Doctor's Dilemma: Vaccination for older adults. Professor Amitav Banerjee.

[00:00:05]Greetings and a warm welcome to everyone in attendance. I'm Rimpa, your moderator for today from Clan it and I extend my cordial greetings to all the delegates from across the country. We sincerely appreciate all the doctors who have taken the time to attend the session with us today. Allow me to briefly introduce our platform Clan it. It is in this most trusted live digital CME platform which allows doctors to create their own medical content. Now it is my proud privilege to make the marquee note speaker for today, Dr. Amitabh Banerjee, sir. Sir holds a degree in MBBS MD, professor and the head of department of community medicine at DY Patil Medical College, Pune. A distinguished academician and public health expert, Dr. Banerjee has made significant contribution to community medicine, preventive health care and medical education.

[00:00:52]So, we're delighted to have him today with us and today sir will be talking on the topic doctor's dilemma, vaccination for older adults. Now, without any further delay, sir, we welcome you wholeheartedly to our platform. You can begin the talk.

[00:01:07]>> Thank you, Rimpa, and it's always a pleasure to come on the Clan it platform and there's a slight correction in my designation. I am currently professor emeritus. I was formerly head.

[00:01:19]Since 2 years I am professor emeritus in the same institution.

[00:01:23]>> Okay.

[00:01:25]>> Pleasure to come on this platform and why I am talking of dilemma? Because uh we are having newer and newer vaccines and elderly population is also increasing in our country. Presently, it may be around 10% to 15% above 60 years, but it is fast increasing and the vaccines are also increasing and so there are a lot of for the thinking doctor it is a dilemma, I would say. But for the otherwise it is just all the vaccines available you may recommend all the vaccines. But that is not scientific practice. Scientific practice is tailored to each elderly person because elderly persons have a lot of com- They have got a compromised immune system. So it's a cash 22 situation because of the compromised immune system >> Sir, sir, sir, sorry for interrupting you, sir. Your slides are not visible.

[00:02:22]>> I will I will be I will be sharing shortly.

[00:02:26]I'm just So because of the compromised immune system they are vulnerable to infections and at the same time their response to vaccine may not be ideal.

[00:02:36]They may that also may get compromised.

[00:02:38]So it's a >> [clears throat] >> That's the problem. So we have to weigh each individual. So I'll just share these slides and just we'll go over the So this is the topic vaccination for older adults. Doctors' dilemma as I said for the thinking doctors, otherwise many people it is something like you have got a something on the menu card. Everything on the menu you don't order. You order what according to each patient. So that is the These are the talking points. Vaccine mar- markets are moving fast and rather too faster because the newer technologies are also coming up like on the anvil is the mRNA technology which is rolled out in the USA. It may our country also but that will add to the dilemmas because the consensus is divided on the benefits and risk of mRNA vaccine. Then how we What are the inputs if we want to practice evidence-based medicine?

[00:03:43]Particularly for elderly vaccination what inputs we require? We can Actually we take everything what is given in the West, we adopt. But in infectious disease, there are a lot of factors.

[00:03:56]We'll go through this.

[00:03:58]And how to measure the vaccine efficacy and impact. So, there are two measures. I'll just give the concept. I'll not go into too much of statistical details.

[00:04:08]There is a relative risk reduction and attributable risk reduction. And how it makes a difference in how we interpret it.

[00:04:17]Then, what are the effect modifiers in different population?

[00:04:21]With reference to elderly. As I said, what is applicable in the West may not be applicable because of our population density, because of our demographics, because of our exposure to different here from young age. Our elders may not resemble the elders in the Western countries.

[00:04:40]And very recently, last month only, the Indian Academy of Geriatrics in their journal, they have come out with the guidelines. So, I'll be just going over the guidelines, which are the recommendations.

[00:04:56]They have recommended about five vaccines. I'll go through them.

[00:05:00]And uh I have a my reservation on the term vaccine hesitancy. I think vaccine hesitancy should be removed from the vocabulary.

[00:05:09]I have even got my objection to the WHO, which has introduced this term vaccine hesitancy. Science is always hesitancy.

