I fail to make any sense because of long convoluted sentences which can be construed to mean anything.Any way it gives me an opportunity to restate my view points on HB

i) Vertical transmission constitutes an important,if not,the predominant mode of HB transmission. Upto 30-50% carriers may be due to this mode. Almost 2,60,000 carriers are being added annually because of vertical transmission.
ii) HB in UIP must be able to prevent both vertical and horizontal transmission
To be able to do this HB vaccination must start at (Within 48hrsof) birth. With 80% births occuring at homes and 50% not even being attended by TBWs,this is logistically impossible.
iii) Any HB vaccination program not focussing on (or ignoring) vertical transmission has not been shown to be cost effective in any model
iii)Available HB morbidity & Mortality data is highly inadequate. Largely based on tertiary care centres studies and Taiwanese model,this appears to be highly exaggerated.
iv) Any recommendation of incorporating a vaccine in the National program must
asses Feasibilty(logistics),efficacy,safety,and cost effectiveness of the vaccine .
While efficacy and safety of HB are not much in doubt(Although mercury component does raise some doubts),but logistics and cost effectiveness are definitely not in favour of HB vaccination in UIP.
v) Any health intervention such as HB vaccination programme should also be able to asses its cost effectiveness vis a vis other heath intervention programmes.Again when assed against this parameter HB vaccine does not assume any priority. Disease like diarrheas,HA,HE.Enteric etc are far more prevalent. Single step of Safe Water supply and sewage disposal will take care of most of these (and many others) .Even If the proposed annual outlay for National HB programme can be spent to ensure safe water supply and sewage disposal in just a few districts, to my mind this would have greater efficacy in reducing morbidity & mortality in the country. Then again it is a greater priority to reach package of CSSM ( ANC,safe delivery &NN care) services to unreached population than to give HB vaccine in UIP.

If the proponents of introducing HB vaccine in the UIP are so sure of their recommendations (&their data) why not have an open debate in any public platform
like the National IAP conference? I ,for one, is willing to throw an open challange to anyone interested in this debate.
With best wishes for A VERY HAPPY NEW YEAR to you and all others who may be reading this message.
Dr SKMittal
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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin,
Thanks for sending me Dr Mittal's comments on my views. I do not have his e mail id in my address list. Nor is it in the forwarded message.

Will you kindly ask him to identify those sentences that are complex and difficult to understand and I will make the meaning clearer by elaborating it.

It is obvious that Dr Mittal has followed my reasoning in part and he has agreed with some of them. He has restated some points, many of which are widely accepted with no disagreement.

The major point of deviation is regarding hepatitis B vaccination versus clean water supply. I know of no evidence that HB vaccination stands in the way of clean water supply, politically, ideologically or economically. There is no constraint that we can control either water-borne infectious diseases or hepatits B virus diseases. This conflict is imaginary and unhelpful. If Dr Mittal or yourself or any person has evidence that the assessment of the need for HB vaccination and its recommendation for inclusion in national immunisation program has affected drinking water supply, please let me know details.

Regards
T Jacob John

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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Guest · Posted: Sat Jan 04, 2003 6:14 pm Post subject:

Dear Vipin
I found the debate between Prof T Jacob John and Prof S K Mittal thought
provoking

Let us try and understand this parable from the printing unit at CMC Vellore.

At the outset I must state that I am aware that the employees at CMC are
some of the most underpaid in the sector, and yet they are a highly
motivated and productive unit.

The story at their printing press is different. We are told that the
employees at the printing unit resented their poor wages, and that they
were demoralized and unmotivated. As a result the hospital had to get all
its quality printing outside. The hospital thus paid the workers wages and
also for he outside contracts.

As a Manager, Dr Jacob John decided to pay the money, which CMC was already
paying to the outside contractors, as an incentive to the hospital press
workers themselves. Presto! The workers were producing good quality work.
The hospital did not have to pay anything extra more than what it was
paying already.The workers got their wages with incentives.

In this idyllic situation, with high worker satisfaction, it maybe
sacrilegious to ask if the hospital would make a greater saving by
continuing to get the work done outside and closing down the inefficient
in-house printing unit. Under these circumstances less money will need to
be paid to get the job done through a more efficient outside agency and the
money paid in wages would be saved!

After this parable we are told that India produces good Hep B vaccines and
that by using Hep B vaccine we will boost the Indian Economy.

This is like saying, "India makes the Ambassador Car" It is said to be a
good car for Indian roads. "If only the Government of India would buy a
car, for each family in our country, it would solve all our economic problems.

