Why India needs an Universal COVID Vaccination Strategy
By Arunima Rajan
In an interview with Dr. Chandrakant Lahariya, the public health policy expert explains the urgency to provide vaccines free of cost to all citizens.
'None of us will be safe until everyone is safe,’ was rightly uttered by WHO to promote the COVID vaccination drive. The words have been repeated by many world leaders including our Prime Minister.
India began its COVID vaccination drive on Jan 16, 2021, opening it to high-risk population of frontline workers and above 65-year population. On April 1, the government allowed it for above 45-year population. At least 10 states in India had reported a vaccine shortage and many vaccine centres had been reported shut before the country rolled it out for the entire adult population on May 1.
Only the Centre was involved in procuring vaccines from the indigenous makers i.e. Serum Institute of India and Bharat Biotech until May. It was doing so at a cost of INR 150 per dose. This month, it opened up to states governments and the private sector to procure 50 percent of doses. The Centre to procure the other 50 percent of vaccines at the same price. The price of Covishield manufactured by SII is set at INR 300 per dose for states and INR 400 per dose for private sector. Covaxin manufactured by Bharat Biotech can be bought by states for INR 400 and INR 1200 for the private sector. Both Centre and State would provide the procured vaccines for free unlike the private sector.
As of 8 May, MOHFW displayed that 16.7 crore shots had been administered in India since the drive began. It translates to about 11-12 percent of India’s population; as 20 percent of have received two doses and 80 percent have been inoculated with one dose. WHO estimates that to reach herd immunity, 80 percent of its population needs to be vaccinated i.e. one in five Indians. With its current vaccination rate, when can India be safe from COVID?
Arunima Rajan spoke with Delhi-based public policy, vaccines and health systems expert Dr. Chandrakant Lahariya to explore the question. Dr. Lahariya has been at the forefront of India’s policy response to COVID-19 pandemic. He has extensive work and engagement on India’s outbreak, epidemic as well as 2009-10 H1N1 pandemic flu response including involvement in the H1N1 pandemic vaccine deployment plan. Between 2008-11, he advised the Indian Ministry of Health and Family Welfare on new vaccine introduction and routine immunization strengthening and contributed to drafting of India’s national vaccine policy 2011. He is also the co-author of Till We Win: India's Fight Against The COVID-19 Pandemic, published in Dec 2020.
What do you think is the reason for the surge in the number of cases in India?
If we read the history of pandemics, we know that they always come in multiple waves. The influenza pandemic of 1918-20 had four waves; and the second wave was the most significant and devastating. In one year of the COVID- 19 pandemic, we have seen many other countries had two or three waves. In nearly all, there were far higher cases and hospitalization in the second waves compared with the first wave. Therefore, there was no reason to believe that India would not have a second wave. Instead, the only unknowns were when and how big. And a lot can be attributed to this complacency and the messaging of ‘Indian exceptionalism' which sent the message that the pandemic is already over in India.
There are multiple reasons that we are in this situation. We know the virus has mutated at regular intervals, and there are several new strains. We know that India has UK strain, the double mutant and triple mutant strains, based upon the data on genomic sequencing available from the country. We know UK strain has higher transmissibility, and we are not saying the same about Indian strains, but it is just that we have not studied those aspects in detail. There is no reason to think that new Indian strains do not transmit at a higher rate with such a devastating wave unless someone proves it otherwise. We already have heard a lot about the drop in COVID appropriate behaviour and mask-use by people and about confused messaging of political leaders calling for rallies, Kumbh Mela, and letting the festivals happen. All of these contributed.
Is it a positive move to open vaccination for all age groups?
A sine qua non for a successful vaccination programme is the availability of supply, in this case, vaccines. In the past, there have been times when the government had postponed the national polio immunization drive as vaccine supplies were not secured. Therefore, when it was clear that India doesn't have a sufficient COVID-19 vaccine supply, opening to an additional population does not make any sense. Even before the vaccination was opened to 18 to 44 years of age, there were reports of a vaccine shortage. The vaccine requirement shot up three-fold by opening to an additional target population, while the supplies remained essentially unchanged. We know that the vaccine supply is unlikely to change or increase for a few more weeks, maybe months. I believe more time should have been spent on the planning before announcing this decision. It should not be a populist approach but science-based and pragmatic strategy.
Do we have enough supply to meet the new demand?
The current COVID-19 vaccine supply- the combined production of Covishield and Covax- in India is 70 to 80 million doses per month. There was a shortage of supply even when vaccination was not opened for people younger than 45. With the target population going up (by opening for all adults) three-fold, it is anybody's guess that the supply is not sufficient.
We are hearing that the production capacity of SII is expected to go up to 100 million per month and 50 million per month for Bharat Biotech. We can expect around 10 to 20 million shots per month from Sputnik V, making it 170 million shots available each month.
