|BRIEF RESEARCH ARTICLE
|Year : 2016 | Volume
| Issue : 2 | Page : 145-149
Estimates on state-specific Pneumococcal Conjugate Vaccines (PCV) coverage in the private sector in the year 2012: Evidence from PCV utilization data
Habib Hasan Farooqui1, Sanjay Zodpey2, Maulik Chokshi3, Naveen Thacker4
1 Assistant Professor, Indian Institute of Public Health, Delhi, India
2 Director, Indian Institute of Public Health, Delhi, India
3 Associate Professor, Indian Institute of Public Health, Delhi, India
4 Past President, Indian Academy of Pediatrics (IAP), India
|Date of Web Publication||23-Jun-2016|
Habib Hasan Farooqui
Indian Institute of Public Health-Delhi, Plot No. 47, Sector 44, Institutional Area, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The pneumococcal conjugate vaccine (PCV) is not available through universal immunization programs but is available through private healthcare providers. Because the PCV coverage rates are unknown, we developed a Microsoft Excel-based coverage assessment model to estimate state-specific PCV coverage for the year 2012. Our findings suggest that in the private sector, the "overall PCV coverage" was around 0.33% that ranged between a minimum of 0.07% for Assam, India and a maximum of 2.38% for Delhi, India. Further, in major metropolitan areas, overall PCV coverage rates were: 2.28% for Delhi, India, 13.31% for Mumbai (Maharashtra), India 0.76% for Lucknow (Uttar Pradesh), India, 1.93% for Kolkata (West Bengal), India, and 4.92% for Chennai (Tamil Nadu), India highlighting that urban centers are major drivers for PCV utilization driver in the states with high PCV consumption. Hence, to improve PCV coverage, both demand side (increasing consumer awareness about pneumonia prevention) and supply side (controlling vaccine prices and indigenous vaccine production) interventions are required.
Keywords: Coverage, immunization, pneumococcal conjugate vaccine (PCV)
|How to cite this article:|
Farooqui HH, Zodpey S, Chokshi M, Thacker N. Estimates on state-specific Pneumococcal Conjugate Vaccines (PCV) coverage in the private sector in the year 2012: Evidence from PCV utilization data. Indian J Public Health 2016;60:145-9
|How to cite this URL:|
Farooqui HH, Zodpey S, Chokshi M, Thacker N. Estimates on state-specific Pneumococcal Conjugate Vaccines (PCV) coverage in the private sector in the year 2012: Evidence from PCV utilization data. Indian J Public Health [serial online] 2016 [cited 2019 Dec 14];60:145-9. Available from: http://www.ijph.in/text.asp?2016/60/2/145/184572
Pneumonia is one of the most common causes of morbidity and mortality in children younger than 5 years in India. For India, Child Health Epidemiology Reference Group (CHERG) established by the World Health Organization (WHO) predicted around 43 million pneumonia cases (23% of the world's total) in 2008.  The latest India-specific analysis suggest that in 2010, 3.6 million (3.3-3.9 million) episodes of severe pneumonia and 0.35 million (0.31-0.40 million) all deaths caused by pneumonia occurred in children younger than 5 years in India. Further, it was reported that 0.56 million (0.49-0.64 million) severe episodes of pneumococcal pneumonia and 105 thousand (92-119 thousand) pneumococcal deaths occurred in India.  However, it is expected that with the availability of a new generation of vaccines that prevent pneumonia, the situation would improve.
New generations of pneumonia-preventing vaccines include Hemophilus influenzae B vaccine (Hib Vaccine), pneumococcal conjugate vaccine (PCV), influenza vaccine, and others. The PCV are a significant improvement over the previous generation of polysaccharide vaccines, as they are immunogenic in infants, elicit longer lasting immune memory, and additionally prevent nasopharyngeal carriage. This new generation of PCVs have serotype coverage for around 52% to 64% invasive pneumococcal disease prevalent in India. Hence, it can potentially prevent significant fraction of invasive pneumococcal disease. 
