Brief Report: IMA Subcommittee on Immunization Report on Meeting of Experts 14 May 2006 Hotel Imperial Janpath
http://www.imanational.com/Hepatitis/Report.htm
This is a brief report of the meeting of Experts held at Hotel Imperial on 14/5/06. The meeting was sponsored jointly by the IMA and PLAN international (India)
Indian Medical Association
Subcommittee on Immunization
Report on Hepatitis B and Poliomyelitis in India
Chairperson Professor S K Mittal
Indian Medical Association
New Delhi 2006
Contents
Section 1
Brief Report 3
Section 2
Systematic Review of Hepatitis B in India 24
Section 3
Position paper on Polio Eradication Initiative in India 82
Section 4
Discussions and recommendations of Expert Committee 125
On Hepatitis B and Polio
Brief Summary
Preface
The issue related to introducing Hepatitis B immunisation and controversies regarding the polio eradication program have been causing concern among medical professionals in the country. The National President of the Indian Medical Association, Dr Sundipo Roy set up a subcommittee under the chairmanship of Prof S K Mittal with Dr. Dharam Prakash as Convener, to look at the issues involved. The committee first met on 19 October 2005 . It was decided to hold a national level consultation on 14 May 2006 to discuss the issues related to Hepatitis B immunization and polio eradication in India. It was resolved that prior to this, the sub committee must draft a White Paper to act as a position document.
The background papers were circulated to a host of eminent experts in the country, spanning several specialties including Pediatrics, Gastroenterology, Public Health, Biostatistics and Social Sciences. The experts studied the documents and met together for a workshop on May 14, 2006 at New Delhi. Besides researchers, Dr. P. M. Bhargav, Vice Chairman of the National Knowledge Commission, Dr. Jay Wenger, Project Manager of the WHO National Poliomyelitis Surveillance Project, representatives of the Indian Academy of Pediatrics (IAP) and India Expert Advisory Group on Polio Eradication were invited. The background papers were presented and each member present was asked to respond. The comments of all members were tape recorded. The final conclusions were drawn by consensus at the end of the day. Thereafter the summary of the proceedings was circulated by e-mail to all participants who were again invited to suggest further modifications. These responses along with the proceedings of the work-shop used to develop a set of conclusions and recommendations. The full text of the two White papers presented and the discussion at the consultation is available on line on the IMA website imanational.com. This booklet contains a short summary of the proceedings of the day and the recommendations of the IMA Subcommittee on Immunization on the issues of Hepatitis B vaccination and Oral Polio Vaccine in India.
Full report is available on the IMA website: imanational.com
Brief Summary
Report on meeting of experts
IMA National Consultation of Experts on Immunization
A national consultation of experts was held on 14 May 2006 co-sponsored by Plan International (India). Plan International (India) was represented by the India Health Advisor Dr Nalini Abraham. The President of the IMA Dr Sanjiv Malik, and Honorary General Secretary General, Dr Vinay Aggarwal were dignitaries present from the IMA.
The program was inaugurated with a welcome address by Dr Vinay Aggarwal. The inaugural address was given by the IMA President Dr Sanjiv Malik. Professor S K Mittal as Chairperson of the Subcommittee on Immunization spoke of the objectives of the workshop.
Workshop on Hepatitis B in India
The first session was on Hepatitis B. Professor SK Mittal was the Moderator and Dr Joseph Mathew was rapporteur. Dr Jacob M Puliyel presented the draft White Paper. The White Paper was based on a systematic review of literature and a meta-analysis of the point prevalence data on hepatitis B and data on resultant deaths from Hepatocellular carcinoma. Also a search of literature using broad and inclusive search terms was performed for studies evaluating the pilot project in India. Systematic search of international literature for efficacy of the 6, 10, 14 week schedule was also presented.
The experts were invited to add references which were missed in the systematic review. Each expert was invited to respond. The entire white paper and discussions are available on the IMA website imanational.com. A summary of the systematic review and the final recommendations is presented in this brief report.
Workshop on the Global Polio Eradication Initiative in India
This second session was held after lunch. The moderator of the session was Professor S K Mittal. Dr Tarun Gera was rapporteur.
Dr J Wenger National Polio Surveillance Project spoke first on the current status of polio eradication in India. He also responded in writing to the position document. His written response is being published unedited on the web site.