[00:05:18]If you remove hesitancy, then you go towards faith. You go towards dogma, not towards science. So, if there is no hesitancy, there's no dilemma. So, vaccine hesitancy is a unscientific term, and I have my strict uh objections to it. And we'll see way forward. So, as I said, we are having newer vaccines for old technology vaccines, which are conventional vaccines. And now, newer technology is also being This platform may come in the future which will bring up its own complexities. MRNA factor as on today we do not have so for today's discussion we are not to bother about MRNA vaccines presently.

[00:06:04]So, what are the inputs we require for evidence practice?

[00:06:08]So, balancing the potential because vaccine may have potential to improve the quality of life of the elderly and to prevent many infections. But at the same time there are the challenges.

[00:06:19]There may be adverse events. They may be having multiple interactions with their other comorbidities and and the senescence and there may be interaction with number of vaccines together. So, these are the challenges.

[00:06:35]And uh We have got vaccine efficacy studies which are done under lab conditions, under clinical trials conditions. So, they may not resemble the actual when you apply the vaccine in the population which may have different genetics because as I said most of the studies are done in the west and we just take it off the shelf which is not actual practice, actual scientific practice.

[00:07:01]So, there may be difference in genetic susceptibility. There may be differences in immunologies. Because all population from their childhood, adulthood and even elders we have got 10 times, 20 times more population density in the west. We may be having already primed. We may be already having natural immunity which we don't know. We require studies and whether we require extra vaccines or not we don't know. So, there is a research gap.

[00:07:29]That is host priming, whether how host are primed and response. So, these are are the gaps in our Indian scenario.

[00:07:39]And how do you measure vaccine sensitivity? It is measured in relative risk. Usually these are the clinical trials.

[00:07:46]It is just simple the number of people vaccinated who get the disease rates in the exposed divided by the rates in the unexposed. Those who are vaccinated you expect them to get higher rates and they are the outcome is measured and nowadays what is happening most of the time they are not waiting for the end results.

[00:08:06]They are going for surrogate measures.

[00:08:08]See antibody response or other response.

[00:08:10]So how much response compared to the unvaccinated the vaccinated generates two times, three times. This is the relative risk.

[00:08:18]Relative to the unvaccinated how many times.

[00:08:22]So this gives a very impressive figure 80% 90%. Naturally the one who is vaccinated will have antibody.

[00:08:29]If we are waiting for end point that trial will have to wait for adequate number of people getting infected in the vaccine and so they mostly go surrogate trials or even for end points the follow up time may be less or we require continuous monitoring. So again that is there is a some sort of compromise in the evidence.

[00:08:52]And other risk other measure which is important for policy public health policy is the attributable risk reduction.

[00:09:01]If you see I will just give the concept.

[00:09:05]Relative risk is under clinical trial conditions. So under ideal conditions so you can So it is three times better, two times better, 90%, one and a half times better. But when you actually apply the vaccine in the population roll out the vaccine population there are many people who get the vaccine and still they get the disease and there are many who have not taken the vaccine they do not get the So this already indicates that vaccine is not a sure shot.

[00:09:37]Some part of the disease some some quantum of the disease may be prevented by vaccine.

[00:09:44]That is called the attributable risk.

[00:09:46]What quantum the vaccine has contributed what proportion the vaccine has contributed compared to the Suppose the person has not taken a vaccine. So, this is a instead of in relative risk you are dividing one by the other. Here you are seeing the difference in the population.

[00:10:05]How many people unvaccinated got it minus how many vaccinated got it. So, this usually comes a very modest.

[00:10:14]And reciprocal of this divide this upside down you get the number needed to treat or number needed to vaccinate.

[00:10:22]We'll give some examples.

[00:10:25]I I will try to make it in a very simple way try to give an example. Suppose uh you have a life jacket that saves you from drowning.

[00:10:36]So, life jacket you test it under in water and other things then you people who are in a boat and there is a very bad weather and the boat capsizes.

[00:10:48]So, life jacket saves lot of lives.

[00:10:51]The same life jacket you distribute in the desert it may not save any lives because the population is not exposed to the rate.

[00:11:00]Similarly with vaccines. So, you give a vaccine it depends what is the base rate of that disease firstly. Then also besides the base rate of the disease it also depends on the host factors.

[00:11:13]Base rate of the disease becomes environment factor the desert and a stormy waters stormy [snorts] sea.

[00:11:18]That is the environment. Then other factors are suppose you are distributing life jacket to people in a boat [clears throat] out of that nine out of 10 90% are very good swimmers. So, even without the life jacket they would have saved themselves.

