Immunization

Vaccination or developing immunity has gained significant attention during SARS-COVID-19 pandemic. Vaccines are developed to target a specific antigen and prevent a specific disease. This can be included in offense strategy or disease-centric strategy of healthcare systems. Ayurveda emphasizes on building a strong defense system, that can fight with any type of antigen. This shows the patient-centric (purusha) views of healthcare in the ancient system of medicine originated in India. The article describes a comprehensive understanding of concepts of immunization in contemporary systems and ancient practices of strengthening immunity.

Contributors

Section/Chapter/topic	Sharira / Immunization and vaccination in Ayurveda
Authors	Karthik K.P.1, Deole Y.S.2
Reviewers	Rekhi Rachna 3 Basisht G.2,
Editor	Basisht G.2
Affiliations	1 Department of Kaumarabhritya, A.I.I.A. , New Delhi, India 2 Department of Kayachikitsa, G.J. Patel Institute of Ayurvedic Studies and Research, Anand, India 3Pediatrician, Daly City, CA, U.S.A.
Correspondence email	kpkarthik131@gmail.com, carakasamhita@gmail.com
Date of first publication:	January05, 2022
DOI	under process

Immunity, immunization, and vaccination: current understanding

Immunity is the ability of the body to resist pathogens, the failure of which results in diseases. It is basically of two types: innate and acquired. The inborn ability of the body to resist pathogens is called ‘innate immunity’. It is the initial and generalized defense mechanism, hence also known as non-specific immunity. The specific resistance developed by the body in the course of life against specific pathogens is called ‘acquired or specific immunity.

Immunization is the process of preparing the body to fight against pathogens or disease. Two types of immunization exist: passive and active. Passive immunization involves supplementing the body of a non-immune person with antibodies. These antibodies are taken from an immune person. Hence, these do not challenge the immune system of the recipient. On the contrary, active immunization is the process wherein a disease or disease-like condition occurs or is induced in the body. It demands the body itself to produce antibodies.

Passive immunization is of two types: Natural and artificial. Natural passive immunization is acquired from the mother before and after birth. Before birth, maternal antibodies are transferred to the fetus via the placenta (IgG, placental antibody). After birth, antibodies (especially IgA) from the mother are transferred via breastmilk.

In artificial passive immunization, serum containing antibodies for a particular disease is introduced into the body of the non-immune individual. They are usually taken from an immune human or an artificially immunized animal. Artificial passive immunization is mainly used in situations where immediate protection against disease is required, as an acute infection. It is also used as a prophylactic measure to prevent disease. Usually, the immunity provided by passive immunization lasts for a shorter duration.

Active immunization is divided into natural and artificial subtypes. Natural active immunization occurs when an individual encounters the pathogen resulting in a clinical or subclinical infection. In clinical infection, the antigen-antibody reaction leads to evident signs and symptoms. Whereas in subclinical infection, the B-lymphocyte activation leads to minimal signs and symptoms.

The artificial form of active immunization involves injecting dead or live-but-attenuated pathogens into the non-immune individual and making the immune system produce the antibodies. When the pathogens are injected, it is called a vaccine. When the toxic material secreted by the pathogen, weakened by preserving its immunogenicity is injected, it is called a toxoid. The duration of protection that an active immunization varies from disease to disease.

Concept of immunity in Ayurveda

In Ayurveda, the concepts of immunity, vitality, strength, and resilience are known with the terms ‘Bala, Ojas, and Vyadhikshamatva’. Bala means strength or power. Ojas is the essence. Vyadhikshamatva means the ability to pacify diseases. It includes the ability to prevent disease occurrence, too. These terms are often used synonymously, though slight differences exist. Bala is characterized by firm and well-built contour, ability to perform all activities involving body, mind, and speech, and efficiency of the sensory and motor organs (indriya) in performing their duties.[Su.Sa.Sutra Sthana. 15/20]

Types of bala

Three types of bala are enunciated in the Ayurvedic classics. The first is innate component (sahaja bala), which is constant throughout the lifetime for an individual of a particular physical and mental constitution. The second type is determined by time or temporal (kalaja). This oscillates with the age of the individual and the seasons. The third component is acquired (yuktikrita) through one’s diet, lifestyle, and other efforts like rejuvenation therapies. [Cha.Sa.Sutra Sthana 11/36]

