Indian Academy of Pediatrics
Update on Policies, Guidelines and
Recommendations on Immumnization - 2001

The IAP Policies, Guidelines and Recommendations which were last updated in January 1999, have been reviewed by the IAP Committee on Immunization in March, 2001. The Academy’s stand on several issues have been classified in three categories:-

1. POLICY
   Policies are the decisions taken by the Academy in relation to the scientific principles and practice of immunization.
   
2. GUIDE LINES
   The Academy expects the members to implement the policies routinely in their day to day practice adhering to instructions regarding immunization schedule, cold chain management, disease survelance etc.
   
3. RECOMMENDATIONS
   The Academy in its role of advocacy expects international agencies, the Government of India and other professional bodies to pursue and implement the suggestions in a timely basis in the best interest of the children of our Nation.

IAP POLICIES ON IMMUNIZATION – 2001

On UIP: The academy continues to encourage and support the Universal Immunization Program and the National Immunization Schedule, recognising the fact that they provide only the basic minimum immunization needs of all children in our country.

On Immunization to be supplemented: The Academy, however, believes that this schedule must be supplemented with other selected vaccines like Hepatitis B, Haemophilus influenzae type b, MMR and Typhoid vaccines, in a phased manner.

On BCG vaccine: The Academy endorses the current GOI policy of administering a single dose of BCG vaccine at birth for all institutional deliveries and for others at 6 weeks latest, simultaneous with DPT and OPV. However, the neonatal BCG vaccine along with the neonatal OPV should be given preferably at birth to 2 weeks so that the subsequent DPT and OPV doses can be continued at 6, 10, 14 weeks.

On OPV: The policy of the Academy is to give all children three primary doses apart from the dose at birth in the first year of life and two more doses are recommended at one and half years and five years. PPI doses should be continued in addition to routine immunization till poliomyelitis eradication is certified.

On DPT, DT, TT, Td Vaccines: Regarding DPT, the policy of the Academy is to endorse the UIP schedule of 3 doses in infancy and one booster in the second year of life and to supplement the UIP schedule with a second booster of DPT in the fifth year of life instead of the current DT booster only. Where possible the combined DPTWC / HB vaccine can be given in preference to DPT vaccine. The Academy endorses the GOI policy of giving TT boosters at 10 and 16 years. Where Td vaccine formulation is available, it is preferred to TT vaccine. IAP also recommends 2 doses of TT to pregnant mothers, first dose at the earliest contact for antenatal registration and the second dose at 4 to 8 weeks interval.

On Measles Vaccine: IAP endorses the GOI policy of giving a single dose of measles vaccine at 9 months (after completion of 270 days ) of age. If missed till 12 months of age, MMR vaccine should be given instead.

On other Selected Additional Vaccines: Varicella and Hepatitis A vaccines may be considered as additional vaccine.

On Hepatitis B Vaccine:

1. All babies except born to HBsAg positive mothers should receive the first dose of hepatitis B vaccine at birth followed by 6 and 14 weeks. If the first dose at birth is missed, the first dose can be initiated at 6 weeks followed by 2 more doses at 10 and 14 weeks. The choice of combination vaccine of Hepatitis B with DTPw can be prefered.
2. For babies born to HbsAg positive mothers, HB vaccine should be initiated from birth onwards, along with HBIG (HB immunoglobulin) within 12 hours, followed by 2 more doses at 6 weeks and 14 weeks. If HBIG is not available, then HB vaccine alone must be given prefferablly , following four doses schedule at birth, 6 weeks, 10 weeks and 12 months for optimal protection to these infants.
3. Regular screening for markers of HB infection is not necessary. If there have been some risk factors of past infections such as acute/ chronic HBV infection within the household or prior blood transfusion, then screening is advised. For this purpose, anti-HBc test alone is sufficient in most situations.

On MMR Vaccine: MMR vaccine is to be given in the second year of life, preferably at 15-18 months. If missed it can be given at any age later.

