|BRIEF RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 3 | Page : 225-229
Pediatricians' perspectives on pneumococcal conjugate vaccines: An exploratory study in the private sector
Sanjay Zodpey1, Habib Hasan Farooqui2, Maulik Chokshi3, Balu Ravi Kumar2, Naveen Thacker4
1 Prof. Director, Indian Institute of Public Health-Delhi, Gurgaon, Haryana, India
2 Assistant Professor, Indian Institute of Public Health-Delhi, Gurgaon, Haryana, India
3 Associate Professor, Indian Institute of Public Health-Delhi, Gurgaon, Haryana, India
4 Past President, Indian Academy of Paediatrics (IAP), Mumbai, Maharashtra, India
|Date of Web Publication||7-Sep-2015|
Habib Hasan Farooqui
Indian Institute of Public Health-Delhi, Plot No 47, Sector 44, Institutional Area, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
There is a lack of information on supply-side determinants, their utilization, and the access to pneumococcal vaccination in India. The objective of this exploratory study was to document the perceptions and perspectives of practicing pediatricians with regard to pneumococcal conjugate vaccines (PCVs) in selected metropolitan areas of India. A qualitative study was conducted to generate evidence on the perspective of pediatricians practicing in the private sector regarding pneumococcal vaccination. The pediatricians were identified from 11 metropolitan areas on the basis of PCV vaccine sales in India through multilevel stratified sampling method. Relevant information was collected through in-depth personal interviews. Finally, qualitative data analysis was carried out through standard techniques such as the identification of key domains, words, phrases, and concepts from the respondents. We observed that the majority (67.7%) of the pediatricians recommended pneumococcal vaccination to their clients, whereas 32.2% recommended it to only those who could afford it. More than half (62.9%) of the pediatricians had no preference for any brand and recommended both a 10-valent pneumococcal conjugate vaccine (PCV10) and a 13-valent PCV (PCV13), whereas 8.0% recommended none. An overwhelming majority (97.3%) of the pediatricians reported that the main reason for a patient not following the pediatrician's advice for pneumococcal vaccination was the price of PCV. To reduce childhood pneumonia-related burden and mortality, pediatricians should use every opportunity to increase awareness about vaccine-preventable diseases, especially vaccine-preventable childhood pneumonia among their patients.
Keywords: Awareness, pediatricians, pneumococcal conjugate vaccine (PCV), prices, vaccination
|How to cite this article:|
Zodpey S, Farooqui HH, Chokshi M, Kumar BR, Thacker N. Pediatricians' perspectives on pneumococcal conjugate vaccines: An exploratory study in the private sector. Indian J Public Health 2015;59:225-9
|How to cite this URL:|
Zodpey S, Farooqui HH, Chokshi M, Kumar BR, Thacker N. Pediatricians' perspectives on pneumococcal conjugate vaccines: An exploratory study in the private sector. Indian J Public Health [serial online] 2015 [cited 2022 Jan 19];59:225-9. Available from: https://www.ijph.in/text.asp?2015/59/3/225/164667
The incidence of community-acquired childhood pneumonia in low- and middle-income countries (LMIC) is reported to be 0.22 episodes per child-year. For India, the estimated incidence was 0.29 episodes per child-year, with 11.5% of the cases progressing to severe episodes.  New generations of vaccines to prevent childhood pneumonia have become available in the recent years. One of them is pneumococcal conjugate vaccine (PCV) that protects against pneumonia, meningitis, and other invasive bacterial diseases.  PCVs have emerged as one of the key interventions against pneumococcal disease. Randomized clinical trials conducted across various developing and developed nations have proved the safety and efficacy of the currently available PCVs. ,,,, PCVs have not been introduced in universal immunization programs (UIPs) of the Government of India. However, they are available through pediatricians engaged in private practice to their clients since 2008 in India.
There is a lack of information on supply-side determinants, their utilization, and the access to pneumococcal vaccination in India. The objective of this exploratory study was to document the perceptions and perspectives of practicing pediatricians with regard to PCV in selected metropolitan areas of India.
A qualitative study was designed and conducted from January 2012 to June 2012 across 11 metropolitan areas in India to generate evidence on the perceptions and perspectives of pediatricians regarding PCVs. The pediatricians were selected through a multilevel stratified sampling method. The first level of stratification was into four geographical zones (east, west, north, and south), whereas the second level of stratification was based on the IMS vaccine audit/sales data for PCV and was into high, medium, and low sales within these geographic zones. Thus, pediatricians practicing in the private sector and registered with the Indian Academy of Pediatrics (IAP) located in three metropolitan areas (representing low, medium, and high PCV sales) from each geographical zone (east, west, north, and south) were selected to conduct in-depth interviews. However, the selection of a pediatrician in each metropolitan area was purposive. In the pilot study, we had observed that in-depth interviews with four to six pediatricians were good enough to achieve saturation levels for information. A total of 62 pediatricians across 11 metropolitan areas (Kolkata, Patna, Nagpur, Surat, Bhopal, Meerut, Ludhiana, Lucknow, Chennai, Hyderabad, and Kochi) were interviewed for this exploratory study.