Immunization practices in Ayurveda

The ayurvedic medical system follows procedures that aid normal pregnancy, puerperium, and healthy progeny. These procedures start from preconceptional period till the adolescence of the progeny. Some of them are socio-cultural practices with medical importance. The sixteen sacred rites (shodasha samskara) are practiced in India with vernacular variations. They are conception (garbhadhana), ensuring a healthy progeny (pumsavana), hair-parting (simantonayana), birth rites (jatakarma), naming ceremony (namakarana), taking the child outside the home for the first time (nishkramana), giving solid food (annaprashana), shaving head (chudakarana), earlobe-piercing (karnavedhana), sacred-thread initiation ceremony (upanayana), starting to study veda and learning (vedarambha), graduating (samavartana), marriage (vivaha), renouncing the familial responsibilities (vanaprastha), complete renunciation (sanyasa) and death rites (antyeshti). The rites having a significant impact on developing immunity are discussed below.

The procedures can be divided into three parts according to the time of observation.

1. Preconception
2. Gestational period
3. After the birth of baby

Preconception practices

Garbhadhana (conception)

Planning for healthy progeny starts with the improvement in the reproductive health of parents for the normal conception and development of the embryo. These are called ‘preconception practices’.

The male is administered ghee and milk fortified with drugs that are sweet in taste and the female with oil and black gram-based food. [Cha.Sa. Sharira Sthana 8/4] [Su.Sa. Sharira Sthana 2/28] The couple are advised to spare seven days starting from the first day of menstruation. Then involve in coitus for a desirable child up to 12 days. The later the day, the more conducive it becomes for the longevity, health, physical and mental strength, and excellence of the senses of the progeny. Day 13 or further is not encouraged for conception. This indicates the days of conception can influence the health of progeny. Medicinal formulations like Mahakalyanaka ghee and Phala sarpi are advised in this context. These formulations are used in the first trimester and to treat cases of infertility. [Arunadatta on A.H. Sharira Sthana 1/18]

Gestational period

Pumsavana

Pumsavana, literally means practices for a healthy progeny. When applied in the best of places and times, these procedures always bear the desired fruit. After examining the woman who has conceived recently, before the signs of gestation become apparent, (the physician) should administer pumsavana (procedures to beget a healthy offspring) on her.

The practices include the following procedures:

• On the day of Pushya constellation, banyan leaf buds are given orally with curd and two grains of masha (Phaseolus radiatus Linn - black gram) or shweta sarshapa (Sinapis alba).
• Milk processed in the paste of all or each of herbs like Jivaka, Rishabhaka, Apamarga, and Sahachara is administered orally.
• On the day of Pushya constellation, a handful of water with kudyakitaka (a type of insect) or matsyaka (a type of fish) is given orally.
• Curd, milk, or water with the miniature male statuettes made of gold, silver, or iron are given to drink.
• Vapors of rice paste that is being cooked are inhaled, and the drops of water from the same pot have to be self-administered into her nostrils.

These practices need more focused research to validate scientifically.

Preconception dietary and lifestyle regimens of various kinds have been found to have conducive effects on the growth of the fetus. Lipid-based supplementation of micronutrients along with polyunsaturated fatty acids, and minimal amounts of protein and energy along with improved environmental conditions to women planning for conception at least 3 months before conception showed decreases of 44% in stunting, 24% in wasting, and 26% SGA in comparison to the control group in which no preconceptional dietary modification was given. Preconceptional diet predominant in fruits, with minimal fast foods, sugar-sweetened beverages, and glycemic load, has been found to improve fertility and reduce time to pregnancy.

Diet and lifestyle during pregnancy also play a significant role in framing the strength and immunity of the child. This is knowns as prenatal regimen (garbhini paricharya). The diet in each trimester has been designed in synchronization with the fetal developments. The first-trimester diet comprises food items that are sweet in taste, cold in potency, and is predominantly liquid. This ensures proper nutrition and prevents dehydration. The second-trimester diet focuses on the formation and growth of muscles and organs. It is rich in proteins. The third-trimester diet is mostly about dealing with constipation, water retention, and facilitating the process of parturition. This includes mild laxatives and enemas. Epigenetic modifications are changes in gene expression without changes in DNA sequences. They occur due to factors like DNA methylations, histone modifications, and miRNA expression modulation. The presence of excess methyl donors in the maternal diet may lead to an increased risk of allergic airway disease in the offspring, whereas sensitization to certain pathogens reduces the risk. An inappropriately high-fat diet has been identified to be a potential risk factor of fetal non-alcoholic fatty liver disease. The deficiency of polyunsaturated fatty acids was found associated with an increased risk of cardiovascular diseases.

