India’s vaccine saga continues with COVID-19 providing an opportunity to boost vaccine literacy

India’s efforts at vaccines since ancient times have served as the foundation for its modern vaccination strategies and as a framework of global vaccination concepts. The public health sensitisation achieved by COVID-19 can help galvanise a broader understanding of vaccination.

Published : Jan 23, 2021 06:00 IST

The cGMP facility with BCG vaccines being flagged off at the BCG Vaccine Laboratory at Guindy in Chennai on July 31, 2020. The laboratory planned to supply 170 lakh doses between July 2020 and March 2021. BCG was introduced in 1962 to combat tuberculosis. Photo: B. Jothi Ramalingam / The Hindu

The cGMP facility with BCG vaccines being flagged off at the BCG Vaccine Laboratory at Guindy in Chennai on July 31, 2020. The laboratory planned to supply 170 lakh doses between July 2020 and March 2021. BCG was introduced in 1962 to combat tuberculosis. Photo: B. Jothi Ramalingam / The Hindu

Medical science in ancient India and China were relatively developed and highly organised. The history of India’s foray into Western medicine and, therefore, to vaccination, and the subsequent emergence of vaccine hesitancy are intertwined with British colonial rule. The British recognised the soft diplomacy and economic returns of smallpox vaccination in British India soon after its introduction in Britain. As the historian Niels Brimnes puts it, vaccines were the “sympathising heart and the healing hand” of the British, as well as embodying the “advances” and “advantages” of European civilisation. In this article, we present a brief overview of the vaccination saga in India from ancient India through the colonial era and post-Independence that served both as the foundation for modern India’s vaccination strategies and a framework of the global vaccination concepts as we know it today.

From proof of concept to a product

In 1802, a three-year-old girl became the first person to receive a vaccine—the smallpox vaccine—in India under British rule. Vaccination evolved to become a massive undertaking in India, with the polio vaccine reaching 127 million children on a single day in 1997 and 134 million children on a single day the following year. Today, in terms of volume, India’s vaccination efforts will dwarf those of any other nation.

Also read: Race for COVID immunity

The word vaccine derives from the cowpox virus, vaccinia. The term was introduced following Edward Jenner’s work, An Inquiry into the Causes and Effects of Variolae Vaccinae, in 1798. However, the conceptual basis of vaccination was chronicled by Thucydides in 430 B.C. and Abu Bakr (also known as Rhazes) in A.D. 910, who recognised that people affected by smallpox were protected. One of the best recorded smallpox epidemics was reported from Goa in A.D. 1545 , when an estimated 8,000 children died, prompting historians to refer to smallpox as the Indian plague. It is possible that such pandemic challenges helped scholars of ancient India practice the concept of variolisation.

Variolisation is an ancient proof of concept for vaccination. The obsolete process was in practice in the countries of the east before the modern concept of vaccination, in which a susceptible person is inoculated with material taken from a vesicle of a person who has smallpox, was adopted. A person may die of the disease or survive it after variolisation. In vaccination, the risk of death and severe disease is avoided through minimising the dose of exposure to the virus (often through inactivation or selecting parts of a virus), systematic research to assess adverse events, and also through improvements in the method of exposing a person to harmful viruses (injection of purified products as opposed to pus from sick persons).

Anecdotal evidence indicates that smallpox inoculation (variolisation) was practised in China in around A.D. 1000 and in India, Turkey and, probably, Africa as well. Inoculation with smallpox virus material preceded smallpox vaccination and was one of the accepted approaches to protection from the disease. Evidence to the fact that inoculation was widely practised in India is found in a detailed description given by Dr J.Z. Holwell in 1767 to the President and other members of the Royal College of Physicians in London. The inoculation practice has been documented from different parts of India, especially in Bengal and Bombay presidencies. Even a ban by the Bengal Presidency in 1804 had a limited effect on the practice. However, there is a limited record of how many people were annually inoculated using variolisation during that period. Many of India’s ancient medical concepts may not have been recorded systematically or branded as a product as we know about vaccines and medicines in modern times.

Also read: Quest for Covid-19 vaccine

The process of converting concepts (such as the utility of inoculation) into scientific discoveries, their documentation (through repeatable processes and publications of those efforts) and ultimately the development of products (such as vaccines) as systematised in modern times are probably a product of European industrialisation and largely flourished from the 19th century.

There is no evidence of the concept reaching Europe before the 18th century. Incidentally, there is a British connection to revolutionising vaccination, and the credit goes to Edward Jenner. It is not known if the concept of variolisation prevailed in many parts of the world simultaneously or was transferred across civilisations from India and China.

