<div>Dear friends at PHM, Ravinarayan and Dr Ekbal,</div>
<div>Greetings from Drug Action Forum - Karnataka, India,</div>
<div>I am here with forwarding the letter, which contains the minutes of the meeting held on, Friday, 3rd March 2006 sent by Dr Jacob Puliyel who along with Dr Santosh Mittal and Dr Vibha attended the WHO - SEARO, Delhi meeting, at the invitation of WHO. (Though I was invited for the meeting I could not make it to Delhi, because of some personal prolems).
</div>
<div>The meeting has made a good beginning and in a way is a success. Many thanks to the PHM network. </div>
<div>I am deleighted that at the meeting WHO has agreed to look at the major concerns of Universal Immunisation with hepatitis - B vaccine as expressed by Drug Action Forum - Karnataka, Jana Swasthya Abhiyan and the People's Health Movement. (Please go through the minutes of the meeting as detailed below by Dr Jacob Puliyel and also the draft that we had sent to WHO - SEARO before the meeting). Myself and Dr Jacob Puliyel would like to thank Dr Ekbal, Dr Ravinarayan and the global office PHM for having supported with us on this important public health issue. We are over whelmed by all your support and we both feel that the success of the meeting was largely to all your support.
</div>
<div>Nevertheless I must add that we at Drug Action Forum - Karnataka and PHM need to do a follow up on this issues that have been raised at the meeting, for its logical conclusion. For which again we seek your support and involvement. I also request you to circulate this letter to all those in PHM concerned.
</div>
<div>Thanking you all again.</div>
<div>Best wishes</div>
<div>From:-</div>
<div>Dr GOPAL DABADE,</div>
<div>President, <br>Drug Action Forum - Karnataka,</div>
<div>57, Tejaswinagar,</div>
<div>Dharwad 580 002.</div>
<div>INDIA<br><a href="mailto:drdabade@gmail.com">drdabade@gmail.com</a></div>
<div>Cell +91 (0)9448862270</div>
<div> </div>
<div><br><br>---------- Forwarded message ----------<br><span class="gmail_quote">From: <b class="gmail_sendername">Puliyel</b> <<a href="mailto:puliyel@gmail.com">puliyel@gmail.com</a>><br>Date: Mar 4, 2006 12:29 AM
<br>Subject: Meeting on 3/3/06 on Hepatitis B at WHO office Nirman Bhawan, New Delhi<br>To: <a href="mailto:wiersmas@who.int">wiersmas@who.int</a>, <a href="mailto:burgessc@whosea.org">burgessc@whosea.org</a>, <a href="mailto:alagvi@npsuindia.org">
alagvi@npsuindia.org</a>, <a href="mailto:thapaa@searo.who.int">thapaa@searo.who.int</a>, <a href="mailto:sagarka@npsuindia.org">sagarka@npsuindia.org</a>, mittal santosh <<a href="mailto:skmittal44@yahoo.com">skmittal44@yahoo.com
</a>>, to Down <<a href="mailto:vibha@cseindia.org">vibha@cseindia.org</a>>, Gopal Dabade <<a href="mailto:drdabade@gmail.com">drdabade@gmail.com</a>>, <a href="mailto:leej@who.int">leej@who.int</a><br><br>
</span></div>
<div style="DIRECTION: ltr">Dear All,<br>We thank all of you who attended today's meeting.<br>The full text of our submission that was presented at the meeting is attached. I am sorry I did not have sufficient number of hard copies for everyone at the meeting.
<br><br>It was acknowledged at the meeting that there was literally no data available from the GAVI funded, Hepatitis B Pilot study in India, to suggest that the project was successful and for it to be scaled up as a national program.
<br><br>The GAVI pilot project has been in place for over 5 years in some places. It was agreed that such a study must be undertaken now.<br><br>A well stratified sample of 10,000 children (under 5 years) would be studied in 1 or 2 or 3 areas (10,000 per area studied) where the pilot study is underway.