Dr Onkar Mittal and Dr C Sathyamala presented the position document. They discussed the strides made in control of the disease and the costs both monitory and to other public health initiatives. They highlighted the problems of vaccine induced poliomyelitis and the unexplained, unprecedented increase in non-polio acute flaccid paralysis. The issue of the use of monovalent polio vaccine as part of a Phase 4 trial without following established national guidelines evoked expressions of concern.
Conclusion
Immediately after a tea break a draft of recommendations was formulated having incorporated the opinions of all the experts and presented to the group. A formal set of recommendations was then emailed to the experts. This booklet summarizes the position papers and the final recommendations.
Vote of Thanks
Dr A Gambhir General Secretary IMA Academy of Medical Specialities HQs, gave the vote of thanks to the sponsors, and participants.
Brief Summary
Systematic Review and Meta-analysis of Papers Related to Hepatitis B in India
Executive Summary
Objectives
• To assess the prevalence of Hepatitis B in the country, and collect available data on deaths from hepatocellular carcinoma.
• To evaluate what the immunization program will cost the country.
• To look for evidence of the success of the pilot project.
• To collect evidence from world wide literature on the results of Hepatitis B vaccination starting at 6 weeks
Search strategy
Searches were made in Medline, Cochrane Library and Best bets and previous reviews, including cross references.
Data analysis
Done using standard Meta analysis software
Main results
1. The true prevalence of Hepatitis B, in non-tribal populations in India is 2.1 (95% CI 1.8-2.5). This corresponds to a chronic carrier rate of approximately 1.6%. Among tribal populations it is 19.4 (95% CI 15.3–23.5)
2. The death rate from Hepatocellular carcinoma is very low in the country and constitutes 1.6% of all cancer deaths.
3. The pilot project has not been evaluated properly.
4. The proposed schedule of immunization starting at 6 weeks has not been shown to be efficacious (in reducing prevalence) in any country in the world.
5. The cost outlay for universal immunization in India is Rs 500 crores each year.
Author’s conclusions
An evaluation of the pilot project is required before the Government of India decides to incorporate Hepatitis B immunization in the EPI. The data required are:
1. Coverage (with 3 doses of Hepatitis B vaccine) in the pilot area.
2. The fall in carrier rate in the pilot study area
3. Carrier rate among those immunized at 6 weeks compared to those immunized at birth
This is essential because the proposed schedule of immunization starting at 6 weeks, has not been shown to be efficacious (in reducing prevalence) in any country in the world.
Professors SK Mittal on the importance of preventing vertical transmission
Vertically acquired hepatitis B results in chronic carrier state in 90% compared to only 5% when infection acquired after 6 year of age. It is therefore responsible for most cases of HCC due to Hepatitis B infection. It is important to know the extent of vertical transmission before formulating Public Health Policies for Universal Infant Immunization
In China, horizontal transmission important. Qu ZY report that the number of chronic carriers increases from infancy to childhood.
Prevalence of HBsAg +ve in China:
0-1 yr 3.2 %
1-4 yr 8.9%
5-9 yr 10%
In India however there is no significant difference in prevalence of Hepatitis B markers among infants 0-6 months old and children 4-5 years old (Jain V. et al, Tandon BN et al.) Thus there is little evidence to support hypothesis of the acquisition of Hepatitis B infection in infancy/early childhood by horizontal transmission in India. Most children are carriers by 5 years of age in India. 2/3rd of all carriers probably occur due to vertical transmission
Synopsis of comments of the experts
Dr Anand Phadke pointed out that point prevalence must be multiplied by 0.67 to get the carrier rate. He said the meta-analysis showed India was a low endemicity country.
Dr Ashok Gupta cited a thesis where no vertical transmission was recorded
Dr Ashok Kale said the previous estimate of 4.7% carrier rate was an arithmetic mean and hence methodologically incorrect.
Dr C Sathyamala said that the forest plots in the white paper showed very narrow CI suggesting the data is well powered to interpret it reliably.
Dr CP Bansil also wanted vaccines to cover both vertical and horizontal transmission.
Dr Joseph L Mathew said that the HBV program must be looked at against other pressing health care needs.
Dr Naveen Thaker said that the major route of transmission was horizontal but the most important was vertical transmission.
Dr Panna Choudhury said deaths from cirrhosis due to HBV must be studied. He also favored a study in the pilot areas of Delhi and Andhra Pradesh. He said the present evidence was insufficient to decide on a vaccination policy.
Professor R Agarwal suggested that horizontal transmission was the major problem in India.
Dr Raju Shah suggested that cost efficacy be compared with other vaccines. He said one third carriers were due to vertical transmission. He felt the program may cost only Rs 135 crores.
