The fight against COVID-19 is possibly entering its final stages, with the Prime Minister announcing the kick-off of the vaccination drive from January 16. This announcement precedes a herculean task ahead, in which 300 million Indians will be vaccinated in the first phase of the drive. The first phase caters primarily to healthcare and frontline workers, the elderly, and those with comorbidities.
However, there will be initial hiccups in carrying out this task. The problems in carrying out vaccination on this massive scale are apparent, but not intractable.
One, states should be prepared for adverse events following immunisation (AEFI). Although unlikely, in some cases, untoward medical occurrences can follow vaccination. For instance, in the US, several people have experienced severe allergic reactions — also known as anaphylaxis — after getting a different COVID-19 vaccine. States should immediately address this issue, otherwise this will undermine public confidence in the vaccine. Therefore, a team of specialist doctors should be placed at every vaccination site to deal with AEFI. Also, there can be legal issues of culpability arising out of severe adverse events. These issues yet remain to be addressed, aggravated by the timeline of trials having been compressed.
Two, initially, states should also prioritise vaccinating people with comorbidities and elderly residing in clusters affected most by COVID-19. This can be a more targeted approach in the first phase, especially when the availability of the vaccine will be scarce. Will it make sense to vaccinate individuals in towns and villages where positivity rate is low? Shouldn’t states focus on clusters and localities where the case fatality rate is high or localities with high population densities? A young person in Mumbai, without comorbidities, might be a more eligible beneficiary than someone from the army in Arunachal Pradesh.
Three, those who have been vaccinated can potentially carry the SARS-CoV-2 virus and unwittingly spread the disease to others, especially to their family members who are caregivers. The government might consider vaccinating caregivers and family members residing with frontline workers and the elderly who will be vaccinated. This is along the same lines as the point made above. At a time of shortage, there must be some mechanism for allocation beyond frontline workers — that identification is presently based on age and comorbidities, regardless of place of residence. Universal coverage, in identified geographical areas, might be a better way to proceed and allocate a vaccine in short supply.
Four, as things stand, we do not know whether a vaccine will have uniform efficacy rates and are not yet aware of the efficacy of these vaccines in different populations such as immune-immature infants, children, pregnant women, and immunocompromised individuals and immunosenescent individuals aged greater than or equal to 65 years. Most likely, the same vaccine will have different efficacy rates in diverse populations. Hence, based on the relevant data, our vaccination strategy will also have to change/evolve. As the efficacy data of phase 3 trials of various vaccines are released, they should be included in the public vaccination programme for those who cannot afford the vaccines. The inclusion of multiple vaccines from different manufacturers would enable the government to better negotiate prices with the manufacturers.
Five, there is also a need for involving the private sector in vaccine delivery and administration. This would reduce the burden on public healthcare facilities. Doctors in the private healthcare system can be a great asset in carrying out a vaccine program at such a large scale. Their services can also be used to deal with AEFI.
Six, at the same time, whoever can afford these vaccines should be allowed to buy from the open market. For example, Pfizer has sought permission to import the vaccine for sale and distribution in the country. Fiscal and logistical constraints may not allow India to include Pfizer and Moderna type vaccines in public vaccination programmes immediately. But the private health infrastructure should not be inhibited from creating its distribution. This also has a bearing on the costs of vaccination. There are no grounds for vaccination to be universally free, subsidised by government.
Seven, private sector organisations and PSUs can be allowed to hold vaccination drives for their own employees, relieving some burden from public health authorities. This is being done in the UAE.
Eight, the United Nations has proclaimed December 27 as the International Day of Epidemic Preparedness. India should also prepare itself for fighting with pandemics akin to COVID-19. The nationwide vaccination drive is mostly a decentralised process, where state governments are preparing the list of elderly, people with comorbidities, healthcare and frontline workers. Having a national health ID could have made the task of identifying people with comorbidities much easier. This is probably the right time to push for a national health ID, so that we are better prepared in the future. Nevertheless, data privacy concerns of various stakeholders should be addressed. The personal data should be anonymised before being made available to government agencies. The patient’s consent should be sought at every instance, even when her data is shared with health departments for public health interventions such as vaccination.
This article first appeared in the print edition on January 14, 2021 under the title ‘Getting the vaccine right’. Debroy and Sinha are, respectively, chairman and assistant consultant at the Economic Advisory Council to the Prime Minister.