India has poor immunization levels, slightly better in urban than rural areas

PREVALENCE OF DISEASE IN WEST BENGAL

Immunization Rates of India

Childhood immunizations have been an important part of maternal and child health services since the 1940s. BCG immunization (TB, meningitis, and military TB) was started in 1948 and by 1951 was organized on a mass scale to cover all those below 25 years of age. The Indian government's Fourth Five-Year Development Plan (1969-74) included plans for DPT immunization of infants and pre-school children.

In 1978 as part of national health policy, the Government announced the expanded program on immunization (EPI) followed in 1985-6 by the universal immunization program (UIP) with the objective of reducing morbidity, mortality, and disabilities by delivering free immunization services, easily available, for all children and tetanus toxic injections for pregnant women. The objectives of the UIP included covering at least 85 percent of all infants by 1990 against the six immunizable diseases. By 1990, all districts in the country were served by the UIP.

Despite these implemented regulations, immunization levels still remain low in India. They are slightly bettered in urban than rural areas. In rural areas the illiteracy of the parents, lack of knowledge about health-care services, low socio-economic status and limited accessibility to health services are difficult barriers for the proper utilization of health care services. There is also a significant difference in immunization levels among the poor then the rich. There also exists a female disadvantage in immunization, in both urban and rural areas and across most household wealth quintiles. Dropout rates remain troubling for multiple-dose vaccines. Data from 1998-99 showed 35 percent of living children ages 12-23 months were fully vaccinated (had received BCG, all three doses of DPT/OPV and measles), 17 percent were not immunized at all, and the rest had received some of the recommended vaccinations. Immunization coverage varies considerably across states, the northern states faring far worse then the southern states.

West Bengal is among the poorer performing states, with only 23.8% of rural children and 34.2% of urban children being fully immunized, and 32.7% of rural children and 30.6% of urban children not being immunized at all. The Indian Academy of Pediatrics recommends the following:

Vaccine	Age Recommended
BCG (TB Meningitis, Miliary TB)	Birth - 2 weeks
OPV (Oral Polio Vaccine)	Birth, 6, 10, 14 weeks 15 - 18 months, 5 years
DPT (Diphtheria toxoid-Pertussis vaccine-Tetanus toxoid)	6 weeks, 10 weeks, 14 weeks 16 - 18 months, 5 years
Hepatitis B	Birth, 6 weeks, 14 weeks / 6 weeks, 10 weeks, 14 weeks
Hib Conjugate (Haemophilus influenza B infection)	6 weeks, 10 weeks, 14 weeks 16 - 18 months
Measles	9 months plus
MMR (Measles-Mumps-Rubella)	15 months
Typhoid	Above 2 years
2 doses of TT (Tetanus toxoid)	Pregnant Women

Prevalence of Amoebiasis (Amoebic Dysentery)

Amoebiasis is a type of gastroenteritis caused by a tiny parasite, Entamoeba histolytica, which infects the bowel. Amoebiasis can affect anyone, however, the disease mostly occurs in young to middle aged adults. Amoebiasis is generally associated with people living in areas of poor sanitation and is a common cause of diarrhea among travelers to developing countries. It is difficult to estimate the incidence of diarrhea disease in India since many people are unaware that they harbor the disease and most cases are not reported. Very little data is available, but outpatient data from Kerala, India collected during the dry season showed that one-fifth (20%) of those reporting to the clinics had diarrhea; 80% of these cases were bacterial and the remainder were amoebic in origin.

Prevalence of Cholera

Cholera is an infection of the small intestine caused by the bacterium Vibrio cholerae, resulting in profuse watery diarrhea. In 1950, there were 1,76,307 reported cases of cholera in India, with 86,997 deaths. A study done in 1994 showed only 4958 cases of cholera in India and only 32 deaths due to cholera in that year. These numbers show a steady decline in the cases of cholera over the last fifty years for India in general. Unfortunately frequent flooding due to El Nino has caused cholera to return as a problem in the areas of West Bengal, Orissa, and Bangladesh in the last 5 years. The National Institute of Cholera and Enteric Diseases, Kolkata, conducts continuous surveillance for cholera in Kolkata in particular, and in India in general. During September-October 1998, they observed an increase in the incidence of cholera, and new strains of the bacteria have been found. Presently, the total number of cholera cases in a year range from 2000 to 10,000.