In 1774, Benjamin Jesty, an English cattle breeder, conducted an experiment with cowpox pus inoculation on his wife and two children, an informal discovery of the first smallpox vaccine. Actually, Jenner had heard of this phenomenon in the late 1770s from a Bristol milkmaid who boasted: “I shall never have smallpox for I have had cowpox. I shall never have an ugly pockmarked face.” Twenty years after Jesty’s experiment, Jenner was the first to scientifically confirm this hypothesis with a crude but real-world experimentation on an eight-year-old boy named James Phipps in 1796. Jenner gave what became known as the first “vaccinia vaccine”—that is, a vaccine made from the cowpox virus. Jenner took pus from the cowpox lesions on a milkmaid’s hands and introduced that fluid into a cut he made in the arm of James Phipps. Six weeks later, Jenner exposed the boy to smallpox, but the boy did not develop the infection then or on 20 subsequent exposures to pus from cowpox. James Phipps had a normal life trajectory living to 65 years of age during which he married, had two children, and lived long enough to attend Jenner’s funeral in 1823.

Also read: Oxford vaccine enjoys advantages

Initial British efforts to import vaccines to India faced challenges, such as shipwrecks, leading to the concept of dried vaccine. The first batch reached Bombay (now Mumbai) via Constantinople (now Istanbul) and Baghdad in 1802. Bombay served as the hub for further distribution to Pune, Hyderabad and Madras (now Chennai), and Ceylon (now Sri Lanka). (This concept is now known as the hub-and-spoke model for health interventions.) The impetus for the English East India Company for investing in vaccination in the British Raj was the economic, diplomatic and marketing (of British global good) advantages of smallpox vaccination among the general population. The East India Company urged Indian states to support vaccination.

Health systems—lessons from Travancore

The princely state of Travancore was the pioneer in welcoming the British overtures for vaccination, with the Diwan being one of the first “local potentates” to receive this “great novelty” in 1804. The East India Company routinely vaccinated European and Indian Army regiments and camp followers stationed in Travancore. In 1807, the Company in Madras Presidency began a vaccination drive in Travancore while keeping a close eye on vaccination in neighbouring Madras. Vaccine was introduced to the general population of Travancore in 1810.

The success of vaccination in any country is underpinned by the success of its public health infrastructure. This is true even today, and much of the challenges faced today for vaccination globally are directly linked to the resiliency and efficacy of the public health infrastructure.

Also read: The vaccine race

The history of Western medicine in India dates back to 1600, when the first medical officers arrived in India along with the East India Company’s first fleet as ship’s surgeons. A medical department was established in Bengal in 1764, and expanded in 1785 to the Bengal, Madras and Bombay presidencies. In 1937, the Central Advisory Board of Health was set up with the Public Health Commissioner. In 1939, the Madras Public Health Act was passed, which was the first of its kind in India. Modern vaccinations in India began in 1802 when a Superintendent General of Vaccination was appointed. Notable adaptation of the vaccination concept was reported for Travancore. Although introduced in 1804, the “vaccine establishment” of the princely state remained stationary for several decades.

In 1827, four European superintendents of vaccination and one Indian vaccinator were appointed to the Bombay Presidency. By mid-century, vaccination remained the direct responsibility of successive Durbar (royal court) physicians, who oversaw the activities of the Head Vaccinator and a few travelling vaccinators. In the 1860s, a dedicated department was established under a Superintendent of Vaccination. Over time, the British India vaccine system evolved as a complex management system. Similar to the practice of major vaccination initiatives of today, much of the activities in Travancore during the British times was achieved through these itinerant vaccinators. Only 35 of them served a population of over two million in 1869. As the vaccinators travelled across their assigned catchment areas, the usefulness and safety of vaccination was announced by tom-tom. Vaccinators performed the operation mostly in public spaces such as markets and roadsides, and less frequently in households. Vaccinators in Travancore were usually at least 18 years of age, possessed some rudimentary reading and writing skills, predominantly male, mostly drawn from the Malayalee Sudra (or Nair) caste, with some Muslims and Christians as well.

Bovine Lymph vaccines

In the 1890s, bovine lymph vaccines harvested directly from vesicles induced on cattle and preserved in media such as glycerin, lanoline or a mixture of both became available. Although the British believed that the sacred nature of the cow would make these vaccines socially appealing, this method proved as unacceptable as vaccination with humanised lymph. In fact, Travancore developed a Central Vaccine Depot in 1888 and introduced calf lymph as a substitute for arm-to-arm vaccination.

Vaccinators and vaccines at the end of the 1800s faced significant challenges with respect to the administration and acceptance of vaccines. This included poor performance of vaccinators and resistance from socially advantaged population groups, and access issues to remote areas.

Political stewardship was the key to vaccination then as it is today. There are reports of significant vaccination stewardship from local rulers in India such as Rani Gouri Laxmi Bai, the queen of the princely State of Travancore. With a view to protecting her subjects from the outbreak of smallpox, which was frequent in those days, the queen sanctioned the establishment of a Smallpox Vaccination Section in 1813. As vaccine hesitancy became a concern (because of the fear of vaccination), the queen reassured her subjects by first getting all the members of the royal household vaccinated. In 1864, the Smallpox Vaccination Section was converted into a division in the Medical Department. A royal proclamation, issued in 1879, made vaccination compulsory for all “government servants, pupils in schools, advocates, persons seeking help from hospitals, inmates of jails and persons dependent on state charities”.

