1. Toryalai Hart
  2. Vaccines and delivery technologies
  3. Monday, 04 June 2012

Hi All,

After several years of working in Immunization related activities to help others, I find myself on the other side of the fence, with a 2 month old baby, in Senegal, trying to get her shots. She was born in the US, and we opted not do the HEP B at birth and figured to start at 2 months. We went to a fancy pharmacy in Saly, where they only had DTaP + PCV + Hib + Polio as a cocktail and didn't know anything about RV and then Hep B as a standalone.

I had in the past heard concerns about such cocktails (which may be rumour), but then came across this article India Serves Up Costly Cocktail of Vaccines and wondered if the claims regarding adverse reactions and deaths are true.

If we want to avoid cocktails, is it possible to do so still? Would there be any benefit to dividing immunizations up so that DTP/Polio/Hep B are on one schedule, and PCV/Rota are on another, and a month out of phase (for example)? Is Hib really necessary?

I'm sorry to post a question of such a personal nature on Technet, but the amount of information online regarding child immunization is overwhelming and riddled with contradictions. WHO and CDC policy are one thing but also developed as blanket approaches to maximize the overall benefit to populations (no?). I have the ability to take as as many trips as needed to the pediatrician, and can afford to buy vaccines separately - should I?

Many thanks,


Accepted Answer Pending Moderation
Thanks for asking Toryalai! There has not been much news on the AEFI in India. That may be part of the media policy- not to provoke debates. However we hear that Pentavalent is now scheduled to be used in the national programme in 2013- so maybe the reports are about to be released. The Bhutan AEFI and the Sri Lanka AEFI were declared to be not connected to the vaccine. However- if one has a choice it seems sensible to stick to D-acellular P-T (with IPV if that is possible) with standalone Hep B. Many parents in India take the DPT one fortnight and the Hep B a different fortnight and there seems to be no medical reason not to do this. The proof on HiB seems weak to me and anecdotally it seems to be what tips the pentavalent towards AEFI (no large scale reports of AEFI with quadrivalent yet). Rotavirus seems to have started getting reports of AEFI again. However a "western-born" (eg born in Europe esp- as water tends to be infection free) infant in Asia/ Africa might be at risk more than a local born middle class child. so that is something to be decided between the parents, the pediatrician and probabilities. On a personal note- my younger bother developed worms (in fact had to be operated for a ball of worms in the gut/ stomach at Colombo in 1965) after a visit to India at the age of 2 (born in Birmingham)- so even coming from an Asian family does not easily protect children who come from the "west". I suppose the interest in Pneumococcal is because the child may face winters in Europe in future. Most pneumonias in warm nations in well nourished children are treatable with antibiotics. Hope this opinion (rather specific- not population directed) is not too confusing. But it does show the complexity that faces the individual health worker in the field faces when talking to an individual parent. Each child is an individual and each family deserves informed decisions based on a full social history.
Accepted Answer Pending Moderation
Thank you for the response Dr Moser. But the following link does not work: Separating Fact from Fiction, published by Columbia University Press in 2011 (Link: http://www.cup.columbia.edu/book/978-0- … /excerpt). Neither does the search function on the Columbia University Press website yield any leads. Please can you also fill in your profile details. Thank you!
Accepted Answer Pending Moderation
Posted on behalf of Dr Thomas Cherian, with many thanks for the response. Several different combination vaccines are licensed for use in infants. These contain various combinations for diphtheria, tetanus, Hib, hepatitis B, IPV and pertussis vaccines (some contain acellular pertussis and others whole cell pertussis vaccines). Many of these combinations are also prequalified by WHO. All the combination vaccines that are licensed by regulatory agencies that are fully functional and are pre-qualified by WHO are safe and effective; comparison of safety and efficacy of the combination against vaccines administered individually is part of the assessment process for licensure. We are not aware of a combination vaccine that includes PCV in the above mix. Perhaps you are mistaken about that. Combination vaccines have several advantages in that they reduce the number of immunization clinic visits, the number of injections required by the child, improved compliance and, thereby, higher coverage. Some studies have shown that some of the combination vaccines have a higher rate of local reactions (local pain and redness) than when the vaccines are administered separately. In the subset of studies that used combinations with whole cell pertussis vaccine, this did not seem to be the case and the increased rate of local reactions did not reach statistical significance. While there have been reports of deaths following the use of combination vaccines, in no instance have these been found to be causally linked. In Sri Lanka, the national programme did temporarily suspend the use of pentavalent vaccine, but they continued to monitor deaths following vaccination. The rates observed when they reverted to tetravalent vaccine were no different from those observed following the pentavalent vaccine, indicating that these represented coincidental child deaths that were only temporally related to administration of the vaccine dose. All the countries referred to in the articles “India Serves Up Costly Cocktail of Vaccines” are currently using the pentavalent vaccine, as are over 170 countries worldwide. WHO policy recommendations do aim to maximize population benefit, but not at the expense of safety, which in all cases remains paramount. Wherever there are areas of uncertainty, the WHO position papers do clearly lay these out. While I fully agree with Prabir that each family needs to be fully informed and make decisions based on their social situation, there are a few inaccuracies in his response that deserve comment. The increase in reports of AEFI following the pentavalent vaccines in a few countries, as compared to quadrivalent vaccines, is more likely related to the fact that AEFI monitoring processes were concomitantly strengthened in those countries. As indicated above, further investigation in Sri Lanka revealed that the AEFI rates remained the same when they suspended the use of pentavalent vaccines and reverted to using tetravalent vaccines. Prabir’s response also seems to imply that rotavirus disease is less common in populations where there is access to safe water. In fact, this is not true. Rotavirus is a “democratic virus” equally prevalent in communities with and without access to safe water. Rotavirus is more often transmitted through contact than through contaminated water. It is also not true that those coming to Asia from the West are naive and, therefore, more likely to suffer from severe rotavirus diarrhoea. In fact, the reverse is true. The incidence of severe rotavirus diarrhoea is much higher in high child mortality populations, which is why the vaccine is likely to have greater benefits despite lower vaccine efficacy. In addition, data from Vellore, where Prabir trained, show that urban Indian children are more likely to suffer from severe rotavirus diarrhoea following second or subsequent infection whereas in the West severe disease mainly occurs with the first episode of infection. It is also a misconception that pneumococcal pneumonia occurs more commonly in colder climes. In fact, the reverse is true. Available evidence through well conducted studies show that the incidence of invasive pneumococcal disease and pneumococcal pneumonia are higher in developing countries (http://www.who.int/immunization_monitoring/burden/Pneumo_hib_estimates_2000/en/index2.html). While it is true the pneumococcal pneumonia can easily be treated with antibiotics, timely access to antibiotics is low in most developing countries. Even if pneumonia can be treated with antibiotics, vaccines reduce unnecessary pain, suffering, and the longer-term consequences to the child by preventing pneumonia. Well-to-do parents also would much rather their child does not develop pneumonia, than wait to treat if pneumonia develops. Dr. Thomas Cherian Department of Immunization, Vaccines and Biologicals World Health Organization
Accepted Answer Pending Moderation
Thank you all for your comprehensive replies! My daughter has gotten 2 rounds of Tetravalent (DPT+Polio) and Hep B. No reaction at all both times. When this set is done, we'll give her Pneumo and Rota before the fall when these diseases are said to be most prevalent in Senegal. At this stage, we'll probably pass on influenza and then move onto the remaining vaccines as per the charts on the CDC website. Aicha "thanks" you! http://www.technet21.org/components/com_agora/img/members/2193/P7091888.jpg
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