India’s success with immunization is an achievement not only for the country but also for the world. India has consistently contributed to the global Sustainable Development Goals (SDGs) by focusing on the immunization of newborns, infants, children, and pregnant women. Under its Universal Immunization Programme (UIP), India provides vaccines against 11 diseases nationally and one disease sub-nationally, targeting close to 2.7 crore newborns and 2.9 crore pregnant women every year.
Vaccination is one of the most cost-effective public health interventions, which saves lives by protecting people, especially children, from dreadful vaccine preventable diseases. Since the discovery of the smallpox vaccine over two centuries ago, vaccines have effectively reduced the burden of diseases such as polio, measles, tetanus, whooping cough, influenza, and lately, Covid-19. A recent study in the medical journal The Lancet estimates that vaccines have prevented up to 3.7 crore deaths in the last 20 years in low- and middle-income countries alone.
Vaccines also have economic and social benefits. A study published in Health Affairs estimated that for every rupee invested in immunization against 10 pathogens in LMICs from 2021-30, the return on investment will be 52 rupees.
India has a long history of successful vaccination with historical accounts of inoculation dating back to the 18th century. After being declared smallpox-free in 1977, India launched the Expanded Programme on Immunization (EPI) in 1978, and introduced the BCG, DPT, and OPV vaccines. Since then, India’s immunization programme has steadily improved in reach and the arsenal of childhood vaccines provided under its umbrella.
Newer vaccines, better infrastructure, and innovative strategies to improve both demand and supply of vaccines have been integral components of programme expansion. Along with a government-driven eradication plan, a multi-faceted communication approach helped the entire population achieve public ownership to be polio-free in 2014.
Since 2014, immunization activities have been intensified with catch-up rounds such as Mission Indradhanush to ensure that full immunization coverage of >90% is achieved and sustained across the country. In 2016, India became the first country in Asia to launch the Rotavirus vaccine under the UIP. And in 2017, the Pneumococcal Conjugate Vaccine (PCV) was introduced and scaled up using Made-in-India vaccines to prevent rotaviral diarrhoea and pneumococcal pneumonia in children.
PCV produced in India costs around Rs 200 per dose, making it affordable and accessible to protect young children from pneumococcal pneumonia in India and other parts of the world. Despite the Covid-19 pandemic, the vaccine was scaled up to all states of the country in 2021. Additionally, the introduction of the pentavalent vaccine in the routine vaccination provides protection against five diseases with no added infrastructure costs and fewer missed doses for individual vaccines.
Data from the National Family Health Surveys (NFHS) provide direct evidence of India’s success: childhood vaccination rates have consistently improved over the last two decades with the proportion of children who are ‘fully vaccinated’ reaching 76% as per the latest 2019-21 survey. As India and the world set themselves up to eliminate measles by achieving a sustained vaccination coverage of 95%, the data from India look promising.
Measles vaccination rates have increased from 59% in 2006 to 88% in 2021. Mass immunization campaigns have prevented tens of thousands of measles deaths in children. India launched an ambitious Measles-Rubella (MR) vaccination drive and vaccinated over 3 crore children in three years. All the diseases prevented, and lives saved also translate into economic and social benefits.
India has achieved remarkable feats with childhood vaccination, and continues to do so with Covid-19 vaccination. India has overcome challenges across time and geography to reach much of its population, ensure last-mile delivery, finance a sustained large-scale operation at the government level, and develop and sustain trust among the people.
During the pandemic, lockdowns led to disruptions in routine immunization services and the closure of health facilities. And while we saw global collaboration to bring out vaccines at an unprecedented speed, we also saw an ‘infodemic-fueled’ vaccine hesitancy in people who previously trusted vaccines.
Sustained vaccination services, along with cultivating continued vaccine trust and basic knowledge of vaccine benefits in the general population, has helped prevent outbreaks of vaccine-preventable diseases such as measles and polio that are being seen in some parts of the world. Use of technology like the Electronic Vaccine Intelligence Network (eVIN) system that digitizes the entire vaccine stock management, their logistics and temperature tracking at all levels of vaccine storage from national to the sub-district, further ensures vaccine availability and vaccine safety.
What accounts for India’s success?
One, since Independence, India has built up its biomedical enterprise including research and development, and manufacturing capacity. A fruitful public-private partnership has helped bolster this development. The indigenously produced Rotavirus and PCV vaccines, and the speed with which India was able to indigenously produce two Covid-19 vaccines, are examples of the return on these investments.
India also built its delivery infrastructure by establishing cold chain systems, and by developing and training a community health cadre of workers who established last-mile services. Today, India is the single largest producer of vaccines in the world, providing quality vaccines at low cost, and helping immunize other LMICs. It is estimated that almost two-thirds of the children in the world receive at least one vaccine manufactured in India.
Two, the infrastructural developments were accompanied by an improvement on the demand side through social and behavioural communication campaigns.
Such campaigns target all segments of the population to generate awareness about vaccine-preventable diseases and build trust and confidence in vaccinations. In our studies with pregnant and breastfeeding women across various states in India, we documented a continued positive attitude towards childhood immunization mostly because of accurate knowledge about vaccines and their benefits, and about vaccine-preventable diseases.
This awareness can be attributed to sustained communication campaigns as part of UIP. India uses various available platforms of communication to convey consistent and accurate information. Community health workers such as ASHAs and Anganwadi workers go door-to-door to provide information and identify the missed-out children and pregnant women for any due dose. They have been a cornerstone of the polio endgame through their role in vaccination and active surveillance.
While national leaders and celebrities spreading messages through mass media has proven to be useful, engagement with local community influencers who are “closer” to people has also tremendously helped build vaccine confidence. As media outlets proliferated, the government incorporated dissemination through new channels such as mobile messaging and social media as part of its evolving communication strategy.
Despite multiple challenges, vaccination is indeed one of India’s public health success stories. As the world aims to bring about improved uptake of, and equity in Covid-19 vaccination, policymakers and public health practitioners can learn from India’s vaccination programmes. Advocacy, capacity building, investment in research and manufacturing, community engagement, mass- and social-media engagement, and social mobilization have helped India reach its current vaccination coverage.
Dr Pinnamaneni is a Research Fellow at the Harvard T H Chan School of Public Health and a physician. Dr Dhawan is a Data Programmer Analyst at Dana Farber Cancer Institute. Prof Viswanath is Lee Kim See Professor of Health Communication at the Harvard T H Chan School of Public Health, and Director of Harvard T H Chan School of Public Health, India Research Center. Their projects focus on translational health communication to influence public health policy and practice. Some of their projects include Project SANCHAR that trains health journalists and civil servants in India, and work with the MoWCD on maternal and child nutritional behaviours.