On Haemophilus influenzae type b Vaccine: Since Hib prophylaxis is age dependent, and it involves boosting of the natural immunity, either 3, 2 or 1 dose/s at 6 weeks – 6 months, 6 – 12 months and 12 – 15 months respectively, followed by a booster at 15 – 18 months are recommended. Beyond 18 months - 59 months only one dose is recommended. This vaccine is not recommended after 5 years of age.

On Typhoid Fever Vaccines: IAP encourages the aroutine of immunization against typhoid fever in all communities.

1. For urban overcrowded communities, with known prevalence of typhoid fever cases especially children under 5 years, the whole cell killed vaccine when available, is recommended at an appropriate age based on local epidemiology from age 6 months upto 2 years.
2. When available, the unimmunized children between 2 to 6 years of age, the whole cell vaccine is recommended in urban overcrowded communities and in low income group families. For those families who can afford the cost and administration, the Vi antigen vaccine can be given as a single dose.
3. For previously unimmunized children of 6 or more years, the above recommendations hold good, except that the choice now includes the oral typhoid vaccine also.
4. In general, a child started on any of above mentioned vaccines, may be kept on the same vaccine by periodic boosters once every 3 years or if so desired, a child may be given the whole cell killed vaccine below 2 years, followed by Vi vaccine at or after 2 years, and the oral vaccine at or after 6 years.

On Hepatitis A Vaccine: Continues to be an additional vaccine. It may be offered to children belonging to a high socio-economic level as these children are at higher risk of developing the infection. Two doses of pediatric formulation can be given the first dose at the elected date and the second 6 months later after 2 years of age. Adult formulation will have to be given after 19 years of age.

On Varicella Vaccine: Continues to be an additional vaccine. A single dose may be offered to those children beyond one year and up to 12 years who have not had varicella previously. For children older than 12 years without past history of varicella two doses should be given 4 to 8 weeks apart. However, the vaccine can be given anytime after one year under special circumstances.

IMMUNIZATION CAMPS AND CAMPAIGNS: IAP encourages the participation of its members in all campaigns organised by GOI to augment routine immunization coverage and the special campaigns for Polio Eradication, Measles elimination etc. For other camps and campaigns organised by professional bodies, service organizations and group of doctors etc., IAP stipulates the following guidelines:

2. When immunization camps/campaigns are organized for non UIP vaccines, the information given to the parents and the public should be accurate and appropriate.
3. If parents are asked to pay the cost of vaccine, special provision must be made to provide vaccine free of cost, or at subsidized cost, to the families known to be poor. If such equity in service cannot be provided, then, such camps/ campaigns should not be organized/encouraged.
4. The organizers/ participents of immunization camps/campaigns are not entitled to any financial profit or promotion of vaccines.
5. The organizers of such camps/campaigns should obtain the prior approval of the relevant local health authority, for which purpose the plan of action may be vetted by the local branch of IAP.
6. Precautions should be taken to maintain proper cold chain, strict adherance to the use of quality disposible needles and syringes, apporpriate dosage/ schedule/ route and site of administration/provision for emergency care with the involvement of qualified personnel under strict medical supervision.(Duplication of vaccination should be avoided)

These guidelines may be brought to the attention of those who might be planning to conduct such camps/campaigns, especially school authorities, school health agencies, voluntary organizations, and parents/parent-teacher associations. If any member of the Academy becomes aware of any violation of these principles, it is the member’s duty to bring it in writing to the state/ district President or Secretary. The branch may deal with the matter according to the decision of the office bearers andadvise the organizers of the camp to take remedial steps. If further steps are necessary, the branch shall write to the Secretary General IAP for referral to appropriate Committee/Experts.

IMMUNIZATION RECORDS: Every dose of any vaccine given to children must be documented on an appropriate Card or Booklet to be retained by the parents. The Immunization Card of the IAP is highly recommended for this purpose. Parents must be instructed to keep the document safely and to present it to any doctor, clinic or immunization centre, to be kept updated on all doses of vaccines. Parents may be advised to note the number of doses given in PPI campaigns also, for any future reference. An immunization certificate at school entry is worth considering.