Dr Ritu Priya said 1% of all deaths were due to chronic liver disease. She wanted clarity on what proportion of this was due to HBV.
Dr Tarun Gera said that there was indeed no study in world literature where the 6,10,14 week schedule was found efficacious.
Dr V Sreenivas said that the ICMR cancer registry was reliable and accepted the world over. He also said evidence based medicine was the best approach although traditional wisdom has its own place.
Dr V N Tripathi strongly supported the birth dose
Prof B N Tandon felt that academic discussions need to be abandoned and we need to get on with immunization but it must be decided whether to vaccinate universally or selectively. He too thought the cirrhosis deaths due to HBV need to be studied. He opined that we had become slaves to evidence based medicine.
Prof Parthasarthy suggested routine testing of pregnant mothers and birth dose to babies born to HBsAg positive mothers.
Prof U Jhamb said 0.5% admissions in children were due to Chronic liver disease and 20% of this was due to HBV.
Professor Nirmal Kumar felt Evidence Based Medicine was not the appropriate approach to arrive at right answers. He felt that vertical transmission needs to be prevented and suggested that if costs of vaccine came down, people would buy their own vaccine.
None of the experts cited papers that had been missed out from the systematic review.
Plain Language Summary
The pilot project areas can provide useful data on feasibility, cost and efficacy of the Hepatitis B vaccination program starting at six weeks. It is difficult to defend the incorporation of Hepatitis B vaccine in the EPI without evaluating experience from the pilot project. More research is needed, especially as there is no data in literature that vaccination starting at 6 weeks is efficacious. Costs must be looked at against competing priorities
Recommendation on Hepatitis B vaccination in India
Conclusions and Recommendations from the National Consultative Meeting on Hepatitis B Vaccination
Indian Medical Association
May 14, 2006 at New Delhi
Conclusion 1
On meta-analysis the true prevalence of Hepatitis B in India among non-tribals is 2.1% (95% CI 1.8 - 2.5). This is the meta analysis of data of point prevalence not carrier rate. It was pointed out that chronic carriers by definition have to be positive on repeat testing at least 6 months later. The carrier rate is approximately 80% of the point prevalence rate. This corresponds to a chronic carrier rate of 1.6% for India
Conclusion 2
“Hepatocellular carcinoma constitutes only 1.6% of all cancers in India, hence is very rare.” However, it is not clear how many of these are related to Hepatitis B. The estimated annual deaths attributable to hepatocellular carcinoma due to hepatitis B are only 5000. A better marker of burden of Hepatitis B may be obtained by a registry counting cases of cirrhosis as about a third of cases of cirrhosis in adults is related to Hepatitis B. Reliable data on this is not available.
Recommendation
In view of these estimates, the cost efficacy of universal immunization with Hepatitis B needs to be re-evaluated.
Conclusion 3
Vertical transmission of infection from mother to child is an important mode of acquiring Hepatitis B infection, especially in establishing chronic Hepatitis B carriers. The exact incidence of vertical transmission is not known in our country but it may be contributing at least 30% to 40% of the pool of chronic Hepatitis B carrier rate.
Recommendation
Before launching any national program it would be vital to assess the contribution of vertical transmission to the overall Hepatitis B carrier pool. If universal hepatitis B vaccination is to be carried out, currently available data, though inadequate, would strongly favour initiation of Hepatitis B vaccination starting at birth.
Conclusion 4
There is no scientific data from anywhere in the world that the schedule of 6,10 and 14 weeks has been found to be effective in reducing the carrier rates of Hepatitis B. The pilot project carried out in Andhra Pradesh and Delhi with 6, 10 and 14 weeks has not been evaluated for its efficacy. We need to know the effect on carrier rates among the children who received the vaccine at 6, 10 and 14 weeks compared to the unvaccinated children.
Recommendation
It will not be advisable to initiate a National/ Sub-national immunization program without proper evaluation of the pilot project.
Conclusion 5
The overall prevalence of chronic carrier rate among the tribal population is very high (19.4%) (95% CI 15.3 – 23.5) which is comparable to those living in the East Asian Countries
Recommendation
A well designed epidemiological study is needed in this population to study the natural history of the disease. If necessary, a vaccination program, with first dose being given at birth, could be considered in these population groups.
