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Wednesday, April 14, 2021

The long, hard road of immunisation

Vaccine equity, smooth user experience, understanding prevailing motives and behaviours and bridging the digital divide are all vital in India’s fight against COVID-19.

Written by Rajib Dasgupta |
Updated: March 10, 2021 8:36:11 am
At a vaccination centre in Mumbai (AP)

Beginning January 16, COVID-19 vaccination in India has crossed 20 million with an overall target of vaccinating 250 million people by July. Global COVID-19 vaccine trackers point to the relatively low population level full vaccination coverage in India, 0.28 per cent currently. In the final analysis, that is the crucial factor which will lead to the progress of the pandemic slowing down at national and sub-national levels. Among countries or entities with large populations as well as those with some of the highest incidence and mortality, the coverage in the US, UK, Brazil, France and Italy is respectively 9.35 per cent, 1.68 per cent, 1.27 per cent, 2.86 per cent and 2.74 per cent. Israel leads with a figure of 41.85 per cent.

India’s prioritisation strategy rightly focused on protecting the healthcare and other frontline workers first and hence the seemingly low coverage till this point. The enthusiasm witnessed in the first few days since moving on to the next group of 270 million people — those aged above 60 years as well as those between 45-59 years with co-morbidities — was also marked by some shortcomings in the technology (booking of slots) and vaccine supply. These shall surely be fixed quickly given India’s depth of experience and capacity of the immunisation programme. The vice president, the prime minister, several chief ministers and Union ministers took the vaccine in the first couple of days of this phase to lead the campaign from the front and reinforce vaccine confidence and demand. The minister of state for health and family welfare informed the Rajya Sabha in February that fewer beneficiaries than planned attended inoculation sessions due to transient technical issues in the Co-WIN portal and vaccine hesitancy in the early phases.

What has been the experience so far with the immunisation of health care workers (HCW)? With a target of immunising about 0.3 million HCW on the first day (January 16) across 2,934 sites, 10 million HCW should have received the first dose in about 30 days (mid-February). However, 7 million were vaccinated with the first dose till March 8, with considerable variation across states. This does point to a modicum of vaccine hesitancy in some states and/or within the states, that too among a group who actually have some of the highest risks. The other emerging concern is about two-thirds of HCW turning up for their second dose on the due date (weeks). This may in part be attributed to the WHO’s current position that the vaccines can be more effective when given apart in a 6-12 week window; India’s policy prescribes a 4-6 weeks interval. This calls for rapid appraisals to develop a layered understanding of the prevailing opinions, motivations, behaviours and attitudes of key stakeholders within their organisational and socio-cultural matrix. Equally important shall be the elucidation of the contents of rumours and social media content, including political and socio-cultural factors.

Another sobering aspect is the epidemiological situation in at least half a dozen states that are witnessing a spike in fresh infections. Vaccination is an important pillar in the multi-pronged strategy to the pandemic response. The opening up of the immunisation programme to private providers (with capping of prices) is an important and welcome step, one that had been recommended for some time now by experts and state programme leaderships. There is also a distinct possibility of the vaccines being available in the open market in about a month’s time. If so, this shall be both on account of large amounts of vaccine stocks being available as well as to facilitate quicker uptake of the available vaccines. These will be important steps in boosting the immunisation coverage.

The sustainability of the first wave of enthusiasm shall be contingent upon the user experience in the next few weeks. This shall entail ensuring vaccine supply, fixing technological glitches and responding to cases of Adverse Effects Following Immunisation (AEFI). Else, this momentum may slow down. A critical ingredient of success shall be taking user feedback to improve programme responsiveness and according greater flexibility to state and district level programme managers. These will also need to be backed up with communication messages as well as proactive responses to issues of hesitancy, rumours and misinformation that the social media shall amplify.

Accessing the vaccine depends substantially (though not exclusively, there is a walk-in option) on being able to book an appointment (of up to four persons) on the internet. The vaccination certificate is to be downloaded. In this context, the digital divide is something to reckon with. About 400 million Indians have no access to the internet. The internet density in rural areas, particularly in some regions, is as low as 25 per cent compared to 90 per cent in urban areas. The gender digital divide is also substantial, with far fewer women with access to mobile phones and internet services. Frontline health workers shall have a crucial role to play, particularly for the non-urban beneficiaries.

With substantial vaccine stocks available and nearly all sectors of the economy open now, India may also consider expanding the scope of the definition of frontline workers and prioritising their immunisation. These can justifiably include a wider array of workers such as teachers, shopkeepers, those in the services sector such as bank and postal employees or public transport workers or delivery personnel as well as factory and industry workers. This will help reduce risks to this large working population as well as boost the post-COVID recovery of the economy.

Media reports and visuals of the initial days of March represent an empowered urban middle-class phenomenon. The empowerment is in terms of access to information as well as information technology, and a plethora of public and private providers. It will need quality service deliveries through the next few weeks to promote and expand demand beyond this segment to rural and peri-urban populations. India’s achievements in COVID-19 vaccination are indeed large in terms of absolute numbers being vaccinated but should not bring a false sense of security of achieving herd immunity quickly enough, which is a function of both coverage and vaccine efficacy. India’s depth in vaccine manufacturing capacities and resilience of the immunisation programme — notwithstanding the fact that this is a new adult vaccination campaign — should help in achieving vaccine equity as well.

This article first appeared in the print edition on March 10, 2021 under the title ‘The vaccine prescription’. The writer is chairperson, Centre of Social Medicine and Community Health, JNU

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