There would be a great boost in demand for Hindustan Motor cars. The
company will employ more workers and pay them better. These employees will
have more money in their pockets and they will go out and buy soaps,
cigarettes, TVs , fast food, - the lot. This will then give an impetus to
all these sectors. The workers at fast food outlets will get better wages
and they will buy more and so on. All the countries problems would be
solved if the Government can be persuaded to buy 1 car for each family!"

The wealth of a country is not governed by its consumption but by its
production and exports. This is how rich countries become richer - by
exporting to other countries - cars, vaccines, whatever. The world as a
whole is not getting richer. The rich are getting richer The poor are
getting poorer. And our Globe is getting poorer in the race for
consumption and squandering of our resources in unsustainable ways.

This brings me to the question Prof John asks. Why bring in the issue of
the absence of drinking water in the country? Where is the evidence that
Hepatitis B vaccination prevents supply of clean water? After all, vaccines
fall in the domain of the health sector, while water supply does not. The
two are not competing for the same budgetary allocation.
It is sad when we can see only our own sector. We forget that all
interventions are paid for form the same national kitty, by the taxpayers.

Dr John says experts of the both IAP and Indian Association for the Study
of Liver Diseases (INASL) have argued strongly for inclusion of HB vaccine
in national program. The INSAL made an economic evaluation of Hep B vaccine
use and published this in the Indian J of Gastroenterology (Dec 2000). This
was so full of errors (see Sept 2001, Nov 2001 and Mar 2002, issues of the
India Journal of Gastroenterology) that the Corresponding Author has
finally written, that he cannot any longer defend the calculation of the
INASL and "the calculations need to be sent back to the experts" (Dr SK
Sarin, Indian J of Gastroenterology 2002;21:87)

In the same vein Dr John says the cost of a single dose of the vaccine is
Rs 20 to 30. I hope he is not confusing the cost at which vaccine companies
are willing to supply vaccines to the Government for a pilot project, with
the price of the vaccine. Drug companies are more than willing to give
drugs as free samples for clinical trials. It would be wrong in an economic
calculation to count the cost of drug as zero because free samples were
made available for the trial!!

The Chairman of the Serum Institute of India said recently that a 20 infant
dose vial of their Indian Hep B vaccine costs Rs 1400. The cost of a dose
is Rs 70. assuming no wastage from this large multi use vial. He speculated
economies of scale may bring the price to Rs 40.

We know Hep B is spread by the use of unsterile needles. Surely we are not
going to use re-boiled needles, to give Hepatitis B vaccine. We need to add
the cost of disposables.

Does Dr John recommend that the vaccine is given at birth? If so has the
cost of giving the first dose to babies born at home been added?

How can Rs 70 (or consider Rs 40 as cost of vaccine), plus cost of
disposables, plus cost of giving the first dose at home, total up to Rs 20
to 30. Are these cost not to be reckoned?

There is a good evaluation that suggests that, given India's GNP, and the
lives saved by vaccination, Hepatitis B vaccine will be cost effective
when the price comes down to Rs 6 /dose.
My argument is not that we must not vaccinate with Hepatitis B. We need
honest costing. Unfortunately when that is done the vaccine is not cost
effective.

Warm regards and all good wishes for the New Year
Jacob M. Puliyel

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin,
Thanks for the forwarded mail.

I can see how people get misguided and 'though vanquished, yet will argue'.
If Dr Puliyel got the CMC story completely wrong, no wonder how wrong he is on hepatitis B vaccine aslo. No clarifications needed? Sarcasm is the attempted wit of the witless.

I do not manufacture nor sell nor profit from hep B vaccine personally. In the interests of the health and development of our people, the vaccine is a must. I do not have any need, urge nor responsibility to debate the issue with Dr Mittal or Dr Puliyel, nor to get their views changed. If the debate is serious, it is my duty as a teacher to repond, but only if it is; not otherwise. Let them continue in their belief; history is replete with such episodes and persons. If they are so sure, let them convince the policy makers.

Getting clean water to people is not just their idea, or recommendation, but everyone else's too. I have not come across any opposition to it. Championing a common cause is no support for a different cause. One does not prove one's credibility or competence by supporting apple pie and motherhood. How naive.

Regards.
T Jacob John.

_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin

It is unfortunate that Prof Jacob John finds my letters witless
However he is still to answer the question about how he arrived at the conclusion that it costs Rs 20 -30 to give one dose of Hepatitis B vaccine

1. Is he including price of "free samples for clinical trials" and drugs-given-at-concessional-rate to the government, for study purposes, as 'cost of the drug'?

