Transparent, Timely and Trustworthy Communication is Essential for Success of Vaccination Programmes: Chandrakant Lahariya.
By Arunima Rajan
Dr Chandrakant Lahariya is a medical doctor and leading public policy, vaccines and health systems, expert. He is the lead author of the recently published book "Till We Win: India's Fight Against The COVID-19 Pandemic". In an exclusive interview with Arunima Rajan, he talks about what India can learn from other nations and what sort of vaccine strategy the country should adopt.
What can India learn from the vaccine strategy of countries like the UK and US?
In responding to COVID-19 pandemic, the local epidemiology is a significant determinant to deploy a suitable combination of strategies. The UK is facing challenges of a high rate of transmission, new strain and overburdened healthcare services. We know that this has happened despite a series of interventions such as circuit breaker lockdown etc. It has often been reported in media that the adherence to the COVID appropriate behaviours (CABs) has remained low. That is the background in which the UK has imposed the new lockdown. UK is also the first country to have initiated SARS CoV-2 vaccination. However, we know that vaccines need to reach a relatively reasonable proportion of the population and sufficient time after completed schedule to be effective. In the fight against COVID-19 pandemic, all the approaches are complementary, and none is alternative to others.
At present, India seems to be in a good situation. The active cases, new cases and deaths are relatively less—something that we had seen in the early stage of the pandemic in India, April May 2020. Yet, we cannot be complacent. We need to be alert and cautious, and people need to keep adhering to CABs and hope vaccination will guide us out of the pandemic.
Do we need to vaccinate 1.35 billion people? Would we have enough doses for the vulnerable population? What sort of strategy should we adopt?
First of all, the word 'inoculation' is widely used while referring to the vaccination, which is not the same. Inoculation was practised for centuries and had been legally banned in many countries, including India after smallpox vaccination started in the early nineteenth century. Inoculation is done with infective agents which can cause the full-fledged disease. Vaccines can never cause full-fledged disease. It may appear a small issue but it is a science communication, which should be accurate and therefore, and the process of administering vaccines should always be referred to as vaccination.
Second, who should be vaccinated first is not as black and white as it is referred to. It depends upon the purpose a country wishes to use the vaccination. If the purpose is to reduce the mortality, then the high-risk population should be vaccinated. If the purpose is to reduce the transmission, then vaccinating healthy working-class adult could be more effective. Of course, we need to protect the frontline, and essential services workers and nearly all countries have rightly prioritised them. In the end, a combination of approaches are likely to be used with some prioritisation. For example, Indonesia has opted for vaccination of healthy adults to reduce the transmission. It is also going to be a dynamic approach.
Third, operational feasibility is an essential part of such campaigns. If we start testing people for antibody and then do the vaccination, considering the cost of antibody testing will be far higher. The mere presence of the antibody without knowing the antibody's protective levels is not helpful. Therefore, I would go for vaccination without testing for prior antibody testing, which will have cost and consume many financial and human resources with limited value addition. Even for those who have developed an infection in the past, since we don't know how long protection lasts, I suggest offering the vaccination.
Fourth, at least at present, the SARS CoV-2 vaccination of 100% of India's population is not a plan. No vaccine is yet approved for under 18 years of age, around two-fifth of the Indian population. They might be considered at a later stage. Similarly, pregnant women— who constitute another 2% of total population—- are not part of the plan. In short, at present, these vaccines are approved for specific population which comprise around 55 to 60% of Indian population. Therefore, there is no question of vaccinating 1.38 billion people in India. Though it may change in coming months and that would happen over a period of two to three years. Moreover, vaccination strategy would be dependent upon many factors which are unknown at present. For example, how long protection last after completed vaccination. If it is not that long, maybe the same population will need to be vaccinated again after a specific time. When pandemic is declared as over (which would happen at a certain point of time), the strategy will differ from what we are doing now. It has to be, and it is going to be a very dynamic and evolving approach.
What will be the role of technology in the vaccine rollout?
Technology is an enabler. Of course, maintaining the paper record is cumbersome and has challenges, and technology gives distinct advantages. However, we should also be mindful that a tool or an application is not a solution in itself. Our online and mobile-based tools are going to be useful if we get our offline basics right. We still need people to enter data and regularly update them. Technology comes with its challenges. Let's not get enamoured that with technology and mobile-based apps, everything will be hunky-dory. Let's use them optimally.
What sort of financing model should India follow?
There have to be two separate approaches, one for the period of pandemic and another, once pandemic is over.
As long as the world is in mid of the pandemic, the cost of vaccination for identified/prioritised population should be covered by the government— union or state. Till we are in the pandemic, the vaccine should be free for all the people, who are prioritized for vaccination. The logic is simple. The SARS CoV2 vaccines are public good. If an individual gets vaccinated, it is likely to reduce transmission to many other people and thus contribute to control of pandemic. If he is protected from serious disease, it will free of the hospital services and reduce the cost on healthcare services. In addition to medical and public health objective, there is a social rationale. People have already suffered due to the pandemic and the indirect cost they have paid in the form of loss of wages; hardship and other costs. Individual protection would help to protect society. That is enough to say that the government should pay.
