A view from here
“We will flood the each household with OPV and will appoint one SMO to each block in UP!”
–Dr Jay Wenger, Project Officer, NPSP India responding to what will be the strategy if UP continues to report 50 odd wild polio cases for next couple of years during a workshop on polio at Aligarh.

OPV vs. IPV: ‘Wild’ vs. ‘Civilized’ Vaccine!

Yes, OPV is a wild vaccine! Simply because it behaves in that manner. It needs to be given several times and even after 10 doses; one can not predict full- protection to the vaccinee! It has the tendency to revert to a more neurotropic form and cause paralysis in the recipient, a process known as ‘VAPP’. Another ‘wild addiction’ of the vaccine is its fondness to transmission capabilities of its progeny, a phenomenon known as ‘cVDPV’- where mutant vaccine virus recombines with other enteroviruses and acquire high transmissibility similar to wild virus. And, perhaps OPV is the only vaccine that would need an eradication strategy to thwart any future threat of reintroduction of the disease, against which it is used to provide protection! Riddance of this ‘wild’ vaccine would be the next agenda for the world after disease eradication is achieved.

On the other hand, IPV (read enhanced potency ‘eIPV’) is a more cultured, more civilized and a more benign vaccine. It respects the basics of immunology and adheres to norms set by science. It is highly immunogenic- providing almost 100% protection after 3 doses, provides reasonably good mucosal and herd immunity for probably lifelong duration, does not require stringent cold chain conditions, and phenomena of VAPP and cVDPV are unknown to it. Hence, IPV is the perfect vaccine for individual protection. But, exorbitant cost and limited availability of the vaccine are the two limiting factors for wide scale use in any country.

Impact of introduction of IPV in Indian market
Soon, IPV is going to be introduced in the Indian market. The move will definitely affect our vaccination practices. But considering its high cost and scarce availability in the world market, the odds against wide scale use of the vaccine are quite high. And if IPV can not be used on a mass level particularly in the ongoing eradication program, there is no point in making it available here. Its probable use will be restricted to very miniscule population of immunocompromised individuals, if used judiciously, but mainly to some well-off sections of the society who can afford the vaccine but on a closer scrutiny would not perhaps need it! This will further create a divide among the different sections of the society, will create confusion and chaos over OPV and will rob the society a ‘concept of equity’ bestowed upon by pulse polio activities over past one decade or so!

India will be better off financially without eradication!
The prospects of wide scale use of IPV during post-eradication phase also are not very bright. Even WHO does not want it, and most of the donor international agencies and industrialized world would not approve it. That’s why they have left the decision of using IPV during post-certification era to individual country implying subtly that they are not willing to share the huge economic burden of the move! The Technical Consultative Group (TCG) of WHO has suggested two options for poor developing countries: gradual phasing out of OPV under umbrella cover of IPV or to stop all forms of polio vaccination preceded by mass campaign with OPV (without using IPV at all!). Right now, India is spending more than Rs 600 crore per year on polio eradication program, only 20% of which is being granted by the international funding agencies. If it were to start using IPV, the expenditure would jump 20-25 times higher considering each dose of IPV costing Rs 125 against a meager Rs 5 per dose for OPV! Consequently, financial burden would be enormous and economically India would be better off without eradicating polio than to plunge in to another web of financial debt after eradication. Hence, economically using IPV during post-eradication era would not be desirable. Therefore, the most likely scenario is that India will continue to use OPV in periodic mass campaigns for few more years after certification and then abruptly stop it altogether without even considering IPV as an option. Thus, IPV in all probability will never be used on a mass level and its introduction in Indian market now would not make much impact on polio incidence in the country.

The only scenario!
However, the one scenario where IPV use on a mass level can be considered is if the current eradication efforts derail (chances of which are quite remote) and the program is converted in to a ‘polio control program’, then IPV can be introduced in the routine immunization schedule in form of a combination quadruple vaccine (DPT-IPV). To address the issue of high cost, indigenous production of the vaccine would be an answer. In fact, as early as during 1980s, the Indian government had initiated efforts to establish a plant under Ministry of Gas and Petroleum and had spent Rs 50 crores on the project. But, in 1998, the project was abandoned and further steps stalled in the belief that India did not require it. Had that initiative reached to its conclusion, India would not only be in a better position to devise its own strategy for polio eradication but would have also benefited immensely by earning precious foreign reserves by export! Again, it is a sort of a mystery why a country despite using billions doses of a vaccine annually for over decades had not ever thought of manufacturing even a single dose of that indigenously!
-Dr. Vipin M. Vashishtha

 

Bottom-line
“Eradication approach is more of an emotional response to a complex problem”
--Dr Amod Kumar, St. Stephens Hospital, Delhi in Pediascene, Vol 6, Issues 2 & 3; 2003

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