The unveiling in May 2013 of a low-cost, locally-produced rotavirus vaccine represents a shot in the arm for India’s efforts to reduce child mortality. If approved, the vaccine, dubbed ROTAVAC, will cost approximately Rs 54 (less than US$ 1) per dose for three oral doses, significantly less than the Rs 1,000 (US$ 16) per dose the other two rotavirus vaccines on the market currently fetch. Diarrheal diseases account for around 300,000 child deaths per year in India, with rotavirus the leading culprit of severe diarrhea among children under five. Thus, if widely promoted and distributed, the vaccine has the potential to save thousands of children’s lives per year.
However, merely offering the vaccine on the open market is not enough to protect children against diarrheal diseases. On November 19, the international community celebrated the twelfth anniversary of World Toilet Day, an annual UN-recognized event that aims to raise awareness about sanitation. As some health analysts have argued, if India truly wants to combat child mortality, it must concurrently improve access to clean water and sanitation. Additionally, with only sixty-one percent of infants in India fully immunized, the Indian government must improve vaccine delivery and distribution, particularly in remote rural regions.
The Disease and its Causes
Worldwide, diarrheal diseases are the second leading cause of death after pneumonia, and the leading cause of malnutrition for children under five. Key measures for preventing diarrhea include exclusive breastfeeding (particularly in areas with poor sanitation), ensuring access to clean drinking water, and practicing good personal and food hygiene.
Currently, there is significant room for progress on a number of these fronts in India. Over half of the population defecates in the open (compared to seven percent in neighboring Bangladesh) and only thirty-one percent use improved sanitation facilities. Only six percent of rural children under five use toilets and forty-four percent of mothers dispose their children’s feces out in the open. Additionally, twelve percent of India’s 1.2 billion-strong population continues to consume unclean water. Moreover, there are sharp inequalities in access among regions and income levels: for example, nearly seventy percent of rural households do not have access to sanitation facilities versus only nineteen percent of urban households. Finally, rates of exclusive breastfeeding have hovered around forty-six percent since the early 1990s. Regarding this last point, UNICEF estimates that infants who are not breastfed are eleven times more likely to die of diarrheal diseases than those who are exclusively breastfed for the first six months of life.
With the largest birth cohort in the world and a diverse geographic and demographic landscape, India faces many health care delivery challenges. While the ROTAVAC vaccine represents a huge win for India—it is locally produced, inexpensive, and relatively easy to administer—it should not be treated as a panacea for child mortality, or even diarrheal disease. Indeed, a recent study published in the Bulletin of the World Health Organization concluded that if a rotavirus vaccine was delivered as part of a national program, it would prevent about four percent of under-five deaths in India—a small but valuable contribution.
Moreover, India’s current vaccine financing and delivery system will make it difficult for ROTAVAC to reach the segments of the population that need it the most. Despite its low cost, the vaccine may still be out of reach for the poorest households, and introducing the new vaccine into the government’s Universal Immunization Program (the pre-approved sequence of vaccines provided free of cost to the population) could take years. The bulk of the government’s immunization budget has traditionally been dedicated to the polio vaccine, and while vitally important, polio eradication efforts have reduced the time and money spent on other child health initiatives. Finally, delivery and storage of vaccines remain spotty in many parts of the country, particularly in rural areas that are subject to frequent power outages.
Thus, ROTAVAC should be viewed as a small, but important, piece of the puzzle. Equally important will be efforts to bolster the ranks of community health workers in rural areas and ensure that at the village level they promote good hygiene, exclusive breastfeeding, and proper feces disposal. Instilling the habit of regular handwashing alone is estimated to reduce diarrheal diseases by forty percent and costs very little. Ensuring that all mothers have access to, and are trained to administer, oral rehydration therapy is similarly cost-effective and helps treat diarrhea. Additionally, mapping the location and functionality of public toilets, and using the information to press municipal governments for more and better facilities, could be a useful tool for informing policy. Finally, the government should increase the amount of resources it allocates to the Ministry of Drinking Water and Sanitation and ensure that its activities complement those under the National Rural Health Mission’s umbrella, as well as strengthen water infrastructure throughout the country.
Without these complementary activities, ROTAVAC will be more a shot in the foot than a shot in the arm.