Prevalence of Diphtheria

Diphtheria is an acute infectious disease caused by the toxin-producing bacteria Corynebacterium diphtheriae. It usually affects the respiratory tract (primarily the larynx, tonsils, and throat). But it can also affect the skin, and the toxin produced by the bacteria can damage the nerves and heart. In 1995, there were 1257 reported cases of diphtheria in India, a number that has also been on the decline for the last ten years.

Prevalence of Leprosy

Leprosy (Hansen's disease) is an infectious disease, which is characterized by disfiguring skin lesions, peripheral nerve damage, and progressive debilitation. India is presently faced with the enormous problem of having to bear 56% of the world's estimated cases (1.15 million world cases) of leprosy, which means that the number of estimated cases of leprosy in India is 0.64 million. That is quite a public health problem in India where the number of registered cases (62% of the global burden) is 0.55 million. In spite of much progress in India, the country falls far short of the World Health Organization target (1 per 10,000) with the prevalence rate per 10,000 at the end of 1997, being 5.91. The number of new cases detected in India during 1997 was 0.43 million. In 1997, persons with leprosy who had visible disability were 3.9% and sufferers with actual deformity due to leprosy numbered 1.49 million. It is possible that many victims of leprosy, who are now cured bacteriologically, still suffer physically, emotionally, psychologically, socially and economically; in India, these persons who have been affected by leprosy number 7 million. The numbers of leprosy cases vary greatly state wide. West Bengal, with a population around 75 million had 61185 cases on record between 1996 - 7, making a prevalence rate of 8%. New cases of leprosy detected in 1996 - 97 numbered 23375.

Prevalence of Liver Disease

The most common causes of liver disease are cirrhosis and hepatitis - both of which occur in a variety of forms and are chronic conditions. Cirrhosis is an ongoing liver disease that may occur over a period of months to years. Cirrhosis destroys liver cells, which causes the liver to eventually shrink and harden. Ultimately, the liver will lose too many cells and lack proper blood flow. This process results in liver failure. There are different causes of cirrhosis. Primary biliary cirrhosis destroys the bile ducts in the liver. When bile ducts are destroyed, the liver can no longer secrete bile. Bile is required for the breakdown and digestion of fats. Alcoholic cirrhosis is the widespread death of liver cells caused by long-term alcohol drinking. Hepatitis is an inflammation of the liver often caused by hepatitis A, B, or C or other viruses such as the Epstein-Barr virus (EBV) or cytomegalovirus (CMV). Inflammation of the liver can also be caused by alcohol abuse and drug use. Hepatitis A usually does not result in liver failure, but is still a serious diseases that needs treatment. Hepatitis B and Hepatitis C are the most common reasons of serious liver disease in India. Liver disease is a major health problem in India. The leading cause of liver disease in India is the hepatitis virus. HBV infection especially is a serious concern among cases of liver disease. 4.7% of the population of India is a carrier of HBV, a total load of 42.5 million HBV carriers. There are several different genotypes of HBV, with different prevalence rates in different parts of India. The number of HBsAg carriers total is 24.4%. While HBsAg/ayw is predominant in North India while HBsAg/adw and HBsAg/adw are predominant in South India. In India, liver disease due to HBV infection is considered to be the fourth or fifth most important cause of mortality in the most productive period of life, 15-45 years. 25 % of all HBsAg positive newborns develop chronic liver disease by third to fourth decade of life. It is estimated that 15 - 40% of those with chronic HBV infection will eventually form serious complications, such as liver cancer or cirrhosis, and die. Hepatitis C also remains significant as a cause of liver disease. Prevalence of Hepatitis C in various parts of India is different. There is a prevalence rate of 26% in South India, 16-20% in Bombay and 10-15% in North India. The major way that Hepatitis C presents itself is chronic hepatitis.

