Once a Covid-19 vaccine becomes available in India, how does the government go about immunising the population? Which groups should get the vaccine first, and who should get it free? In an interview to Prabha Raghavan, India’s leading public health expert, Prof K Srinath Reddy, weighs in.
Why is it important to get vaccinated against Covid-19?
If a safe and effective vaccine becomes available, after convincing clinical trials and judicious regulatory approvals, it is best to get vaccinated. Covid-19 is a highly infectious virus which causes varied clinical manifestations with a wide range of severity. It has not been easy to predict who can be safe from it. Even young persons have been known to have become severely ill or die, though not as often as the elderly. The level of viral load a person is exposed to, the innate immunity status or pre-existing health conditions may be factors which influence this severity. Because of this unpredictable nature, everyone should feel vulnerable and seek protection.
A natural infection can provide differing levels of immunity, based on the variable viral load different persons are exposed to. We do not know how long such immunity lasts in each person. A vaccine administers a standardised dose that elicits a good immune response which is likely to last longer than a natural infection of variable viral exposure and clinical severity. For that reason, getting immunised is a good idea. Further, other countries may not allow an non-immunised person to travel there if the virus is still actively circulating. Employers may not permit non-immunised workers entry to a worksite.
The Exper Professor K Srinath Reddy is president of the public-private initiative Public Health Foundation of India. Specialising in cardiology and epidemiology, he has held positions in several institutions, including as former Head of the Department of Cardiology at AIIMS and currently as Adjunct Professor of Epidemiology at Harvard. Winner of several awards including the Padma Bhushan, he is the author of Make Health in India: Reaching A Billion Plus.
Which groups should get the Covid-19 vaccine first?
The two main criteria for selection of the initial groups to be offered the vaccine are essentiality and vulnerability. These criteria overlap in some groups. For example, healthcare providers who test, trace, treat or counsel persons infected with the Covid-19 are both essential service providers and also very vulnerable to becoming infected due to their repetitive exposure to high viral loads. They will be the top priority everywhere. Other essential services include sanitation, security, transport and those involved in the production of essential goods and supplies.
Applying the vulnerability criterion, elderly persons and people with known comorbidities which enhance the risk of severe illness or death are a high priority. The coexisting health disorders which increase such risk include high blood pressure, heart disease, diabetes, obesity, chronic lung disease, malnutrition or any condition in which body’s immunity has been reduced by disease or drugs. The problem in identifying this group is that several persons who have these conditions may be unaware of them, because the weak health services in urban slums, small towns or villages have not screened or tested them. In such cases, it is best to apply the age criterion as a probability predictor and move steadily down decade by decade from the 60+ age group to the 20+ age group.
Young persons constitute an interesting challenge. They are essential for current economic activity or need to pursue education which is an investment for future economic revival and growth. They are highly exposed to the virus because of their higher mobility and socialising. While they are at a low risk of severe infection, they can infect others, especially the elderly members of the family. Are they an early priority for immunisation or a later priority? Opinions are divided on that. It depends also on the amount of vaccine available. If only limited quantities are available initially, the older age groups will take priority and the demographic bulge of young persons will need to wait.
How prepared is India to carry out a mass vaccination campaign?
This depends on the vaccine(s) available. I am assuming we will be able to choose from a set of safe and effective vaccines which do not have stringent cold chain requirements of severe sub-zero temperatures for storage and transport. Some of the successful vaccines will probably need to be stored at only 2–8°C or even stay well at room temperatures. If we can access those, our supply chain logistics will not pose problems in the initial stages when clearly demarcated groups of essential workers and the elderly will be immunised.
By the time our supply chain expands to cover the general population, we would have gained experience and would be able to handle the higher numbers that come later, with greater efficiency.
The main challenge will be the actual administration of the vaccine, as an intramuscular injection in two doses set 3-4 weeks apart. Those who are at present authorised to administer such injections are doctors, nurses and auxiliary nurse midwives. Due to our past neglect, their numbers are inadequate in many parts of the country. Those who are available will also be busy providing other health services, including care of Covid-19 infected persons. Even if we use the general election personnel for assembling, identifying and regulating the flow of people to be vaccinated, who will actually give the injection and monitor side effects? Will medical, dental and nursing students be pressed into service, after short training? Can we also train other groups of vaccinators, through training administered to young science graduates? Will existing regulatory restraints be relaxed to permit these new groups of vaccinators? These are questions that central and state programme managers must consider.