An in-depth interview schedule was designed to enquire about their perceptions and perspectives regarding PCV vaccination. It was pilot study conducted among a sample of pediatricians for validity and robustness. The respondents were briefed about the purpose of the study, the methods adopted, and the potential use of the study findings. The data collected through the in-depth interview schedule were analyzed using standard qualitative techniques. These responses were categorized into relevant domains and were analyzed for comparisons, conflicts, and consensus between the various respondents. In addition to the narratives and qualitative responses, the key findings were categorized and reported as proportions wherever relevant. Appropriate ethical approvals were secured from the ethics committee of institution for the conducting this study.
Of all the pediatricians interviewed, 56 (90.3%) were males and six (9.7%) were females. The mean age of the pediatricians was 49.4 years [Table 1]. In terms of the practice scenario, the mean duration of clinical practice was 21.5 years and the mean number of children seen per day was 47.3.
When inquired about the trend of clinical pneumonia in their practice through the question, "Has there been any change in the proportion of pneumonia cases in your practice?" the majority (66.7%) of the pediatricians mentioned a declining trend in pneumonia, whereas some (17.4%) reported an increasing trend of clinical pneumonia [Table 2]. Similarly, in response to the question, "How often do you prescribe antibiotics for pneumonia?" the majority (91.9%) of the pediatricians mentioned that they always prescribed antibiotics for suspected pneumonia while 6.4% prescribed frequently and 1.5% prescribed rarely.
With regard to the question on vaccination for childhood pneumonia, "How often do you recommend a vaccine to prevent pneumonia?" the majority (70.9%) of the pediatricians mentioned that they always prescribed vaccines for the prevention of pneumonia while 25.8% prescribed them frequently and 1.6% rarely. When the pediatricians were specifically enquired about their advice on PCV for the prevention of pneumococcal pneumonia, the majority (67.7%) mentioned that they followed the IAP guidelines and always prescribed PCV while 32.2% of the pediatricians said that they recommended PCV only to those who could afford it.
On inquiring about the acceptance or denial of PCV by their clients, the pediatricians mentioned that the acceptance rate for PCV was higher among those with a high level of awareness for pneumonia disease and vaccine (52.6%). Some clients accepted vaccination after personalized advice and counseling (26.3%). However, for some clients (17.5%), affordability of PCV was the key determinant. The main reason mentioned for the denial for pneumococcal vaccination was the cost of the vaccine (97.3%).
Some of the key themes that emerged from the in-depth interviews relate to the paradox of need and demand with reference to the risk of pneumococcal disease versus access to PCV. As one pediatrician put it clearly, "The need of PCV is in rural India but the current uptake is in urban areas, as most of the people in rural India cannot afford it;" this pediatrician was a doctor in a multispecialty child hospital.
Another pediatrician mentioned that he generally made a value judgment based on his client's ability to pay before recommending PCV or advising against it.
"My clinic is in the upper middle class locality and hence, most of them are able to pay; even though I advise all patients, I recommend only to those parents having the ability to pay based on my assessment of their financial status," said a doctor of an individual clinic.
In response to the question, "Should PCV be included in the UIP?" the majority (74.1%) of the pediatricians responded affirmatively. However, some (17.7%) pediatricians said "no" and 8.0% were not sure. When probed further about the reasons for introduction of PCV in UIP, the key arguments put forth were high pneumonia burden (34.7%) and safe and effective vaccine (30.4%) followed by potential price reductions as a result of increased demand (23.9%).
PCVs have been a key intervention for the prevention of pneumococcal pneumonia in developed nations. However, in India it is still not a part of UIP. Hence, access to PCV is available only through pediatricians engaged in private practice. Our study also highlights that pediatricians are one of the key drivers for the uptake of vaccines. We observed that the majority (96.7%) of the pediatricians recommended vaccines to prevent clinical pneumonia always or frequently. However, only 67% recommended PCV, in particular highlighting the fact that the high cost of PCV is still a key barrier to access, which has significant implications as the majority of children under 5 years of age seek care in the private sector for acute respiratory infections (ARIs).  Inability to offer PCV to this population would represent a missed opportunity.
In addition, the treatment of pneumonia may appear more attractive than prevention because of the high cost of vaccine. However, studies have reported that the expenditure trend for the treatment of an episode of pneumonia in outpatient and inpatient departments runs into thousands of rupees. ,, Moreover, at the societal level, economic evaluation studies have reported PCV to be cost-effective. ,,,
Majority (74.1%) of the pediatricians in our study argued that PCV should be introduced in UIP. The key argument for the introduction of PCV in UIP was to enhance equity in the access to PCV with the potential to bring down retail prices by making the market more competitive. It is expected that such a measure would ensure the access of PCV to an impoverished population which is also at high risk of pneumonia while the others can access PCV from the private sector. On the contrary, some (17.7%) of the pediatricians were against the introduction of PCV in UIP. They argued for the need to introduce other priority vaccines (namely, Hib, rotavirus, typhoid, etc.) before PCV in UIP. Others questioned the efficacy and effectiveness of PCV in an Indian setting as no clinical trial has been conducted in India.