<br>The following will be studied in all the children <br><br>1. HBsAg status<br>2. Vaccine induced antibody levels<br>3. Vaccination history to check if the were immunised at birth, or at 6 weeks, or not vaccinated.<br><br>
The following inferences can be drawn<br>1. How effective is the pilot in terms of coverage?<br>2. What percentage got immunised at birth?<br>3. What is HBsAg status in, in under-fives, compared to what it was before the pilot study started
<br>4. What is HBsAg status of those vaccinated at birth, compared to those vaccinated starting at 6 weeks and those not immunised.<br><br>The study would be done in 6 to 12 months.<br><br>Professor Mittal and I agreed to help with the design and execution of the study.
<br>----------------------------------------------------------------------------------------------<br>We insisted that, as the WHO was in agreement with us, that there was no worth while data to suggest that the pilot project was a success the
<span style="BACKGROUND-COLOR: rgb(255,255,51)">WHO must in all fairness ask the Government not to scale up the program pending the new study. <span style="BACKGROUND-COLOR: rgb(255,255,255)">In the end Dr Craig agreed to write to the Government outlining the gaps in knowledge and about the new study to fill this gap prior to scaling up - with a copy to us.
</span></span><span style="BACKGROUND-COLOR: rgb(255,255,51)"></span><br>--------------------------------------------------------------------------------------------------<br><br>We had hoped to send transcripts of the recording of the morning meeting to all who asked for it. Unfortunately most of us were speaking softly and none of us used a mike system and so it is uncertain if the recording is
complete.All the same an effort is being made to get the transcript ready. Please let us know if you want a copy. Copies of the tape can also be provided on request<br><br>I<span style="BACKGROUND-COLOR: rgb(255,255,102)">
have summarised the proceedings as I remember them (from my perceptions).</span><br style="BACKGROUND-COLOR: rgb(255,255,102)"><span style="BACKGROUND-COLOR: rgb(255,255,102)">I will appreciate suggestions for correction to be sent by return email.
</span><br style="BACKGROUND-COLOR: rgb(255,255,102)"><br>Thank you again<br>Sincerely<br>Jacob Puliyel <br>___________________________<br>Jacob M. Puliyel MD MRCP MPhil<br>Sara Varughese DO FRCS MSc(LSHTM)<br><br>eFax 00 44 7092-124285
<br>Phone 00 91 11 2946388 <br> 00 91 9868035091 <br clear="all"></div>
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<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: center" align="center"><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Meeting with WHO on Hepatitis B immunization in India</span></b></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: center" align="center"><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">3/3/06</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> Nirman Bhawan
</span></b></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: center" align="center"><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></b></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Thank you for taking time to discuss this issue with us.</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">For the discussion to be meaningful we had outlined only 2 preconditions</span></p>
<ol style="MARGIN-TOP: 0in" type="1">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l0 level1 lfo1"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">That we limit discussion to evidence based literature and data and not include personal opinions
</span></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l0 level1 lfo1"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">That we are prepared for all our deliberations to be on record.</span>
</li></ol>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">I am a paediatrician. We are a not anti-vaccinationists. We are not anti-free market spokes persons. The WHO represents the biggest force for public health in the world. We see ourselves as staunch supporters of that noble cause
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">We are here today discussing Hepatitis B vaccine in </span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India
</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The Government of India plans to include Hepatitis B in the UIP, to be given starting at 6 weeks. This seems o defy logic.
</span></p>
<ol style="MARGIN-TOP: 0in" type="1">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l3 level1 lfo2"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The country cannot afford to protect large numbers in our population against DPT. In many areas the coverage is less than 20%. Hepatitis B is vastly more expensive
</span></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l3 level1 lfo2"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The plan to vaccinate against hepatitis B at 6 wks (after vertical spread has already taken place) appears especially inexplicable.