[00:11:31]So, the attributable risk will come down.

[00:11:34]Attributable to the vaccine. You cannot attribute to So, similarly, if a lot of people have developed natural immunity as I said in developing countries, people are exposed. So, even without the vaccine they would not have got So, these are just the hypothetical thing.

[00:11:49]These are just We have to keep in mind because just to explain how population It's a It requires a lot of thinking through.

[00:11:59]So, this is And the relative risk is also like it is something again another example is that automobiles. They give the fuel efficiency which are under test conditions.

[00:12:11]So, it is very impressive, but once you take out the vehicle So, under driving conditions, traffic congestion, driver skill and all that, the efficiency goes down. Similarly, is the relative risk you see when the vaccine is introduced, they claim 80% 90% then gradually you find 50% 40% That is one factor. Other factor is the particularly you are talking of viruses like influenza virus RNA virus. There is a rapid strain Even though bacteria also pneumococcal there are 90 serotypes, so they may keep changing. So, these changing conditions the zero the self-life of the RCTs also gets limited if the strain changes.

[00:12:52]The vaccine is ineffective. From 90% even the relative risk may come down to 15%.

[00:12:58]So, they are That's why these are the dilemmas and you just give now mostly what happens Most doctors they have to practice defensive medicine. Vaccine is there you have to give tomorrow the person may get the disease and it will attribute that because lack of vaccine was not given, therefore they got the disease. So, nobody is taking chance. But when you are thinking from the research point of view, these are the gaps in knowledge and these are the gaps in data.

[00:13:27]So, calibrating the vaccine to the rapid it's just like chasing a deer in the forest. I'll give you an example of influenza only. How do they do the year strain vaccine they manufacture they keep monitoring the changing serotypes. NIV Pune and then WHO globally. And depending on the prevalent strains, they prepare the vaccine. So, first they have to take the samples from patients influenza-like illness and all that and then they these are the serotype which are these are the strains which are circulating. H1N1, H3N2 or and they make the and the influenza B also. They are Yamagata and Victoria strain. So, then they make the vaccine. But if you see one thing as I was saying if we we are in a crowded high-density population. If the strain is there, by the time the vaccine is manufactured the people might have already got exposed to it. Just hypothetically.

[00:14:24]But in a western country where the population density is much less, elderly are isolated they may it may apply to them. So, we have to think if and by by the time you give the vaccine the strain may change again. So, so this we will show you papers where they found that influenza vaccine millions of people they followed up observational study because observational study as I said RCT has got a limited self-life. One RCT in a particular strain does not next year the strain changes. So, it has got a though they say it is gold standard but under these circumstances when the whole target is moving, the gold standard is also becomes self-life is very less. So, we'll see a paper where they found key very high vaccination coverage increased above 60 years but the hospitalization and deaths from influenza did not come down. So, this is rather disappointing.

[00:15:21]So, effect modifier so these are the effect modifiers.

[00:15:25]See, it is not straightforward. It's something like cricket in the olden days test page, the fast bowler would be very fast on English pitches, Australian pitches. In India, the bowler may not function very well, fast bowler, because we have pitches are meant for spinner.

[00:15:40]Similarly, Western countries, the vaccine may work in our population. And other factors, genetic, priming, and >> [sighs] >> Uh so, this I have already given this example, so we will skip over it. Host factors, how many are good swimmers.

[00:15:56]Vaccine may be a savior, but not a sufficient due to other factors such as host resistant, prior infection, all so.

[00:16:04]And similarly, if the life jacket is very badly manufactured, it does not inflate, it breaks down. So, if a vaccine has got even relative risk is very low, it has [clears throat] and that strain has changed. So, even then, even uh may not function in a stormy water, also. So, these are lot of different factors which interact and which affect.

[00:16:29]So, attributable risk reduction is based on these factors.

[00:16:33]How much can be attributed to the vaccine?

[00:16:37]So, it is very modest.

[00:16:41]So, if the if the disease incidence prevalence is very low, the AR AR will attributable to the vaccine will be very low. So, this example we'll give from some disease.

[00:16:50]And again, as I said, if they all are good swimmers, so life jacket saving is very low.

[00:16:56]Similarly, if all of have developed natural infection, attribute tools to the vaccine would be very low.