At some point in time— when there is enough vaccine supply— the individual and corporates may be allowed to purchase and get the vaccine. However, that should not result in people who can afford, jump the queue and get the vaccine out of turn. Else, there is a real risk that people who are not in the priority list but because they can afford to purchase may delay vaccination for those who should get it on a priority basis.
I also think that cost of vaccines for sale in the private market should be well-regulated and should not be many folds of what cost the government is paying. All vaccines, including SARS CoV2 vaccines, are 'public good', and affordability should be ensured through regulation, the way the cost of COVID-19 testing and treatment services were/are being regulated since the early period of the pandemic.
Of course, once pandemic will be over, the approach and financing have to be very different. Then, it could become more of an individual responsibility. However, health workers and essential services worker should continue to get SARS CoV-2 vaccination free of cost.
What sort of communication strategy can fortify public confidence?
In large scale vaccination program, the transparent, timely and trustworthy communication is essential for success. India has long experience of implementing universal immunisation program. There has been a lot of experience generated from various campaigns done in India over some time. These are from polio vaccination campaigns to large scale measles and then measles and rubella (MR) campaigns.
What is essential is that credible communication, science-based information, and trustworthy and credible sources. As and when any rumour spread, the immediate response and fact should be shared. It will be essential to manage Adverse Events following Immunisation (AEFIs) effectively. If we can plan these aspects well and manage effectively from the beginning of the vaccination drive, that will be task half done. Most of these are widely known, and in fact, Ministry of Health and Gamily Welfare in the Government of India has come up with a very comprehensive communication strategy for SARS CoV2 vaccination. All that is needed is effective implementation.
There have been reports about some states offering QR codes as proof of vaccination. What is the ideal way to go about vaccine certification
QR code-based proof of vaccination is impressive. To start with, I need to understand why we need such proof. It may be useful for a handful of people (compared to India's population) for international or even domestic travel and other aspects, for some period. I don't see any value in paper-based proof of vaccination either. Why waste millions of sheets of paper and burden people to keep them safe? In that sense, I would say that a QR code-based documentation is the effective use of technology, as long as we have clarity on how we will use that.
There are already multiple rumours about the efficacy of COVID-19 vaccines. What are the unknowns related to India's vaccination plan? How important is transparency to create trust?
I would put it differently. Of two vaccines licensed in India, we have data on efficacy for one and on safety and immunogenicity for both. Phase III of clinical trials provides the first set of data on efficacy and additional information on the vaccine's safety. They are critical.
There are provisions such as when correlates of protection are known, the vaccines can and have been approved without phase III trial, globally, and in India. Therefore, though the context may vary, this approval of vaccine without phase III data is not something which has never happened.
A few SARS CoV-2 vaccines have been developed on an entirely new platform such as mRNA and Viral vector. Those efficacies were never known in the past and have been approved with phase III trials data only.
Of course, in normal circumstances, no vaccine should be used without data on efficacy. However, can a vaccine on a proven platform such as inactivated virus be approved with safety and immunogenicity data in a mid of pandemic? Essentially, that's what has been done in India, and the jury is still out. We are in the mid of the pandemic, and the regulatory system has some provision of restricted use and early authorisation. This is likely to be debated in weeks and months ahead. Health expert debate is good for science, and it helps in progress in science. Who knows this debate may result in additional criteria for the restricted-use licensing of vaccines, in future? This is the scientific and expert debate which has and will help us prepare for future pandemics and even faster vaccine development and deployment.
There are reports that patients won't be given a choice to select the COVID vaccines. Is it a good move? Will India adopt mix and match vaccine policy?
Availability of vaccine is not enough, and delivery to the targeted beneficiary in an equitable manner is equally essential. And delivery is an operational aspect. When the available quantity is limited, from the operational perspective, it needs to be distributed pragmatically. I am not aware that even the countries with two or three licensed SARS CoV-2 vaccines are offering choices in selecting vaccine.
At present, people would have a difficult choice of vaccine or no vaccine. There would be many people who want vaccines, but they are not on the priority list. Soon, there will be multiple vaccines and choices such as one vaccine which could be free from the government and then another choice of person sourcing in from the private sector and paying for it. It will be an evolving situation, and I am comfortable with the limited choice we have.
I am more thrilled about the power, and potential the vaccine research and development have shown during the pandemic, which essentially leapfrogged the vaccine research by a decade. This much in a normal circumstance would not have been possible even in a decade. This is an area where the pandemic challenge has been converted into an opportunity. That is fabulous, and that is great hope.