IAP Position Paper on Burden of Mumps in India and Vaccination Strategies.

JUSTIFICATION: Mumps, despite being a widely prevalent disease in the country, is considered as an insignificant public health problem mainly because of poor documentation of clinical cases and lack of published studies. In the absence of adequate published data on disease burden, Government of India has recently decided to introduce measles-rubella (MR) vaccine in its National Immunization Program and neglected mumps component. PROCESS: Following an IAP ACVIP meeting on December 6 and 7, 2014, a detailed review of burden of mumps in India along with vaccination strategies to control the disease was prepared. The draft was circulated amongst the members of the committee for review and approval. Revised final draft was later approved by IAP executive board in January 2015. OBJECTIVES: To provide a review of community burden of mumps in India; and to discuss the vaccination strategies to impress upon policymakers to include mumps vaccination in National immunization program. RECOMMENDATIONS: A total of 14 studies and two media reports on mumps outbreak were retrieved. The outbreaks were reported from all the regions of the country. Mumps meningoencephalitis was responsible for 2.3% to 14.6% of all investigated hospitalized acute encephalitis syndrome or viral encephalitis cases in different studies. Data from Infectious Disease Surveillance (ID Surv) portal of IAP and Integrated Disease Surveillance Program (IDSP) of Government of India (GoI) were also reviewed. While a total of 1052 cases were reported by the IDSurv, IDSP had investigated 72 outbreaks with 1564 cases in 14 states during different time periods. Genotypes G (subtype G2) and C were found to be main genotypes of the mumps virus circulating in the country. Three studies studied serological status of young children and adolescents against mumps, and found susceptibility rates ranging from 32% to 80% in different age groups. CONCLUSIONS: Mumps poses a significant disease burden in India. This calls for inclusion of mumps vaccine in the National immunization program.

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years--India, 2014 and updates on immunization.

JUSTIFICATION: There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology. PROCESS: Following an IAP ACVIP meeting on April 19 and 20, 2014, a draft of revised recommendations for the year 2014 and updates on certain vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus. OBJECTIVES: To review and revise recommendations for 2014 Immunization timetable for pediatricians in office practice and issue statements on certain new and existing vaccine formulations. RECOMMENDATIONS: The major changes in the 2014 Immunization Timetable include two doses of MMR vaccine at 9 and 15 months of age, single dose recommendation for administration of live attenuated H2 strain hepatitis A vaccine, inclusion of two new situations in high-risk category of children in context with pre-exposure prophylaxis of rabies, creation of a new slot at 9-12 months of age for typhoid conjugate vaccine for primary immunization, and recommendation of two doses of human papilloma virus vaccines with a minimum interval of 6 months between doses for primary schedule of adolescent/preadolescent girls aged 9-14 years. There would not be any change to the committee's last year's (2013) recommendations on pertussis vaccination and administration schedule of monovalent human rotavirus vaccine. There is no need of providing additional doses of whole-cell pertussis vaccine to children who have earlier completed their primary schedule with acellular pertussis vaccine-containing products. A brief update on the new Indian Rotavirus vaccine, 116E is also provided. The committee has reviewed and offered its recommendations on the currently available pentavalent vaccine (DTwP+Hib+Hepatitis-B) combinations in Indian market. The comments and footnotes for several vaccines are also updated and revised.

IAP perspectives on measles and rubella elimination strategies.

The Academy's Expert group on Immunization has discussed various issues pertaining to rubella vaccine introduction in to the Universal Immunization Program. Though the move to introduce rubella vaccine in to the UIP is laudable, the decision to overlook mumps seems inexplicable and illogical. Logistics also support the use of measles-mump and rubella (MMR) vaccine instead of measles-rubella (MR) vaccine. Regarding the timing of administration of MMR/MR vaccine, the academy recommends that the vaccine should be given early to have much higher coverage than introducing it late at the time of 1st booster of DPT. According to available evidence, both these vaccines (MMR/MR) can be given safely at different ages including at 9 months of age. The second dose should also be of the same antigen (MMR/MR) and be given along with 1st DPT booster at 16-24 months of age.

Adverse event following immunization (AEFI) surveillance in India, position paper of Indian Academy of Pediatrics,2013.

