How will India vaccinate 'sawa sau crore' Bharatiya?
From storage of the Covid vaccine to post-delivery surveillance, how ready are we?
- Total Shares
This Monday, Congress leader Rahul Gandhi posed four questions to Prime Minister Narendra Modi. All questions were on one topic – vaccine distribution. It turns out the topic is currently under study and so no answers came Rahul’s way. What came his way were digs at being clueless about what’s happening in the country because he is holidaying in Goa. Never mind that Goa is in India too and that Goans too would need the vaccine.
The PM must tell the nation:1. Of all the Covid vaccine candidates, which will GOI choose & why?2. Who will get the vaccine first & what will be the distribution strategy?3. Will PMCares fund be used to ensure free vaccination?4. By when will all Indians be vaccinated?— Rahul Gandhi (@RahulGandhi) November 23, 2020
Politics of parties aside, there is a politics of vaccines too. The world came together in its hunt for the vaccine but nations have also wanted to be the first to reach the finishing line. That has been a healthy competition for public health, leading to the fastest making of not one but several vaccines.
It’s the several that pose the first problem for vaccine distribution. There are four frontrunners in India, apart from about 20 other back-runners. Which one will India distribute and why?
Spoilt for choices
There is the AstraZeneca-Oxford vaccine, which Serum Institute of India (SII) would sell in India as Covishield. SII CEO Adar Poonawalla has said about 100 million doses will be made available in India by January 2021.
Then there is Pfizer-BioNTech vaccine. Pfizer estimates say it could have up to 50 million doses of its vaccine candidate available by the end of 2020, and up to 1.3 billion doses by the end of 2021. How many it can provide to India is under discussion.
There is capacity, but there isn't enough capacity to store Covid vaccine. (Photo: Reuters)
Then there is Moderna, which says it can provide a vaccine by next month, and India’s very own Covaxin.
So will it be first come, first serve, or more factors will come into play?
There are several factors because of which we are hearing more about the AstraZeneca-Oxford vaccine than others. Covishield scores above others because Covishield is being developed using a 50-year-old platform. The platform is a chimpanzee adenovirus vector-based antigen, which has been used in clinical trials for other vaccines. On the other hand, what Pfizer and Moderna are using is a messenger RNA (mRNA) platform, a new technology with no approved vaccine before.
Covishield works for India because it can be stored at a temperature of 2-8 degree Celsius. India does not have the cold storage network that other vaccine candidates may require. For instance, the Pfizer vaccine needs a temperature of -60 to -90 degree Celsius. Not just India, but many other countries too do not have cold storages to keep things that cold.
The Moderna vaccine, which is being built using a new technology, can be stored at regular refrigerated temperatures. India has those cold storages but there may not be enough. Cold storages can’t spring up overnight. The ones that exist are already filled with what they were built to store.
The same is the case with Russia’s Sputnik vaccine, which is under trial in India. It needs to be stored at -18 degree Celsius in the liquid form and 2-8 degree Celsius in the freeze-dried form.
There is capacity, but there isn’t enough capacity to store it.
Vaccines aren’t just to be stored in cold storages. They have to be administered to people. Each vial will move in the supply chain and the temperature conditions have to be maintained during the movement. If people have to travel long distances to get vaccinated, there are chances they will avoid both the travel and the vaccine. Earlier vaccination drives have shown people having to be convinced to take vaccines since they show resistance to self-convincing. So, the vaccine has to be taken to people and not people to the vaccine.
You, me or her?
Then there is the crucial question of who gets its first? This is the government’s preferred question at the moment because it knows the answer well – healthcare professionals, frontline workers, senior citizens, special category people, in that order.
A list of one crore healthcare and frontline workers, we are told, is ready. India, however, is a country of 130 crore and counting. If one has 10 vials to distribute and 100 healthcare workers, how does one decide who gets it first?
The special category people that the government wants to reach out to with the vaccine are an undefined category. Not to forget each person considers she is special. There is no database on people with co-morbidities and which morbidity is more morbid than the other.
There is no database on people with co-morbidities and which morbidity is more morbid than the other. (Photo: Reuters)
And what happens when we reach the healthy individuals? Most vaccination programmes worldwide have inadvertently followed a distribution system prioritising wealth and access. If you have the money, and more importantly, if you know someone who knows someone who can get you the vaccine, you can get the immunity earlier.
India, remember, has no adult vaccination programme. The only adults covered under some sort of vaccination are pregnant women. There is a child vaccination programme. Less than 20 crore children have been vaccinated against polio in 25 years. While that was enough to break the chain of transmission, the same may not happen in the case of coronavirus. The task ahead is to vaccinate ‘sawa sau crore’ Bharatiya, rising by the second, in as little time as possible.
Supposing, there are enough doses of vaccine and no storage hurdles and a clear list of who gets the vaccine when. Also, supposing, the list is miraculously undisputed. The question now is who pays for it?
Even if the vaccine were to cost, say, Rs 1,000 for two doses, as Adar Poonawalla seems to have indicated, not everyone in India can afford that amount. Poor people with large families won’t be able to pay, while people in Bihar, if the election promises were to hold, do not need to pay. Will rates and vaccine subsidies then be fixed by state governments?
Will the Centre opt for an LPG-distribution kind of subsidy, where giving up your subsidy will be an option, or will it be a PDS-style distribution, where who gets it free depends on who cannot pay for it? What if those asked to pay for it do not want to do so; will the government be able to make vaccination compulsory in that situation? Anthony Fauci, the United States' top infectious diseases official, had in August said vaccination against Covid won’t be compulsory. But we are in India and even in the US, the administration has since changed.
Now suppose it has all worked out and everyone has been vaccinated without anyone showing any vaccine hesitancy and government systems working beyond expectations. How will the post-delivery surveillance work?
The Covid vaccine will be the fastest to make it to the shelf. It will thus be several times more important to monitor those who get it.
In April 1955, over two lakh children in five US states received a polio vaccine. Within days came reports of paralysis in 40,000 children and 10 deaths. Subsequent studies proved the process of inactivating the live virus proved to be defective in the vaccine. A modified vaccine, continued to paralyse its recipients every year through the 1980s and 1990s.
Even if such an eventuality is ruled out, which we can do at our own peril, human bodies do react in varying ways when they receive vaccines. These reactions may vary from mild fevers to severe allergies. The speed at which India vaccinates will have to match the speed at which the surveillance network grows.
You can’t leave a population having inoculated it with pathogens, dead or alive, and then realising you do not have the infrastructure to go back and check on them.
No government was prepared for the pandemic. But all governments must be prepared to work out these modalities. There can be no shying away from questions therefore.