Brief Summary
Global Polio Eradication Initiative
in India-1995- 2006
Prepared for IMA Conference by
Dr. Onkar Mittal. Dr. C. Sathyamala
Summary
Main Points
1. Circulation of Wild Polio Virus (WPV) continues despite 12 years of intensive efforts.
2. There has been a dramatic increase in the number of AFP cases in the last 2-3 years, with a national average rate of 6.3/1,00,000 and even higher incidence of 12-13 /1,00,000 in endemic states of UP and Bihar, against an international average of 1/1, 00, 000.
3. There is an urgent need for a complete epidemiologic investigation into the cases of AFP with a view to find out the reason for the rising incidence, to know the exact cases and nature of these AFP cases, and to provide appropriate treatment and rehabilitation.
4. Strategy of increasing the number of pulse polio rounds each year ( the NIDs and SNIDs) to meet the challenge of continuing transmission of WPV does not seem to be meeting the desired objective of stopping the transmission of WPV and needs to be reviewed.
5. The monovalent Oral Polio Vaccine-1 (mOPV1) has been introduced in India since last year, through the polio eradication programme. More than 5-6 pulse polio rounds have been undertaken in the selected districts of UP and Bihar with mOPV1, contrary to the recommended 1-2 doses. Impact of these multiple rounds of mOPV1 needs to be assessed.
6. Inactivated Polio Vaccine (IPV) has been introduced in many developed countries, to tackle the problem of Vaccine Associated Polio Paralysis (VAPP) due to OPV, while maintaining the immunity against wild polio virus. Desirability, feasibility and cost efficacy of this strategy needs to be discussed in the national context.
7. Strategies that need to be adopted, if we fail to stop the transmission of WPV, need to be discussed as much as the ‘post- eradication- strategies’ which would be required if we are somehow able make the achievement of stopping the wild polio virus transmission.
One Way Forward
1. The year 2006 should be the year of the phased withdrawal and closure of the National Pulse Polio Program.
2. Urgent investigation should be carried out on the actual incidence of Post Polio Residual Paralysis (PPRP) in the cases of reported AFP in the last 10 years.
3. The activities of the polio-immunization should be re-integrated into the Universal Immunization Program.
4. An expert committee should review the present evidence base on efficacy of the IPV and cost –benefit- ratio of substituting IPV for OPV and other issues related to the relative merits of these programs in the prevention of the transmission of WPV.
5. The improvement of sanitation and hygiene should be taken up as the highest priority, specially, in those urban and rural pockets of UP and Bihar, which have been reporting the cases of WPV in the last three years. Adequate funds are available under the ‘Rajiv Gandhi Drinking Water and Sanitation Mission’ for this purpose and more can be provided by the Central and State Governments. The public health professionals should put their time and energy for the effective implementation of this program.
6. An independent commission should be appointed to review all aspects of National Pulse Polio Program in the last ten years and appropriate lessons should be drawn for the health policy formulation, program implementation and health governance in this country.
7. A comprehensive policy and program for the rehabilitation of the children who have been paralyzed during the period of the polio eradication initiative should be worked out.
Synopsis of comments of the experts
Dr A D Tiwari said that his personal experience was that there was a lot of under reporting from Bihar.
Dr A Kale spoke of the threat of bioterrorism with polio virus.
Dr A Phadke thought that polio was not eradicable
Dr Ajay Gambhir said doctors were developing apathy to PEI He said there was no attention being paid to water supply and sanitation.
Dr Ashok gupta said water and sanitation need to be looked at and the possibility of using IPV.
Dr CP Bansal felt workers at the grass root level were poorly paid and not motivated.
Dr Jay Wenger’s response was that great progress was already made with polio eradication. He felt that the 1/100,000 rate of non polio AFP was only a minimum target not the international average. He felt that once OPV is stopped VDPV and iVPDV will disappear after some time. He felt that the authors must tone down the “experimental drug rhetoric.”
The full text of his response is published on the web site: imanational.com.
Dr Joseph Mathew felt evaluation of surveillance must be by an external agency independent of the NPSP/ WHO. As long as OPV is used, VAPP will occur hence poliomyelitis cannot be eradicated with the current strategy. Since elimination of wild virus circulation (with the current strategy) is not the same as eradication of poliomyelitis by definition, the emphasis must shift from surveillance of poliomyelitis to surveillance for poliovirus.
Dr Mahesh thought there was fatigue among PEI workers.
Dr Naveen Thacker said WPV was localized to a few pockets. He said the IEAG had recommended IPV in these areas.
Dr P M Bhargava spoke of the plan in 1980 to manufacture IPV in India and how the plan was shelved for no explicit reason. He spoke of his experience of the poor condition of the cold chain in district hospitals.