Also read: The race for a Covid-19 vaccine

Under British rule, in 1870, the task of vaccination was delegated to the supervision of Sanitary Commissioners and their staff. In 1880, vaccination of children in municipalities and cantonments became mandatory. Smallpox was the main target, but plague and other diseases were considered.

Variolation was also used initially to control smallpox. In 1864 and 1865, 556 people were vaccinated in Bengal, the United Provinces, and Punjab. By 1902, more than five million people had been vaccinated in the same provinces. In British India, the vaccination rate increased from 3 per cent in 1880 and 1881 (budget of Rs.0.7 million) to 4 per cent in 1902 and 1903 (budget Rs.1.1 million). Similarly, vaccinations at birth increased from 20 per cent in 1880 and 1881 and 39 per cent in 1902 and 1903. In 1873, the Birth and Death Registration Act was passed. Vaccination and sanitary staff were responsible for the maintenance of vital statistics, that is, the registration of births and deaths.

Modern immunisation policies developed in India in the 19th century largely followed global standards. The initial years saw considerable investment in research and development in vaccines, and about 15 vaccine institutes were established. Notable achievements include the first plague vaccine by Haffkine (in 1897) and the indigenous cholera vaccine. By the time Indians inherited the leadership of the above institutions from the British, routine vaccine production took priority over research and technological innovations.

The vaccine landscape

India launched its first vaccine about 60 years ago. BCG was introduced in 1962 to combat tuberculosis. In 1977, India became smallpox free and, subsequently, in 1978, in sync with the World Health Organisation (WHO) recommendations, India launched the expanded programme on immunisation, or EPI. Initially, meant for children up to five years of age, the EPI included BCG (bacillus calmette-guerin), DPT (diphtheria, pertussis, tetanus—three doses) and typhoid vaccine; and the oral polio vaccine (OPV) was added the next year. In 1985, the programme evolved into the universal immunisation programme (UIP) with the goal of reaching “all” eligible children and pregnant women with the respective vaccines.

Achieving self-sufficiency in the production of vaccines was also a part of the EPI and the impetus for India’s pharmaceutical vaccine industry development. It would be reasonable to assume that when a country makes vaccines, residents of that country would have adequate access to them. Unlike in other underdeveloped and developing countries, the Indian pharmaceutical companies’ foray into the field of vaccine helped India produce vaccines at affordable costs.

Also read: Challenges and opportunities presented by the vaccine

Despite this opportunity, India has higher rates of missing vaccines among children than in comparable countries. In fact, globally India ranked fourth in experiencing polio outbreaks (along with Nigeria, Pakistan, Afghanistan) until 2011. On March 27, 2014, India was declared polio free.

Vaccine hesitancy has thrived in India from the colonial days and persists to this day. Anti-colonial sentiments may have played a role in vaccine hesitancy among some population groups in India similar to the boycott of the English language and British clothes.

India’s intense efforts on smallpox and polio eradication may have come at the expense of other vaccines. Until recently, the Indian government underspent on vaccines in general, and India’s population does not demand vaccines, which is probably attributable to the negligence of public health education. Further, when confronted with other challenges of life, including care for the sick, vaccines may be seen as a distal necessity and not a proximal urgency.

COVID-19, an opportunity to boost vaccine literacy

Despite the shortfalls in India’s vaccination efforts, COVID-19 provides authorities in India yet another opportunity for the social marketing of the vaccine concept that had prevailed in India for centuries. The public health sensitisation achieved by COVID-19 is remarkable and should be proactively used to galvanise a broader understanding of vaccination, not just of COVID-19 vaccines but also other vaccines. It is also a time for India to highlight and celebrate its historical contribution to the science and practice of modern vaccination as a public health strategy that has helped the global eradication of smallpox and potentially polio in the years to come. Nations grow stronger when they learn from the collective challenges they face, such as COVID-19. Nations become smarter when such lessons learned are used to build programmes for the betterment of their populations. Nations become richer when their populations are healthier.

Vaccines are heralded as the best public health investment when the returns through economic savings and averted human sufferings are taken into account. COVID-19 has taught us that economic security of nations will rely largely on their investments in health security. Just as ancient Indians learned about variolisation, exploiting the opportunity posed by COVID-19 to leap towards a healthier India through improved vaccination uptake becomes a strategic necessity for India. However, central to the fulfilment of this strategic necessity is the accountability and transparency of the systems of governance and of the political leadership that controls them. The Travancore Diwan becoming one of the first local potentates of the vaccination initiatives of the period in 1804 is an example of the governance system and political leadership adhering to essential requisites of accountability and transparency. The big question is how well and in what scale contemporary India will adhere to these requisites as it advances the social marketing of the COVID-19 vaccine.

Dr Shahul Hameed Ebrahim is professor, University of Sciences Techniques and Technology, Bamako, Mali.

Dr Muhammed Shaffi is Research Analyst, Boston University, United States.

Dr N.M. Mujeeb Rahman is Medical Superintendent (on leave), MES Medical College, Perintalmanna, Malappuram, Kerala.

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