World Immunization Week: Vaccines are probably one of the biggest innovation of the 20th century, says Dr Soumya Swaminathan
“We have to look beyond childhood immunization now and really look at life course immunization,” Dr Swaminathan tells First Check in an interview
According to the World Health Organization six lives have been saved every minute for the last 50 years, because of essential vaccines — that is 15.4 crore lives in five decades. “In these 50 years, vaccination accounts for 40% of the improvement in infant survival, and more children now live to see their first birthday and beyond than at any other time in human history. Measles vaccine alone accounts for 60% of those lives saved,” according to the WHO.
Read More: https://firstcheck.in/vaccines-biggest-innovation-dr-soumya-swaminathan/
Despite its life saving properties, vaccine development and deployment are many a times hindered by hesitancy fuelled by misinformation, and sometimes even disinformation, campaigns. Recent global developments, including the cutting of funds into research on vaccine hesitancy and how to increase immunisation levels, have made it a more acute problem.
This World Immunisation Week, we spoke to Dr Soumya Swaminathan, the Chairperson of the M.S. Swaminathan Research Foundation (MSSRF) and former Chief Scientist at the World Health Organization (WHO), on the sidelines of the World Health Summit Regional Meeting in Delhi, on the importance of vaccines, India’s robust Universal Immunization Programme, the time taken to develop vaccines, and how to address vaccine hesitancy.
Here are the excerpts from that conversation:
Mariyam Alavi, for First Check: Thank you Dr Soumya for speaking to us. As you know, this is immunization week now and I know at the World Health Summit as well, you were part of multiple panels that were talking about vaccines — development, the importance of it, etc. So just to take our readers through that, why are vaccines so important to public health, and by extension the health of the country?
Dr Soumya Swaminathan: If you really asked me, I think vaccines are probably one of the biggest innovation of the 20th century, because till we had vaccines, we just had to accept deaths from infectious diseases, like measles, diphtheria, smallpox, and polio. And the very fact that today we have the confidence to know that in a new pandemic, we are able to develop and deploy vaccines at scale, at a global scale, within a very short period of time, just shows the huge impact that vaccines have had and the confidence that we now have in vaccines as a tool to protect humanity against infectious diseases.
I think it’s good to remind ourselves, because what is happening today is that people who are young today don’t remember things like smallpox and polio and measles, and the huge toll and the misery that these diseases caused. So there’s less belief or trust, or the faith in vaccine sometimes is being questioned, but that’s because I think… the older generation would remember people in their families dying, or being scarred from smallpox, or crippled by polio, which today we don’t. We have to remind ourselves of that history.
I will come to that hesitancy in just a bit, but before that, I just wanted to talk to you, about India’s universal immunisation programme. Because in India, we had all these diseases, but the UIP, has had an impact. According to you from a public health perspective, what do you make of the program? Is it good as it is or do we need any additions to it? Are there any other immunizations that you think need to be added to the program?
I think we have a very good program and it’s been evolving and getting strengthened over the years. Mission Indradhanush was really a turning point and really expanding the access and really reaching the unreached, because that was the whole mission of that. We still have maybe a few pockets, which are unreached, but by and large are immunization coverage, childhood immunization coverage is very good.
In terms of what do we do in the future, I think we have to look beyond childhood immunization now and really look at life course immunization, because that’s something that has been neglected not just in India, but globally. COVID was the first time we woke up to the fact that adults might need mass vaccination. So now when we think about diseases like TB or influenza or dengue or many of the emerging infections that are causing increasing morbidity, we will need to think about reaching school children, adolescents, and also adults and the elderly. If you think about pneumonia and the elderly, you want to vaccinate against flu, against pneumococcal disease and so on.
Those are the programs now that we will need to strengthen. And of course, now India will roll out HPV vaccine and there can be a package of vaccines that go into the adolescent age group and the elderly age group, which is a growing demographic in India that needs attention.
That’s very interesting because you have spoken about this. I was at the panel where you spoke about the need for a TB vaccine. But one point that you also highlighted is that there are multiple TB vaccine candidates, but they’ve been sitting in that trial phase for a long time, which means vaccines take a long time to develop. But at the same time, for the common man, it’s hard to understand, because during COVID we were able to develop a vaccine and roll it out almost immediately. So why were we able to do it there, but not here? Why do vaccines take so long?
It’s very simple. I think it essentially boils down to the urgency that is felt by society, the political will and the finances that are available. Because I think that science is already now in a very well-developed stage. And when you get that additional push, it’s not just the resources, but it’s also collaboration and partnerships. So what happened during COVID is everybody opened their doors and there was a single mission. The whole world was on a mission to develop vaccines or diagnostics or drugs, you know, all the three. But vaccines, I think was what everyone was really focusing on.