Dr Panna Choudhuryfelt that dissemination of information by the NPSP was selective leading to confusion and concern.
Dr Parthasarthy felt that looking at the numbers we might be looking at a resurgence of WPV. He felt IPV must be used.
Dr R N Srivastava said the problem in western UP was lack of political will. He said that 45 – 49% of non polio AFP were not in fact AFP.
Dr Rajeev Tandon said we should aim at eradication not control.
Dr Raju Shah felt that IPV was not affordable and that eradication was still possible. He said VAPP was not a big issue.
Dr Ritu Priya said that by epidemiological classification the agencies were not aiming for eradication.
Dr Verma (NPSP) felt polio eradication was the only option available. He said that mOPV was being used as phase 4 trial. Professor Mittal wondered why consent from parents as for a phase 4 trial was not being obtained.
Dr Yash Paul wondered if the population in North India was resistant in its response to OPV or genetically predisposed to WPV
Recommendations on Polio
Conclusions and Recommendations from the National Consultative Meeting on Polio Eradication Initiative
Indian Medical Association
May 14, 2006 at New Delhi
Gains achieved by the program:
• Confirmed wild polio cases down significantly.
• Number of ‘infected’ states has decreased.
• Very focal transmission now.
• P3 almost absent.
• Less genetic bio-diversity now.
• Coverage during pulse polio rounds is ‘improving’.
• “Excellent” surveillance system in place.
• Large scale social mobilization operation in India that cut across several barriers (during pulse polio rounds).
The costs:
• Financial cost involved is upwards of Rs 4000 crores.
• Higher priority health problems have receded to the background.
• Even routine immunization has suffered, as evidenced by higher number of cases of traditional VPDs.
• No mention of VAPP at all in the grand reports of covering 170 million per NID and 67 million per SNID.
• Fatigue at all levels.
• Confidence of public and professionals shaken.
• A close look shows that with the current strategy “polio cannot be eradicated”. (Please see point made to Dr. Wenger’s comments)
• Now the WHO plans to label the absence of WPV cases for three years as certification of eradication and leave countries in the lurch as to future plans to maintain this status.
Conclusion 1
Continuing circulation of the wild polio virus in a few states, despite intensified pulse polio activities, with multiple changes in strategies and interventions, is a matter of serious concern. At the same time a large number of states which have been free of WPV for last several years are being unnecessarily being exposed to hazards of VAPP due to OPV
Recommendation
Strategies need to be reviewed by setting up a National Expert group. Possible use of IPV (alone or in combination with OPV) needs to be considered strongly. (See also Conclusion /recommendation 4)
Conclusion 2
There is an alarming increase in the number of clinical AFP cases, particularly in the states of UP and Bihar. Such high incidence of non-polio AFP has not been reported from anywhere else in the world.
Recommendation
These reported cases need thorough evaluation, including clinical follow-up, to assess the possible causes, and sequelae thereof. There is also an urgent need of establishing an independent agency (separate from NPSP) for carrying out surveillance activities.
Conclusion 3
Administration of multiple doses of mOPV1 in a pulse manner to a very large number of children in different states of the country is unprecedented. It is alarming that the same is being done as phase IV clinical trial without following the established national guidelines for such trials.
Recommendation
There is a need to immediately evaluate the impact and side effects, if any, of the use of multiple doses of mOPV1.
Conclusion 4
At present, there does not appear to be a coherent policy for the future keeping in mind the possibilities of
a) Pockets of continuing circulation of WPV; or
b) Ultimate cessation of circulation of WPV
Recommendation
There is a need for an independent National Expert Group to consider future strategies, which would be best, suited to our country within the overall objectives of the Global Polio Eradication Initiative. The feasibility and desirability of introducing IPV and the suitable timing for the same also needs to be examined by this expert group. There is urgency for deciding on these issues with a view to establish and achieve self sufficiency in manufacturing of IPV in the country, if it is considered desirable to introduce IPV in the immunization program.
Conclusion 5
The number of cases of VAPP is not available in the public domain. It is not even known whether there is a definition of VAPP or compatible VAPP.