Prevalence of Malaria

Malaria is a parasitic disease characterized by fever, chills, and anemia. Malaria is caused by a parasite that is transmitted from one human to another by the bite of infected Anopheles mosquitoes. Data from 1995 shows 2.8 positive cases of malaria per one million people in India. Data from that year also reported 1061 deaths from malaria that year. India by far has the highest incidence of malaria compared to all other South East Asian countries. More recent data showed that 7 cases of malaria per 100,000 persons were reported to the United Nations in 2000. This data also showed 6 deaths due to malaria per 100,000 children ages 0 - 4 years, and 3 deaths per 100,000 persons from all age groups.

Measles (Rubeola) is a highly contagious viral illness characterized by a fever, cough, conjunctivitis (redness and irritation in membranes of the eyes), and spreading rash. Most cases occur in children 2-years-old or younger. To prevent measles, one injection of the vaccine should be given to a 15-month-old baby along with a Mumps and Rubella component. Measles is still seen in India; with the latest data from 1995 showing 26,986 reported cases. In February 2001 a mysterious disease named "Siliguri fever" emerged in North Bengal and was thought by many to be a strain of measles encephalopathy without the manifestation of the rash. Close to 32 people died from this outbreak. Exact data on the prevalence of measles in West Bengal is not available.

Mumps is an acute, contagious, viral disease that causes painful enlargement of the salivary or parotid glands. Although the disease is relatively mild, up to 10% of patients can develop aseptic meningitis. Less common complications include encephalitis, deafness, sterility, and pancreatitis. Mumps is considered by many to be part of one's childhood in India, since many still do not get immunized. Data from a study done in Delhi showed a prevalence rate of 12.5 per 1,000 girls.

Worms and other intestinal parasites that infest human beings are common in tropical and subtropical areas. Most of these worms and parasites gain entry into the body either through the mouth or through the skin of the feet. Children are more prone to infection from these worms than adults. There are several types of intestinal worms. The most commonly noticed parasites in India are roundworms, hookworms, threadworms and tapeworms. The prevalence of some other parasites often seen in India is outlined below:

Another problematic parasitic disease in India is Lymphatic Filariasis. India accounts for 41% of the global burden of lymphatic filariasis, and the economic loss to India is $1.5 billion a year. Lymphatic filariasis is a parasitic disease caused by microscopic, thread-like worms. The adult worms only live in the human lymph system. The lymph system maintains your body's fluid balance and fights infections. Wuchereria bancrofti and Brugia malayi are the two lymphatic dwelling nematode parasites causing filariasis in India, the former being responsible for over 95% of the problem. Globally, filariasis is the second major cause of permanent disability. Every year, there are 429 million people exposed to risk of infection, leading to 7.8 million lymphoedema elephantiasis cases, 31.3 microfilaria carriers, and 12.9 million hydrocele cases. Nine states (Andhra Pradesh, Bihar, Gujarat, Kerala, Maharashtra, Orissa, Tamil Nadu, Utter Pradesh and West Bengal) contribute around 95% of overall burden.

Polio (Poliomyelitis) is a disorder caused by a viral infection (poliovirus) that can affect the whole body including muscles and nerves. Severe cases may cause permanent paralysis or death. Cases have continued to decline and India is moving towards complete eradication of this disease. In 1995, there were 3406 reported cases of polio in the country of India. Polio eradication is progressing in India, but eliminating the virus from urban slums and hard-to-reach populations will be an arduous and expensive task. Polio cases have continued to decline from 1,126 in 1999 to 263 in 2000, with the bulk of cases in Uttar Pradesh and Bihar. It is estimated that 98.5% of Indian children under-five years were immunized in 2000. In 2001 only 537 cases were reported globally, but India still remains as having the highest rate of transmission among the remaining endemic countries.