</span></li></ol>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The Indian Minister for Health says he is doing this on the advice of the WHO (Press cutting already sent to WHO)</span>
</p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The WHO on its part says it "takes it's mandate and direction from member states, including </span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">"</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Let us not waste time on these circular arguments.</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<div style="BORDER-RIGHT: medium none; PADDING-RIGHT: 0in; BORDER-TOP: medium none; PADDING-LEFT: 0in; PADDING-BOTTOM: 1pt; BORDER-LEFT: medium none; PADDING-TOP: 0in; BORDER-BOTTOM: windowtext 1pt solid; mso-border-bottom-alt: solid windowtext .75pt">
<p class="MsoNormal" style="BORDER-RIGHT: medium none; PADDING-RIGHT: 0in; BORDER-TOP: medium none; PADDING-LEFT: 0in; PADDING-BOTTOM: 0in; MARGIN: 0in 0in 0pt; BORDER-LEFT: medium none; PADDING-TOP: 0in; BORDER-BOTTOM: medium none; mso-border-bottom-alt: solid windowtext .75pt; mso-padding-alt: 0in 0in 1.0pt 0in">
<span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">You are experts on Hepatitis B delegated to allay our anxieties about the program.</span></p></div>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">We are all aware of how data has been fudged in the past to make the case for hepatitis B vaccination. Dr Mark Miller of the CDC and WHO calculated 250,000 people die of hepatitis B in
</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> each year. We suspected that he had simply projected mortality data available from Taiwanese males on the population of
</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">. We wrote to the journal Health Economics. Dr Miller replied that he had used country specific data stratified by geographic area and income group.
<span style="mso-spacerun: yes"> </span><span style="mso-spacerun: yes"> </span><span style="mso-spacerun: yes"> </span></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">We wrote in the journal that Dr Miller must publish this model or retract the paper. Dr Miller wrote he did not have a model as it was 'lost' but the paper has not been retracted yet. (Health Economics 2004;13:1147-8)
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">An 'expert group' from </span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
, The Association for Study of the Liver, published a 'consensus statement' that made out the vaccine to be cost-effective and sent off it's recommendation to the Government. (Indian J of Gastroenterology 2000;19 (Supp3) C 54) However in the columns of the same journal so many errors were pointed out that the corresponding author of the consensus statement finally wrote that the cost calculations must be redone by the 'experts' The retractions were not sent to the Government.
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">You can see our reason for distrust of 'expert opinions' and why we insist that all the data presented is verifiable.
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The questions before us are</span></p>
<ol style="MARGIN-TOP: 0in" type="1">
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l4 level1 lfo3"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Is there a need for the vaccine in </span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">?</span></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l4 level1 lfo3"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">If so will the vaccination program be cost-effective?</span></li>
<li class="MsoNormal" style="MARGIN: 0in 0in 0pt; tab-stops: list .5in; mso-list: l4 level1 lfo3"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Is it affordable and feasible?</span></li></ol>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">A) To answer the questions we need to know what is the WHO projection of the hepatitis B chronic carrier rate in </span>
<span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">?</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">(What is the primary data used and from which regions. How is the national projection made from this data)</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The best data to date seems to be a systematic review that suggests that the rate is less than 2% (Lodha R et al Hepatitis B in India Ind Ped 2001;38:349-71)
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">B) How many people die of Hepatocellular carcinoma, cirrhosis and acute liver failure due to hepatitis B each year?</span>
</p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">The data from the Indian Council of Medical Research says it is 5000 in the population of 1 billion.</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Your letter says 25% will die prematurely. This is a throw back of the Dr Mark Miller argument. The term 'prematurely' is meaningless in this context. At what age do they die of HCC? Life expectancy in
</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> is 63 years. Perhaps shows that people die of other natural causes before HCC sets in. Is it worth vaccinating this population?
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">C) The letter from the WHO says that the decision to include the birth dose should be made by the country itself taking into consideration it's own data on perinatal transmission.
</span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font color="#000000"><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">In </span></span><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
India</span></span><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> the decision to vaccinate after 6 weeks, is not based on data on 'absence of perinatal spread' but on the fact that it cannot afford immunisation at birth.
</span></span></font></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font color="#000000"><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"><span style="mso-spacerun: yes"> </span>As experts do you think </span></span>
<span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span></span><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> does not have a problem of perinatal spread that it does not need the dose at birth?