2. Has he included price of a disposable syringe

3. Has he included the cost of going to each newborn baby's home and giving the first dose at birth? (70% mothers deliver outside hospitals and nursing homes)

The Indian Association for Study of the Liver (INASL) calculated its cost benefit analysis assuming the vaccine costs Rs 50/person
When this was challenged, the Corresponding author for the INSAL Professor SK Sarin, was gracious enough to openly declare in the Indian Journal of Gastroenterology that the figure was arrived at using out-dated data and the calculations need to be redone by the expert group.

There is no compulsion for Prof John to answer the issue here, but as an adviser to the Government of India, he owes it to the country to explain if he is using 'out-dated figures' that may mislead the Government

This debate started because the TV channel, 'Aaj Tak' exposed the WHO for exaggerating benefits (claiming 250,000 lives are saved from hepatitis B related cancer, where the actual figure is 5000). (Details of which were published in Pediascene). The other aspect is this underestimating of costs, to make it appear as cost effective.

Sincerely
Jacob M.Puliyel
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

message edited!
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin
I am not a doctor, nor a health sector expert. I am just a concerned citizen who is excited by the fact that such important issues are being debated in an open manner without confining it to a select group of
experts . I have been fortunate to view from the sidelines the ongoing HB vaccine discussion.

I have chosen to break my silence because I am finding it difficult to understand why Dr. Jacob John refused to comment on the substantial part of Dr. Pulliyel s response and instead confined himself to commenting on the attempted sarcasm [and debunking of the CMC press example].

I would have loved to see Dr. Jacob John s serialized response to the following points raised by Dr. Pulliyel. [I have simply given numbers to Dr. Pulliyel s remarks in the hope that Dr. John would respond to each of them]

1. Puliyel said, This brings me to the question Prof John asks. Why bring in the issue of the absence of drinking water in the country? Where is the evidence that Hepatitis B vaccination prevents supply of
clean water? After all, vaccines fall in the domain of the health sector, while water supply does not. The two are not competing for the same budgetary allocation. It is sad when we can see only our own
sector. We forget that all interventions are paid for form the same national kitty, by the taxpayers.

2. Puliyel said, Dr John says experts of the both IAP and Indian Association for the Study of Liver Diseases (INASL) have argued strongly for inclusion of HB vaccine in national program. The INSAL made an economic evaluation of Hep B vaccine use and published this in the Indian J of Gastroenterology (Dec 2000). This was so full of errors (see Sept 2001, Nov 2001 and Mar 2002, issues of the India Journal of
Gastroenterology) that the Corresponding Author has finally written, that he cannot any longer defend the calculation of the INASL and "the calculations need to be sent back to the experts" (Dr SK Sarin, Indian J
of Gastroenterology 2002;21:87) .

3. Puliyel said, In the same vein Dr John says the cost of a single dose of the vaccine is Rs 20 to 30. I hope he is not confusing the cost at which vaccine companies are willing to supply vaccines to the Government
for a pilot project, with the price of the vaccine. Drug companies are more than willing to give drugs as free samples for clinical trials. It would be wrong in an economic calculation to count the cost of drug as
zero because free samples were made available for the trial!!

4. Puliyel said, The Chairman of the Serum Institute of India said recently that a 20 infant dose vial of their Indian Hep B vaccine costs Rs 1400. The cost of a dose is Rs 70. assuming no wastage from this large multi use vial. He speculated economies of scale may bring the price to Rs 40. We know Hep B is spread by the use of unsterile needles. Surely we are not going to use re-boiled needles, to give Hepatitis B
vaccine. We need to add the cost of disposables.

5. Puliyel said, Does Dr John recommend that the vaccine is given at birth? If so has the cost of giving the first dose to babies born at home been added? How can Rs 70 (or consider Rs 40 as cost of vaccine),
plus cost of disposables, plus cost of giving the first dose at home, total up to Rs 20 to 30. Are these cost not to be reckoned?

6. Puliyel said, There is a good evaluation that suggests that, given India's GNP, and the lives saved by vaccination, Hepatitis B vaccine will be cost effective when the price comes down to Rs 6 /dose. My
argument is not that we must not vaccinate with Hepatitis B. We need honest costing. Unfortunately when that is done the vaccine is not cost effective.
Regards,

Santhosh Mathew IAS
National Executive Director
LEAD India
B-10, f.f. GK Enclave Part-II
New Delhi 110048
www.lead.org ; Email: mathew@leadindia.org
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin

Like Mr Santosh Mathew I have read this debate with growing excitement. Dr T Jacob John has written in his first letter that "Experts advising Government" must not have a conflict of interest. In his third letter he writes for himself, that he does not manufacture nor sell nor profit from Hepatitis B vaccine personally.