After birth

Jatakarma (Birth rites)

The birth rites involve the administration of honey and ghee, gold, and breastmilk. It marks the first nutritional input as well as the first immunological challenge for the neonate. Prelacteal feeds (food items given before breastfeeding) are not generally recommended nowadays, as they hinder the intake of breastmilk. However, this may deprive the neonate of the nutritional and immunological benefits imparted by traditional practices. Swarna bhasma (calcined powder of gold), honey and ghee, when administered in infants, though not as prelacteal feeds, are found to be safe and have effective immunomodulatory activity.

Honey is a source of multiple plant pollens and is probably one of the first sensitizations of the infant. However, due to the possible presence of Clostridium botulinum spores that leads to infant botulism, honey is not recommended for use before 12 months of age in some regions. Gamma irradiation has been found to make honey sterile (free from spores). However, this honey is not widely available and there are conflicting opinions in this regard. More research is needed on standard pharmacological use of honey and its utility to develop immunity in neonates.

Placing a consecrated water-filled earthen pot just near the head of the neonate was practiced earlier. This was done for the regulation of atmospheric temperature.

Annaprashana (first solid diet)

Weaning is a critical period related to the immune status of a person for a lifetime. The weaning period is characterized by a vigorous immune response of the gut microbiota, perturbations of which lead to several immunological pathologies in adult life, especially colitis, allergy, and cancers. Hence the diet introduced at weaning is pivotal in framing the immunity of the child for the future. Ayurveda sets a time window for starting induction of solid feeds, i.e., six and ten months of age. Of them, fruits are recommended in the sixth month as per the pediatric guideleines in Ayurveda classical texts like Kashyapa Samhita. Solid foods can be started at tenth month. [Ka. Sa. Khila Sthana 12/15] Another landmark that indicates the eligibility for solid foods is the growth of milk teeth.

The diet recommended at weaning is red rice, or navara rice that is six months to one year old, washed and well-cooked along with ghee and salt. Ghee and rice form the primary nutritive component and salt the carrier, which enhances the bioavailability. Currently available evidence recommends complete avoidance of salt in the initial six months (of exclusive breastfeeding). WHO recommends a daily intake of salt less than 5 g/day (less than 2 g/day of Sodium) in adults and in children, necessary reductions based on energy requirements are to be made. Wheat and barley powder can be used according to the ethnic variations. Embelia ribes (vidanga), with fatty substance and salt, are also advised, probably due to its anthelminthic property. For an infant who has had repeated episodes of loose stools, Paspalum scorbiculatum or kodo millet (kodrava) is recommended. In pitta predominant conditions, grapes, honey and ghee are advised. In vata, Citrus medica (matulunga) along with salt is the preparation of choice. These diets shall be introduced at a frequency of once in two or three days according to the region, season, the strength of the child, and the state of his or her digestive capacity (agni). [Ka. Sa. Khila Sthana 12/19-23] The diet should be gradually increased in synchronization with the tapering of breastmilk. This ensures that the health of the infant is not adversely affected by the complementary feeding process. [A. Sa. Uttara Sthana 1/43] Therapeutic supplementation according to the nutritional requirements of the infant shall be selected, for which three examples have been advised:

Table 1: Therapeutic supplementation according to the nutritional requirements of the infant

Weaning dumpling (Modaka)	Therapeutic action
Buchanania latifolia (Priyala) fruit rind, Glycyrrhiza glabra (Madhuka), honey, parched rice, sugar candy	Nourishing (prinana)
Unripe fruit of Aegle marmelos (Bala vilva), Elettaria cardamomum (Ela), sugar candy, and parched rice	Carminative (dipana)
Woodfordia fruticosa (Dhataki) flower, sugar candy, puffed rice soaked in water (tarpana)	Styptic (sangrahi)

Karnavedhana (earlobe piercing)

On the sixth, seventh or eighth month of the year, ideally between mid-November and mid-January (Hemanta rtu), the infant, if healthy, is placed comfortably on the lap of the mother. Then his or her earlobes are pierced at the thinnest spot with the appropriate instrument. This procedure confers the child protection from diseases and is also of ornamental value. [Su. Sa. Sutra Sthana 16/3] Auricular point acupuncture for four weeks has been shown to decrease the interleukins IL-1𝛽, IL-2, IL-6, and calcitonin gene-related peptide [CGRP] and augment IL-4 in a blood sample of low backache patients along with relief in the clinical condition, indicating a correction through the immunological pathways.