This qualitative study was exploratory in nature since PCV uptake and utilization is limited largely to urban metropolitan areas where private pediatricians practice and especially to the affluent class that can afford the vaccine (complete course of any PCV is approximately ₹10,000-15,000 per child). Hence, the findings may have limited generalizability. In addition, our study was not designed to capture a disconnect between the practice and preaching of the surveyed pediatricians with regard to issues discussed in the interview schedule. Still, this study fills an important knowledge gap on pneumococcal vaccination by exploring the perceptions and perspectives of pediatricians and the utility of PCVs in the Indian scenario.
The Global Alliance for Vaccine Initiative (GAVI) is providing support to eligible countries for the introduction of PCV in their immunization programs.  However, with the lack of pneumococcal pneumonia burden estimates and vaccine efficacy estimates in India and other operational constraints, there is an environment of skepticism on the overall effectiveness of the vaccine. Modeling exercises (disease modeling and decision modeling) are helpful in forming a policy in such scenarios. Hence, cost-effectiveness for pneumococcal vaccination in India should be conducted. In addition, IAP through its network of pediatricians should increase awareness about vaccine preventable diseases among their clients and should bridge the knowledge action gap by facilitating informed decision-making.
We would like to acknowledge the technical advice provided by Dr. Niteen Wairagkar and the support of all the pediatricians and their clients interviewed for this research.
Financial support and sponsorship
Bill and Melinda Gates Foundation through contract number 22693.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rudan I, O'Brien KL, Nair H, Liu L,Theodoratou E, Qazi S, et al
.; Child Health Epidemiology Reference Group (CHERG). Epidemiology and etiology of childhood pneumonia in 2010: Estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health 2013;3:010401.
Black S, Shinefield H, Fireman B, Lewis E, Ray P, Hansen JR, et al
. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 2000;19:187-95.
O'Brien KL, Moulton LH, Reid R, Weatherholtz R, Oski J, Brown L, et al
. Efficacy and safety of seven-valent conjugate pneumococcal vaccine in American Indian children: Group randomised trial. Lancet 2003;362:355-61.
Lucero MG, Nohynek H, Williams G, Tallo V, Simões EA, Lupisan S, et al
. Efficacy of an 11-valent pneumococcal conjugate vaccine against radiologically confirmed pneumonia among children less than 2 years of age in the Philippines: A randomized, double-blind, placebo-controlled trial. Pediatr Infect Dis J 2009;28:455-62.
Nunes MC, Madhi SA. Safety, immunogenicity and efficacy of pneumococcal conjugate vaccine in HIV-infected individuals. Hum Vaccin Immunother 2012;8:161-73.
Klugman KP, Madhi SA, Huebner RE, Kohberger R, Mbelle N, Pierce N; Vaccine Trialists Group. A trial of a 9-valent pneumococcal conjugate vaccine in children with and those without HIV infection. N Engl J Med 2003;349:1341-8.
IIPS. District Level Household And Facility Survey (DLHS-3). India: International institute of Population Sciences; 2010. p. 106.
Krishnan A, Arora NK, Pandav CS, Kapoor SK. Cost of curative pediatric services in a public sector setting. Indian J Pediatr 2005;72:657-60.
Madsen HO, Hanehøj M, Das AR, Moses PD, Rose, W, Puliyel M, et al
. Costing of severe pneumonia in hospitalized infants and children aged 2-36 months, at a secondary and tertiary level hospital of a not-for-profit organization. Trop Med Int Health 2009;14:1315-22.
Hussain H, Waters H, Omer SB, Khan A, Baig IY, Mistry R, et al
. The cost of treatment for child pneumonias and meningitis in the Northern Areas of Pakistan. Int J Health Plann Manage 2006;21:229-38.
Tasslimi A, Nakamura MM, Levine O, Knoll MD, Russell LB, Sinha A. Cost effectiveness of child pneumococcal conjugate vaccination in GAVI-eligible countries. Int Health 2011;3:259-69.
Knerer G, Ismaila A, Pearce D. Health and economic impact of PHiD-CV in Canada and the UK: A Markov modelling exercise. J Med Econ 2012;15:61-76.
Madhi SA, Cohen C, von Gottberg A. Introduction of pneumococcal conjugate vaccine into the public immunization program in South Africa: Translating research into policy. Vaccine 2012;30(Suppl 3):C21-7.
Ray GT. Pneumococcal conjugate vaccine: Review of cost-effectiveness studies in Australia, North America and Europe. Expert Rev Pharmacoecon Outcomes Res 2008;8:373-93.
[Table 1], [Table 2]