The definition of 'Conflict of Interest' is broader than this. In the January 2003 Issue of the journal of the Indian Academy of Pediatrics - 'Indian Peditrics" there is an Editorial on 'Conflict of Interest' and this defines competing interest as
1. Reimbursement for attending symposia
2. Fee for speaking
3. Fee for organizing education
4. Fund for research
5. Fund for consultation received in last 5 years from an organization that will gain or lose
financially from the conclusion (vaccine companies in this case)
Will Dr John make a statement of the absence of conflict of interest in this context?
Will he resign from his post as advisor to Government if there is a conflict of interest and he has himself said that 'experts must have no conflict of financial interest'?
This is not essential but it may be the decent thing to do!

Dr. Rajiv Mittal
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Why is mortality from Hep-B being debated as an issue ? I think all should realise that hepatitis B - the disease - is a terrible disease and even if one does not die from it, it can cause a lot of morbidity, it can get transmitted and treatment can be much more expensive than the vaccine. Hence, if there is a vaccine which can help prevent the disease, it should be welcomed rather than looked upon with scepticism. Forget the figures on mortality; a dead person remains a statistic - morbidity from the disease is living hell; that should be the key issue.

Dr V.Bhatnagar
Additional Professor,
Paediatric Surgery,
AIIMS,
New Delhi
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Dr.Vipin Vashistha,

From my comment " First Dose of Hepatitis-B Vaccine (HBV) in Infants" which appeared in Indian Pediatrics of October 2002, the following last paragraph was deleted -

"And quite ironic too, as this was the kind of scenario highlighted as preventable with the use of HBV when it was first introduced with such fanfare few years ago. Not just the skeptics who always doubt, but even the naive who always believe in the revealed truth in such guidelines, will wonder about the reasons for such creative ambiguity in the new Guide Book. But such matters are too unwholesome to be discussed or even mentioned in the hallowed pages of a professional journal like Indian Pediatrics, though our profession is not unknown for such fallibilities."

I was not at all surprised by the delition, though it would have explained much of the reasons for these debates. We have big MNCs trying to sell their products at any cost to the purse and even the health of the people, and we have organizations like the IAP which just act like salesmen for these MNCs. And a large pool of shameless professionals who just do what the salesmen tell them to do. But then how else can one enjoy the big bashes at Five Star Hotels provided by the MNCs in the name of continuing education ? And get "educated" and return home to start writing prescriptions for newer and costlier remedies for real and imagined maladies. And get richer too !!

With regards,

Dr.Alexander Mathew, F.A.A.P.
Dept. of Pediatrics
St.Joseph's Hospital
Manjummel, Kochi, 683 501
_________________
Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

