Lamenting this sordid state of affairs, the noted pediatrician aired an appeal to frontline health workers, particularly the country's family physicians, to make vaccination their priority intervention. "To tell you honestly, it is not the pediatricians who are giving the vaccine; it is the family physicians. They are the ones at the forefront of vaccination," Bravo told Medical Observer. She explained that the Philippine Pediatric Society is more visible regarding these issues mainly because the society is very much older than the fledgling Philippine Academy of Family Physicians, which should really be spearheading such an advocacy.

    In recent years, the outlook toward vaccination as preventive medicine extended beyond the health concerns of infants and youngsters, encompassing immunological issues in adults, especially older persons who are now identified as a very vulnerable sector in the face of both old and emergent diseases. The priority given to senior citizens in developed countries receiving their annual influenza immunization is testimony to this current thinking.

    In the Philippines, the government's Expanded Program on Immunization (epi) proved to be a resounding success in the late 1980s when the government raised national fully-immunized-child levels to over 90 percent. After over 20 years, however, the political climate may not be as it was; neither would the dominant scientific recommendations of experts on vaccination priorities and schedules. Financial limitations have always cramped the political will of government health-care managers who looked longingly at the new, costly vaccines that could not be incorporated into the national program because of budgetary constraints.

Stumbling blocks

    A good case in point is the hepatitis-B vaccine. Its prohibitive cost prompted health executives of the Aquino and Ramos administrations to plead with international donors to channel their support of the immunization program toward vaccine-production capability, especially for recombinant hepatitis-B vaccine. This, however, was a capability that was a long time coming; and the vaccine continued to be donated in limited quantities or imported at a staggering price. Bravo noted how hepatitis-B vaccine started out at US$100 per dose. With such limitations, then epi manager Dr. Elvira Dayrit was only allowed to phase in the hepatitis-B-immunization coverage at a very slow rate, while struggling with various stumbling blocks to the procurement of this vaccine.

    Twenty years hence, through the altruism and technological breakthroughs of the global health-care industry, the unit cost of this vaccine has gone down to a mere US$0.35, thereby making it accessible to most of the world's population. To his credit, Health secretary Francisco Duque iii has, for the first time ever, committed to 100-percent hepatitis-B vaccination coverage in the epi scenario for this year.

    Bravo pointed out that had the Philippines been able to do this in 1990, we would now enjoy the same low seroprevalence experienced in Thailand and Taiwan, which committed to 100-percent hepatitis-B immunization 26 years ago. Moreover, we would not experience the rejection of so many potential overseas workers on account of their infection or carrier status.

    The hepatitis-B experience is illustrative of the observation of the World Health Organization's Western Pacific Regional Office that the Philippines is a transitional country where new and underutilized vaccines should be part of the intervention program for child survival strategies. Congruent with this outlook, the Philippine Foundation for Vaccination advocates the inclusion of some of these new antigens into the government's epi. "It's there in black and white: the recommendation for rotavirus, pneumococcal virus, and HiB," Bravo pointed out. "Those vaccines that are underutilized and relatively new need to be in place so we can achieve the target of reducing child morbidity and mortality by 2015, which is the fourth Millennium Development Goal," she continued.

New antigens

    In her work on the control of diarrheal diseases in various communities, Bravo stresses the need for health workers to be able to communicate with and educate mothers on the management of diarrhea through oral rehydration, and its prevention through healthy practices and vaccination. "In developing countries, rotavirus is the leading cause of hospitalization for diarrhea," she indicated. "We have evidence to show that 500,000 children die from this virus worldwide each year; 95 percent of which are in developing countries. That's why the United States included it in their immunization program. It is costing them a lot to manage the cases," she illustrated.

    "Rotavirus is the specific cause of very severe diarrhea. It generally leads to hospitalization or even death among unattended cases. As in the case of cholera patients, children suffering from rotavirus infection can be severely dehydrated and can die in one or two days," Bravo stressed.

    While rotavirus is tagged as the leading cause of death in children aged one to two years, pneumococcal infection is noted as the number-one vaccine-preventable cause of death in children under five. The American Heart Association recommended the vaccine's inclusion in the US immunization program to prevent heart failure, Bravo recounted.

    "Pneumococcal disease is a major public-health burden with increasing antibiotic resistance…. And the impact of universal vaccination is not just in immunized children, but also in the broader community," she said at the recent Asian and Oceanian Congress of Child Neurology in Cebu City (see related story on page 65).

    About 9,000 Filipino children die of pneumonia every year. Among those under five, the mortality rate from pneumonia is placed at 37 per 100,000 population.

    Bravo cited the declining trends in ipd incidence in countries where ipd has been made a component of national immunization programs, stressing that the inclusion of pneumococcal vaccines in national immunization programs is among the top priorities of the who.

On the edge

    These new recommendations bear witness to Bravo's assertion that vaccination, like most medical science, is a dynamic and rapidly changing concept. If practitioners fail to update themselves, they may be banking on their 20-year-old knowledge and, therefore, know nothing, she stressed.

    She related an experience she had while conducted training and seminar workshops for pediatricians and discovered how a staggering 30 to 50 percent of the doctors who attended did not have adequate knowledge on the scheduling and dosing of vaccines. "Shocking!" Bravo exclaimed.

    In spite of this, it is still the seasoned specialists who suppress the efforts of other health workers in conducting mass vaccination efforts. "Some specialists are angry at the midwives because they know how to vaccinate, being taught by the Department of Health," she recounted. "Most pediatricians think it is their turf!"

    It should not only be in the hands of the pediatricians, she indicated. "As long as those who will use it are knowledgeable, are trained, and are given enough education on this, then they could do it," she asserted.

    "While we often regard family physicians as general practitioners, they are actually specialists in primary health care," Bravo indicated. "Primary health care is what this country needs, as evidenced by the World Health Organization, and so many other agencies. If you can look at all health institutions and programs, primary health care is the root of all health-care delivery." M

 

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