Lehana (electuaries)

Lehana denotes both the formulation (medicated electuary) and the process of intake (licking the medicine).

Suvarnaprashana (gold-based electuary)

Suvarna prashana is a common practice in India to improve immunity in children. It is considered to be conducive to intellect, appetite, and immunity/strength. It increases longevity, is auspicious, aphrodisiac, improves luster, and prevents affliction by extrinsic pathogens. One month of practicing suvarnaprashana improves intellect and also protects from diseases. Six months of the same imparts high grasping power and retention of information. A randomized control trial conducted among 119 healthy full-term neonates (with birth weight more than 2.5 kg) showed that ghee and honey, when administered alone or along with gold, or along with gold and Acorus calamus (vacha), showed significant improvement in anthropometric parameters. IgG levels were found to increase in the second group and IgG, IgM, and Globulin levels were increased in the third trial group. The liver and kidney function tests of the infants were within normal range after the intervention indicating their safety in infancy. Recent advances related to the application of gold in immunology is the use of gold nano-particles in preparing antibodies and vaccines against viral, bacterial, and parasitic pathogens. This is probably due to the stimulation of antigen-presenting cells, ensuring controlled antigen release, hence directly influencing humoral and cellular immunity. As shown through animal studies, they reduce the intensity of the symptoms when administered along with virulent pathogens. The safety of swarna bhasma has also been established in vitro, in crystallite size of 28–35 nm which showed no blood cell aggregation, protein adsorption, or cytotoxicity. It also exhibited negligible activation of a complementary system. Swarnaprashana has also exhibited nootropic and anti‑AChE action, making it a possible solution for improving memory in children and management of Alzheimer’s disease. There are varying practices regarding the frequency of administration from daily administration for 28 days to bimonthly, on the Pushya constellation.

Rasayana (rejuvenation therapy)

Rejuvenation therapy is one of the eight branches of Ayurveda, concerned with healthy ageing, increasing longevity, intellect, strength, immunity, and also cure of the diseases that have occurred. Rasayana, when administered in the early or middle years of life, with proper preparatory measures (like prior cleansing of the body, pleasant mind, etc.) bestows the individual with longevity, intellect, memory, youth, luster, sweetness of voice, the strength of body and senses, etc. It is considered to be the most superior way to bring the excellence of bodily tissues, hence bringing about their optimal functioning and enhancing the Bala or immunity. While most of the rasayana are general promoters of health, some are specifically dedicated to providing protection against some diseases. Some are designed to be used in the management of particular diseases.

Tinospora cordifolia (guduchi) is a rasayana drug that has been extensively studied and established for its immunomodulatory activity. It acts primarily on the non-specific immune mechanism, stimulating the same. Besides the immune-boosting activity, it has been studied for antioxidant, adaptogenic, antimicrobial, anti-cancer, anti-anxiety activities, and also the protective effect on liver, heart, bones, etc.

A review on chyawanprasha compiled several clinical studies wherein it was given to healthy as well as ill individuals of multiple age groups. This study inferred that it significantly improved the overall health and immunity, and also had curative effects in multiple conditions, like acute bacterial tonsillitis, infectious mononucleosis, other bacterial infections, chronic depression, pulmonary tuberculosis, etc.

Other traditional immunization practices

Several formulations mentioned specifically in the pediatric population are potential immunomodulators. Rajanyadi churna, when administered along with honey and ghee as adjuvants, improves the strength (bala) and luster of the child. The ingredients of this formulation show an immunomodulating effect.

In the text Arogyakalpadruma (a compendium on Ayurvedic pediatrics, in practice over South India), a group of formulations has been mentioned. These are advised at multiple stages of growth and development. They are called ‘Prakara yoga’ since they protect the body of the child against pathogens like a fortress against enemies. It has been advised from the first month of birth to 12 years of life. Uramarunnu, Janma ghunti, etc. (meaning medicine that is rubbed and the paste thus obtained is administered with suitable adjuvant), are widely in practice over various parts of India. Janma ghunti has been studied in pre-clinical settings for safety and efficacies. It was identified to be antihistaminic and intestinal motility-promoting. In male and female Wistar rats, the No observed adverse effect level of the same was found to be above 12 mL/kg and under these doses, and the formulation did not show any signs of toxicity.

