Trends in Urban Immunization Coverage in India: A Meta-Analysis and Meta-Regression

Objectives To assess the gaps and trends in child immunization coverage among urban and rural areas in India, and compare the success of immunisation program in each. Methods PubMed, Scopus, and Crossref, and Google Scholar electronic databases were searched on October 9, 2019, and March 21, 2020, for studies that measured and reported immunization coverage indicators in India. Random-efects metaanalyses and meta-regressions were conducted. Results The authors' search identifed 545 studies, and 2 were obtained by expert suggestion. Among these 68 studies and 6 surveys were included. They found that full immunization coverage has grown yearly at 2.65% and 0.82% in rural and urban areas, respectively whereas partial immunization coverage declined by ?2.44% and ?0.69%, respectively. Percentage of nonimmunized children did not show a statistically signifcant trend in either. Conclusion While rural immunization coverage has seen a large increase over the past two decades, the progress in urban areas is weak and negligible. This was largely attributable to a focus on minimizing dropouts in rural areas. However, a lack of signifcant reduction in unimmunized children may indicate left-out children or pockets in both rural and urban areas. The poor performance of immunization programs in urban areas, coupled with a larger impact of COVID-19, warrants that India urgently adopts urban-sensitive and urban-focused policies and programs.

Medical Officers’ Certificate Programme (MOCP) Competencey Based Curriculum Of Public Health, Maharashtra.

Background: We herewith describe a novel methodology of teaching Medical Officers working at the Primary Health Centers under the Public Health Dept. of Maharashtra State. This course intends to develop competencies to manage adult and pediatric patients with common emergencies at primary health centre. There has been an immense shortage of Pediatricians & Physicians for the last 5 years due to 50-60% vacancies. Besides this, many of the patients in rural areas need to be addressed by a Pediatrician or Physician. With this in mind a short term certificate programme for the Medical Officers was designed. Method: Medical Officers working at Primary Health Centers were deputed like resident doctor for 6 months in the Pediatric/ Medicine Dept. of a Medical College. The methodology used was videoconferencing lectures, motivational lectures by renowned Pediatricians and Physicians, Professors, Padma Awardees from Mumbai, Nagpur, Pune and Aurangabad. The sessions were interactive with active involvement of the Doctors . They also attended all postgraduate programmes of the Department of the Medical College. They attended night duties, speciality clinics like resident doctors. An examination was taken at the end of 6 months after they had learnt state-of-the-art techniques in the subject. 169 students were taught from 2011 in 4 batches till date. The passing percentage varied from 88 to 96%. Result : At the end of the training, the students had acquired sound knowledge of theory and practicals in Medicine/ Pediatrics, had acquired necessary hands on skills, learnt state-of-the-art methodology and had established linkages with teachers in Medical Colleges. Conclusion: MOCP is thus a unique course successfully working only in the State of Maharashtra in India.

Profile of bone marrow examination in HIV/AIDS patients to detect opportunistic infections, especially tuberculosis.

Morphological evaluation of 140 bone marrow aspirations received in haematopathology laboratory with serologically established HIV infection, along with other relevant special haematological tests, was done during 1st Jan 1999 - 31st Dec 2002 at state government run tertiary care General Hospital in Maharashtra state, India. Out of 140 cases: 118 (84.28%) patients had anaemia, 25 (17.86%) had leukopenia, while 13 (9.28%) were thrombocytopenic. Dyserythropoiesis was present in 18 (12.86%) cases, dysmyelopoiesis 37 (26.43%) and micromegakaryocytes were noted in 44 (31.43%) cases. Haemophagocytosis was evident in 8 (5.71%) cases. Plasmacytosis encountered in 120 (85.71%) cases was a common feature. Based on clinical profile and results of other investigations 56 (40%) patients were clinically diagnosed to be of Mycobacterium tuberculosis (TB). Of these, 18 (12.86%) bone marrow aspirates were positive for AFB, Mycobacterium tuberculosis. In 4 cases cryptococci were demonstrated (Mucicarmine stain). There was one case each of Histoplasma capsulatum and leishmaniasis. One patient showed dense parasitemia with Plasmodium falciparum. One patient had immunoblastic lymphoma and showed bone marrow infiltration. Findings in this study strongly indicate that in HIV/AIDS, AFB stain should be done on each marrow aspirate to rule out tuberculosis in countries like India; where TB and AIDS are marching together.

Fetal hydantoin syndrome with rheumatic valvular heart disease.

Research has shown that anticonvulsants are teratogens and pose a risk for fetal malformations. Though Fetal Hydantoin Syndrome (FHS) was first reported by Langhman and others, wide phenotypic variability of this syndrome has lead many clinicians to question its very existence. We report a twelve year old girl with FHS with rheumatic valvular heart disease.