Adverse event following immunization (AEFI) is a critical component of immunization program. The risk of AEFI with vaccination is always weighed against the risk of not immunizing a child. There is an evolving AEFI surveillance system in India for the vaccines delivered through universal immunization program (UIP) of government sector, but the reporting remained suboptimal for long in the country, and there is almost no participation from private sector. The AEFI reporting from private sector will provide vital information on the safety of new and underutilized vaccines, not part of the UIP in India. The national guidelines are recently revised and updated. The Indian Academy of Pediatrics believes that pediatricians, especially in private sector have a crucial role to play with reporting of AEFI with newer/underutilized vaccines. Programmatic error, vaccine reaction, injection reactions, coincidental and unknown are the five broad categories of AEFI for programmatic purposes. The serious AEFIs (death, disability, cluster and hospitalization) need to be reported immediately and investigated in detail as per the laid down procedures. Once a serious AEFI happens, primary or urban health centre should be immediately informed by the pediatricians practicing in rural or urban areas, respectively. This advocacy paper from the academy provides guidelines to practitioners on how to report cases, and suggests ways for IAP members to help in ongoing efforts of the government in improving AEFI surveillance in the country. The details about the diagnosis and management of known/expected AEFI with UIP and newer vaccines shall be published later.

Measles control strategies in India: position paper of Indian Academy of Pediatrics.

Measles continues to be a major cause of childhood morbidity and mortality in India. Recent studies estimate that 80,000 Indian children die each year due to measles and its complications, amounting to 4% of under-5 deaths. Immunization against measles directly contributes to the reduction of under five child mortality and hence to the achievement of Millennium Development Goal 4 (MDG 4). The live attenuated measles vaccines are safe, effective and provide long lasting protection. The key strategies being followed globally for measles mortality reduction are high coverage of measles first dose, sensitive laboratory supported surveillance, appropriate case management, and providing second dose of measles vaccine. Prior to 2010, India was the only country in the world that had not introduced a second dose of measles vaccine in its National immunization program. We herein discuss the current status of measles vaccination along with the rationale and challenges of providing a second opportunity for measles vaccination, and the principles of measles catch-up campaigns.

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years, India, 2013 and updates on immunization.

JUSTIFICATION: There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology where new developments are taking place regularly at short intervals. PROCESS: Following an IAP ACVIP meeting on 3rd and 4th August, 2013, a draft of revised recommendations for the year 2013 and updates on certain new vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus. OBJECTIVES: To review and revise recommendations for 2013 Immunization timetable for pediatricians in office practice and issue statements on new vaccine formulations. RECOMMENDATIONS: The major change in the 2013 Immunization timetable was made in the recommendations pertaining to pertussis immunization. Taking in to the consideration of recent outbreaks of pertussis in many industrialized countries using acellular pertussis (aP) vaccines and subsequent finding of faster waning of the same in comparison to whole-cell pertussis (wP) vaccines and superior priming with wP vaccines than aP vaccines, the committee has now recommended wP vaccines for the primary series of infant vaccination. Guidelines are now also issued on the preference/selection of a particular aP vaccine in case it is not feasible to use wP vaccine, and use of Tdap vaccine during pregnancy. The administration schedule of monovalent human rotavirus vaccine, RV1 has been revised to 10 and 14 weeks from existing 6 and 10 weeks. Recommendation is made for the need of booster dose of live attenuated SA-14-14-2 JE vaccine. Updates and recommendations are issued on new typhoid conjugate vaccine, inactivated vero-cell culture derived SA-14-14-2 JE vaccine, inactivated vero-cell derived Kolar strain, 821564XY JE vaccine, and new meningococcal conjugate vaccines. This year the recommended immunization schedule with range for persons aged 0 through 18 years is being published together instead of two separate schedules. A subcategory of general instruction is added in footnotes. The comments and footnotes for several vaccines are revised and separate instructions for routine vaccination and catch-up vaccination are added in the footnotes section wherever applicable.

Pertussis vaccines: position paper of Indian Academy of Pediatrics (IAP).

Pertussis continues to be a major public health problem in both developing and developed countries. Data on exact burden and incidence of pertussis in the developing countries including India is sparse. However, the disease is widespread, even if not adequately measurable. Pertussis incidence has been increasing steadily in the last decade especially in industrialized countries. Outbreaks are reported from many developed countries in recent years despite widespread use of acellular pertussis vaccines with high coverage. The current status of coverage with pertussis vaccines is still sub-optimal in many states of the country. There is scarcity of data on vaccine efficacies of both whole-cell and acellular pertussis vaccines from India and other developing countries. Most of the recommendations on pertussis vaccination are based on the experience gained from the use of them in industrialized countries. Taking in to the consideration the recent evidence of faster waning of acellular pertussis vaccines in comparison to whole-cell vaccines and superior priming with whole-cell than acellular pertussis vaccines, Indian Academy of Pediatrics has now revised its recommendations pertaining to pertussis immunization in office practice. The Academy has now proposed whole-cell pertussis vaccines for the primary series of infant vaccination. Guidelines are also now issued on the preference of a particular acellular product. The Academy has also recommended use of Tdap during each pregnancy to provide protection to the very young infants. It urges the Government of India to initiate studies on the quality of available pertussis vaccines in India and to set indigenous national guidelines for the manufacturers to produce and market different pertussis vaccines in the country.