</span></span></font></p>
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<span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"><font color="#000000">Our research suggests that 50% of chronic carriers acquire it vertically. Nayak NC et al (`J Med Virol 1987;21:137-45) that the pattern of spread in India is that in Africa where a third get it vertically from mothers and the remaining get it from those who got it vertically. For this reason prevention of vertical spread is crucial where the overall coverage is going to be low.
</font></span></span></p></div>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"><font color="#000000">Much is being made of the funds available through GAVI to help the vaccination programme. The answers to parliamentary questions (which are in the appendix below) is revealing. The pilot study costing Rs 270 million was done with GAVI funds. They supplied self destroying syringes.
</font></span></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span class="q"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"><font color="#000000"> </font></span></span></p>
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<span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">The program of universal immunization<span style="mso-spacerun: yes"> </span>will cost Rs 5250 million every year and will have to be continued indefinitely. No fancy self destruct syringes this time around. The vaccine will be given with re-useable needles after boiling. The number of children who get hepatitis B, HIV and other infections because of this mass immunization program with unsterile needles, will make the subject of an interesting study.
</span></p></div>
<p><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">GAVI funded this study and it was a success we are told.</span></p>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l2 level1 lfo4"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-ansi-language: EN-US; mso-bidi-font-family: Symbol">
<span style="mso-list: Ignore">·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">What is the measure of success of the program?</span>
</p>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l2 level1 lfo4"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-ansi-language: EN-US; mso-bidi-font-family: Symbol">
<span style="mso-list: Ignore">·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">What is the carrier rate among babies under 2 years in cities where the pilot was done compared to the carrier rate before the introduction of this prophylaxis? That would be very useful to know – to prove that the birth dose is not needed
</span></p>
<p><span style="BACKGROUND: yellow; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US; mso-highlight: yellow">There is no data</span><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"></span></p>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l1 level1 lfo5"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-ansi-language: EN-US; mso-bidi-font-family: Symbol">
<span style="mso-list: Ignore">·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">What is the carrier rate in those who are immunized compared to those not immunized.
</span></p>
<p><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">Except for data from tribals in Andamans ( Murhekar MV Vaccine 2004;23:399-403) <span style="BACKGROUND: yellow; mso-highlight: yellow">there is no data
</span></span></p>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l1 level1 lfo5"><span style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-ansi-language: EN-US; mso-bidi-font-family: Symbol">
<span style="mso-list: Ignore">·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">What is the uptake of vaccine in the pilot project areas.
</span></p>
<p style="MARGIN-LEFT: 0.25in"><span style="FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">We have one study from East Delhi that says that the coverage with hepatitis B was 14% - only marginally more than the baseline 9% before the vaccine was made available free of cost by the GAVI (Sokhey J et all J Trop Ped 2001;47:199-203) Another study from Delhi found coverage of 19 to
21.6% (Dasgupta R Health Policy Planning 2002;17;99-105</span></p>
<p><span lang="EN-GB" style="BACKGROUND: yellow; FONT-FAMILY: 'Arial Narrow'; mso-highlight: yellow">Is this true scientific rigor</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">?</span></p>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">When GAVI started the pilot project what did it set out to test?</span></p>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">We know 270 million rupees have been spent. <span style="BACKGROUND: yellow; mso-highlight: yellow">Is this the mark of success.</span></span></p>
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<p style="BORDER-RIGHT: medium none; PADDING-RIGHT: 0in; BORDER-TOP: medium none; PADDING-LEFT: 0in; PADDING-BOTTOM: 0in; BORDER-LEFT: medium none; PADDING-TOP: 0in; BORDER-BOTTOM: medium none; mso-border-bottom-alt: solid windowtext .75pt; mso-padding-alt: 0in 0in 1.0pt 0in">
<span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">We know that 'n' number of doses have been consumed. <span style="BACKGROUND: yellow; mso-highlight: yellow">Is that the hallmark?</span></span></p></div>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l1 level1 lfo5"><span lang="EN-GB" style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore">
·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">If we do not know how many people die of HCC and cirrhosis due to Hepatitis B we do not know how many will be saved by the vaccine
</span></p>
<p style="MARGIN-LEFT: 0.5in; TEXT-INDENT: -0.25in; tab-stops: list .5in; mso-list: l1 level1 lfo5"><span lang="EN-GB" style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore">
·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">If we do not know how many are infected vertically, we cannot know how many will benefit in spite of missing the birth dose
</span></p>
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<p style="BORDER-RIGHT: medium none; PADDING-RIGHT: 0in; BORDER-TOP: medium none; PADDING-LEFT: 0in; PADDING-BOTTOM: 0in; MARGIN-LEFT: 0.25in; BORDER-LEFT: medium none; TEXT-INDENT: -0.25in; PADDING-TOP: 0in; BORDER-BOTTOM: medium none; tab-stops: list .5in; mso-list: l1 level1 lfo5; mso-border-bottom-alt: solid windowtext .75pt; mso-padding-alt: 0in 0in 1.0pt 0in">