Given the fact that PCV is not available through the universal immunization program of the Government of India and can only be accessed through private sector pediatricians, the PCV coverage assessment was felt necessary. Further, anecdotal evidences suggest that even in the private sector, uptake of PCVs is significantly limited to an affluent class of urban metropolitan areas.  The objective of this research was to generate evidence on state-specific PCV coverage in the private sector.
We developed and parameterized a Microsoft Excel-based coverage assessment model to estimate PCV coverage across major Indian states for the year 2012. The input parameters for the coverage assessment model were: The number of eligible children for PCV immunization in selected states, the number of PCV doses consumed across those states, and the number of doses required for complete PCV immunization. The numbers of eligible children for PCV immunization across selected Indian states were estimated from the 2011 census of India.  The number of doses of PCVs consumed was estimated from the PCV sales figures (value and volume across brands) from IMS Health sales data for the year 2012.  For the present study, IMS vaccine sales audit data on PCV for selected Indian states was used as proxy indicator for vaccine utilization in the private sector. The selection of 14 Indian states was driven by IMS vaccine sales data availability. However, these states comprise around 90% of Indian birth cohort.  The number of doses and schedule for PCV immunization was based on Indian Academy of Pediatrics Committee on Immunization (IAPCOI) recommendations (i.e., three doses at 6, 10, 14 weeks, and a booster at 15 months).  We assumed that any child receiving one dose of the selected vaccine has received all the subsequent doses and completed the schedule.
| Calculations for Pcv Coverage Assessment|| |
Step 1: The model estimated the number of eligible children immunized with PCV by dividing the total number of PCV doses (all brands) sold in each state in the private market in 2012 by recommended dosing schedule of IAPCOI.
Step 2: The PCV coverage figures for 2012 birth cohort across states were estimated for two scenarios, i.e., overall coverage and urban coverage. The "overall coverage" model assumes that sold PCV doses in private market were consumed by any child (urban and rural) in the birth cohort in the respective state whereas in the "urban coverage" model assumes that only the urban birth cohort consumed the PCV doses sold in the respective states.
Overall or Urban PCV coverage (%) = Children fully immunized by PCV in private sector/Birth cohort (urban + rural) or (urban) of the respective states 100%.
In addition, correlation coefficient analysis was conducted to observe relationship between state-level PCV coverage in the private sector and state-specific sociodemographic variables viz the level of urbanization (defined as the proportion of population living in urban areas), female literacy level, state specific per capita income, and state-specific gross domestic product (GSDP). The study has received appropriate ethical approval from the institutional ethics committee.
Our findings suggest that at an all India level, "overall PCV coverage" in private sector was around 0.33% that ranged between a minimum of 0.07% for Assam, India and a maximum of 2.38% for Delhi, India [Table 1], [Figure 1]. However, the "urban PCV coverage" in the private sector was 2.10%, with a range of minimum of 0.41% and 2.45% for Kerala, India and Delhi, India respectively [Table 1]. Further, we repeated similar analysis for the major metropolitan cities from the selected states where the urban population was significantly high (capital city) to understand the impact of differential utilization of PCV in urban areas on overall PCV coverage rates. The overall PCV coverage rates for 2012 birth cohort were 2.28% for Delhi, India, 13.31% for Mumbai (Maharashtra), India, 0.76% for Lucknow (Uttar Pradesh), India, 1.93% for Kolkata (West Bengal), India, and 4.92% for Chennai (Tamil Nadu), India [Table 2]. This led to the realization that estimated annual "urban PCV coverage rates" for capital cities in the private sector was 46.68 times higher for Chennai, Tamil Nadu, India, 14.27 time higher for Mumbai, Maharashtra, India, 3.89 times for Kolkata, West Bengal, India, and 1.61 times for Lucknow, Uttar Pradesh, India as compared to respective states annual "urban PCV coverage rates." This highlights the fact that urban centers are major drivers for PCV utilization driver in the states with high PCV consumption. It is recognized that in India, immunization coverage rates are influenced by sociodemographic factors and other household factors. In correlation analysis, we observed a strong correlation between state-specific private sector PCV sales and state-specific female literacy rates (r = 0.70), state-specific per capita income (r = 0.61), and state-specific level of urbanization (r = 0.71) [Table 3]. However, the correlation was weak with the state-specific Gross Domestic Product (r = 0.35).