So you need a mission. Then you need the funding, you need the political backing and once you have that, then the scientific collaboration usually comes. Scientists want their products to move forward. They have spent their life and their passion on it.
If you’re moving slow, it’s because we haven’t felt that sense of urgency. And this is what I keep saying about TB. That even though it still kills — it’s the number one infectious disease killer and COVID overtook it for a couple of years, but then now it’s back to being number one. But when COVID was killing, that many people, we were all jumping up and down saying, where’s the solution? And how can we move fast? But TB kills the poor in all countries, and of course it’s more prevalent in the poorer countries. Therefore it doesn’t have that kind of… if you look at R&D budgets, the stop TB partnership has been tracking and predicting how much you need for TB program and for TB R&D. So both are predicted and year after year we fall short by more than 50% of the R&D budget.
During COVID, its estimated that the world may have spent $80–100 billion on R&D. In TB we are spending one billion dollars a year. So that’s a big difference.
I know you spoke of a lack of sense of urgency and a lack of will as well, in some ways. So is it because COVID, for e.g., was a sort of an equalizer — it was affecting everybody, no matter your socio-economic background, whether you’re from the Global North or Global South. But some of these other diseases where vaccine is still being developed, they are more in the Global South. Is that an issue?
Yes. Definitely it is an issue. Even HIV, the reason it got all the attention was it started affecting people in high income countries and those people were very vocal and they were the activists who actually pushed NIH and others to invest so much in R&D and to include them in clinical trials. So it was the gay activists in the US, and of course, they were activists in South Africa and other countries as well.
When a disease affects high income countries, like when monkeypox reached Europe and the US, suddenly there is a flurry of interest in R&D. But monkeypox has been killing Africans for a long time, you know? But no one really was pushing to develop a vaccine or anything like that.
This is where the equity issues really become very clear.
But interestingly, even after all these hurdles, if you’re able to develop a vaccine and you try deploying it, we’ve seen time and again that there’s a sense of hesitancy among people. You are flooded with misinformation, regarding potential side effects. It could be during the COVID time, the rumours spread from side effects of killing you to making you impotent to it’s a mass way of sort of sterilizing people, etc. We are hearing of the same kind of resistance when it comes to the HPV vaccine as well. Why do you think this is happening? What’s the reason for this vaccine hesitancy and how do we deal with it?
Vaccine hesitancy is not a new phenomenon. I think it’s been there from a very long time. What has changed now is that we have social media. And social media obviously has its pros and cons. It can help you to really scale up the good things, very quickly and spread messages, but it also amplifies the messages which are wrong. So the misinformation and disinformation gets amplified. And in this case, there is a big anti-science, anti-vaccine lobby. What motivates them, I cannot answer that question, because I have not understood what would motivate somebody [to do this].
In some cases, it’s a genuine fear or it’s a personal experience that may have happened to a family member. Because we have to remember also that, however safe of a health product is, there could be a one in a million or one in a ten million risk always of an adverse event and could be a serious adverse event.
Now, when you approve a product for use, the regulators weigh the benefits and the risks; particularly for a vaccine, the benefits have too far outweigh the risks. Because the vaccine is given to an healthy individual to protect against disease. Whereas if you’re already suffering from a disease, you’re getting a treatment, you may be willing to take a slightly higher risk because you want to be cured. A vaccine you can’t.
So, the benefit-risk-safety ratios has to be very high, and that’s what the regulators look at. And during COVID also, that’s what was looked at. But there’s still that one or two in a million chance of your being that unfortunate person who has (an adverse event).
I think for scientists also we have to communicate it in a way that nothing is a hundred percent safe. However, if you are going to save millions of lives, you would proceed with something, knowing very well that a few tens dozens could actually suffer from side effects and hopefully, if you’re aware of them, you can you can watch out for them, you can treat those patients, avoid deaths, but there could be also that chance that you end up with an extreme situation where the person dies.
So, how do you deal with vaccine hesitancy? I don’t know, but one of the things that public health people need to do is to talk about, vaccine development, the process of clinical trials, the regulatory process, the post marketing surveillance. What are the public health authorities doing to ensure that firstly, you’re introducing vaccines once you’re confident of its efficacy and safety, and once introduced, you continue to monitor and follow up the population to ensure that any unexpected side effects (are dealt with).
Clinical trials are done on a few thousand individuals. Once you roll it out in lakhs and crores, you might see things signals which you didn’t see before. So this is why you have that the pharmacovigilance program to actually address that.