[00:17:06]So, this is a one Usually, what happens, the vaccine manufacturers, they give the relative risk. They will not mention attribute. It doesn't look impressive.

[00:17:14]So, I'll just give example of shingles vaccine as the among all the adult vaccines, the shingles vaccine chicken pox after that the post herpetic neurology and all that shingles vaccine is got the highest attributable risk reduction and that is also highest one is attributable risk reduction is only 3.22% but still it is higher than the flu and pneumococcal where it is flu vaccine pneumococcal vaccine the attributable risk reduction to the which can be attributed to the vaccine is just 1 to 2% less than 3% shingles has got the largest you see it is become like more of a faith key vaccine is that it is protecting you it may be protecting individual level it is something like wearing a helmet fast bowler is there he may hit you very bad and you don't want to become like Nari Contractor so you do not take a chance like disease which I got a very high mortality like tetanus at 20-30% you don't take a chance and the old person may be working in the garden handling manure so he is facing the fast bowlers tetanus I take a fast bowler and other diseases which may have many factors may be mild or maybe depending suppose that person is already a couch potato seeing TV only he is sedentary I would like to give him a say pneumococcal influenza vaccine because his risk so you have to I'm just giving some thinking out loud key you have to see the patient his hobby his how much activity is if he's active up and about so as you know pneumonia influenza it is people who are sedentary bedridden they get any elderly but if he's active he's a pneumonia and influenza risk may be less and his tetanus and other may be more he may be an active old man so accordingly so shingles car in shingles if you see the relative risk is 90 to 96%. That is under test conditions.

[00:19:17]Those who are vaccinated, those who have the antibody naturally will get shingles, so that they will say 95% increase in anti- But attributable reduction in practice because many persons suffer from chickenpox.

[00:19:29]Few people get it.

[00:19:31]So, but it it depends on the individual then. Then there is a communication between the doctor and the patient. You have to explain to the patient these are your risk and so I don't want to take So, it is the patient choice and the doctor's after explaining what is that and attributable risk reduction in shingles is 3% and reciprocal to that that is 100 divided by 3.

[00:20:00]1 upon 3 or 100 divided by 3 is 31.

[00:20:04]33.100 divided by 3.22 is 31. That means to prevent one case of shingles, you have to vaccinate 31 people, elderly. 31 elderly will be vaccinated and and out of that only one person will benefit. Only thing is you don't know which one. So, you give it to all. 30 people would not have benefited from the vaccine because they might not have got shingles in either way. I mean, I'm just trying to explain the concept.

[00:20:34]At individual choices are different.

[00:20:36]See, I don't want to take a chance in one in 30 also. I But when you are thinking of say national program, you have to see the cost-benefit study. So, this type of calculation matters. So, I'll just dust it that way.

[00:20:51]So, this is the um burden of risk factors. Then this is a very recent paper, 2026 paper. Just I think last month only it had come.

[00:21:01]And this paper was quoted in the media that there is evidence that influenza vaccine is indicated. So, this is the first step only in evidence. This only gives the burden.

[00:21:13]This is a burden because we don't have any data. So, they did a study, very big study.

[00:21:20]Within 5 years to find out how many elderly got influenza. And the vaccine uptake is also very low. Influenza rate is less than 3%, 2%, 5% in our country, NFHS 5 and 6 data.

[00:21:33]So, they found that so many people have suffered from influenza. And then they They have authors have said this is a This is the authors' conclusion.

[00:21:44]See, large number of cases naturally elderly get influenza, those who are confined to bed. 70% of uh uh respiratory illnesses are due to influenza viruses and S3N2 and other. So, then they They said this findings highlight the burden that influenza associated respiratory illness, older adults.

[00:22:06]These results provide potential evidence. This is not evidence-based medicine. This is the burden. This is the first step in evidence-based medicine. Yes, there is influenza problem.

[00:22:16]And future strategies now second part is whether the vaccine will prevent it.

[00:22:22]Whether the life jacket will prevent It is a not a desert. It's a stormy sea.

[00:22:26]Whether the whatever life jacket we have got, the quality.

[00:22:31]Whether they are adequate quality or it will not function.

[00:22:34]So, unfortunately, studies as I said, because of the changing strains, the influenza vaccine efficacy is very modest. But an elderly because of senescence and other things, the immune response also goes down. So, these are the another study. If you see this, they had seen the efficacy of vaccine after roll out. They have compared it with the increase in uptake.

