Till We Win: India’s FightAgainst the Covid-19 Pandemic , written by Dr Chandrakant Lahariya in partnership with Dr Gagandeep Kang, probably the best known face among Indian virologists, and Dr Randeep Guleria, eminent pulmonologist and Director of the All India Institute of Medical Sciences, New Delhi, was one of the first books by health experts for a popular audience to be published in 2020. Dr Lahariya is a medical doctor, an epidemiologist of repute and a public health and policy expert. He has written regularly in the popular media, especially since the pandemic unfolded last year. In this interview with Frontline , Dr Lahariya talks about the gaps in the official data on vaccination, the “cardinal mistakes” committed during the course of India’s faltering vaccination drive, on whether children ought to be vaccinated and vaccine hesitancy. Excerpts:
What are the gaps in the availability of official statistics on vaccination in India? I start with this because it is the subject of one of your recent papers . How does the availability of official statistics affect our capacity to fight the pandemic or understand its scope?
India has its CoWIN dashboard, which provides real-time data on various aspects of vaccination. To me and anyone concerned about these things, that kind of dashboard is very promising. It has great potential, but that is also where the problem lies. Once that primary data is available, it would not take much for the government to put stratifiers on the data in order to analyse it and make them available in the public domain.
The data that is gathered has the potential to tell us many things—for example, whether the person vaccinated is from a rural or urban setting. The dashboard has data at the district, or even the facility level. It also has registration data, and if we put all of that data [together], it would be very easy for anybody to develop a programme that gives us data at a very granular level. We can then have the data in terms of male/female, rural/urban, age-group wise, the subgroups of population targeted, right at the district level. This is the kind of data we need.
An epidemiologist, or someone who is trying to understand the pandemic, or even a policymaker, wants to know which sections of the population are not being covered by vaccination. Aggregates hide everything. This is the problem with the current pandemic data. It will not take the government much in terms of additional effort or cost. It may take a little more time if we have to gather comorbidity data of those being vaccinated. To summarise, the CoWIN dashboard has potential; secondly, there is data that is available but which is not being filed or used in a manner that facilitates a stratified perspective. For instance, it is a challenge to determine at the district level what proportion of those in the 18-44 or 45-60 or 60+ [age-group] population has been vaccinated. Similarly, it is difficult to know which gender or which section of those with comorbidities has received vaccines. This is the kind of data that people like me would require.
The challenge in pandemic response is that in a situation like the current one when we have a vaccine shortage, we need to have granular data so that we can target interventions. We can then apportion scarce vaccines for sections we determine are more vulnerable. This kind of targeting will reduce the impact of the pandemic in subsequent waves.
Such an organisation and presentation of data would also help us address other dimensions of vaccination, such as vaccine hesitancy or adverse events following immunisation; currently, we have no data. Forget about the public domain, even in academic circles we do not know whether that kind of data is being analysed by the government. We have delivered more than 40 crore vaccines; that kind of scale can provide us rich data. For instance, we can know what the commonest side-effects are. Or we can determine what percentage of persons develop fever after vaccination or suffer a particular kind of harm. Data of that kind can provide tremendous reassurance to people and help in tackling vaccine hesitancy.
The data is already there. It just requires tapping it for use…
As I understand, it will require some changes in the algorithms being used. Somebody just needs to develop a programme, and within minutes you can have the data in the form that you need. CoWIN has been developed by the National Health Authority, which runs the National Digital Health Mission. It is a pity that it has not thought this necessary.
There appear to be two sets of problems: one, of data that are collected but not presented and, two, of data that are not even collected.
No. We do not even know whether that data are being analysed by the government. Some of the aspects I mentioned, like comorbidities, are probably not even available. It is quite possible that data are being collected but not analysed at the backend.
Vaccination challenges
What is your assessment of India’s COVID vaccination drive so far?
In a single word, underwhelming. The reason is as follows: India is the largest vaccine manufacturer in the world. It has excellent experience in running large vaccination programmes for many years—measles, polio and rubella campaigns, for instance. India also has the infrastructure to deliver large-scale vaccination programmes. With these achievements, India should have done far better with the COVID-19 vaccine delivery. Of course, there are challenges: the supply is limited; we now have to vaccinate adults, which we had not done in the past. But even factoring for these, India could have done far better. Even in terms of our policy planning, in terms of assessing supplies and deliveries, we know it has been underwhelming and has performed far below its potential.