Rubella is a contagious viral infection with mild symptoms associated with a rash. Rubella vaccine has emerged as the most effective public health measure against the consequences of congenital rubella infection (CRI). After the devastating pandemic of rubella between 1962 and 1965, the United States licensed the use of vaccine in 1969, which resulted in 99% reduction of cases. Encouraged by the dramatic success of the vaccine, the European Regional Committee of the WHO adopted the goal of "Elimination of Congenital Rubella Syndrome (CRS) by the year 2000 A.D." in the health for all program. The endemicity of rubella has been well established in India. However, no official data is available regarding the prevalence of acquired and congenital rubella infection as it is not a notifiable disease. About 50% of children acquire rubella antibodies by the age of 5 years and 80 to 90% become immune by the age of 15. Studies from India and abroad have found that 10-20% women in child bearing age are susceptible to rubella. Between 6-12% of babies born with con-genital malformations or infections have serological evidence of rubella.

Salmonella enterocolitis is an infection in the lining of the small intestine caused by the bacteria Salmonella enterica. The infection is acquired through ingestion of contaminated food or water. Infection caused by this organism is endemic in India. There are 130 different serotypes of this bacteria, Salmonella Typhimurium being the most common. Studies showed an isolation rate of S. enterica sterotypes to be between 4 - 5 % of cases of diarrhea in the Kolkata, West Bengal region.

Shigella enteritis is an acute infection of the lining of the small intestine caused by 1 of 4 different strains of the shigella bacteria. Outbreaks of shigella enteritis are associated with poor sanitation, inadequate water supplies, contaminated food, crowded living conditions, and fly-infested environments. Shigellosis occurs both in epidemic and endemic forms in children and remains a major public health problem in developing countries. The problem with Shigella is that there are so many species of the bacteria and that most species have become drug resistant. The annual number of Shigella episodes worldwide has been estimated to be 164.7 million with 1.2 million deaths. Very little information is available about Shigella species and serotype distribution. This information is essential for the implementation of appropriate vaccination programs. There is only one licensed vaccine and it is available only in China.

Smallpox is a viral disease characterized by a skin rash and a high death rate. Before the nineteenth century, smallpox was a major cause of death in most of India. Smallpox was endemic to India, but had an epidemic cycle of four to seven years. In epidemic years smallpox could account for a third of all deaths and then be barely noticeable for the next few years. The available age data suggest that in unprotected populations 85 to 90 percent of all smallpox deaths occurred among infants and young children. The disease had a strong seasonality, peaking during the mid-summer. The introduction into India of primary vaccination against smallpox in 1802 was eventually successful in largely controlling the disease. Although it took between seven to nine decades to establish the practice, mass primary vaccination resulted in a major decline in smallpox mortality by the end of the nineteenth century. The last recorded case of smallpox in India occurred in Assam in 1975. In 1980, the World Health Organization declared that smallpox was finally eradicated from the world.

Tetanus is a disease caused by the toxin of the bacterium Clostridium tetani that affects the central nervous system, sometimes resulting in death. Tetanus toxoid immunization is an integral part of the maternal and child health program in developing countries. Many women get immunized as children so they already have antitetanus antibodies at the time of their first antenatal visit. A single dose of tetanus toxoid injection can boost the levels of antitetanus antibodies in these women. Studies done between 1992 - 93 showed that 53.8% of pregnant women were immunized with TT during pregnancy, 74.4% of urban women and 47.7% of rural women. Another study showed that in 1995 there were 5668 cases of tetanus, 1896 of these being neonatal tetanus. This shows a huge drop in the number of cases from years prior to 1995.

Tuberculosis is a bacterial infection, mainly involving the respiratory system. India alone contributes one fourth of the global incidence of TB. Even though the majority of the diseases occur among middle aged and elderly males, more women die of TB than due to all of maternal causes combined. There are an estimated 13-14 million TB cases at any point of time, of which one fourth are infectious in nature. TB is the largest killer of adults in India and there is one death because of TB every minute. Various tuberculin surveys conducted in the past have revealed the Annual Risk of tuberculosis Infection (ARI) of 1 to 2.5% in different parts of the country. This is 50 - 100 times of that in developed countries. Overall, 40% of India's population is infected with tubercle bacilli. The TB situation is expected to worsen in the immediate future, as a result of demographic factors (population growth and changes in age structure of the population) and an increase in HIV seroprevalence rates. Three fourths of this increase is expected to be due to demographic factors and the rest from a balance between decline in incidence due to intervention measures and increase in incidence due to HIV epidemic. As the drug resistance spreads, TB threatens to become an incurable disease for future generations and TB deaths will rise.