II IAP GUIDELINES ON IMMUNIZATION PRACTICES:
Detailed guidelines to benefit the practitioners of childhood immunization practices on individual vaccines have since been developed by the Academy in the form of a booklet entitled “IAP Guide Book on Immunization” and is available for members on request.

III IAP RECOMMENDATIONS ON VACCINES
Hepatitis B Vaccine:

1. The Indian Academy of Pediatrics strongly recommends to the Government of India the universal introduction of HB vaccine incorporating the same in UIP schedule and preferably, schedule the first dose at birth with subsequent two doses at 6 weeks and 14 weeks of age. It is important to note that the first dose at birth is essential to prevent perinatal transmission. If the first dose at birth is missed, it should be given at 6 weeks, 10 weeks and 14 weeks of age. If prefered it can be given in combination with DPT wc at 6 weeks and 10 weeks at 14 weeks of age
2. Whenever feasible, the Academy also recommends that a policy should be adopted for testing of pregnant women for HBV chronic carrier (infection) state and if positive, to endorse a policy to give Hepatitis B immune globulin plus HB vaccine to the new born, or at least HB vaccine alone, in the first 12 hours after birth.

Measles, Mumps and Rubella Vaccine:
IAP strongly recommends to the GOI the inclusion of MMR vaccine in the UIP Schedule. The vaccine can be scheduled at 15 – 18 months along with the DPT, OPV booster.

Typhoid Fever Vaccine:

1. IAP recommends the inclusion of Typhoid vaccine Whole cell vaccine in the UIP schedule.
2. 2. IAP recommends the reestablishment of manufacture of the whole cell killed Salmonella typhi vaccine in the Public sector vaccine manufacturing units in the country.
3. IAP further recommends that killed vaccine need to contain only S. typhi and not S. paratyphi, thereby improving its quality and reducing its adverse reactions.
4. IAP suggests that the manufacturing units undertake some research to improve the process of killing of the organisms so that its immunogenicity could be better preserved and the reactogenicity further reduced.

ON COMBINATION VACCINES:

2. IAP welcomes and encourages licensing of currently available combination vaccines including a future pentavalent DPT wc/HB / Hib formulation.
3. IAP recommends that wherever combination vaccines are available, they can be substituted for monovalent formulations in the National Immunization Schedule wherever indicated.
4. IAP recommends to the indigenous vaccine manufacturers to explore the feasibility of producing pentavalent DPT wc/HB/Hib formulation.

ON INCLUSION OF ADDITIONAL VACCINES IN THE UIP SCHEDULE
Vaccine Recommended for inclusion in the National Immunization Schedule

On Polio Eradication:

1. IAP congratulates the GOI for its sustained efforts in Polio eradication and also for readily accepting its recommendation to divide the entire country into high, medium, low burdened zones and to adopt 2 NID’s plus the required number of sub NID’s in the respective zones.
2. IAP endorses the current strategies for polio eradication efforts in India namely, Pulse Polio Immunization and AFP Surveillance, as advocated by WHO, UNICEF, GOI and IAP experts.
3. Joint meetings of WHO, UNICEF, GOI & IAP experts should be organised once in three or six months to review the progress and problems of polio eradication.
4. The possible incidence of Vaccine Associated Paralytic Polio (VAPP) should be evaluated.

On Improving Routine Immunization Coverage:

1. IAP voices its concern over decreasing coverage in routine immunization and strongly recommends Intensified Routine Immunization Coverage Campaign (IRICC), especially in those states/regions where routine immunization is very low.
2. IAP also recommends that the school authorities should insist production of an Immunization Certificate at school entry and this should be regularised by the State and the Central Governments.

On Membership of Coordination Committees/ Expert Group:

1. IAP recommends the inclusion of its National President, the Chairperson and the Convenor of its Committee on Immunization in the:
   1. Advisory Committee on Immunization Practices and Vaccines in India
   2. National Polio Eradication Experts Group
   3. Committee for consideration of introduction of newer vaccines in the National Immunization Schedule.
2. IAP also recommends that its District Presidents and Secretaries should be included as members of Distric Coordination Committees on Immunization and Polio Eradication.