Kerala is likely to be the first Indian state to have its vaccine policy.
A seven-member committee headed by Dr B Eqbal, neurologist and chairman of the state’s Covid Expert Committee, recently submitted its recommendations to Health Minister Veena George.
The panel has recommended focusing on adult vaccination. Besides, it mooted prophylaxis (preventive) vaccines against rabies for risk groups and adult immunisation against influenza and pneumococcal infections.
The committee also mooted mandatory vaccination against Enteric fever and Hepatitis A for all those handling food. Guest workers, too, should be regularly vaccinated, the committee suggested.
Kerala officially refers to blue-collar workers from other states as guest workers.
The committee’s report will be forwarded to the chief minister for further action.
South First discusses some of the recommendations:
A spurt in the stray animal population and the consequent increase in rabies cases have been dogging Kerala, with the issue even reaching the Supreme Court. Against this backdrop, the committee recommended a pre-exposure prophylaxis vaccination against rabies for individuals at a higher risk of dog bites.
Kerala had reported 1.96 lakh dog bites and 21 rabies deaths in the seven months from 1 January 2022.
“This vaccine would be worthwhile for Kerala as it can avoid the need for the expensive rabies immunoglobulin serum and reduce the rabies vaccine doses required in case of accidental exposure in future,” the report recommended.
Further, it mooted vaccinating children since they are more prone to dog attacks.
Speaking to South First, Dr Rajeev Jayadevan, former President of the Indian Medical Association (IMA), Cochin, who has studied and written extensively on dog-human behaviour, explained the need for such a vaccine.
“All pets and stray dogs need to be vaccinated, which seems like an impossible task. It is easy to say on (news)paper and television channels that all of them should be vaccinated but in reality, regularly jabbing the dogs won’t happen,” he said.
“So, it seems impossible to eradicate rabies-virus reservoir, whether they are pet dogs or strays,” he added.
Dr Jayadevan opined that not all children should be vaccinated. He suggested those in high-risk areas need to be provided pre-exposure prophylaxis will eradicate the need for the expensive and not so readily available Rabies Immuno Globulin (RIG). “Only a booster dose will be necessary after a bite,” he said.
The committee recommended preventive vaccination for all in the high-risk category: Animal handlers, pet owners, police personnel, on-field postal employees and delivery executives. Kerala has 2.89 lakh stray dogs, according to the Livestock Census, 2019.
Rabies is fatal but a preventable zoonotic, viral disease. It can spread to people and pets if bitten by an infected animal. The virus infects the central nervous system and spreads faster to the brain if bitten on the victim’s neck or face. If proper medical care, including vaccines, is not provided, the bite could prove fatal.
Mandatory vax certificates in school
The Dr Eqbal-headed expert committee also recommended making vaccination certificates mandatory for school admissions. The panel mooted the idea since it will be a major step towards achieving universal vaccine coverage.
The committee, however, cautioned that the recommendation should be discussed with legal experts, Department of Education officials and the members of the public since the Right to Education is a fundamental right enshrined in the Indian Constitution.
“Intensive IEC (Information, Education and Communication) activities to engage with and educate parents of children without vaccination certificates are needed. The vaccination status of all students should be recorded at the time of joining school or college,” the committee suggested.
“The details of students with incomplete immunisation status should be reported to the local health authorities. A digital platform integrated with e-Health (the state’s eHealth portal) may be developed for this purpose,” the recommendation read.
No need for HPV vaccination
Interestingly, the committee did not see an immediate need to introduce Human Papillomavirus (HPV) vaccination for adolescent girls against cervical cancer. Its stand is contrary to the central government’s recent announcement that HPV may be included in its immunisation programme.
The committee believed that there has been a steady decline in cervical cancer cases in Kerala. Currently, the state has eight lakh cases of cervical cancer.
The committee recommended that HPV vaccination may be considered in Kerala only if the cervical cancer incidence increases from the baseline.
Focus on immunocompromised persons
With corona and monkeypox viruses making a significant number of people in the total population immunologically compromised, the state-appointed committee delved deep into the issue of vaccinating such people.
The committee also looked into those undergoing organ and stem-cell transplantations and developed detailed guidelines for immunising them.
“Given the new developments in vaccinology and the re-emergence of vaccine-preventable infections like diphtheria and measles in adults, state-specific modifications may be adopted into the existing UIP (universal immunisation programme) schedule,” the panel recommended.
If not fully immunised, healthcare workers are at an increased risk of contracting diphtheria, measles, varicella, rubella and Hepatitis B due to occupational exposure. Hence, the committee recommended mandatory Td (tetanus-diphtheria) + MMR ( (measles, mumps and rubella) + varicella (chickenpox) + Hepatitis B vaccines for them.
Possibility of polio re-emerging
Though eradicated in the country, the committee noted the presence of poliovirus in neighbouring nations. Hence, it feared the possibility of immunity provided by bivalent Oral Poliovirus Vaccines (OPV) waning and suggested considering the provision of Inactivated Poliovirus Vaccine (IPV) at the age of 18 months as well.
“As we are in a period of epidemiological transition with neighbouring countries still having polio transmission, it will be better to consider IPV at one-and-a-half years also to cover all three types of poliovirus,” it said.
India received the ‘polio-free’ certificate from the World Health Organisation on 27 March 2014.
Vaccination cards for migrant labourers
Considering the influx of guest workers in the state, the committee felt their immunisation is important.
“Immunization status of all guest workers [migrant labourers] in Kerala should be assessed. Vaccination Cards should be made mandatory for all guest workers in Kerala,” the panel recommended.
Meanwhile, the report recommended a mechanism to ensure that all guest workers are registered, their vaccination status is checked, and catch-up vaccination is administered.
According to estimates, Kerala has 31.4 lakh guest workers, and their number is expected to swell to nearly 60 lakh by 2030.
Vaccinate food handlers against Hepatitis A
All food handlers and those who work in food-processing units should be vaccinated against Enteric fever and Hepatitis A. A uniform, mandatory vaccination card should be issued to them.
“A digital platform integrated with e-Health should be created to capture and collate all data concerning immunization status of guest workers, inbound travellers, and food handlers,” the committee mooted.
The panel also recommended that Keralites going to other states to pursue education/jobs should have their immunisation status verified. They should be administered Hepatitis A, typhoid and cholera vaccines if not already immunised.
Besides Dr Eqbal, the committee had Dr Aravind R, Assistant Professor of Infectious Diseases, Government Medical College, Thiruvananthapuram (Convener), Dr Chandni R, Professor of Medicine, Government Medical College, Kozhikode, Dr Preetha PP, Member, State Technical Advisory Group on Immunization, Dr Prathapa Chandran C, Surveillance Medical Officer, WHO, Dr Sajith Kumar R, Professor of Infectious Diseases, Government Medical College, Kottayam and Dr Jayaraman TP, Pediatrician, Government Women and Children Hospital, Palakkad.