Comparative efficacy of three measles vaccines in Indian children.

A Comparative study of three types of measles vaccines was undertaken among 1005 children. Of these 527 were vaccinated with the Serum Institute of India (SII) vaccine, 230 with Schwarz (SC) and 248 were vaccinated with Edmonston-Zegreb (EZ) vaccine (imported from Zegreb). Though the majority of children reacted favourably with all the three vaccines (SII: 98.43%; SC: 93.40%; EZ: 93.0%) with a rise in titre, but the percentage of seroconversion was significantly higher with the SII vaccine (p < 0.01). The Schwarz and Edmonston Zagreb vaccines showed significantly less GM titre as compared with the other age group i.e. 9-12 months (p < 0.05). With Serum Institute of India (SII) vaccine the GM titres were almost similar in the different age groups. The overall GM titre obtained with the SII vaccine was significantly higher than the SC vaccine (p > 0.001) as well as the EZ vaccine (p > 0.001). It is of interest to note that among the infants, 22.5% children had measles antibody in them before vaccination.

Efficacy of two dose measles vaccination in a community setting.

OBJECTIVE: To compare the efficacy of two dose and single dose measles vaccination in a community setting. DESIGN: Two community ICDS blocks with populations of 8990 and 8550 children below 12 years of age were selected. Block A had 1560 children between 9 mo to 1 year of age and Block B had 1380 children between the age of 9 mo to 1 year. METHODS: All eligible children between 9 mo to 1 year of age were given measles vaccination in October 1994. Only the children in Group A were given a second dose of measles (as MMR) in April 1995; six months after the first dose. A survey was undertaken from January 1996 to April 1996 to clinically evaluate the number of cases of measles in both these blocks. RESULTS: In Block A 3 children developed measles, whereas in Block B, there were 16 cases of measles (p < 0.01). All other parameters in both groups, e.g., cold chain maintenance were similar. CONCLUSION: This study supports the superiority of two dose measles vaccination given at an interval of 6 months over a single dose measles in a community setting.

Non enzymatic glycosylation of alpha-1-proteinase inhibitor of human plasma.

Human plasma contains inhibitors, which control the activity of proteolytic enzymes. Alpha-1-proteinase inhibitor and alpha-2-macroglobulin are two of them present in high concentration in human plasma, which inhibit action of trypsin among other proteinases. The trypsin inhibitory capacity (TIC) of human plasma is observed to be decreased in pathological conditions like diabetes mellitus. The mechanisms of decrease in TIC was due to nonenzymatic glycosylation of alpha-1-proteinase inhibitor (A1PI). A1PI was partially purified from normal human plasma by steps involving ammonium sulphate precipitation, DEAE Sepharose CL6B chromatography, Concanavalin A Sepharose Chromatography and Sephadex G-100 Gel filtration. Purified inhibitor was glycosylated in vitro by incubating it with varying glucose concentrations, under nitrogen for different periods of time in reducing conditions. After glycosylation, the molecular weight of inhibitor increased from 52 kDa to 57 KDa because of binding with glucose molecules. The percent free amino groups in the protein decreased with increasing glucose concentration and days of incubation. The TIC of such modified inhibitor decreased significantly. Decrease in TIC was dependent on the glucose concentration and period of incubation used during in-vitro glycosylation of native inhibitor.

Immunogenicity study of Haemophilus influenzae type B conjugate vaccine in Indian infants.

OBJECTIVE: To assess the immunogenicity in Indian infants to Haemophilus influenzae b oligosaccharide conjugate vaccine (HbOC). DESIGN: Prospective multicenter study. SETTING: Pediatric Out Patient Department of general hospitals in Pune and Mumbai. SUBJECTS: 124 full term healthy infants brought for routine DPT/OPV immunization. METHODS: Infants were administered 3 doses of 0.5 ml of HbOC, on the same day as their DPT/OPV immunization, injected intramuscularly on the limb opposite to that where DPT vaccine was administered. Data on local reactions and general symptoms was collected for three days after every dose. The children had their blood collected for assay of anti PRP (polyribosil ribitol phosphate) antibody titers, along with the first injection and one month after the third injection. One hundred and three infants completed the study protocol with two blood collections. RESULTS: The initial geometric mean titers (GMT) of 0.124 mcg/ml rose by 37 times to 4.552 mcg/ml. Ninety eight children (95.1%) had a final titer of > or = 0.15 mcg/ml, the minimum level associated with protection, and 77 children (74.8%) had a final level of > or = 1.0 mcg/ml, a level associated with long term protection. CONCLUSION: HbOC is immunogenic in Indian infants when used as per the locally recommended DPT/OPV immunization schedule.