Dear Vipin
I have replied only after really spending time to read the comments and counter comments and have a few points to offer:
PLEASE STOP THIS DISTASTEFUL EXCHANGE OF WORDS unbecoming of men of your stature for it lowers each of your own reputations!
1. The tone of Drs. Jacob John, Jacob P. and Mittal in various degrees appear in extremely bad taste and are personal mudslinging exercises not expected of wonderful teachers whom I personally have respected... till their various published remarks at different forums. I'm not sure that they even realise that most Paediatricians now see only a series of personal attacks on each other through their combative articles. They in their attempt to get the upper hand stray from the debate making on-lookers wondering what exactly is the discussion about? This is certainly not a healthy debate!
2. They obviously realise that that they all have points that they agree upon but will not say it to each other publically for fear of losing face!!! Can you imagine if they all work together, acknowledge that they are wrong in some issues and right in others and together reach a consensus on the issue puting their obvious personal feuds behind. Then I among others will salute them all as true experts! Are they BIG enough to do so is the important question?
3. As I see it there are additional questions the three experts have to answer (they are permitted to use each others arguements giving credit to each other)
- How are experts chosen at every level - IAP, Task Forces, Government - who assist in deciding such decisions affecting our children? Should we recommend criteria for the future to define experts? Maybe an assessment of existing expert task forces will reveal the pure politics and conflicts of interests involved!! Can these senior gentlemen point these out to the Academy?
- What are our children's health needs and priorities before Paedaitricians and therefore Government? Should we list the same and publish it and then tell the Government and IAP the true priorities before our country's children?
- Accepting that Hepatitis B is one problem (We must agree that though connected to adult mortality it may be not too high on our priority list but with an available vaccine it has a potential to be introduced), when should it be recommended ideally to restrict and maximize cost benefit? What one ideal time tested schedule do we recommend? Do we then acknowledge a few mistakes and recommend changes to the IAP and National recommendations?
- Are there other simpler measures whcih need to be stressed and 'marketed' aggressively to prevent such diseases on par with the industry's marketting techniques purely of the vaccine? Should we recommend public posters, advertisements illustrating these measures as being the best and most cost effective measure of educating the public? Or do we silently permit the industry to have a ball?
- Given the availablity of the vaccine now not as expensive as it used to be, by all permutations and combinations, arent there issues regarding refusing to offer it to those who would like to take it and could afford it versus those who cannot afford to take it considering our nation's majority economic status and possible risk? Shoudl we be recommending vaccines based on an individual or community need? If community how can I ignore the individual and vice versa?
- Should we accept that there have been conflicts of interest that MAY have crept in and that it really may be the honourable way out? Imagine the scientific honesty and courage in declaring the conflict whcih may or may not have played a role in our decisions at various levels!? Maybe we can then point to others their roles in various decisions making processes and clean the system.
- Are there other vaccines more important then this one which the three of you can insist on based on health priorities of our children - regional or national; mortality versus morbidity? Are there vaccines introduced and marketted even on plastic supermarket carry bags prior to the actual need being propogated and told to the public whcih are too expensive and may not make public health sense?
As a committed teacher like yourselves I usually tell my students that any public health decision made should be based on the priorties and needs of the community (eg. children) and economic cost-benefit clinical issues become most important not only for the protection of the individual but also for the community as a whole. As children's advocates it is our job to protect the children we care for and assist in decision making for their welfare (even if it is food, water, hygiene, disposable needles versus a vaccine; complications versus costs of vaccinating all at the expense of leaving behind a vulnerable population; recommending a schedule change versus the accomodation of the industry's latest combination product, etc.)
We all do look forward to a Jacob, Jacob and Mittal consensus statement on "Issues in Hepatitis B Vaccination and Lessons learnt" in the near future especially in the absence of adequate published Indian data to assist all three of you !
Warm Regards (and, on a lighter note, please dont attack me personally unless you really feel the urge!!)
Sanjiv Lewin
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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India

Vipin Vashishtha · Joined: 09 Dec 2002 Posts: 49 Location: Bijnor, India

HEPATOCELLULAR CARCINOMA DEATH IS LOW- SO WHAT? WHY NOT VACCINATE WITH HEPATITIS B TO REDUCE INCIDENCE OF HEPATITIS AND DEATH DUE TO FULMINANT HEPATITIS?

Dear Dr. Vipin,

Let us look as how the argument for hepatitis B vaccination has developed over the years.

Hepatitis B is a relatively uncommon cause of hepatitis in children in India. Pandey et al suggest that it is responsible for 20% of acute viral hepatitis ( while hepatitis A is responsible for 56%) [ Pandey SK, Datta R, Gupta A et al. Tropical Gasteroenterology 1989; 10 : 106.] Tandon et al says hepatitis B is responsible for only 9% of cases ( while hepatitis A is responsible for 67% cases) [ Tandan BN, Gandhi BH, Joshi YK. BULL WHO. 1984; 62:67.].
Look at fulminent hepatic failure. Only 12% are due to hepatitis B ( 22% are due to hepatitis C , 42% are due to Non A non B hepatitis) [ Irshad M, Acharya SK . Intervirology 1994; 37:396-72.]
NEITHER ACUTE INFECTION NOR FULMINANT HEPATITIS COULD JUSTIFY THE MASSIVE EXPENSE REQUIRED FOR UNIVERSAL VACCINATION WITH HEPATITIS B.

If hepatitis B is such a minor actor why vaccinate with hepatitis B vaccination
We were told acute infection is unimportant . Hepatitis B can result in a chronic carrier state.

That 2-4% of India's population are chronic carriers.
That 25% of chronic carriers will die of sequelae - of cirrhosis leading to hepatocellular carcinoma ( HCC).
That 250,000 people die of HCC each year in the country.
NOW IT SEEMS THAT THE FIGURE 250,000 IS WRONGLY PROJECTED FROM THE TAIWAN FIGURES . THE REAL FIGURE IS 5000.

It looks as if there is no real justification for making the vaccination part of universal immunization programme in India. On the basis of cost benefit analysis - the burden of illness due to acute hepatitis , fulminant hepatitis and chronic hepatitis together , is too miniscule compared to the cost involved in universal vaccination.

Dr Vineet Tyagi
Pediatrician

Govindpuram colony

Ghaziabad U.P.

e-mail: vin_tyagi@rediffmail.com
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Dr Vipin M. Vashishtha,
Bijnor-246701(UP)India