Typhoid fever is a bacterial infection characterized by diarrhea, systemic disease, and a rash. It is most commonly caused by the bacteria Salmonella typhi. The feces or urine of people with the disease or those who are S. typhi carriers generally transmits the organism. The death rate is approximately 16% for untreated cases and 1% for those given appropriate antibiotic therapy. Typhoid fever is highly endemic in India, Pakistan, Bangladesh, and Sri Lanka, but exact data is not available.

India is experiencing a rapid and extensive spread of HIV. This is particularly troublesome since India is home to a population of over 900 million people. It is estimated that nearly one percent (or 4 million persons) of the adult population is infected with HIV. In six states, more than one percent of the general population is HIV positive based on antenatal clinic surveys. Around 50,000 - 100,000 cases of AIDS have already occurred in the country. Surveillance data shows that the virus has started to spread from high-risk groups to the general population and to move from urban to rural areas.

Almost 90 percent of the cases reported fall within the most economically productive age group of 15 to 44 and one in four cases of HIV in India is among women. HIV sentinel surveillance surveys indicate infection rates between 1 to 2 per cent among antenatal mothers. HIV/AIDS is already affecting India's children. By the end of 1999, UNAIDS estimated that approximately 160,000 children in India under age 15 were living with HIV/AIDS.

The first HIV case in India was reported in 1986 in Chennai, capital of the state of Tamil Nadu in southern India, and in 1993, the National AIDS Control Organization (NACO) was established. NACO estimated in 2000 that there were, 3.86 million people in the country were living with HIV, with an estimated total adult HIV infection rate of 0.7 percent. Given India's large population, a mere 0.1 percent increase in the prevalence rate would increase the number of adults living with HIV/AIDS by over half a million persons.

The epidemic in India is heterogeneous as each state is at a different stage. In many ways, the HIV epidemic in India comprises a number of epidemics. All the states, union territories and three large cities have set up AIDS control societies to manage the HIV/AIDS control programs. Many private donors and foundations also support HIV prevention and care work in the country.

Both married and unmarried men visiting sex workers fuel this epidemic. Contrary to traditional belief, sexually transmitted diseases and sex with multiple partners are common in India, both in urban and rural areas. An estimated 3 to 4 percent of some rural populations have a sexually transmitted disease. HIV is rapidly spreading to rural areas through migrant workers and truck drivers. Surveys show that 5 to 10 percent of truck drivers in the country are infected with HIV.

The most rapid and well-documented spread of HIV has occurred in Mumbai and the State of Tamil Nadu. In Mumbai HIV prevalence has reached the level of 50 percent in sex workers, 36 percent in STD patients and 2.5 percent in women attending antenatal clinics. Certain regions, such as eastern India (Calcutta area) and northern India (New Delhi region), still show a lower prevalence of HIV (1 to 2 percent) among sex workers. In a sentinel study to check the number of AIDS cases in various states, West Bengal scored relatively low, showing only a 0.6% prevalence of AIDS in STD clinics in 2001.

An estimated 1 to 2 million cases of tuberculosis occurs in India every year. In Mumbai 10 percent of the patients presenting with tuberculosis are HIV-positive. Tuberculosis is the presenting symptom of AIDS in over 60 percent of AIDS cases.