Reactogenecity of indigenously produced measles vaccine.

OBJECTIVE: To assess the safety and reactogenecity of indigenously produced measles vaccine derived from EZ strain. DESIGN: A longitudinal clinical follow up after vaccination. SETTING: Hospital based and home follow up, as required. SUBJECTS: 12,470 children, 9 to 15 months old, immunized with measles vaccine of EZ strain, in accordance with the National Immunization Schedule, at five centers. METHODS: A clinical follow up of children at 1 day, 1 week, 2 weeks, 3 weeks and 6 weeks after measles vaccination. A detailed clinical neurological examination in children showing side effects. RESULTS: Mild side effects were documented in 31%. Of these, 90% were seen in the first two weeks, out of which two thirds were seen during the first week. Commonest side effects were coryza (10%), fever (9.8%), cough (3.2%) and diarrhea (3.2%). Convulsions, with no later sequelae were documented in 2 cases only. CONCLUSIONS: Measles vaccine manufactured in India, using EZ strain is a safe vaccine. It has a level of reactogenecity including neurological aspects, lower than that reported in India with the Schwarz strain vaccine.

Immunogenicity and reactogenicity of indigenously produced MMR vaccine.

OBJECTIVES: To study immunogenicity and reactogenicity of indigenously produced MMR vaccine and to assess the booster effect of MMR immunization on measles seroconversion. DESIGN: A longitudinal follow up. SETTING: Hospital based and home follow up, as required. SUBJECTS: 89 children already immunized for measles, between 15 to 24 months of age for immunogenic evaluation and 866 subjects for the reactogenic component. METHODS: Prevaccination and postvaccination samples collected one and four weeks after vaccination were studied by ELISA for IgG and IgM antibodies against the three diseases. A clinical follow up of immunized children was done at 3 days, 7 days, 6 weeks and 6 months after immunization. RESULTS: IgG positivity 4 weeks after immunization rose from 75% to 100% for measles, from 12% to 92% for mumps, and from 13% to 99% for rubella. Only mild side effects including pain and swelling in 37 (4.3%) cases, mild fever in 51 (5.9%) cases, cough in 40 (4.6%) cases and a transient rash in 7 (0.8%) cases were observed. CONCLUSIONS: The indigenously manufactured MMR vaccine has an excellent immunogenicity and low reactogenicity with a booster effect for measles seroconversion in children already immunized for this disease.

Serum amino acids and genesis of protein energy malnutrition.

Twenty four patients of classical marasmus and kwashiorkor along with equal number of healthy controls were selected for the study. Their serum amino acid patterns analysis revealed a mean ratio of glutamate to alanine in fasting samples of normal individuals to be 0.33, while it as 9.3 in kwashiorkor and 1.6 in marasmus. This differences in controls, kwashiorkor and marasmus was statistically significant. This observation may explain evolution of marasmus and kwashiorkor in children with similar diets. On the basis of the present observation it is postulated that in kwashiorkor, the conversion of pyruvate to alanine in presence of glutamate, an aminogroup donor does not proceed normally, resulting in accumulation of glutamate and low alanine. Thus the development of marasmus and kwashiorkor may not be related to dietary inadequacy alone but also to the transaminase function. This could be genetic in origin.

A randomised multicentre study to compare the safety and efficacy of albendazole and metronidazole in the treatment of giardiasis in children.

A randomised control multicentre study to compare the safety and efficacy of albendazole and metronidazole in the treatment of giardiasis in children is reported. One hundred and fifty children of either sex (age range: 2-10 years) were randomised to receive either a single dose of 400 mg of albendazole suspension, or 22.5 mg/kg/day of metronidazole in 3 divided doses for 5 consecutive days. At the end of therapy, majority of children in both treatment groups were symptom free. Two days after completion of therapy, 97% of children in both treatment groups were giardia free in the stools. Side effects were noted in 3 children in the albendazole group, and in 20 children in the metronidazole group. We conclude that albendazole suspension is as effective as metronidazole in the treatment of giardial infection in children. It is safe and has fewer side effects as compared to metronidazole.

Experience with a measles vaccine manufactured in India.

Five hundred and twenty seven children between 7 months and 2 years of age were vaccinated with measles vaccine manufactured by the Serum Institute of India. The sero-conversion rate in children who had no antibodies previous to vaccination was 98.4% as tested in HI. Ninety per cent of children who had pre-vaccination measles antibodies showed a two-fold or more rise in HI antibodies. The side reactions of the vaccine were negligible.