<span lang="EN-GB" style="FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"><span style="mso-list: Ignore">·<span style="FONT: 7pt 'Times New Roman'"> </span></span></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
If we are not able to get DPT vaccine (that costs pennies) to large masses of our population how do we imagine we will do better with Hepatitis B</span></p></div>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">There has been a sea change in what the WHO perceives as its public health role in recent years. A statement of how the vaccine came to be recommended in 1992 is not much relevant anymore.
</span></p>
<p><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">For </span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">, this will arguably be the most expensive intervention ever undertaken to save 5000 lives a year. We expect that the WHO experts will have figures and data pertinent for different regions in
</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> to show that the programme they are encouraging, is cost beneficial for the country. If it does not have such data, can we hope that the WHO will advise the Government of
</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> to hold the programme in abeyance till the data is available. It owes this not to a resource poor nation like
</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">India</span></b><b><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"> but to its own credibility.</span></b></p>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Dr Gopal Dabade,<br>President, <br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Drug Action Forum - Karnataka<br><a href="mailto:drdabade@gmail.com">
drdabade@gmail.com</a> </span></p>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">and </span></p>
<p><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Jacob M. Puliyel, <br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Department of Pediatrics<br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
St Stephens Hospital<br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Tis Hazari, </span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Delhi</span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">
110054<br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"><a href="mailto:Puliyel@vsnl.com,Mobile">Puliyel@vsnl.com</a></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">,<br>Mobile 0091<span style="mso-spacerun: yes">
</span>9868035091,<br></span><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'">Fax 00 44 7092-124285</span></p>
<p style="MARGIN-LEFT: 0.25in"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"></span> </p>
<p style="MARGIN-LEFT: 0.25in"><span lang="EN-GB" style="FONT-FAMILY: 'Arial Narrow'"></span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">Appendix</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">GOVERNMENT OF </span><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">INDIA</span><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">MINISTRY OF HEALTH AND FAMILY WELFARE</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">RAJYA SABHA</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">UNSTARRED QUESTION NO 3428 </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">INCLUSION OF HEPATITIS B VACCINE IN THE NATIONAL IMMUNISATION PROGRAMME . </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">3428. </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">DR. D. MASTHAN </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td></tr>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td></tr></tbody></table>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"><br>Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:- <br><br>(a) how many people/children have died due to Hepatitis-B virus during the last three years in the country;
<br><br>(b) whether Government will include Hepatitis-B vaccine in the National Immunisation Programme to eradicate this killer virus; and <br><br>(c) if answer to part <br><br>(b) of the question be in the negative, the reasons therefor? ANSWER
</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">ANSWER</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">MINISTER OF STATE OF THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI DALIT EZHILMALAI) <br><br>(a) No authentic data is available of the number of the deaths caused by Hepatitis-B infection alone. However, according to available data, the number of cases of viral Hepatitis (all types) during 1995 to 1997 (provisional) is as follows:-
</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">______________________________________________________________________________________________</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p style="MARGIN-BOTTOM: 12pt"><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">Year No. of Persons infected No. of persons died</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">_______________________________________________________________________________________________</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p style="MARGIN-BOTTOM: 12pt"><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"> </span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">1995 98943 943</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">1996 117954 801</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">1997 89038 962</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">_______________________________________________________________________________________________</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">(b) and (c) Hepatitis B vaccination has not been included under the National Immunization </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p style="BACKGROUND: #ffff66"><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">Programme as the estimated cost will be around Rs. 525 crores per annum and the measure if</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p style="BACKGROUND: #ffff66"><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">initiated will have to be continued indefinitely to cover all children born in the country </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; BACKGROUND: #ffff66; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">with 3 doses</span><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">. Availability of funds to sustain this over such a long period cannot be assured.
