Some ethical issues arising from polio eradication programmes in India

Bioethics

Volumn 19, Issue 4, 2005, Pages 393-406

  Paul, Yash ^a   Dawson, Angus ^b  

^a Bani Park   (India)

^b KEELE UNIVERSITY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

INACTIVATED VACCINE; ORAL POLIOMYELITIS VACCINE;

ERADICATION THERAPY; HEALTH CARE POLICY; HEALTH PROGRAM; HUMAN; INDIA; INFECTION RISK; INFORMED CONSENT; POLIOMYELITIS; POLIOMYELITIS VIRUS; REVIEW; SAFETY; VACCINATION; WORLD HEALTH ORGANIZATION;

HEALTH CARE AND PUBLIC HEALTH;

CHILD; HUMANS; IMMUNIZATION PROGRAMS; INDIA; PARENTAL CONSENT; POLIOMYELITIS; POLIOVIRUS VACCINES; PUBLIC POLICY; RISK ASSESSMENT; VACCINATION; WORLD HEALTH ORGANIZATION;

EID: 23944456934     PISSN: 02699702     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2005.00451.x     Document Type: Review

References (42)

1. M. Verweij & A. Dawson. Ethical principles for collective immunization programmes. Vaccine 2004; 22: 3122-3126.
2. The number of new cases of polio has fallen by over 99% since the introduction of the eradication initiative in 1988, to around only three per day in 2003. See D.L. Heymann & R.B. Aylward. Eradicating Polio. 2004. N Engl J Med 351; 13: 1275-1277.
3. See WHO website: www.polioeradication.org/history.asp (accessed 7 December 2004).
4. See Heymann & Aylward, op. cit. note 2, who discuss recent problems in Nigeria.
5. There has recently been a setback due to transmission from Niger and Nigeria to previously polio free countries. See CDC MMWR April 29, 2005; 54 (16): 408-412.
6. WHO. 2003. Global Polio Eradication Initiative. Strategic Plan 2004-2008. Geneva: WHO.
7. P.D. Minor. The molecular biology of poliovaccines. J Gen Virol 1992; 73: 3065-3077.
8. H. Yoshida, H. Horie, K. Matsuura, T. Kitamura, S. Hashizume & T. Miyamura. Prevalence of vaccine derived polioviruses in the environment. J Gen Virol 2002; 83: 1107-1111.
9. OPV vaccination might also offer herd protection, in circumstances where uptake rates are so high that unvaccinated individuals are protected from contact with the virus.
10. Herd immunity should be distinguished from herd protection. Herd protection is where high rates of vaccine uptake in a population mean that the risk of an epidemic in that population is low. See Y. Paul. Herd immunity and herd protection. Vaccine 2004: 301-302.
11. These problems would have been known as the likely consequences of a programme using OPV. Indeed, debate about the relative merits of the two forms of polio vaccine has been ongoing since the 1950s. See L. Garrett. 2001. Betrayal of Trust: The Collapse of Global Public Health. Oxford/New York. Oxford University Press.
12. See Paul, op. cit. note 10.
13. A. Dawson. 'Informed consent: Should we insist upon it?' New Review of Bioethics 2003; 1(1): 59-71.
14. A. Dawson. 'The determination of 'Best Interests' in relation to Childhood Vaccinations' Bioethics 2005; 19(2): 187-205.
15. Global Polio Eradication Initiative. 1999. Advocacy: A Practical Guide, with Polio Eradication as a Case Study. Geneva. WHO.
16. Polio Eradication Initiative. 2002. Communication for Polio Eradication and Routine Immunization. Geneva. WHO.
17. For example, in a publication entitled 'Together we make India polio free' produced jointly by the Indian Academy of Pediatrics and UNICEF, it is stated: 'Discussion of VAPP should be restricted to only academic circles' (p. 14).
18. Y. Paul & T.J. John. Contraindications of OPV. Indian Pediatrics 1999; 36: 318-320.
19. See Paul & John, 1999, op. cit. note 17.
20. V.M. Vashishtha. But Do We Have Other Options? Indian J Pediatrics 2004; 71: 183-184.
