Challenges in National Immunization Program

The immunization program needs to be beefed up for vaccination against several potentially harmful diseases like chickenpox, and HPV which causes cervical cancers
Immunization of infants in Iran has achieved more than 98% coverage.
Immunization of infants in Iran has achieved more than 98% coverage.

The national childhood immunization program has played a significant role in the control, elimination and eradication of some major infectious diseases. But there are challenges as the program does not provide vaccines for ailments like rotavirus, pneumococcal bacterial infection and human papilloma virus (HPV).

The Health Ministry, however, plans to introduce rotavirus vaccine (RV) and the pneumococcal conjugate vaccine (PCV) in the national program.

While RV prevents severe diarrhea in children, PVC protects against pneumococcal bacteria that can result in infection of the blood, middle-ear, or cause bacterial meningitis. Annually, around 1,000 children under five years lose their lives to diarrhea in Iran.

The current immunization provides lifesaving protection against several diseases such as diphtheria, pertussis, tetanus, polio, measles, rubella, mumps, tuberculosis, hepatitis B, and Haemophilus influenza- introduced in the national program in 2015.

“Immunization of infants has achieved more than 98% coverage in the country but children without ID cards are likely to be missed out,” Mohammad Reza Panjtan, ophthalmologist and a board member of Gilan University of Medical Sciences, told the Financial Tribune.

According to the Education Ministry regulations, children can’t be enrolled in schools without producing the certificate of immunization.

Furthermore, the program needs to be beefed up for vaccination against several potentially harmful diseases like chickenpox, and HPV which causes cervical cancers. While the HPV vaccine is available in Iran (it costs $240 to receive all three doses), and is recommended between ages 9 and 13, it has not been placed in the national immunization program. Many Iranians are not still aware of the availability of HPV vaccine in the domestic drugstores.

Annually, around 1,000 Iranian women are diagnosed with cervical cancer. Nearly all cases of cervical cancer are caused by HPV. At present, cervical cancer is the fifth leading cause of death among Iranian women and is the second leading cause of cancer morbidity after breast cancer.

In response to a query on the weaknesses in the immunization program vis-a-vis visual health, Panjtan said, “Herpes zoster is an infection caused by the same virus that causes chickenpox and can infect the eye.”

But as the rate of herpes zoster is not high (4-5 in 1000 individuals), the vaccine has not been earmarked in the national program given that there are more important priorities such as the RV vaccine.

  Shift from OPV to IPV

No new incidence of polio infections have been registered in Iran since 2001.

But there are issues regarding use of oral poliovirus vaccine (OPV) instead of inactivated vaccine (IPV). OPV is currently preferred because of the endemic situation of polio in Afghanistan and Pakistan (eastern neighbors). Last year that ended in March, IPV was imported for the first time with the goal of reaching the World Health Organization’s target of introducing at least one dose of IPV into routine immunization programs in all countries by the end of 2015.

Presently, at least one dose of IPV is administered to Iranian babies as all four doses are unaffordable, given the high costs of the vaccine. The cost for each imported vial of IPV is about $2 and 1.5 million babies are born annually who should be immunized. Each child should be administered four doses (at 2 months, 4 months, 6-18 months, and a booster dose at 4-6 years).

OPV is a live attenuated vaccine which is superior to IPV as it is easy to administer, and there is no need for sterile syringes, as with IPV. But a major concern about OPV is its ability to revert to a form that can cause paralysis.

So far, outbreaks of vaccine-associated paralytic poliomyelitis (VAPP) have been reported in many countries. For example, in 2006, about 1,600 cases of vaccine-induced polio occurred in India.

According to WHO, routine immunization with OPV must cease after the eradication of poliovirus because of the danger of outbreaks of circulating vaccine-derived poliovirus and the risk of VAPP.

  Razi to Produce IPV

In 2016, all trivalent OPV (tOPV) were collected from Iran’s health centers in an effort to switch to bivalent OPV (bOPV), since one of the three polio viruses in the vaccine had been eradicated in 1999 as using the redundant ingredient in OPV could cause VAPP.

The Health Ministry has given the green light to Iran’s Razi Vaccine and Serum Research Institute to produce IPV. The institute which started OPV production 40 years ago has helped the nation become polio-free.

Over the past two decades, the recommended vaccination schedules in many countries has grown rapidly and become more complicated as many new vaccines have been developed to combat the diseases.

Austria, Cyprus, Germany, Greece, Italy, Spain, and Switzerland have already introduced chickenpox vaccine in their national immunization program.

And 127 countries across the world including Austria, Belgium, Denmark, France, Germany, Ireland, Latvia, Luxembourg, Norway, Portugal, Slovenia, Spain, Sweden, Switzerland, and the UK have placed HPV vaccine in their national childhood immunization program.