The Covid-19 pandemic has changed humankind in far-reaching ways—from the way we shop to the way we work to the way we unwind. Maybe even the way we approach disease prevention. For the adolescent population, if the response to India’s mass immunisation programme is anything to go by, getting a jab has become part of their ‘to do’ list.
India has perhaps never rolled out as massive a vaccination programme for its adolescent population as it has during the Covid-19 pandemic. As of April 21, more than 25.3 million adolescents had received their first shot of the Covid-19 vaccine, according to data from the Union health ministry. This, perhaps, sets the stage for a dedicated inoculation programme for adolescents for vaccine-preventable diseases or VPDs; it is also a signal to the pharma industry to invest in this space, considering the high uptake of Covid-19 vaccines. But more on that later.
The vaccine story for adolescents in India has largely been unimpressive, though there were more than 250 million adolescents (those between the ages of 10 and 19) in the country in 2021, according to UNICEF. And while India’s Universal Immunisation Programme (UIP) is one of the largest in the world in terms of the quantity of vaccines used and the number of beneficiaries, it is largely targeted at infants and children under five years of age. In fact, the pharma industry’s vaccine segment that caters to the adolescent and adult population witnessed de-growth of about 17 per cent in the past one year, according to AWACS, a pharma market research company.
Data shows that GSK Pharma, a segment leader, recorded de-growth of 51 per cent for its pneumonia vaccine for the March 2021-February 2022 period. Likewise, Sanofi India’s sales for its tetanus combination vaccines fell 25 per cent, and 44 per cent for its influenza vaccine, while Biological E. recorded a fall of 8 per cent for its tetanus vaccine. Then, Bharat Biotech witnessed over 44 per cent de-growth for its anti-rabies vaccine in the same period. Similarly, Zydus Cadila, which makes Covid-19 vaccines for adolescents, saw de-growth of 49 per cent for its influenza vaccine; and Indian Immunologicals had de-growth of 22 per cent for its anti-rabies vaccine, AWACS data shows.
India also witnessed the biggest drop in routine childhood immunisation coverage in recent times, according to data collated by the World Health Organization (WHO) and UNICEF in 2020. If India’s flagship routine immunisation programme, Mission Indradhanush, was dealt a massive blow, the direct impact on adolescent and adult vaccination uptake was obvious. “If one looks at the type of vaccines that have de-grown significantly, a majority of them fall in the adult vaccines category,” says Sheetal Sapale, President-Marketing, AWACS, adding that Covid-19 may be a possible reason for the dip in adult inoculations. As for the fall in children’s vaccinations, she says it could be because many couples postponed having children during the pandemic (most such vaccines are given within the first year of birth).
The pandemic has made individuals, including adolescents, aware of the importance of a jab. With an uptick in the number of adolescents receiving Covid-19 shots, the central government is planning to review its life-course vaccination schedules, say sources in the health ministry. “Covid-19 vaccination uptake in adolescents proves that a mass vaccination programme can be successful for all age groups in India. We have been pushing for an adolescent immunisation programme and consulting with the states,” says Dr N.K. Arora, Chair, National Technical Advisory Group on Immunisation (NTAGI), which is under the health ministry.
The government, meanwhile, has approved four Covid-19 vaccines for adolescents: Bharat Biotech’s Covaxin for 15 years and above; Zydus Cadila’s ZyCov-D for 12 years and above; Biological E.’s Corbevax (12-18 years); and Novavax’s protein-based Covid-19 vaccine, which Serum Institute of India (SII) will market as Covovax (for 12-17 years age group).
This has given a fillip to pharma companies that are looking to invest in the space. For SII, which makes Covishield for adults, Covovax is the missing piece of its Covid-19 vaccine puzzle: Covishield isn’t approved for use in adolescents, though it makes up the bulk of jabs given in India. “Now, SII can target adolescents through Covovax,” says Prashant Khadayate, Pharma Analyst at GlobalData, a data and analytics firm. Covaxin leads the 15-18 years segment, while Corbevax dominates the 12–14-year segment. “Vaccination among adolescents should grow after the Covid-19 experience. HPV (human papilloma virus) can prevent cervical cancer; other vaccines can prevent... other deadly diseases,” says SII CEO Adar Poonawalla. Besides SII, other Covid-19 vaccine manufacturers like Bharat Biotech are also looking at the adolescent segment.
Pfizer, one of the market leaders in pneumococcal vaccines, says it has consistently tried to raise awareness of pneumococcal disease and the need to prevent it since childhood. “The pandemic has transformed the way healthcare information is sought and consumed, with digital platforms playing a critical role in this process,” says S. Sridhar, MD, Pfizer Limited. Agrees Dr Parag Sheth, Regional Medical Director, Abbott India, who adds that bridging knowledge gaps about vaccination options is crucial to scaling up immunisation.
