Need to include hepatitis B
vaccination into national immunization programme
By Syed M. Aslam
August 16 - 22, 1999
Some five million children, born in Pakistan every year, face fatal
health risks due to the failure of the government to include hepatitis B vaccine into the
national immunization programme despite World Health Organization's (WHO) recommendation.
In 1991, the World Health Organization (WHO) called for all countries
to add hepatitis B vaccine into their national immunization programmes. So far, 100
countries have added the highly contagious disease hundred times contagious than
AIDS on their national immunization programmes. Some two billion people around the
world are infected with hepatitis B virus including over 350 million who are the chronic
carriers. Hepatitis B is blamed for causing 1-2 million deaths in the world every year.
According to the Pakistan Medical Association, one in every ten persons
in the country is a carrier of hepatitis B. It also attributes hepatitis B as the basic
reason of the 62 per cent of lever cancer cases in the country. There is no cure for
Hepatitis B which makes prevention all the more important.
A person may have hepatitis B virus while not being aware of it as
sometimes in the case of HBV infection, the primary cause of the disease, has no symptoms
at all. The newborns are at particular risk as they can get HBV at birth.
The failure of the government to include hepatitis B in the
immunization programme and the absence of creating the public awareness that the situation
demands, is putting millions of new borns at high risk. This is more fearful as Pakistan
already has a high infant mortality rate of 88 per 1000 and under-five mortality rate of
even higher as 123 per 1000.
While children are at particular risk, the huge majority of adult
population is also at the risk due to lack of public awareness in Pakistan. Even the
medical profession, which should have played its due role to create the public awareness,
has failed to fulfill its obligations to a great extent.
For instance, a fairly educated father of a new born baby was given a
vaccination card by the doctor at the clinic where his son was delivered. While the card
listed six fatal diseases poliomyelitis, neo-natal tetanus, pertussis, diphtheria,
tuberculosis and measles, included on the Extended Programme of Immunization (EPI) of the
government, it only mentioned hepatitis B vaccination as optional.
This is also the case with the majority of the maternity hospitals as
the government has not officially included the hepatitis B vaccination in the EPI. The
majority of population, not only the vast number of illiterates but also many in the
fairly educated group, are thus unaware that hepatitis B vaccination is no more optional
but a must. The mass unawareness and the lack of concern on the part of the government is
putting the lives of the majority of newborns at grave risks.
Sources in the medical profession, who chose to remain anonymous,
blamed the indifference of the government to include hepatitis B in the national
immunization programme on account of non-allocation of funds. As is, the health sector has
been allocated a meager Rs 2.7 billion in the Budget 1999-2000 which translates into just
2.3 per cent of the funds allocated for the development expenditure only a part of which
will go the existing EPI.
Sources blamed the reluctance on the part of the government to
officially include the hepatitis B in the national immunization programme as it would mean
making provisions for funds. As hepatitis B vaccination is fairly expensive the inclusion
would mean an allocation of Rs 3.25 billion to vaccinate about 5 million babies every
year. However, the economic justification is medically and morally unacceptable as it put
the lives of babies at great mortal risk.
The cost of hepatitis B vaccination, which is administered in three
doses over two months, is high for a poor country like Pakistan where many find it
unaffordable. Unlike developed countries where hepatitis vaccines cost no more than buying
a bottle of mineral water in a restaurant, the cost of the vaccination in Pakistan, which
is totally dependent on imported vaccine, is highly expensive. Hepatitis B vaccination in
Pakistan costs Rs 645 for children and almost Rs 1,100 for adults for all three doses.
While the government has chosen not to play a role in the vaccination
of hepatitis B, the Pakistan Medical Association (PMA) has been trying to create public
awareness on the issue for the last two years. However, it was only recently that the PMA
initiated a media campaign to set up hepatitis B vaccination centres in the country.
The PMA has established 12 centres in Karachi offering hepatitis B
vaccination for both, adults and children, at a discounted rate. PAGE visited
one of the twelve centres, at PMA House, on two consecutive days and found not a single
administration of the vaccination. The attendant, however, claimed that the campaign,
started two weeks ago (to end on August 15), vaccinated some 30-35 persons per day
initially and some 65 persons a day in its finishing phase. Half of those administered
vaccination were children, he added.
The multinational pharmaceutical company, SmithKline Beecham, is
providing the hepatitis B vaccine, imported from its parent company in Belgium, at a
discounted rate for the PMA campaign. Beecham is providing the two dosages of the
vaccine 10 mcg for persons upto 19 years of age and 20 mcg for all those above
at four per cent discount. While the vaccine is available for Rs 205 and Rs 340 at the
designated vaccination centres as compared to Rs 214 and Rs 354 in the open market, the
centres does not charge for disposable syringes and the fee, a saving of about Rs 30.
Sources told PAGE that while the PMA awareness drive, over the last two
years, has been able to create a greater awareness about the hepatitis B, much remains to
be done as not even one per cent population of Pakistan is vaccinated against the deadly
Though the awareness has grown somewhat in the urban centres, the bulk
of population still remains oblivious to the risk that hepatitis B poses to their health.
The situation in the rural areas, which houses the majority of Pakistans population,
Even in the urban centres, such as Karachi, the campaign has elicited
diametrically opposite response from basically two segments of the populace, those who can
afford it and those who can not. Sources told PAGE that the lower income group has shown
much greater interest in the campaign as compared to those who could easily afford it.
However, despite the overwhelming response the former are finding it difficult to afford.
On the other hand only a small portion of those who can afford it, has chosen to get
vaccinated, PAGE was informed.
Beecham which has been marketing Engerix-B in the country for over a
decade, has emerged as the market leader though there are a number of other imported
hepatitis B vaccine available in the country. There are Hepavaxdene and Amvax both of
Korean origin and Heperbiovan which is imported from Cuba. The Korean and Cuban vaccines
are about Rs 15 cheaper than the Beechams product.
Sources told PAGE that bulk of imports can help cut the price of
hepatitis B vaccine by as much as one tenth to make them affordable. This means that the
prices of 20 mcg and 10 mcg dose of hepatitis B vaccine can be brought down to an
affordable level of Rs 35 and Rs 21 if the government chooses to import it in bulk. It is
still not too late to invest in the health of the nation, particularly children's,
People born in Southeast Asia, Africa, the Amazon Basin, in South
America, Pacific Islands and the Middle East are at higher risk to get infected by HBV.
Children born in these countries even if they have migrated to any developed, country such
as the US, are also in the high risk group.
Hepatitis B is not spread through food, water or by casual contact. It
is spread through one of the following ways direct contact with the blood or blood
fluids of an infected person for instance through sex or sharing syringes. A baby can get
it from an infected mother. Living in the same house with someone infected with HBV also
increases the risk of getting infected.
Once infected, carriers never fully recover from the infection. They
carry the HBV virus and can infect others. This is true for the babies who get HBV at
birth. The carriers are highly prone to liver cancer or liver cirrhosis.
While sometimes there are no symptoms, one should watch for the
* eyes or skin may turn yellow
* loss of appetite
* nausea, vomiting, fever, stomach or joints pain
* extreme tiredness, inability to works for weeks or months.