|Figure 1: Private sector PCV coverage for selected Indian states in year 2012|
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|Table 1: Estimated state-specifi c PCV coverage (overall and urban) for the year 2012 in the private sector|
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|Table 2: Estimated PCV coverage (overall and urban) in the private sector for the year 2012 across selected cities|
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To our knowledge, this study is a first of its kind on PCV coverage assessment in India. Our estimates for overall PCV coverage in the private sector in India for year 2012 were 0.33% (minimum 0.07% and maximum of 2.38%). Further, we observed that annual "urban PCV coverage rates" for capital cities was 46.68 times higher for Chennai, India, 14.27 times higher for Mumbai, India, 3.89 times for Kolkata, India, and 1.61 times for Lucknow, India as compared to respective states annual "urban PCV coverage rates", highlighting the fact that PCV is predominantly an urban vaccine and its uptake and coverage are largely concentrated in private sector clients. A national survey conducted among the private sector pediatricians registered with the IAP has additionally reported that majority (85.6%) of pediatricians administer PCV vaccine selectively or routinely.  District level health surveys have reported as well that for acute respiratory infections (ARI) mothers prefer to visit private health care provider.  In another study conducted in Chandigarh, India regarding newer vaccines (Hepatitis B, Hib, measles mumps rubella (MMR), and others), it was observed that more than 50% children got immunization from the private sector.  Hence, improved access of PCV in the private sector should contribute significantly to pneumonia prevention in children.
In our benchmarking exercise, we observed that PCV coverage rates in selected states and capital cities are still much lower than Hib coverage rates in the private sector.  Similar findings were reported for other newer vaccines earlier. In Chandigarh, India, the coverage rates for other newer vaccines was (44.7%) for Hepatitis B, followed by Hib (27.8%), and MMR vaccine (27.6%) in 2005.  In addition, it has been reported that in the private sector, access to PCV is significantly higher in clients belonging to a high-income group as compared to a low-income group.  The limited access of PCV to a high-risk population is further constrained by the lack of awareness, geographic location, and affordability. In addition, it has been reported that the perceptions of disease susceptibility and severity or of vaccine safety and efficacy were not associated with routine PCV vaccine administration by pediatricians.  This may lead to a situation where populations who are at the highest risk of pneumococcal pneumonia may not have an access to the PCV.
One of the limitations of our analysis is a lack of primary data on PCV utilization. Because vaccines are perishable commodities and require robust cold chain, so IMS vaccine audit sales data is reliable proxy for PCV utilization. Further, given the limited access to vaccine and very low anticipated coverage, the WHO's 30-cluster sample survey design was technically, practically, and financially not feasible. 
In conclusion, we observed that the private sector although complements the public sector in enhancing access to care and delivery of immunization services but potentially increases inequity in care as well. Hence, public sector intervention is required to ensure equitable access to vaccines. In this regard, Government of India's Mission Indradhanush initiative is worth mentioning and commendable.  With reference to inequity in PCV access (i.e., population with a high risk of pneumococcal disease have poor PCV access as compared to those with low disease risk) it is highly pertinent to improve PCV coverage among population by both the demand side (increasing consumer awareness about pneumonia and pneumonia prevention) and the supply side (controlling vaccine prices and indigenous vaccine production) interventions.
We would like to acknowledge the technical advice provided by Dr. Niteen Wairagkar and support of all the pediatricians and their clients interviewed for this research.
Financial support and sponsorship
This work was supported by the Bill and Melinda Gates Foundation. (Contract number-22693).
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]