[00:22:58]If If the vaccine works, as I said, RCT has got a very low self-life, so they did a very large observational study, millions of uh episodes of influenza, the effect of influenza vaccination. This is the intervention. The influenza vaccination has been taken increase uptake of influenza vaccination, and they expect if the vaccine works, they expect the influenza cases, particularly we are interested in hospitalization and deaths, it should come down. Unfortunately, in this study I'm just giving the main parts. They're very long papers. So, in this results, the 170 million episodes and 7.6 million deaths, and 65 was associated with increase in seasonal influenza vaccination. I mean, the vaccination has increased, it should no evidence indicated that vaccination reduced hospitalization or mortality among elderly persons. These estimates were precise enough to rule out So, this paper I I have given the references, you can check. So, it's a very modest here.

[00:24:00]So, you see, one has to be you can then say you are having vaccine hesitancy.

[00:24:05]It's not vaccine hesitancy, these are the facts of life.

[00:24:07]Okay, everybody would like So, this is difference between faith and science. Faith will say take a up color take either below below your tablets below to we should not degenerate to that key take a up a vaccine below your up a below your knee over, but real facts are there, it's very modest.

[00:24:25]But as I said, of course, you have to recommend because everybody have talk with the patient.

[00:24:31]She is overall health, she is risk factors. If he is undergoing major surgery, he is better than it is better not to take chance. Recommend the influenza vaccine, may recommend the pneumococcal also. But for a healthy year, these are the pros and cons.

[00:24:47]So, this is a we come to the paper as I said last month only, they have given a very long and very detailed and a very very well worked out paper. And they have what all I was saying, they have uh uh considered these gaps in information and research in our context.

[00:25:07]So, mainly they have recommended the influenza vaccine, recommendation one the They have and they have recommended influenza vaccine with a condition that they are different strains February and September every year or northern hemisphere there are different vaccines and southern hemisphere India. Actually, India and many countries there India itself is a very large country with a lot of climatic variations. So, all the strains move around in India. So, I according to this appropriate vaccine northern or southern for the influenza season, whatever season. So, it's very difficult to keep up the timing and space and synchronization.

[00:25:48]So, influenza vaccine they have recommended whichever strain is here, but safety is that local side fever and but serious side effect are the Guillain- Barré syndrome, as you know.

[00:26:02]So, this is something which you have to communicate to the patient. So, these are some of the dilemmas.

[00:26:08]Efficacy is, as I said, particularly elderly it goes down.

[00:26:13]This is on elderly only. So, you see above 65 years lower efficacy 35% to 40% is the efficacy. That is they give relative risk, not the attributable risk reduction, which is less than 2% influenza. Single has got the highest population level. Individual level is individual choices with the physician and with the other conditions of the patient.

[00:26:39]So, this is the pneumococcal vaccine.

[00:26:43]No, this is a I think uh medical consultation vaccine annual vaccine influenza vaccine, sorry, not pneumococcal. This is the influenza vaccine inactivated influenza vaccine. The quadrivalent contains four strains, that is H1N1, H3N2, and two influenza B strains.

[00:27:06]That Victoria and Yamagata strain.

[00:27:10]And uh trivalent vaccine contains uh S H1N1, H3N2, and one of the beta strain.

[00:27:19]B influenza.

[00:27:22]So, they say whenever there is a contact, as I said, defensive medicine, you may offer influenza vaccine.

[00:27:29]Now, the second recommendation is a pneumococcal vaccine. Again, this is a challenge. This is a because again, this has got 90 serotypes, and most of them we don't know what are the circulating in our country. And there are two types of pneumococcal vaccine, pneumococcal conjugate vaccine, and pneumococcal polysaccharide vaccine.

[00:27:48]And they have got 23 strains. Usually, maximum is 23 serotypes. As I said, influenza, others like PCV20, they So, they recommend in India PCV13 and PCV20 are available among the polysaccharide vaccines, PCV13 and PCV20. So, naturally, they would recommend 20, which covers more serotypes.

[00:28:16]Uh on the availability.

[00:28:19]So, again, the it is not very encouraging when recent studies, though earlier studies younger adults and others, they say 60%, 56% efficacy in vaccine more recent studies showed decreased vaccine efficacy ranging from 14% to 47%. Again, it depends on the region.