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What should be the geographic strategy for a vaccination programme of this scale?
I do not think going state by state would be right, for both public health and political reasons.
There are essential workers and vulnerable people everywhere. It is better to start with the cities where the crowd density is higher, co-morbidity levels are more, risk aggravating factors like air pollution are severe and health services are stronger. The experience gathered there will be helpful as the immunisation programme moves towards small towns and rural areas.
However, if there are hotspots of rapidly increasing cases in any part of the country, urgent immunisation of susceptible persons there should be undertaken.
Who should get the Covid-19 vaccine for free?
I believe all persons should receive the vaccine free. Protecting people from this rapidly spreading infectious disease is the prime example of what economists call a ‘public good’.
If a person does not get vaccinated because it is unaffordable and gets infected, other susceptible persons can be infected by this person even as they await their turn to get immunised. Whether it is the government or employers paying for it, access to the vaccine should not carry a cost to any individual. Since the private sector healthcare providers too will get involved in delivering the vaccine at some stage, to supplement government agencies, financial mechanisms need to be worked out to ensure that individuals are not subjected to out of pocket expenses.
How many phases of vaccination may be required?
However other people may wish to number the waves of the pandemic or phases of the immunisation, I see the immunisation drive passing through key transitions as it evolves.
Initially, the supply to our health system will be limited as the production of any vaccine will be inundated by global demand. That is also the time when we will be applying the essentiality criterion and beginning the learning curve of our vaccine delivery system. The numbers vaccinated will be relatively small and the effort easy as the persons to be immunised are already known and listed.
That will move later to a phase where the vaccine supply will be larger, both due to more vaccines getting regulatory approvals and production volumes expanding for the initial vaccines through outsourced manufacture. The domestic demand for vaccines will also grow as vaccine confidence builds up, if the initial global and country experience demonstrates safety. At this time, vulnerability will become an important criterion for prioritisation but general public too can be covered alongside, age group by age group. The health system too would be moving in full strength to deliver the vaccine, with the existing health workforce supplemented by trained auxiliaries. However, listing and sequencing the persons in the general population will be a challenging exercise.
Further on, we will transit to a steady state when a sizeable proportion of the population has been immunised and the task of immunising the rest becomes a part of the health system’s routine immunisation programme. The capacity for a surge response will need to be kept as a planned reserve even at this stage but both supply side and demand side pressures would have eased.
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What do we still not know about the way the government is preparing to vaccinate the population?
I am basing my response on the information available in the public domain. It is possible that detailed plans have been made which the government has not yet made public.
We do not yet know which vaccine we will begin with. We also do not know what assurances are there for getting the stocks from the manufacturers early on. Have any advance purchase commitments been made? If multiple vaccines become available, what will be the guiding criteria for choice? If multiple vaccines are procured, how will they be distributed across states? Apart from the announcement that health workers, other essential service providers and persons with co-morbidities will be prioritised, the plan for the roll out in the general population has not been revealed. The procurement will be coordinated by the central government. How will the demand of each state be accommodated, at different phases of the rollout? At any stage, can states directly purchase from the manufacturers? If so, will the centre provide quality and cost guidelines to maximally ensure uniformity?
Do some sections of the population have to pay? If so, what would the price be? There is no information on the proposed role of private healthcare providers, pharmacies and employers in the organised sector in the vaccination programme. How will they support the government programme?
How long, realistically, will it take for life to get back to normal?
It depends how the virus behaves over the next year, how early an immunisation programme can begin and how extensively it can cover the country in the months to follow. Will the virus become less or more infectious? We do not know. Will a vaccine pass all regulatory checks to arrive soon? It appears possible but we still need to see the final trial data.
Until much of next year, we will need to diligently observe public health advisories on masks, physical distancing, hand washing and avoiding super spreader events. The advent of summer may give us some respite but not full release.
So, if 2020 has been the year of despair and depression, 2021 has to be the year of discipline and determination to subdue the virus with all the tools we are gathering or making now.x