In 1986, the Government of India established a National AIDS Control Program under the Ministry of Health and Family Welfare. Program activities covered surveillance, screening of blood and blood products, and health education. In 1993, with the support of the World Bank, the Ministry established the National AIDS Control Organization (NACO) to coordinate an enhanced program of preventive activities. NACO provided national leadership and facilitated the development of State AIDS Societies in all states across India. With the HIV prevalence doubling, on average, every one to two years in certain groups, the challenge to keep pace with this rapid increase is immense. India requires increased state commitment, more effective and efficient partnerships between the public sector and NGOs, donors and the international health community, and increased HIV-related work in other sectors, such as education, transportation, and rural development.

In April of 2002 the government announced its National AIDS Prevention and Control Policy to create a proper socio-economic environment for prevention of HIV/AIDS. The government also announced that criminal laws would be reviewed and reformed to ensure that they are consistent with international human rights obligations and is not misused in the case of AIDS patients. The government promised to strengthen anti-discrimination and other proactive laws that protect vulnerable groups of AIDS patients.

Since the AIDS prevalence rate varies from state to state, the state governments are required to devise their own strategy and action program for tackling the disease keeping the national objective in mind. AIDS has thus become the first major disease for the control of which the Union government has announced a national policy, providing for establishment of voluntary counseling and testing centers at various levels as part of the diagnostic facilities. Since in four per cent cases the infection occurs through blood transfusion, the government announced a national blood policy encompassing all aspects of the operation of blood banks, including the voluntary blood donation program and appropriate use of blood and blood products. In 85 per cent cases, patients get the infection through sexual intercourse, both heterosexual and homosexual.

The government's policy provides for an AIDS education program to be known as "Universities Talk AIDS" in schools and universities through curricular and extra-curricular approach. The policy also states that HIV positive persons should be guaranteed the same rights regarding education and jobs as given to other members of society and that one's HIV status should be kept confidential and should not in any way affect one's right to employment and position at the work place.

There are many risk factors that put India in danger of experiencing a widespread epidemic if prevention and control measures are not scaled up and expanded throughout the country. From the paper by Mieko Nishimizu they are as follows:

Appavoo, N.C. and S.P.Pani and P.K. Das. "The Science and Art of Lymphatic Filariasis Elimination in India: Hopes for the next Millennium". ICMR.

Edmundson, Stella A. and Wade C. Edmundson. "Diarrhea in India and Indonesia". Diet, Disease and Development in India and Indonesia: Chapter VIII. 1992. http://www.midcoast.com.au/~wedmunds/c8-dysen.htm

Mathur, Pulkit, Sushma Sharma, Arvind Wadhwa. "Rapid assessment procedures for the health and nutritional profile of adolescent girls: An exploratory study". http://www.unu.edu/unupress/food/8F173e/8F173E0i.htm

Nishimizu, Mieko. "AIDS and the Development Paradigm in India". Business Line. October 7, 2002.

Niyogi, Swapan Kumar, Utpala Mitra, Phalguni Dutta. "Changing Patterns of Serotypes and Antimicrobial Susceptibilities of Shigella Species Isolated from Children in Calcutta, India". Japan J. Infectious Disease: 54, 121-122, 2001. http://www.nih.go.jp/JJID/LEC-109.html

"Polio Pushed to Lowest Levels in History - But Experts Warn Opportunity to Stamp out Disease must be Grasped Now Due to Unstable Global Situation." Press Release WHO/25. 16 April 2002. http://www.who.int/inf/en/pr-2002-25.html

Saha, M.R., D. Saha, P. Dutta, U. Mitra, S.K. Battacharya. "Isolation of Salmonella enterica Serotypes from Children with Diarrhea in Calcutta, India." J Health Population ed Cases of Tetanus in India". Med India Health Statistics. http://www.medindia.net/health_statistics/diseases/tetanus.asp

Parasites	Disease	Occurrence	Mortality
Plasmodium sp	Malaria	2.1 million	400,000
Leishmania sp	Kala-azar	500,000	-
Dracunculus medinensis	Dracunculiasis	Reduced from 39,792 to 60 from 1994-95	-
Ancylostoma duodenale	Hookworm disease	300 million	-
Strongyloides stercoralis	Strongyloidiasis	~7 million	-
Ascaris lumbricoides	Ascariasis	400 million	-