India’s National Vaccination Day: Prickly questions that still confront the vaccine hub of the world

Today, 16 March, is National Vaccination day, which some have traditionally also referred to as the national immunisation day. In a world ravaged by COVID-19 with all hopes hinged on the deliverance with a jab, there is a reason for India and especially its half dozen vaccine companies to take comfort. After all, their response with COVID-19 vaccines is getting them global goodwill like never before. A recent article in The Economist on Serum Institute of India sees it as a company that may be well on its way to account for almost half of the world’s supply of COVID-19 vaccines. Biological E, the other Indian vaccine company based out of Hyderabad for the past 68 years, got a specific mention in the recent QUAD initiative where four countries US, Japan, Australia and India are to partner to ramp up COVID-19 vaccine supplies to the Indo-Pacific region. It talked of a plan to support Biological E’s effort to produce at least 1 billion doses of COVID-19 vaccines by the end of 2022. The hype and colour around vaccine diplomacy along with the image-building for India and the bid to contain China’s influence in the Indo-Pacific and East Asian region are the apparent hard-to-ignore positives for India. But then, the questions that experts are asking is around the rollout within the country and what can be done about ramping this up. The concerns are not just around ways to hasten up the process of vaccination but also on what is being done to build the long-term research capability on vaccines, something that a country like China is aggressively doing. India can hardly afford not to build on its strengths in this space.

India as a vaccine powerhouse for routine immunisation vaccines is well known. To those who were still oblivious to this, prime minister Narendra Modi left no stone unturned to send out a major reminder. Launching the COVID-19 vaccination drive in India on 16 January, he underlined how “all over the world 60 per cent children get made-in-India life-saving vaccines.”

Yet, look around and talk to healthcare professionals and subject experts and prickly questions continue to confront India on both the COVID-19 vaccination and on the child immunisation programme.

On the COVID-19 vaccination, the question uppermost is how is India going to speed up the pace of vaccinations because at the current pace, it is likely to take too long before all can be vaccinated? How does India intend to deal with the apparent vaccine hesitancy? How well equipped are the hospitals and the staff and their preparedness to handle the demands of a huge nationwide rollout for the general population? Also, how robust is the CoWIN vaccination registration app and the other digital scaffolding to the vaccination drive for the general population vaccine rollout?

On the non-COVID vaccines – that is the routine immunisation programme of the country, the key question is how is the lost ground during the last year’s lockdown months and the physical contact hesitancy that followed apart from the diversion of healthcare staff to COVID care, which in all impacted the child immunisation programme, is now to be covered. As some of the experts who have looked at the data point out to the tough task ahead though the government has responded and in February launched the “intensified mission Indradhanush 3.0 with a clear focus on children and pregnant women who have missed their vaccine doses during the COVID-19 pandemic though the exact number on the cases missed out is still not clear.

Those in the know of the data and its reporting point out that the second phase data from the National Family Health Survey (NFHS-5) in states that is now underway following the COVID-19 related disruptions is in all likelihood expected to provide a contrast to the coverage figures from the first set of 22 states where the survey was undertaken in the pre-COVID phase (and the fact sheets published a few months ago).

Beyond The Special Groups

On COVID-19 there is the challenge of vaccine hesitancy that still needs to be dealt with. Dr Gagandeep Kang, a highly regarded medical scientist and professor at the Christian Medical College, Vellore, says “in terms of COVID, we have done well in manufacturing” though she feels more could be done on communication and convincing people to get vaccinated and that one would normally expect that in the coverage of special groups there should generally be a good response and apparently there is some distance to be covered here too and once the vaccination drive reaches the general population, it may be possible to then say on how the programme has been faring. “It is important to focus all energies on reaching out much more effectively to the target audience. We are still at a stage where we are immunising special groups. Once, we reach out to inoculating the general population, we will be able to say how well or badly it is all working,” says Dr Kang, who is also on the board of the Coalition for Epidemic Preparedness Innovations (CEPI), a leading global medical charity.

In terms of COVID-19 vaccine, by mid-March, India has been able to innoculate 2.9 crore people – a little over 2 per cent of the entire population or about 3 per cent of the 70 per cent population, normally required for herd immunity to kick in. Various estimates have been doing the rounds in media on how at this rate, it will be an arduous task to vaccinate all at the earliest.

