Adult immunization: Is time ripe for its initiation.

Sir,

This is in reference to the article “Suggested use of vaccines in diabetes” published as a review article.[1] At the outset, we must congratulate the authors for debating on a neglected issue of public health concern. The topic has in itself the potential to delve on the larger issue of “Immunization in adults and elderly.”

India is home to 40.9 million people with diabetes—nearly 15% of the global diabetes burden; it contributes 1% of the world's diabetes research.[2] Projections show that this will increase to 70 million by 2025. As India has a population of 1.2 billion, 40% of whom are under the age of 18, investment in the health of India's future workforce is crucial.[3] Between 5% and 10% of the nation's health budget is spent on the prevention and treatment of diabetes. Projections show that in the next decade, India will lose US$ 237 billion due to diabetes, stroke, and heart disease.[4]

What this means, therefore is that as with all public health problems, we need a solid prevention strategy in place to combat the losses incurred on managing diabetes. Probably the time has come when we need to give a serious thought to it. The implementation of this strategy has become easy with the launch of National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). The program envisages providing preventive, promotive, curative, and supportive services (core and integrated services) in cancer, diabetes, cardio-vascular diseases (CVD), and stroke at various government health facilities. The range of services will include health promotion, psycho-social counseling, management (out-and-in-patient), day care services, home-based care, and palliative care as well as referral for specialized services as needed. These strategies were proposed to be implemented in 20,000 sub-centers and 700 community health centers in 100 districts across 21 states during 2010-12.[5] NPCDCS would operate through non-communicable disease (NCD) cells under the program constituted at state and district levels.[5] The NPCDCS aims at integration of NCD interventions in the national rural health mission (NRHM) framework for optimization of scarce resources and provision of seamless services to the end user (patients) as also for ensuring long-term sustainability of interventions. The institutionalization of NPCDCS at district level within the district health society, sharing administrative and financial structure of NRHM becomes a crucial program strategy for NPCDCS.

As rightly pointed in the article, diabetes management is primarily aimed at preventing micro- and macro-vascular complications.[1] However, morbidity and mortality due to infections are also significant. The impact assessment of immunization in diabetics may suggest that providing free vaccines to diabetics may go a long way in reducing this. The only hurdle that seems to hold this idea is the practical implementation at community level. Currently, NPCDCS does not envisage immunization in diabetics. However, as we are aware that the free universal immunization program for children is in existence for several decades in this country and NRHM is the backbone for this program. The integration of NPCDCS into NRHM opens up the area for not just immunization in diabetics; it also broadens the horizon of prevention in allowing for capacity development and extension to an adult immunization facility in general.