Limitations of these practices

 There are several challenges in implementing these immunization practices in other parts of the world. Availability of natural and safe food products like cow’s milk,  honey is a challenge to implement the practices. The lack of clinical evidence generated in this domain remains the major concern among the medical fraternity as well as the public for administering them in the pediatric age group. The regional variations and contradictions in these practices also pose a challenge to the popularization and standardization of the same. These practices and their effectiveness as health-promoting and immunity-building measures have been extensively studied. However, their role in increasing the disease-specific immunity or their ability to substitute the conventional immunization techniques are yet to be proved.

Relevance of including traditional practices in immunization

The World Health Organization has targeted Universal Health Coverage for all by 2030. The traditional medical systems of each region have evolved to suit the population's ethnicity, regional and climatic conditions. These are of paramount importance in the maintenance of health, clinical presentations, pathological patterns, and choice of therapeutics. In regions like the West-Pacific and some parts of Asia, traditional medical systems have been extensively utilized to implement the Universal Health Coverage. They have been integrated into the national mainstream health system.

Limitations of current immunization programs

The incidence of adverse events following immunization (AEFI) in many of the vaccines approved by the World Health Organization, though marginal, also necessitates safe and effective alternatives for the same. These adverse events are either related to the vaccine product, its quality, the procedure of immunization, or the anxiety related to the same. They vary from local symptoms like pain, swelling, and redness (about 90-95% in BCG, 50% in DTwP vaccine or Diphtheria, Tetanus and whole-cell Pertussis vaccine, 20% in Pneumococcal conjugate, and about 10% in DT – Diphtheria and Tetanus and MMR – Measles, Mumps, Rubella vaccines) to systemic presentations like fever, irritability, and malaise (about 50% in DTwP vaccine, 20% in Pneumococcal conjugate and DT vaccine) among mild adverse events. The incidence of severe adverse events, though rare, is to be subjected to further analyses. They include dissemination of BCG infection following the BCG vaccine that can turn fatal (0.19 – 1.56/1,000,000). Vaccine-associated paralytic poliomyelitis (VAPP) following Oral Polio Vaccine (2 – 4/1,000,000) is observed. Prolonged crying, seizures (< 1/100), hypotonic and hyporesponsive episodes (1-2/1000) following DTwP vaccine are noted. Febrile seizures, thrombocytopenia, and anaphylaxis (with incidences of one per 3000, 30000, and 100000 cases respectively) after measles vaccine are seen. In this scenario, an immunization method that strengthens the host without targeting the pathogen or inducing the presence of the same in the body of the host becomes considerably relevant. The regional variations of the vaccine schedule have not been included here.

The pathogen-specific approach of vaccines limits the focus of disease centric system. The approach shall be shifted to develop a health-centric system.

Future scope of research

The Ayurvedic understanding of immunity and its implications are areas with large potential for research. The variation of immunity among individuals of various physical constitutions or prakriti, and differences in their responses to immunizations can be studied. Studies on the safety and efficacy of various traditional immunomodulatory practices on larger populations are needed. The immunomodulatory interventions in neonates are yet to be explored, especially for their safety and toxicity. Safer and more potent disease-specific immunizations can be developed in Ayurveda, especially considering naimittika rasayana mentioned in each disease. Transdisciplinary research approaches like symbiotic relation of the gut microbiome with the immunomodulatory drugs mentioned in infancy and weaning period are also fields of study that can make a significant contribution to the understanding of Ayurvedic immunomodulation in a modern way.

Research theses done

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3. Sital S Desai (2011) : Effect of Suvarnaamritaprashana in recurrent attacks of kasa, RGUHS, Bangalore.
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5. Vinamra Sharma (2012) : Toxicity study of Suvarna Binduprashana in albino rats, KLE, Belgaum.
6. Anupriya (2013) : Safety and efficacy study of Swarna Prashana drops prepared from Swarna Bhasma and Swarna Lavana (Dept of RSBK), I.P.G.T.&R.A., Jamnagar.
7. Jyothy.KB, (2013) : A Randomized Controlled Clinical Trial on Swarna Prashana in infants w.s.r. to its immunomodulatory activity, I.P.G.T. &R.A., Jamnagar.
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References