These things have to be explained to the public and doubts have to be cleared. We should not be talking down to the public — that’s one thing we realized in COVID. Sometimes as scientists you think, oh my God, that’s such a stupid question, why is someone asking it? But for that person, it was a genuine question. They want to know if their fertility will be affected. And very often the answers, we could not give in black and white, because early on in COVID we did not know many things — pregnancy, for instance. Initially pregnant women were excluded from COVID vaccination. Later we found out that pregnant women were even more likely to die if they got COVID. They would have benefited the most if they had been included in vaccination programs. But the general practice is, you don’t give anything new to pregnant women because you don’t want to take that risk.
The same thing happens in TB and in every drug development program, pregnant women are the last to benefit from a new advance because of this fear that you would maybe do harm to the foetus. So again, if your risk of dying MDRTB is that much higher, would you rather take the drug with informed consent and everything, explaining to the woman that we don’t know what this will do to your foetus, but it will save your life and then she takes the decision?
So I think people’s autonomy matters we have to respect it. But the age we live in today with so much of misinformation, especially through social media, it requires a huge effort by governments and public health authorities to counter that.
I know you said vaccine hesitancy is not a new phenomenon. It has been around for a while. We have all heard the ‘MMR vaccines cause autism’ claim that has been around since the ’90s. But do you think it has increased in recent times? The reason I’m asking you this is because the number of zero dose children in India has gone up from about 11 lakh in 2022 to 16 lakh in 2023, according to a UNICEF report. Even though as a percentage of population, it is insignificant, in absolute numbers we are second only to Nigeria. So do you think it’s become worse now? Because these are some of the consequences of vaccine hesitancy, right? You’re not vaccinating your kids anymore.
A: I don’t know whether this going up is due to vaccine hesitancy necessarily, I’ll have to look at that data. Research should be done because our country is huge and there are problems of access and poverty and literacy and all of that as well and migrants. So you could be just missing out on people because of that.
Luckily in India, I think we’ve had less hesitancy than, for example, in many European countries. So I wouldn’t ascribe vaccine hesitancy to the zero dose. Could be other reasons.
Another issue you have spoken about repeatedly is tuberculosis, and India’s TB burden. India had set a target of eliminating TB in the country by 2025. You see that happening?
That was an aspirational target, so it was meant to drive a momentum on the program. We’re not going to eliminate TB by 2025; that’s almost certain.
I think it was more meant to galvanize action and have a very bold ambitious target. So we need to continue that effort and now we have new tools, lots of technologies like AI and X ray reading and so on, and we’ve understood more about subclinical TB and how to do active case finding. There are new drug combinations now that have been introduced, like the BPaLM, which really improved cure rates.
So I think in the coming decades, we’ll see, you know, much faster progress on reducing TB incidents.
You also seem to be a big advocate for integrating technology an AI in healthcare to advance innovation and care. So how do you see AI changing the future of health care and how we approach healthcare?
You know, it’s hard to even predict that. I don’t think any of us can imagine how AI is going to change healthcare. There will be a time, I think, when a lot of diagnostics would be done, maybe through like a simple retinal screen, we may not even have to do blood tests, to say what you’re suffering from or what you are at risk for in the future.
But we haven’t got to that point yet, but this is the future, and I think AI is going to be a great tool for healthcare providers and for the ordinary citizen to track their own health and improve their own health seeking behaviours.
Your final thoughts on what we can do to make sure that we remain safe, we are all inoculated against diseases, and what needs to be done so that we have a healthier future for the country.
So I think more stories in the in the media for sure. Stories of vaccine development and maybe going back to history also, and telling the stories of how smallpox was overcome, how polio, which is an amazing success story for India because no one thought we would do it. What are the current efforts going on? So I don’t think these stories are told enough about the research and development and the hiccups which happen because we also need people to participate in clinical trials. And that’s another area where I think literacy about that is low. What is a trial? What do you sign up for? What are your rights as a person? What is it going to lead to, and why it’s important for ordinary citizens to come forward to participate in clinical studies and clinical trials because of the broader public health benefits that it provides.
We have amazing institutions and companies which are doing a lot of R&D. We even have our own homegrown mRNA vaccine candidates, and even DNA. India’s Zydus Cadila was the only company to actually come up with a DNA vaccine for COVID. So I think there is no dearth of possibilities.
We need to address our own health burden. So that’s why I come back to TB again because India does have the highest burden of TB in the world and our region does as well, a very high burden, so I propose that a southeast Asia regional focus and program on TB vaccine development would benefit millions of people around the world.
So we could identify a few such high priority things and have public private partnerships to do that.
Also read: Vaccines will play an important role in eliminating TB: ICMR Chief — First Check