> , Matt Beasley wrote:
> > Dexter wrote:
> > > *Hemidactylus* wrote:
> > >
> > > > But not here yet. A heads up.
> > > -----------------------------
> > > Oh? There's always room in the Bozo Bin.
> > ----------------
> > Nobody listened to the biologists calling for Zero Population
> > Growth 50 years ago, so population doubled, from 4 to 8 billion.
> Please cite data supporting cause and effect. Indeed, given that the majority
> of the population increase has been in places like India and China, please
> cite data showing that the general public even _heard_ of ’the
> biologists’. Further, given again that so much of the population growth was
> in China, despite the extremely draconian one-child-per-family laws, please
> cite data supporting how limiting population, even with the power of a
> Communist state behind it,even works.
Tuberculosis was perceived as a major cause of morbidity and mortality. In May 1948,
the Government of India issued a press note stating that tuberculosis was “assuming
epidemic proportions” in the country, and that it had “after careful consideration”
decided to introduce BCG vaccination on a limited scale and under strict supervision
as a measure to control the disease31. A BCG Vaccine Laboratory at King Institute,
Guindy, Madras (Chennai), Tamil Nadu, was set up in 1948. In August 1948, the first
BCG vaccinations were conducted in India. The work on BCG had started in India as a
pilot project in two centres in 1948. In 1949, the BCG vaccination was extended to
schools in almost all States of India. The International Tuberculosis Campaign (ITC)
supported Government of India in expansion and scale up of BCG vaccination. From
Feb 1949, five ITC teams demonstrated BCG vaccination in various urban centers with
the start of a small scale pilot in Madanapalle. In a Conference in the summer of
1951 attended by representatives of the State Government, a proposal for the
extension of mass BCG Vaccination Campaign throughout India was endorsed. The
Government of India prepared a Plan of Operations laying down the organizational
set-up required in each State to cover the total young population during a
5-7 year period. The BCG vaccination was expanded through mass campaigns in 1951.
The ITC support ended in June 1951 and from July 1951, BCG vaccination was conducted
by the Indian authorities in close cooperation with UNICEF, which continued to provide
financial support, and WHO, which gave technical advice. In 1955-1956, the
BCG vaccination mass campaign covered all the States of the Indian Union35. BCG
vaccination became a part of the National Tuberculosis Control Program (NTCP),
which was started in 1962. The related events of this period were establishment
of Tuberculosis Chemotherapy Center, later known as Tuberculosis Research Center
(TRC) in Madras (Chennai) (now renamed as National Institute for Research in
Tuberculosis) in 1956 and that of National Tuberculosis Institute (NTI) in 1959.
There were targeted efforts to control TB and the efficacy of BCG vaccine in
prevention of pulmonary TB was in questions, since the very beginning. However,
BCG vaccination was the only available protective measure against TB. A large BCG
trial named ‘Feasibility Study for TB Prevention Trial’ was conducted in Chingelput,
Tamil Nadu. This trial was started in 1968, recruitment and fifteen year follow up
for all cases was completed by 1987. The trial showed that BCG vaccination did not
offer significant protection against TB of the lung which occurs mostly in adults.
After that, in India BCG vaccination policy was revised and it was recommended to
be given at an early age preferably before the end of the first year after birth
by integrating under UIP. BCG vaccination policies in many other countries were
also revised as a consequence of the Chingelput trial findings36. This could be
termed as a big success story of Indian research institutes in conducting large
scale vaccine efficacy trial.
During this period and since early 50s, globally the expert started discussion
on the possibility of the eradication of smallpox. After much deliberation in
1958, the World Health Assembly (WHA) passed a resolution to eradicate smallpox,
an event which changed the entire public health in the years to come. Following
this resolution, India started National Smallpox Eradication Program (NSEP) in
1962, with an objective of successfully vaccinating entire population in the next
3 years. The target in ‘attack phase’ was 80% coverage and in ‘maintenance phase’
all newborns, infants and children at the age of 5, 10 and 15 yr were to be
vaccinated. However, after 5 years of implementation, the coverage remained low
and outbreaks were still being reported. This was because the difficult to access
population was not being reached and many a times the same individuals were being
vaccinated for inflating coverage.
In 1967-68, the smallpox eradication strategy was reformulated with increased
focus on surveillance, epidemiological investigation of outbreaks and rapid
containment drives. In 1969, the vaccination technique changed from antiquated
‘rotary lancet’ to a new ‘bifurcated needle technique’. Another major change
was availability of a more potent, heat stable and freeze dried vaccine in 1971,
replacing old liquid vaccine. Both these steps simplified the process and
increased the vaccine uptake significantly.
