CORRESPONDENCE

protein level, that may be a confounder while interpreting REPLY

serum zinc level, is to be evaluated in such a study. It is also
interesting to know whether deworming was given prior to Though data with regards to malnutrition was recorded, it
iron therapy, as the role of parasitic infestation in was not described in the article because priority was given
deficiency is discussed in the presentation. Deworming is to the prime objective of the study which was a correlation
essential to break the negative spiral of worm infestation, between iron and zinc deficiency with memory.
malnutrition and altered immunity [4]. Deworming was done prior to start of supplementation of
all the students who participated in the study. We had met
The dose of iron 2 mg/kg/day and zinc 5 mg/day is the parents of the children every week. Parents of 9
suboptimum to treat deficiency state. The authors have not children complained that the child had sensation of
given any explanation for choosing prophylactic dose for nausea, and 6 of them gave history of frequent
treatment. The reference endorsing the selection of 6-8 passage of stools. Taking the response into consideration
years and 9-11 years as the age for cultivating inspiration and with the references [1,2] mentioned below, the
and wisdom and for formative process and reasoning, dose of supplementation was reduced. The
respectively, as cited in the concluding paragraph is also reference endorsing the selection of 6-8 years and 9-11
missing. years as the age for cultivating inspiration and wisdom and
formative process and reasoning respectively, is Ramesh,
KE ELIZABETH
et al [3].
Professor of Pediatrics,
SAT Hospital, Govt. Medical College, K UMAMAHESWARI
Trivandrum 695 011. umamaheswari.g@hotmail.com
elizake@hotmail.com REFERENCES
REFERENCES
1. Ambruso DR, Hays T, Golderberg NA. Current Diagnosis
1. Umamaheswari K, Bhaskaran M, Krishnamurthy G, & Treatment: Pediatrics. Hematological disorder, Ed. 19.
Hemamalini , Vasudevan K. Effect of iron and zinc USA: Mc Graw Hill; 2009.p.811.
deficiency on short term memory in children. Indian 2. Kleigman RM, Marcdante KJ, Jenson HB, Behrman RE.
Pediatr. 2011;48:289-93. Nelson Essential of Pediatrics. 5th Edition. Philadelphia:
2. Beard JL. Iron biology in immune function, muscle Saunders; 2006.p.154.
metabolism and neuronal functioning. J Nutr. 3. Mishra RC, Dasen PR. The influence of schooling on
2001;131:5685-795. cognitive development: A review of research in India. In:
3. Bhatnager S, Taneja S. Zinc and cognitive development. BN Setiadi, Supratiknya A, Lonner WJ, Poortinga YH
Br J Nutr. 2001;85:S139-45. (Eds). Ongoing Themes in Psychology and Culture (Online
4. Koski KG, Scott ME. Gastrointestinal nematodes, nutrition Ed). Melbourne, FL: International Association for Cross-
and immunity: Breaking the negative spiral. Annu Rev Cultural Psychology. Available from:www.iaccp.org.
Nutr. 2001;21:297-321. Accessed on: July 1, 2011.

Measles Vaccine versus MMR year of (life and not the measles vaccine).

I wonder what lead to the recommendation of a second

I read the article “Introduction Strategy of a Second Dose dose of measles vaccine and not MMR as the second dose
Measles Containing Vaccine in India” [1] with great in the second year. If the entire government machinery had
interest. The move, when enforced, may lead to a lot of been used to push through MMR as the recommended
confusion in the recommendations between the public and dose in the second year, it would have lead to a wider
the private sector. protection against more diseases while at the same time
achieving a uniformity of recommendations between the
In the private sector, pediatricians are already private and the public sector. With the new
administering the measles vaccine at 9 months followed by recommendations, if I now have a child coming to me who
MMR at 15 months and an MMR booster at either 5 years has already taken 2 doses of the measles vaccine at 9
or 9-12 years. In fact, even the routine immunization months and 18 months, I would end up giving him 2 more
protocol in Delhi, Puducherry, Goa and Sikkim already doses of measles in the form of MMR going by the current
use the MMR vaccine as the second dose in the second recommendations for the MMR vaccine.

