Epidemiologist & Health Systems Expert
THREE weeks since India achieved a cumulative 100 crore shots of Covid-19 vaccines, the daily vaccination rate has witnessed a downward trajectory. In the first 10 days of November, the daily vaccination average was 40 lakh shots, the lowest for any 10-day period since July 2021. Only 38% of the eligible adult population has received both shots and an additional 42% just one shot. One-fifth of the adult population, around 18.7 crore, have not received any shot. There are around 12 crore adults who received the first shot and are now eligible, but did not return for their second shot. A silver lining is that India has more vaccine supply than demand and in the second week of November, nearly 13 crore doses were available with the states.
With not even 60% of the target 188 crore vaccine doses administered, there is a long way to go for the Covid-19 vaccination drive in India. However, with the daily new Covid cases coming down to the pre-second wave level in February, vaccine hesitancy (among those yet to be vaccinated) and complacency (among those who should return for the second shot) appear to be the biggest challenges. At this juncture, Covid-19 vaccination drive in India can benefit from expert technical inputs and guidance and a robust operational strategy.
To start with, for a country of the size of India, the achievements in terms of absolute numbers could be misleading. As an example, only half of India’s 60-plus population has received both shots in spite of vaccination for this age-group being opened nine months ago in March 2021. The situation for the 45 to 59 years age-group is also very similar. The vaccination for pregnant women has remained in the range of 15% to 20%. These three population sub-groups are at the highest risk of adverse Covid-19 outcome and would get maximum benefit by the vaccination. Clearly, the vaccine shots are not reaching the priority population groups it should.
There is an urgent need that the Covid-19 vaccination data is analysed by various stratifiers to identify the population sub-groups being missed. The CoWin dashboard and data should be effectively used to identify who and where are the people left behind and targeted strategies need to be implemented to achieve a higher coverage. The pockets with unvaccinated high-risk populations could fuel the next wave and should be prioritised rather than merely focusing upon increasing the overall number of vaccine doses. The drive in states and districts which have low vaccination coverage has to be prioritised. The Covid-19 vaccination data should be linked to clinical conditions and outcomes of beneficiaries to find answers to the epidemiological and programmatic questions of waning immunity and breakthrough infections etc.
Recognising some of these emerging challenges, the government has announced initiatives such as ‘Har Ghar Dastak’ and ‘Vaccination toli’ etc. However, there is a lot from the past efforts such as polio elimination in India. Every round of the polio programme had achieved close to 99% coverage of target beneficiaries, such as effective micro-planning and community mobilisation, and those approaches should be used.
India needs to be prepared for the time ahead, where a decision and planning for Covid-19 vaccination of children as well as on the need for booster dose has to be taken. To facilitate the process, key policy questions in these areas should be identified and the process to generate evidence to answer policy questions initiated. The policy makers and technical experts also need to deliberate upon questions such as whether the available vaccination data is being sufficiently analysed and utilised? Have operational research studies to answer policy questions for the future been initiated? Are Indian states collecting data on the safety of vaccines in pregnant women and lactating mothers and on the vaccine effectiveness over a period? Are studies in progress on the possibility of mix-and-match of Covid-19 vaccines?
The immediate focus has to be on increasing coverage with both shots in the adult population. The time at hand should be used to put institutional mechanisms in place to generate epidemiological data and evidence. The decisions on Covid-19 vaccination of children as well as booster shots should be determined entirely by the scientific evidence and not influenced by external factors such as perceived demand. The Covid-19 vaccination has also brought attention to the role and importance of adult vaccination and the technical expert groups should start deliberating on the future of adult vaccination in India, beyond Covid-19.
There are policies and regulatory issues, which also need calm assessment before the situation turns into crises. The government should take a call on granting (or not) indemnity to foreign-made Covid-19 vaccines and arrive at suitable solutions, else, in the months ahead, Indian manufacturers might be producing the vaccines, which can only be exported and not used in India. The vaccine production and supply in India has stabilised. The Vaccine Maitri can be resumed in an incremental and sustainable manner. With two vaccines from India having WHO Emergency Use Listing, it is an opportunity for the country to show global leadership.
The Covid-19 vaccination drive has reached a vital juncture. It is time to take urgent actions to tackle vaccine hesitancy and complacency, ensure that data is effectively utilised for targeted increase in coverage and technical experts use evidence to develop a roadmap for Covid-19 vaccination in India. The health policy makers in India should also consider commissioning an independent assessment of Covid-19 vaccination drive in the last nine months, to derive learnings for the period ahead.
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