Whereas 200 to 240 million doses a month is required to meet the suggested pragmatic pace of 8 million doses per day. I think it will take a few months and some concerted efforts, before we can achieve it.
Would the opening up of all age groups lead to inequitable distribution?
Far higher demand than supply means a shortage of vaccines for all age groups. When there are limited supply and the government sector has to compete with the private sector to source vaccines, it is a disadvantage for the government and the poor. Also, the differential price for state and union government has resulted in an inequitable availability of vaccines. All of this favours those with paying capacity and put the poor, vulnerable and marginalized at a disadvantage. The only solution is that public goods such as vaccines are provisioned free for citizens, paid through government funding.
What measures are needed to ensure smooth vaccine roll out of COVID-19 vaccine to all above 18?
In my opinion, it will be prudent that the government put the decision to vaccinate citizens of 18 to 44 years of age on hold till supplies are assured and then, open in a phased manner. Till then, a better approach would be to vaccinate the high-risk population in this age group by criterias such as their work and co-morbidities. There could have been many options but opening to everyone 18 years is a little too much to be handled.
Other immediate operational solutions are : increase the gap between two jabs of the Covishield vaccine to 12 weeks. The people who had COVID-19 in the last few months and were tested positive on RT PCR can also delay their vaccination for a few months. Both of these will save some vaccine for those who need them on priority. However, there is no alternative to securing a sustained and assured provision of vaccine supplies.
What are the hurdles for effective vaccine roll out in the country?
India has a well-functioning and matured universal immunization programme. This programme delivers childhood vaccination to 27 million children and 30 million pregnant women through 9 million vaccination sessions every year. India has conducted a large scale national polio immunization programme, year after year and measles and rubella campaigns. Moreover, in the last decade, the programme has matured by strengthening adverse events following the immunization recording and reporting system, training health workers, improving cold chain capacity, and improved communication. So, there is every reason to think that India can do an effective COVID-19 vaccination drive. All it needs, sufficient government financial allocation, a detailed vaccination strategy and assured provision of vaccine supply.
Would compulsory/coercive measures help it? Will it be counterproductive?
The vaccination programmes are and should always be voluntary. There is no role of any mandatory, compulsory or coercive approach in the health programme. Coercive or compulsory vaccination is an idea that should not even be considered; forget about its being counterproductive.
There are reports about a triple mutation strain. What does this mean for India?
The mutations are common in viruses. In SARS CoV2, we know, new strains have been reported from Britain, South Africa and Brazil. From India, double mutant (two mutations in a single strain) and triple mutation (three mutations in single strain) have been reported. However, we need to understand that the number of mutations in a single strain is insignificant, and it could be one, two or three (a single mutation could be more worrying than triple mutation). What matters if a mutation has resulted in increased transmissibility, infectivity or immune escape. We don't know if that is the case for Indian strains. More studies need to be done to understand these aspects of new strains. Both laboratory and clinical studies need to be done whether these mutations in India results in immune escape or increased infectivity and increased pathogenicity, which will help guide policymakers and, if it emerges, to design appropriate interventions. In addition, there is no doubt, India needs to scale up genomic sequencing rapidly.
The price of the COVID vaccine is higher in the private hospitals. Would this have an impact on the vaccination drive?
The limited supply and high price in the private sector mean the rich would have the advantage of getting vaccinated, while they might not be the one who would benefit the most. That is why, in a pandemic, the vaccines should be delivered as a public good— free for people, paid by the government from the pooled fund, for every citizen. We know that, currently, both state governments and private sectors have to compete for the limited supply. Since the private sector will pass on the cost to people, they can afford to buy. The manufacturer also has the advantage of selling to private providers because that would mean higher profit. It risks availability of vaccines for the government, on which the majority of Indian citizens depend. For a health matter, the purchasing capacity of individuals should not determine whether he or she will receive an intervention. The needs of individuals should determine it, and that's why the government should work or intervene in this area.
Should we have universal free COVID vaccination?
Absolutely. That has to be the way. People are already- directly and indirectly- bearing the cost of the pandemic through the hardship, treatment cost, the loss of jobs and employment opportunities. They elect governments for such situations so that they will take care of them. That is why in the pandemic, nearly every country is providing COVID-19 vaccines free of cost. It is illogical that the state and union government have to pay two different prices for vaccine in a country. I also find the argument that all people who can afford it should be paying for the vaccine, as a matter of cross-subsidies, very weak. If anyone is keen to pay for vaccines, let the government create a voluntary fund for the vaccination and let people contribute to that voluntary fund. Use that fund for securing vaccines. However, paying for vaccines should not mean anyone can jump the queue, which is problematic. Many people have spoken, and I have written about in the past: free vaccines for all citizens, paid by the government, procured by the central government. that is the only way to use vaccines till we are in a pandemic.