INDIAN PEDIATRICS 742 VOLUME 48__SEPTEMBER 17, 2011

 CORRESPONDENCE

M SANKLECHA additional cost of mumps antigen with the second dose of

Consultant Pediatrician, measles containing vaccine (MCV).
Bombay Hospital Institute of Medical Science,
Mumbai, Maharashtra. Measles continues to cause significant morbidity and
doctormukesh@gmail.com mortality in young children where vaccination coverage
remains low. Rubella and mumps infection do cause
REFERENCES significant complications in adolescent and older age
groups but once again, the actual burden is not well
1. Gupta SK, Salser S, Halder P, Hombergh HVD, Bose AS.
documented. Introducing mumps and rubella vaccines
Introduction strategy of a second dose measles containing
vaccine in India. Indian Pediatr. 2011;84:379-81.
into childhood vaccination programmes that do not
achieve high coverage (80%) increases the median age
at infection and has the potential risk of paradoxically
REPLY
increasing the public health consequences of the very
The main objectives of our article were to describe the diseases that vaccination is attempting to control. WHO
strategies adopted by Govt. of India to introduce a second position papers on both mumps and rubella vaccines have
dose of measles vaccine in the country and the rationale stated the risks of such “paradoxical effects” in quite
behind those strategies [1]. The correspondent here has unambiguous terms [3,4]. The evidence for the danger of
not questioned the basic rationale behind the introduction paradoxical increase of Congenital Rubella Syndrome
of second dose of measles vaccine per se, but has raised (CRS) owing to private sector usage of rubella vaccine
an issue of choice between measles vaccine and achieving low coverage overall, comes from
combined mumps-measles-rubella (MMR) vaccine and observational and modeling studies [3,4].
has recommended that MMR vaccine be used
These are well known facts regarding mumps and
straightaway in childhood immunization in the National
rubella vaccine introduction in children. In fact, in its
Immunization program in India.
April 2011 meeting, the Strategic Advisory Group of
For private sector clinicians and their clients, the Experts (SAGE) has cautioned against the possibility of
choice of which vaccine to provide is often governed by paradoxical increase of CRS owing to widespread use of
the clinician’s judgment of the expected benefit-risk ratio rubella containing vaccines by private sector service that
of the vaccine and the client’s ability to pay for the goods ultimately achieves low overall coverage (<80%) [5].
and services offered. The key context is benefit to the
individual client and not the community at large. The question posed in the end is actually a non-starter
Conversely, selecting a vaccine for a national immuni- from the perspective of the national immunization
zation program in which the Government bears the programme. At present, Govt. of India policy is to give the
burden of entire costs and has to consider individual as first dose of measles vaccine between 9 and 12 months to
well as community benefit, is quite different. Public all children in the country. The second dose of measles
health policy making is often choosing one practically vaccine will be given through routine immunization
feasible option among many which are ideally possible. between 16 and 24 months of age in 21 states and through
mass vaccination campaigns for 9 months to 10 year old
The Universal Immunization Program (UIP) in India children in 14 states. Thus, in any particular state, a child
is one of the largest immunization programs in the world will get the second dose of measles vaccine through either
and targets an annual cohort of approximately 26 million routine immunization or mass campaigns, not both.
children. Choosing MMR over single antigen measles
vaccine (MV) in the national immunization program SATISH KUMAR GUPTA and STEPHEN SOSLER
would have definite cost implications as MMR is sgupta@unicef.org; soslerst@npsuindia.org
considerably more expensive than single antigen MV.
REFERENCES
In 2008, the National Technical Advisory Group on
Immunization (NTAGI), Govt. of India had deliberated 1. Gupta SK, Sosler S, Haldar P, Hombergh HVN, Bose AS.
on this issue and recommended that the available data did Introduction strategy of a second dose measles containing
vaccine in India. Indian Pediatr. 2011;48:379-82.
not justify including the mumps component with measles
2. Minutes and Recommendations of National Technical
vaccine as the benefits would not be commensurate with Advisory Group on Immunization (NTAGI), 16th June
the additional costs incurred [2]. In 2009 and 2010, 2008, Ministry of Health and Family Welfare,
successive NTAGI sessions once again determined that Government of India. Available at http://mohfw.nic.in/
available epidemiologic evidence did not warrant the WriteReadData/l892s/6664716297file23.pdf. Accessed

INDIAN PEDIATRICS 743 VOLUME 48__SEPTEMBER 17, 2011