An Index of 'Arm-twistability' of Governments Will be Useful

Puliyel J

Response to
Glatman-Freedman A, Cohen M-L, Nichols KA, Porges RF, Saludes IR, et al. (2010) Factors Affecting the Introduction of New Vaccines to Poor Nations: A Comparative Study of the Haemophilus influenzae Type B and Hepatitis B Vaccines. PLoS ONE 5(11): e13802. doi:10.1371/journal.pone.0013802

Response at

An Index of 'Arm-twistability' of Governments Will be Useful

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 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.

Jacob Puliyel


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

5. Sheldon L. Kaplan, William J. Barson, Philana L. Lin, Stephanie H. Stovall, John S. Bradley, Tina Q. Tan, Jill A. Hoffman, Laurence B. Givner, Edward O. Mason, Jr.
Serotype 19A Is the Most Common Serotype Causing Invasive Pneumococcal Infections in Children. PEDIATRICS Vol. 125 No. 3 March 2010, pp. 429-436 (doi:10.1542/peds.2008-1702)

6. Brown VM, Madden S, Kelly L, Jamieson FB, Tsang RS, Ulanova M.
Invasive Haemophilus influenzae disease caused by non-type b strains in Northwestern Ontario, Canada, 2002-2008.
Clin Infect Dis. 2009 Oct 15;49(8):1240-3.

7. Tsang RS, Sill ML, Skinner SJ, Law DK, Zhou J, Wylie J.
Characterization of invasive Haemophilus influenzae disease in Manitoba, Canada, 2000-2006: invasive disease due to non-type b strains.
Clin Infect Dis. 2007 Jun 15;44(12):1611-4.

8. Urwin G, Krohn JA, Deaver-Robinson K, Wenger JD, Farley MM.
Invasive disease due to Haemophilus influenzae serotype f: clinical and epidemiologic characteristics in the H. influenzae serotype b vaccine era. The Haemophilus influenzae Study Group.
Clin Infect Dis. 1996 Jun;22(6):1069-76.

9. Perdue DG, Bulkow LR, Gellin BG, Davidson M, Petersen KM, Singleton RJ, Parkinson AJ.
Invasive Haemophilus influenzae disease in Alaskan residents aged 10 years and older before and after infant vaccination programs.
JAMA. 2000 Jun 21;283(23):3089-94.

10. McConnell A, Tan B, Scheifele D, Halperin S, Vaudry W, Law B, Embree J; of The Canadian Immunization
Monitoring Program, ACTive (IMPACT).
Invasive infections caused by haemophilus influenzae serotypes in twelve Canadian IMPACT centers, 1996-2001.
Pediatr Infect Dis J. 2007 Nov;26(11):1025-31.

11. Adderson EE, Byington CL, Spencer L, Kimball A, Hindiyeh M, Carroll K, Mottice S, Korgenski EK, Christenson JC, Pavia AT.
Invasive serotype a Haemophilus influenzae infections with a virulence genotype resembling Haemophilus influenzae type b: emerging pathogen in the vaccine era?
Pediatrics. 2001 Jul;108(1):E18.

12. [No authors listed]
Invasive Haemophilus influenzae disease in Manitoba in the post-vaccination era suggests a changing epidemiology.
Can Commun Dis Rep. 2006 Jun 1;32(11):125-30.

13. Kalies H, Siedler A, Gröndahl B, Grote V, Milde-Busch A, von Kries R.
Invasive Haemophilus influenzae infections in Germany: impact of non-type b serotypes in the post-vaccine era.
BMC Infect Dis. 2009 Apr 20;9:45.

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.