By mid 1973, efforts were successful in many parts and smallpox was largely
restricted to Uttar Pradesh (UP), Bihar, West Bengal and a few other States.
In the same year, a national mobilization of health workforce was done and
intensive campaign started. In the first phase (July-August 1973) search and
containment efforts were done. In the second phase, UP, Bihar, West Bengal and
Madhya Pradesh States were targeted between October to December 1973. Every
village, every household in these States was visited to detect any suspected
case within a period of one week. The next three weeks were spent in case
investigation and doing containment operations by health staff. In 1974,
following massive efforts, 188,000 cases and 31,000 deaths were reported due
to smallpox. The Government of India intensified the search and containment
and vaccination efforts. The last case was reported in 1975 and efforts to
maintain surveillance continued thereafter also. The details of the events
of during this period are provided in Table V. The world was declared free
from smallpox on May 8, 1980 by the World Health Assembly.
Vaccines availability and manufacturing in India (1947-1977) India was
self-sufficient in the production of smallpox vaccine at the time of
independence. BCG vaccine laboratory was set up in Guindy in 1948 with the
intention of sufficient BCG vaccine production for the requirement in the
country. The important development in vaccine manufacturing was setting up
of vaccine manufacturing units in private sector also (Tables III–V). These
units were involved in the production of vaccines other than smallpox also.
The Pasteur Institute of India developed influenza vaccine in 1957 and an BPL
inactivated rabies vaccine in 1970. This institute developed and produced,
for the first time in India, indigenous trivalent oral polio vaccine (OPV)
in 1970. According to an official statistics, there were nearly 19 vaccine
manufacturing units in public sector and 12 in private sector in 1971.
Majority of vaccines available in global market had become available in
Indian market also. The vaccine manufacturing units in India were producing
not only smallpox vaccines but a few of these were also producing diptheria,
pertussis and tetanus (DPT), diphtheria and tetanus (DT), tetanus toxoid (TT),
oral polio vaccine (OPV) and other vaccines except measles vaccine.
As soon as India was declared smallpox free in 1977, the country decided to
launch National Immunization program called Expanded Program of Immunization
(EPI) in 1978 with the introduction BCG, OPV, DPT and typhoid-paratyphoid vaccines.
The target in EPI was at least 80 per cent coverage in infancy, the vaccination
was offered through major hospitals and largely restricted to the urban areas
and thus understandably, the coverage remained low. Typhoid-paratyphoid vaccine
was dropped from EPI in 1981, reportedly due to considered higher reactogenecity
and low efficacy of the vaccines and also due to perceived reduced burden of
typhoid disease in the country. Tetanus toxoid vaccine for pregnant women was
added in EPI in 1983. The EPI was rechristened with some major change in focus
by the launch of Universal Immunization Program (UIP) on Nov 19, 1985. The
measles vaccine was added to the existing schedule. The objectives and major
focus in UIP were: (i) rapidly increasing immunization coverage and reduction
of mortality and morbidity due to six vaccine preventable diseases (VPDs), (ii)
improve the quality of service, (iii), establish a reliable cold chain system
till health facility level, (iv) phased implementation - all districts to be
covered by 1989-90, (v) introduce a district-wise system for monitoring and
evaluation, and (vi) achieve self-sufficiency in vaccine production and
manufacturing of cold chain equipment.
The immunization received additional importance when it was added to the PM's
20 point programme. Immunization was given the status of one of the five
National Technology Missions launched in 1986. The Technology Mission on
Immunization had the objectives of improving coverage with existing antigens,
and developing self-sustainability in vaccine production. Both considered
important for effective vaccination programme in the country38. The Child
Summit of 1990 also brought attention on increasing immunization coverage
and focus on a few interventions such as polio eradication, increasing
coverage with the existing agents and maternal and neonatal tetanus
The UIP started in 31 districts in 1985 with plan of scale up to additional
districts. The coverage target was all pregnant women and 85 per cent of all
infants against six VPDs by March 1990. With effect from 1990-1991, the
vaccination programme became universalized in geographical coverage and the
target of UIP was increased to cover 100% of the infants. In the beginning
of UIP in 1985, the measles vaccine was being imported in India. The National
Technology Mission on immunization helped in modernization and upgradation of
vaccine facilities and by 1990-1991, the country became self-sufficient for
all vaccines (including measles) except for OPV. Till March 1991, maintenance
of cold chain was under contract between UNICEF and commercial agencies. From
April 1991 onwards, states/union territories had taken responsibility of the
maintenance of cold chain43. A detailed timeline of EPI and UIP in India is
given in Table VI.