Recommendation
District wise and state wise data on VAPP should be made available on a regular basis. Efforts must also be made to asses VAPP among contacts of those vaccinated. It is also important that the state initiates a comprehensive program of rehabilitation and possibly compensation for the victims of VAPP
List of experts invited to the expert consultation and to whom the draft White Papers circulated for comments
1. Dr.J.C.Vij S-477 Greater Kailash-I New Delhi 48 jcvij@hotmail.com
2. Dr. Moon Shrestha Prof of Paed Kathmandu Medical College Sinamangal, POB 21266 Nepal moonshrestha@htmail.com
3. Dr Anant Phadke 8, Ameya Ashish Society Kakan Express Hotel Lane Kothrud Pune-38 Maharashtra cehatpun@vsnl.com
4. Dr Rakesh Lodha A-5 Type # 5 Iari Pusa New Delhi rakeshlodha@hotmail.com
5. Dr Sushil Kumar Kabra Additional Professor Dept Of Pediatrics All India Institute Of Medical Sciences New Delhi skkabra@hotmail.com
6. Dr Rakesh Agarwal Assoc. Prof of Pead G.E. Sanjay Gandhi Post Graduate Institute Raebareli Road Lucknow-226014 UP
7. Dr Jacob Puliyel Dept. of Pead St.Stephen Hospital Tis Hazari New Delhi puilyel@gmail.com
8. Dr. S.K Sareen HOD Dept. of Gastroentrology GB Pant Hospital New Delhi
9. Dr.Ashok P. Kale Associate Professor, Dept of Community Medicine, Padamshree Dr.D.Y.Patel Medical College, Pimpri, Pune Maharashtra Ashokpkale2003@yahoo.com
10. Dr. Rajib Dasgupta Asst.Professor Centre of Social Medicine & Community Health School of Social Sciences-II Jawaharlal Nehru University New Delhi rdasgupta@mail.jnu.ac.in, dasgupta_jnu@yahoo.com
11. (Prof.) Sanjay Chaturvedi UCMS & GTB Hospital Complex Dilshad Garden Delhi
12. Dr. Ritu Priya Professor Centre for Social Medicine, Jawahar Lal Nehru University New Delhi ritupriya@vsnl.com
13. Dr.C.S.Pandav C/o Dr. Sathyamala cpandav@iqplusin.org
14. Dr.Y.Madhvi Yannapu y_madhavi01@hotmail.com
15. Dr.Sangeeta Yadav Prof of Pead Dept. of Pead Maulana Azad Medical College New Delhi
16. Mr. Rama Murthy Secretary Ministry of Health & Family Welfare Nirman Bhawan New Delhi
17. Dr Naveen Thacker D-70 Shaktinagar Gandhidham Kutch 370201 Gujarat drnaveenthacker@gmail.com, presidentiap2007@iapindia.org
18. Dr Vipin M Vashishtha Consultant , Pediatrician & Neonatologist Mangla Nursing Home, Station Road, Bijnor 246701 Uttar Pradesh
19. Dr Onkar Mittal E-43 South Extn., Part I New Delhi o-mittal@rediffmail.com
20. Dr Sathyamala 121, Pocket-B, SFS Flats Sukhdev Vihar New Delhi c_sathyamala@rediffmail.com
21. Dr RN Srivastava 487 Mandakini Enclave Alaknanda New Delhi rnsri@vsnl.net
22. Dr.C.M.Khanijo OSD Pulse Polio Dept of F.W. Govt. of NCT of Delhi Old SDA Build, Malka Ganj, New Delhi
23. Dr.Harish Kumar Consultant IMNCI WHO Nirman Bhawan New Delhi
24. Dr T Jacob John Thekkekara, 439 Civil Supplies, Godown Lane Kamalakshipuram, Vellore, North Arcot 632002 Tamil Nadu vlr_tjjohn@sancharnet.in
25. Dr Nitin K Shah 186-A Vaswani Villa 1st Floor Block # 3 Jain Society, Near Jain Temple, Sion (West),
Mumbai 400022 Maharashtra drnitinshah@hotmail.com
26. Dr Yash Paul A-D-7, Devi Marg Bani Park Jaipur 302016 Rajasthan Dryashpaul2003@yahoo.com
27. Dr SK Mittal 3 Lucknow Road New Delhi skmittal44@yahoo.com
28. Dr Panna Choudhury R-3 Hauz Khas New Delhi drpchoudhury@gmail.com