Sustaining The Scale-up

Dr Soumya Swaminathan, the chief scientist at the World Health Organisation and a veteran medical professional who in her earlier role was leading the Indian Council of Medical Research (ICMR), lauds the way India has unfolded its ambitious vaccination drive says, “India has done really well right from development of vaccines for COVID in addition to all the other childhood vaccines that it produces and now rolling out a massive vaccination programme in a well-planned manner involving both public and private sector. This step-by-step scaling up needs to continue and address any remaining hesitancy that may be still present.”

Back To Routine

The concern on routine immunisation is really around the pace at which it can be brought back to the earlier levels. Though the ‘intensified mission Indradhanush 3.0” is aimed at regaining the lost ground and reach out to those that have been missed.

Rough estimates indicate the lost ground is about 30 to 40 per cent of missed vaccinations and therefore 60 to 70 per cent coverage as compared to 90 per cent coverage every year with most states nearly getting close to it.

Ravi Duggal, an independent researcher who has been studying health care spending by various states in India, tracking health sector and the budgets, says looking at the National Health Mission (NHM)’s Health Management Information System (HMIS) data, “which is published regularly each quarter but this time available for the first quarter report (April-June 2020) shows that the COVID crisis and the lockdown did have an adverse impact on various routine public health services and exposed the vulnerability of the primary healthcare system.” For instance, he says, “in case of routine immunization we saw a drop of 20 to 30 per cent across India for various vaccines when we compare the first quarter of fiscal 2019-20 and 2020-21. Full immunization of children 9-11 months dropped from 58.15 lakhs in April-June 2019 to 43.02 lakhs in April-June 2020 (-21 per cent). Even BCG vaccines for infants slipped from 53.68 lakhs to 43.02 lakhs (-20 per cent), Measles and MR from 58.89 lakhs to 47.27 lakhs (-20 per cent) and Polio OPV3 from 57.39 lakhs to 39.68 lakhs (-31 per cent).”

The Input Challenge

There is now a new worry looming on the horizon and putting a question mark on the way ahead on the vaccine supply pipeline. Some of the vaccine makers have now been talking of constraints expressed by suppliers. This is for inputs required for making vaccines such as filtration assembly, single-use fermenters, filters and others, which find applications in both COVID and non-COVID vaccine-making. All of it, likely to impact in future if the export curbs on account of the Defense Production Act invoked by the US government to boost supplies of these inputs to their local vaccine makers is sustained over a long period. It could not just impact the vaccine-makers outside the US, not just for COVID but also for routine immunisation. How this will pan out, is yet another unknown.

Timeframe Matters

Keshav Desiraju, the former health secretary of India and one who has looked at developments in the Indian health sector closely over the years, feels that while the government and private machinery in terms of hospitals, at least in select regions like say in Chennai, Mumbai or Bengaluru and elsewhere need to be applauded for “doing a good job in the COVID vaccine drive, what is important now is to get a clear picture on-time schedule and the number of people to be vaccinated and the resources committed to achieve that.” Similarly, on the routine immunisation, he feels, we still need to know how much has been made up in term of the ground lost last year in child immunisation and if all the babies born now are getting the full coverage they need and are back on the regular roster?

Important questions that need early answers for the pandemic has shown, the setbacks can be quite costly famously articulated by Bill Gates in the context of the vaccine coverage globally: “we’ve been set back about 25 years in about 25 weeks (of lockdown).”

THE COVERAGE CONCERNS

Universal Immunization Programme (UIP) is one of the largest public health programmes targeting close to 2.67 crore newborns and 2.9 crore pregnant women annually.

Under UIP, immunization is providing free of cost against 12 vaccine-preventable diseases:

Nationally against 9 diseases – Diphtheria, Pertussis, Tetanus, Polio, Measles, Rubella, a severe form of Childhood Tuberculosis, Hepatitis B and Meningitis & Pneumonia caused by Hemophilus Influenza type B.

Sub-nationally against 3 diseases – Rotavirus diarrhoea, Pneumococcal Pneumonia and Japanese Encephalitis; of which Rotavirus vaccine and Pneumococcal Conjugate vaccine are in process of expansion while JE vaccine is provided only in endemic districts.

Rough estimates indicate the lost ground is about 30 to 40 per cent of missed vaccinations and therefore 60 to 70 per cent coverage as compared to 90 per cent every year with most states nearly close to it though it could be lower too as it is expected to pick up with Indradhanush 3.0.

The new challenge to routine immunisation is also likely from the focus now again on the national rollout of the COVID-19 vaccination which may put added pressure on healthcare staff and cadre.