</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">In order to reduce the risk, however State Governments have been advised to provide vaccination </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">to the concerned hospital workers.</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">GOVERNMENT OF </span><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">INDIA</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'">
</span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">MINISTRY OF HEALTH AND FAMILY WELFARE</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">MINISTRY OF 29</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">RAJYA SABHA</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">STARRED QUESTION NO 408 </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">CHEAPER HEPATITIS B VACCINE . </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">408. </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">SHRI BHAGATRAM MANHAR </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td></tr>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td>
<td style="BORDER-RIGHT: #ece9d8; PADDING-RIGHT: 0.75pt; BORDER-TOP: #ece9d8; PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: #ece9d8; PADDING-TOP: 0.75pt; BORDER-BOTTOM: #ece9d8; BACKGROUND-COLOR: transparent">
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">RAJU PARMAR </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td></tr>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td>
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<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"> </span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p></td></tr></tbody></table>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"><br>Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:- <br><br><br>(a) whether it is a fact that Hepatitis-B spreads very easily and one in every twenty Indians is already infected with this killer disease;
<br><br>(b) if so, the steps Government have taken or propose to take for protection against this disease; <br><br>(c) whether cheap vaccines are available in the country for the poor; and <br><br>(d) if not, the steps being taken to procure Hepatitis-B vaccines at cheaper rates?
</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US">ANSWER</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'; mso-ansi-language: EN-US"><br>THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI A. RAJA) <br>
<br>(a) to (d): A statement is laid on the table of the House. <br><br>STATEMENT REFERRED TO IN REPLY TO RAJYA SABHA STARRED QUESTION NO. 408 FOR 12.8.2002 .... <br>Hepatitis-B spreads through unsafe sex, unsafe blood transfusion, unsafe injections etc. and also from mother to child. Hepatitis-B is preventable by ensuring precautionary measures. Studies undertaken so far, indicate that about 3% to 5% of the population in the country is suffering from Hepatitis-B infection. The following measures have been taken to prevent infection of Hepatitis-B :- Central Government hospitals personnel at high risk are being immunized against Hepatitis-B. State Governments have also been advised to take similar steps. Guidelines have been issued for mandatory testing of blood in all blood banks. Promotion of safe sex under National AIDS Control Programme is advocated. Health awareness campaigns regarding the danger of using unsterile syringes and needles under National AIDS Control Programme are held. Guidelines have been issued to State Health Authorities for use of separate sterile syringes and needles for each injection. A pilot project to introduce Hepatitis-B Vaccine in 15 selected cities and 32 districts in 17 States of the country, which are high risk areas, in order to study the impact of administration has been launched.
<span style="BACKGROUND: #ffff66"> The pilot project is estimated to cost Rs.27.19 crores out of which vaccines and AD syringes cost Rs.23.89 crores, which will be funded by the Global Alliance on Vaccines and Immunization (GAVI).
</span><br>Vaccines for Hepatitis-B is available in the country at affordable prices</span><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"></span></p>
<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span lang="EN-GB" style="FONT-SIZE: 9pt; FONT-FAMILY: 'Arial Narrow'"> </span></p></div>
<div style="DIRECTION: ltr"><br>-- <br>Dr Gopal Dabade,<br>57, Tejaswinagar,<br>Dharwad 580 002<br>Tel 0836-2461722<br>Cell (0)9448862270<br><a href="http://www.jagruti.org">www.jagruti.org</a> </div>