29. Dr AK Dutta Flat # 8 Lady Hardinge Medical College Campus New Delhi duttaak@vsnl.net, drdutta@gmail.com
30. Dr AP Dubey 6E Ms Flats Minto Road New Delhi apdubey52@rediffmail.com
31. Dr A Parthasarathy 'Brindavan', 166 Park Road Anna Nagar, Western Extension Chennai 600101 Tamil Nadu apartha2000@yahoo.com
32. Dr Raju C Shah Ankur Children Hospital Behind City Gold Cinema Ashram Road Navarangpura Ahmedabad 380009 Gujarat rajucshah@rediffmail.com, rajucshah@lycos.com
33. Dr Lalit Kant Sr. Deputy Director (ECD) Indian Council of Medical Research New Delhi lalitkant@icmr.org.in
34. Dr Joseph Mathew Assistant Professor Department Of Pediatrics Advanced Pediatrics Centre, PGI Chandigarh jlmathew@rediffmail.com, joseph.l.mathew@gmail.com
35. Dr. Urmila Jhamb Asst. Prof, Deptt. Of Pead Maulana Azad Medical College & LNJP Hospital New Delhi ujhamb@hotmail.com
36. Dr. Gopal Dabade President Drug Action Forum 57, Tejasvani Nnagar Dharwad-580002 (Karnataka) drdabade@gmail.com
37. Dr.A.J. Chitkara 118, Vaishali Pitam Pura New Delhi chitkara@liveindia.com
38. Dr.(Prof) J Muliyel Prof /Pricipal PSM CMC Vellore
39. Dr. Rajiv Tandon Tandon Clinic C-55 Anand Niketan New Delhi rtandon@eth.net
40. Dr.Shyam Kukreja 10, Hargobind Enclave New Delhi drshyamkukreja@hotmail.com
41. Prof. Imrana Qader Centre of Social Medicine & Community Health School of Social Sciences Jawahar Lal Nehru University New Delhi-110067 qadeeroy@vsnl.com
42. Dr.Anoop Saraia Assoc. Prof Dept. of Gastroentrologist All India Institute of Medical Sciences New Delhi
43. Dr. Avinash Kaur Mehta Director Family Welfare Malka Ganj New Delhi
44. Dr.Ajay Gambhir Hony. Secretary, IMA AMS T-721, Saraswati Vihar New Delhi ajaygambhir@rediffmail.com
45. Dr.V.Sreenivas Associate professor of Biostatistics AIIMS, Ansari Nagar New Delhi sreevishnubhatla@gmail.com
46. Dr.Nalani Abraham Health Advisor PLAN International B-4/161, Gulmohar House , 5th Floor, Gautam Nagar New Delhi nalini.abraham@plan-international.org
47. Mr. Pravin Jha Plan International B-4/161, Gulmohar House, 5th Floor, Gautam Nagar New Delhi
48. Dr.Marzio Babillee UNICEF New Delhi mbabillee@unicef.org
49. Dr.M.Galway UNICEF New Delhi mgalway@unicef.org
50. Salim J. Hebayeb WHO-India New Delhi wrindia@searo.who.int
51. Dr. Paul Francis WHO-India New Delhi pfrancis@gmail.com
52. Shri. M.S. Jalaja Addl. Secretary Govt. of india Ministry of Health and Family Welfare Nirman Bhawan New Delhi
53. Dr. P.Haldar Asstt. Commissioner,
UIP 106B, Nirman Bhawan New Delhi pradeephaldar@yahoo.com
54. Dr. P.Biswal Asst. Commissioner-Immunization 106-B, Nirman Bhawan New Delhi polivindia@yahoo.com
55. Dr. Ashok Dayalchand Director- IHMP, Pachod Aurangabad
56. Dr. Roma Solomon CORE
57. Dr. Kumuda Aruldas Population Foundation of India B-28, Qutab Institutional Area New Delhi kumudha@popfound.org
58. Dr. Vinohar Balraj Christian Medical College Vellore
59. Dr.Philip Abraham Prof. Of Gestroentrology KEM Hospital, Parel Mumbai Maharashtra
60. Dr. Murhekar MV Regional Medical Centre ICMR Port Blair Andamon-Nicobar mmurhekar@yahoo.com
61. Dr S.Sehgal pbcicmr@sancharnet.in
62. Dr. Tarun Gera B-256 Derawal Nagar New Delhi Tarun.256@yahoo.com
63. Dr.J.Wenger Head of Dept Natinal Polio Survellence Project WHO Gate No.3, 2nd Floor Jawahar Lal Nahru Stadium, New Delhi wengerj@npsu.org