[00:28:41]And again, the different serotypes may be circulating. Because we have given vaccination against 23 serotypes or 20 serotypes. Other serotypes may come up.

[00:28:51]So, 14% we don't know.

[00:28:55]So, probably immunocompromised patients so they may be with age your immunocompromised the senescence all those requires more research. So, anyway as a defensive practice you offer pneumococcal vaccine because it is a major cause of community-acquired pneumonia lobar pneumonia.

[00:29:19]Elderly may mortality is also high.

[00:29:23]>> [clears throat] >> So, pneumococcal vaccine is highly effective. It is again a contradiction. We have seen 14% to 30 depends so but everybody when the vaccine promoters they keep saying highly effective highly effective to we use that word in in advertently safe and effective. But if you see the literature 14% to 45% elderly may effective at so you cannot call it very highly effective. Any efficacy below 50% is less than satisfactory.

[00:29:55]So, anyway as I said it's available you have to give can't take a chance.

[00:30:01]Then the zoster herpes zoster vaccine this is a recently I think 2022 recent vaccine.

[00:30:10]So, this RZV is recombinant zoster vaccine risk for herpes zoster and postherpetic neuralgia is very painful. It's very painful.

[00:30:21]And there are other risk factors for this herpes zoster. Herpes zoster occurs when there is a immune deficiency I say elderly or diabetes or HIV.

[00:30:32]But the this is the paradox the immune immunity suppression may reduce the response to the vaccine also.

[00:30:40]But anyway they recommend as as per their recommendation uh herpes zoster vaccine is recommended for high-risk adults 50 and above. So, with say comorbidities, so probably.

[00:30:53]So, you can take a call. You can read the paper. I have given the reference.

[00:30:58]The latest latest uh journal of the Indian Academy of Geriatrics, latest issue.

[00:31:07]Then this is the Of course, these are conventional vaccines. So, there are Only thing is the tetanus you're comfortable with tetanus because elderly many people work in the garden, they may get injury, they go so And then diphtheria and pertussis. So, that I think we should require more epidemiological whether whether it is occurring, how much it is occurring among the elderly diphtheria or pertussis or among the young people also because grandparents play with the children and all how whether children Children are vaccinated, so they are given routine childhood pertussis and yeah. But of course, another thing is if you give in childhood, there's a age shift to the older in adulthood also. And pertussis can be quite annoying in adults.

[00:31:53]So, again you have to take a year, but I am more comfortable with tetanus, but uh uh efficacy booster doses every 10 years.

[00:32:04]So, this is also recommended and uh TD tetanus and diphtheria. So, actually market forces also come now, but tetanus definitely one cannot take up because that is a very fast bowler.

[00:32:19]You may survive pertussis or diphtheria.

[00:32:21]Of course, diphtheria can also be here, but are there cases? We have to see for the cases. So, they come which we'll see.

[00:32:28]And five is hepatitis B vaccination. Of course, this is also conventional vaccine. These are not And naturally, I think we can take a call on hepatitis B because elderly they require a lot of procedures, not dental procedures, surgical procedures. So, hepatitis B is blood borne. And again, other risk whether they are living with a partner who is hepatitis B positive. They are the family members. And of of course, we can see the see So, hepatitis B is also recommended.

[00:32:56]These are routine vaccines. And if he's a health care worker or in contact but most of the elderly come in contact with health care.

[00:33:05]So, you have to take a call on that.

[00:33:10]And these are some of the vaccines which are H influenza B vaccine which is usually not recommended. But only recommended in special situations as splenectomy or HSCT patients that stem cell transplant recipients hematopoietic stem cell transplant because they are very compromised immunity. So, H in influenza H influenza B H influenza is usually not recommended but only in special cases.

[00:33:43]And similarly, meningococcal vaccine also not recommended but again they say splenectomy patients or HIV or so. These are optional vaccines.

[00:33:55]So, we have come to say influenza pneumococcal vaccine then the shingles vaccine and tetanus diphtheria I would say tetanus and hepatitis B. So, others are optional. Of course, respiratory syncytial RSV virus infections are common which are this vaccine is not available in India. So, we are the dilemma is not there. Once it comes, the dilemma will be there.

[00:34:23]But these are very efficacy is I mean, you know what's happening nowadays there is a very high pressure marketing and doctors don't have time for such studies or even reading the literature.