21. Verweij & Dawson, op. cit. note 1.
22. See Y. Paul. Evaluation of OPV efficacy is required for polio eradication in India. Vaccine 2005; 23: 3097-3098.
23. For figures in the 1980s see K. Park. 1995. Park's Textbook of Preventive and Social Medicine (14th edition). Publisher's m/s. Banarsidas Bhanot. Jabalpur, India, p. 141;
24. for figures in 1999, see N. Thacker. Polio Eradication Strategy: Need for Re-appraisal. Indian Pediatr 2000; 37: 1395-1396.
25. Changes occurred in 1996 and again in 1999. See Y. Paul. Can polio be eradicated from India through present Polio Eradication Program? BMJ. South Asia Edition. 2003; 19: 499-501.
26. Y. Paul. Need for re-appraisal of acute flaccid paralysis (AFP) case classification. Vaccine 2004; 22: 3829-3830.
27. S. Jaiswal, A.M. Jana, Y.P. Tharwani & K.M. Belapurkar. Ig G antibody response to oral polio vaccine (OPV) immunization. Indian J Med Microbiol 2000; 18: 79-82.
28. The problems with poor seroprotection provided by OPV and the apparently high vaccine failure rate suggest an urgent need for further work to provide new polio vaccines, perhaps with a focus on suitability of use in non-temperate climates.
29. T.J. John. 1996. Can we eradicate poliomyelitis? In Frontiers in Pediatrics. P.S. Sachdeva & P. Choudhury, eds. New Delhi, India.
30. Jaypee Brothers: 76-90. The official WHO quoted rates for risk of VAPP are very low. De Quadros quotes VAPP risk figures for the first dose of OPV of 1 case per 1.3 million doses for the US and of 1 case per 1.5 million doses in Latin America. C.A. De Quadros. 2003. Polio. In The Vaccine Book. B.R. Bloom & P. Lambert, eds. San Diego/London. Academic Press. One obvious question to ask is why the figures for VAPP are so much higher in India? The answer is not clear.
31. Paul, op. cit. note 24.
32. K.A. Kohler, K. Bannerjee, W.G. Hlady, J.K. Andrus & R.W. Suter. Vaccine associated paralytic poliomyelitis in India during 1999; decreased risk despite massive use of oral polio vaccine. Bulletin WHO 2002; 80: 210-216.
33. Official figures from the National Polio Surveillance Project (NPSP). The figures can be seen on the relevant website: www.npspindia.org.
34. See the figures as presented earlier in section 3(a).
35. The relative costs are 10 US cents for OPV and around 10 US dollars for IPV. See UNICEF. 2002. Supply Division Annual Report 2002. Copenhagen. UNICEF Supply Division.
36. Of course, any evidence about the cost of vaccines and cost-effectiveness assessments may also feature in such programme reviews.
37. An additional problem, as Paul has repeatedly argued, is that IPV should be made available for immunocompromised children in India for two reasons: (i) to provide protection against polio disease for such children, and (ii) to provide protection to the community from these children if they become infected. Y. Paul. Polio Eradication Strategy: Need for Re-appraisal. Indian Pediatr 2000; 37: 913-916.
38. Y. Paul. Compassion for the animals, but, no concern for the children. Vaccine 2004; 23: 280.
39. A. Dawson. Vaccination and the prevention problem. Bioethics 2004; 18(6): 515-530.
40. Of course, it might be argued that all polio victims should be compensated. Indeed, there is a strong argument that this would be the fairest option, but this raises issues beyond those that are the primary focus of this paper.
41. Verweij & Dawson, op. cit. note 1.
42. See Heymann & Aylward, op. cit. note 2, for their discussion of parents' fears in Nigeria due to (false) rumours about deliberate vaccine contamination the parents believe to be linked to attempts to reduce fertility.