64. Dr.S.K.Acharya HOD Dept. of Gestroentrology Subratacharya2004@yahoo.com, gastroaiims@yahoo.com
65. Prof. Nirmal Kumar Head , Dept of Gastroentrology & Hepatology Sri Balaji Action Medical Institute Paschim Vihar New Delhi Prof_nirmal@yahoo.co
66. Dr.B.N.Tandan Metro Hospital L-94, Sector-11 Noida UP drvivektandan@revioomail.com
67. Dr C P Bansal (EBM) 1/5, Shahbad Pratap 1 Ashram Lashkar Gwalior, 4 Madhya Pardesh dansaicp@sancharnet.in, cpbansal@hotmail.com
68. Dr Sunil Gomber (EBM) F-4 (A) Vijay Nagar New Delhi sunilgomber@hotmai.com
69. Dr Ashok Gupta (EBM) 25, Chetak Marg Near JK Lon Hospital Jaipur-302004 Rajeshthan dr_ashok@sancharnet.in
70. Dr Vinit K Saxena (EBM) B-3, PWD Collony Parbhat Nagar Merrut -250001 . UP drvineetpeds@yahoo.com, drvineetkilkari@hotmail.com
71. Dr V N Tripathi (EBM) HOD Kanpur P-5, Medical College Campas Kanpur-208002 UP vntripathi@rediffmail.com
72. Dr. Mahesh Kr Goel
(EBM) Toolika Nursing Home Near Church Mission Compound Saharan Pur-247001, UP drmaheshgoel@yahoo.com
73. Dr Verender N Mehendiratta (EBM) 50-L, Model Town Panipat-132103, Haryana mvirender@yahoo.com
74. DR B D Bhatia HOD, Dept of Paediatric Banaras Hindu University Institute of Medical Sciences VARANASI UP baldev_bhatia@rediffmail.com
75. Dr Ashok Rai (EBM) Banaras Hindu University Institute of Medical Sciences VARANASI UP drashokrai@rify.com
76. Dr Atul Aggarwal, Atul Latika Hospital Barelly
77. Dr. .M. M. Faridi President IAP New Delhi iapdelhi@rediffmail.com
78. Dr. Tamaria, Secretary IAP New Delhi iapdelhi@rediffmail.com
79. Dr. A.D. Tiwari HOD Medical College Rohtak dradtiwari@yahoo.com
80. Dr. Joana M. Raid Senior Health Advisor DFID India B-28, Taso Crescent Qutab Institutional Area New Delhi jm-reid@dfid.gov.uk.
81. Dr. Narendra Arora Editor Journal of Indian Pediatrics nkmanan@yahoo.com
narendrakumararora@hotmail.com
82. Dr.Pushpa Bhargava Anveshna `For Qan’, Cottage, 12-13-100, LANE # 1, Street # 3 Taranaka Hyderabad-500017 Bhargava.pm@gmail.com
83. Dr. Parbir Chatterjee Consultant UNICEF 219/2, AJC Bose Road Kolkata-700017 W.Bengal prabirkc@yahoo.com
84. Dr.R.K.Aggarwal State President Rajasthan State Branch 39, Ravindra nagar Airport Road Udaipur (Rajasthan) rk_hospital@hotmail.com
85. Dr. Kulbhushan Sharda 412, Master Tara Singh Nagar Jalandhar-144001 (Punjab) drkbsharda@vsnl.met
86. Dr. Mira Shiva Convener, All India Drug Action A-60, Hauz Khas New Delhi-110016 mirashiva@yahoo.com
87. Dr.I.C.Tiwari 204, Lake View Complex Near Ayushman Hospital, Shahapura, Sector-C Bhopal MP ictiwari@yahoo.com
88. Dr. M.C.Gupta G-17/9, Malviya nagar New Delhi-110017 mcgupta44@rediffmail.com
89. Dr.P.S.Sahni B-30-A Kailash Colony New Delhi
90. Dr.D.K.Taneja Prof. Of PSM Maulana Azad Medical College New Delhi-110002
91. Dr.G.R.Sethi Prof of Paediatrics Maulana Azad Medical College New Delhi-110002
92. Dr.Varinder Singh Prof. Of Peadiatrics Kalawati Saran Hospital New Delhi
93. Dr. Mathew Verghese Director St.Stephan Hospital Tis Hazari Delhi
94. Dr.Rajiv Nayan New Delhi
95. Dr.Puneet Bedi New Delhi drpuneetbedi@gmail.com
96. Mr.Jatinder Singh I.V.D. WHO Ring Road New Delhi singhj@whosea.org
97. Dr.Sudhansh Malhotra malhotras@whosea.org