But what is the need for mass vaccination programmes for adolescents? The WHO’s Scientific Advisory Group of Experts to the Global Programme for Vaccines and Immunization has indicated the need to expand immunisation beyond infancy. Community health experts say that vaccines help in protecting the community by curtailing the spread of infectious diseases along with protecting the vaccinated individual from developing a potentially serious disease.
According to the health ministry, there is a sizeable disease burden due to VPDs in adolescents and adults, which is responsible for large economic losses directly and indirectly. A study published in the journal Indian Pediatrics (IP), the official publication of the Indian Academy of Pediatrics (IAP), says adolescent immunisation is one of the most vital yet neglected fields in India. There is no adolescent-specific schedule in the government’s UIP. Though a separate adolescent immunisation schedule exists for the private sector, there is almost no data on the coverage. The IP study—Adolescent Immunization Schedule: Need for a Relook—says that the only disease targeted for prevention among adolescents and adults till recently was tetanus. But with the launch of the measles-rubella campaign, and the proposed substitution of tetanus-toxoid (TT) with Tetanus-diphtheria (low adult dose Td) vaccine, three more diseases—measles, rubella and diphtheria—have joined the list of VPDs targeted for prevention amongst adolescents. And while the Japanese encephalitis vaccine is also offered to adolescents and adults, it is only in the endemic districts of a few states.
“There is a lack of systematic epidemiological data defining the exact burden of various diseases in the adolescent period. The overall focus of the government is to ensure good coverage rates for the UIP vaccines to infants, and even the booster doses meant for older children are not given adequate attention. Barring TT, there is no data on the coverage of the vaccines given to adolescents in India,” the study says.
“Several VPDs are highly prevalent in India, including influenza, typhoid fever, rotavirus, diphtheria, tetanus, pertussis, Japanese encephalitis and more, which affect all age groups. India has the largest adolescent population in the world… and increased uptake of large-scale immunisation coverage, including across adolescents, is essential to tackle the burden of prevailing VPDs,” says Sheth.
The disease burden among adolescents in India is increasing day by day. Different studies have shown Hepatitis A virus sero-prevalence—the level of a pathogen in a population—to be around 38-92 per cent in different age groups, says the health ministry. “The Covid-19 vaccination for adolescents should be a guiding light for parents to get their children vaccinated for [other] diseases as well,” says Dr Dinesh Kapil, Senior Consultant-Paediatrics, Red Cross Hospital, Delhi.
According to the National Centre for Disease Control (NCDC), despite the heavier burden of diseases, vaccines recommended for adults are not widely used in India. There are several reasons for that, including limited perception and doubts about the efficacy and safety of vaccines for adults. Also, adult immunisation is selective and healthy adults are harder to reach through the public health system and hence the vaccination of this age group becomes difficult, the NCDC notes.
“The adolescent and adult immunisation recommendations introduced by the Association of Physicians of India outlined evidence-based information on vaccines. Recognising the shift in epidemiological diseases affecting the adolescent age group, many nations [have] established adolescent-specific immunisation guidelines. Similar recommendations for India can empower practitioners to recommend appropriate vaccines to adolescents,” says Sheth.
Public health experts believe the initiation of Covid-19 vaccination among adolescents in India may prove to be a game-changer for populations aged above five. “The Covid-19 pandemic is a reminder of the need for life-course immunisation, which is also particularly relevant in the context of the [WHO’s] Immunization Agenda 2030 and GAVI 5.0,” says Dr Naveen Thacker, President-elect, International Pediatric Association, and former civil society organisation representative to GAVI, the Vaccine Alliance.
Dr Devlina Chakravarty, MD, Artemis Hospitals, believes that the logistics, supply chain and outreach to various far-flung areas will improve with time and more adolescents will be vaccinated against Covid-19. The same infrastructure could then be used for adolescent vaccinations, she says.
Experts believe that the government might want to use this opportunity to draft a new policy on adolescent vaccination. “Extrapolating the success of the initial vaccination drive of children less than 18 years of age, it can be anticipated that the same level of vaccination enthusiasm is likely to be there for the Covid-19 vaccination drive of adolescents as well,” says Dr Dipu T.S., Associate Professor, Division of Infectious Disease, Amrita Hospital, Kochi. And, if the population is amenable to vaccination as a strategy to reduce communicable diseases, then the scope of the inoculation programme can be expanded. That way, he says, India can ensure that adolescents, the future of the country, are protected.
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