[00:34:36]So, we require serious researchers to take on the research. These are the gaps. Disease incidence prevalence, we require very good monitoring system.

[00:34:46]Basic model We cannot calculate any of the attributable risk reduction, which is required for public health policy.

[00:34:53]We should have a robust system of disease monitoring in place. Vaccine Like childhood vaccine monitor preventable disease, we have got the system. We should have Without that, if you are launching a program is you are going to a sea without a compass. So, that's what's happening. We are just Whatever vaccines are coming out, we are just recommending.

[00:35:14]Then, we have to capture the adverse events also. This is again a major gap in our country.

[00:35:21]Again, good public health infrastructure, voluntary reporting, digital platform preferably.

[00:35:26]We cannot roll out bullet trains on rickety tracks. That's what we have.

[00:35:30]Very fast vaccines are coming, very new tech But, we are not having the health services infrastructure to report. So, even the doyen of vaccinology, the long-term editor of vaccines, Stanley Plotkin, has co-authored a paper calling for funding post-authorization vaccine safety science. Even he has admitted This is reference number nine. I have given in the list. I have forgotten to write here.

[00:35:53]So, these are the So, these are the conclusion based on cost-effective we have to see individual risk and benefits.

[00:36:03]In the interim, what happens? We are overwhelmed by market forces and keeping up with the zoonoses.

[00:36:09]Whatever is in the West, we give it here.

[00:36:11]Taking our cues from the West and more vaccines are rolled out, whereas our population may be different. Social marketing is likely to outpace serious research. Vaccine hesitancy is I'm very much against this term.

[00:36:24]It is We are trying going for blind faith. That is not science.

[00:36:28]Another very important omission is Indian Academy geriatrics COVID-19 vaccines has not been recommended by Indian Academy Academy of geriatrics.

[00:36:40]That that means we have ignored the zoonoses. Why? Because in USA COVID-19 vaccine is recommended from 6 months of age onwards. And elders to priority they are given on priority.

[00:36:52]COVID-19 So probably there is a tacit understanding that COVID-19 vaccine wasn't very good after all.

[00:37:01]But that is a tacit. They have not This is a very sometimes what is said is not important, what is not said is more important. So here what is not said is the COVID-19 vaccine.

[00:37:13]The efficacy and perhaps adverse events.

[00:37:15]So as I said, we should be careful of the mRNA and other viral vector vaccines. These are gene-based technology. Like we had it in COVID.

[00:37:26]We seen the mRNA. So we should dilemma will increase. Launching of RNA platform will pose more dilemmas. I think that's all and these are the references. So this is a vaccine of nature immunology genetics susceptibility to So these are the epidemiological immune priming. They said we all population may be exposed and they may be primed for natural immunity. We have to do studies. I'm just saying these are the hypothesis.

[00:37:55]therapeutic And this is the reference number six.

[00:38:00]Of course, these are the burden. No, I am just trying to give you the reference.

[00:38:06]meta Uh reference number eight is the latest one.

[00:38:11]That is the Indian Academy of geriatrics which are saying vaccination for older adults in India position statement of Indian Academy of geriatrics journal of Indian Academy of Geriatrics.

[00:38:23]Very recent paper.

[00:38:25]Last month. And the last reference number nine is that what is required is capturing the adverse events.

[00:38:33]So, as you know, the manufacturers, they try to play down the adverse events. So, we should have a very sensitive system, which this is Third author is W. A.

[00:38:42]Plotkin, who edited in that huge book on vaccines and is still editing it in his 90s.

[00:38:47]So, funding post-authorization vaccine safety science. So, this is in New England Journal of Medicine. So, this That's all, I think. So, I have finished. If there are any questions, I am ready to take some.

[00:39:00]>> Thank you so much, sir, for the wonderful talk. We have received a lot of appreciative comments regarding the talk, sir. And yeah, and sir, we haven't received any questions, but we have we have received uh several appreciative comments. So, thank you so so [clears throat] much, sir, for joining with us. With this, we will now conclude with today's session now, sir.

[00:39:21]I'm looking forward to hosting again.

[00:39:23]Thank you so much.

[00:39:24]>> Thank you. Thank you. It's a pleasure.

[00:39:25]Thank you.

[00:39:26]>> Thank you.