Vaccine shortage dents India's coronavirus adult immunisation drive

While ramping up COVID-19 vaccination is the most effective way to limit the staggering rate of coronavirus infections and deaths in India, a massive shortage of vaccine doses is hampering the country’s ambitious plan for adult immunisation, being rolled out in trickles today.

On April 28, India opened up registrations for anyone above 18 years of age for the roll out of the nation-wide drive on May 1. However, most states, including capital Delhi, have delayed this third phase of vaccination citing poor stocks. Only six – Maharashtra, Rajasthan, Uttar Pradesh, Chattisgarh, Gujarat and Odisha – out of India’s 36 states and union territories were able to open up limited number of vaccinations for all adults. Since the beginning of the phased vaccination drive on 16 January 2021, over 24.5 million people have registered themselves on India government’s online registration platform.

India's health minister Harsh Vardhan tweeted on April 30 that the government had supplied more than 163 million free vaccine doses to states and union territories. Ten million more doses were still available in central stocks, he said. Till now the central government was procuring all vaccine stocks from vaccine manufacturers and distributing them across the country. In the adult immunisation phase beginning today, manufacturers — primarily the Serum Institute of India and Bharat Biotech — will be able to directly sell 50% of their stocks to state governments and private hospitals.

To make a dent in the progression of the disease, India needs to vaccinate 10 million people a day, according to infectious diseases modeller Gautam Menon, professor of biology and physics at Ashoka University in Sonepat, Haryana.

Public health experts are unanimous that the only way to get to the other side of the pandemic is large scale vaccination. “There is just no other way,” says Polly Roy, a professor of virology in the Department of Infection Biology at the London School of Hygiene and Tropical Medicine.

The immunisation drive will need to be backed by excellent vaccine management strategy, according to Randeep Guleria, Director of the All India Institute of Medical Sciences. “The production of both available vaccines Covishield and Covaxin will be ramped up and we will soon have more players in the field,” he says.

However, Jacob John, a professor of community health at the Christian Medical College (CMC) in Vellore says the government’s decision to open up vaccinations for those above 18 years of age is not evidence-based given that less than 20% of those above 45 years of age have been vaccinated by the second phase. “The primary target for vaccination should be those over 45 years and those living in the dense urban areas,” he says.

At current manufacturing rates, India may have sufficient vaccines for those above 45 years by July or August, John says. “But this was possible only if we did not open the vaccinations just now for those below 45 years of age. Public policies cannot be run by emotions, there has to be equity and an overall efficiency factor while mapping a policy like this.”

Vaccines are a great investment, says virologist Gagandeep Kang, a professor in the Department of Gastrointestinal Sciences at CMC, Vellore. “We should endeavour to get as many vaccines developed and used as possible.” Since this is India’s first ever adult immunization programme, more efforts need to be made to popularise it, especially in rural areas, and open way more number of outlets for vaccinating.

Epidemiologist Lalit Kant, a former Head of Indian council of Medical Research’s (ICMR) Division of Epidemiology and Communicable Diseases agrees. India’s immunization programme is geared primarily to provide childhood vaccinations, he says. “The only adulthood vaccine we gave was tetanus toxoid to pregnant women.”

Thus far, at over 3 million a day India’s vaccination numbers have been impressive, says immunologist Satyajit Rath, a visiting faculty at the Indian Institute of Science Education and Research (IISER), Pune. In terms of number of doses administered (as on 25 April 2021), India ranks third in the world with about 139.2 million doses, behind US (228.6 million doses) and China (224.9 million doses).

“But this bright picture seems to dim when we see doses administered per capita,” Kant says. India’s per capita vaccination is close to 5% compared to 60% in Israel, 46% in UK and 32% in US. “Our large population dilutes the effort,” he says. The current rate of vaccination is too slow to have a meaningful impact in the near future, he says adding that the private sector healthcare infrastructure must get involved in a big way to make a dent.

Being the vaccine manufacturing hub of the world, India has the ability to beef up production for domestic use as compared to many other developed countries, he says.

Dealing with vaccine hesitancy

Vaccine hesitancy among people is often due to mixed messaging and lack of transparency in vaccine approvals or reporting of adverse events, says virologist Shahid Jameel from Ashoka University. Better communication and transparency often helps people believe in the effectiveness of vaccines, he feels.

Kang says tailor-made messages that inform and address the fundamental apprehensions about vaccines could be the key. “With credible information that counters the widespread misinformation, we need to do a lot more to convince people about the advantages of getting vaccinated,” she says.

Rath says community-based sustained engagement providing contextual and nuanced information, is particularly needed in social media platforms, which are “major present day circuits of gossip and rumour amplification.”

Vaccine diplomacy vs domestic needs

Despite meeting 60% of the world vaccine demands, India is struggling to meet domestic needs during one of the worst escalations of the outbreak across the world. Public sentiment is divided around the country’s vaccine diplomacy efforts to supply doses to other needy countries in this hour of crisis.

“We could take the point of view that the vulnerable everywhere, not just in India, are in equal need of vaccines,” Menon says. “More broadly, infectious diseases are the world's problem, not just a problem of individual countries.”

The World Health Organsation recently recognised India’s vaccine altruism as a facilitator of equitable access to COVID-19 vaccines. Though, how long India can shoulder the financial burden of providing free vaccine doses to neighbouring countries is still a question.

Rath sees vaccine diplomacy as an unethical power game in the present scenario. “The global North insists on 'intellectual property rights', opposes waivers (although some small changes are emerging in that stance), and hoards vaccine doses,” he argues. The tug of war around vaccine diplomacy has also hampered the WHO’s Covax initiative, an equitable and ethical approach to global vaccination, he says.