To me, given the supply constraints we had, it appears that we rushed into opening up vaccination for the 18-44 age group. We would have been in a far better situation if we had not done this at the point we did. Nobody can say that we do not have a vaccine, but we could have utilised better what we had. It appears that once again we had all the right ingredients, but when it came to delivery, we failed. Historically, that is what has happened—India’s health sector has performed below its potential. One more opportunity has been lost. That is my assessment.
What, in your opinion, were the cardinal errors of the “accelerated” vaccine delivery “strategy” that was unveiled in April?
The first cardinal error was the opening up of vaccination for the 18-44 age group. That was a grave mistake. Recall that on April 2, about 4 million doses (actually, 3.7 million) were delivered. After that we were struggling, and by April 10 every State was demanding more vaccines. We also had the Tika Utsav [vaccine festival] around that time when fewer numbers were actually delivered than earlier in the month.
Significantly, problems were never acknowledged. Officials were claiming that there were sufficient numbers of vaccines when we had very little. In April, when we were already facing a shortage of vaccines, we opened up vaccination to an even larger proportion of the population, the 18-44 age group. The size of the eligible population was enlarged threefold—from 30 crore to about 94 crore. This was done at a time when vaccine supplies were stagnant or possibly even shrinking.
The second mistake—I believe that in policymaking, the recognition of a challenge is the beginning of finding a solution—was the unwillingness to accept failures. Possibly resulting from this was the shifting of the burden of responsibility on to State governments. States have zero experience in procuring vaccines. I would say that the entire policy was incoherent.
At the State level, barring the case of possibly Tamil Nadu and Rajasthan, the departments of procurement and supply are possibly the weakest links within the health system at the State level in India. Of course, States are trying to improve, but they are still weak. But above all, States have no experience of procuring directly from manufacturers. And, making States compete with each other and many others was an even bigger mistake. All this created chaos. Also, allocating scarce vaccines to private hospitals added to the problems.
Vaccine production
What about the problems in vaccine production? What were the mistakes there?
For a country like India, with a population of 135 crore, any excessive reliance on private producers is not a good approach. The government keeps saying that it is not in the business of production and that it can always purchase from private producers. I agree that private producers have a role, but there can be no replacement of the government in essential activities.
In 2008, we closed public sector vaccine units. We need to remember that private suppliers, including vaccine manufacturers, always overestimate their production capacity. Recall Adar Poonawala’s statements around this time in 2020, when he said Serum Institute of India [SII] had a capacity to produce 100 million doses a month, implying 600 million shots in six months. The government may have thought that this would be sufficient to vaccinate 300 million people.
If I need to make arrangements to meet my personal family needs, say, for a holiday, I need to make arrangements such as booking a hotel, arranging for food, and so on. I cannot entrust it to someone without making sure that the arrangements are in place. But that is exactly what the government did.
I would not blame the businessman. From his perspective, he would obviously try to oversell his product. But for the government to rely on a private company’s estimates was a huge mistake. Apart from this, it placed orders rather late.
Honestly, in October 2020, I thought the government would have licensed vaccines, secured supplies and then started vaccination the day they were available. Recall, we waited 13 days to start vaccination after they were available. The government was slow, but that is another story. It thought the pandemic was over.
There was also the possibility of Covaxin as a countervailing force, instead of excessively depending on Covishield. Was this opportunity frittered away?
My guess is that the government did not pay attention to the possibility that it would require vaccines on the scale they would be needed. Bharat Biotech [BBIL] has very limited production scales. The Indian Council for Medical Research [ICMR], which was fully involved in the production of Covaxin, ought to have known that inactivated vaccine production takes time. My understanding is that every vaccine batch has to be tested at the Central Drugs Laboratory in Kasauli and that the process takes about two weeks.
The government would have known the production capacity at BBIL. The situation should have been assessed at every stage, but the steps taken seem to suggest that actions were not based on ground realities. For example, knowing fully well that there was a shortage of vaccines, the government opened vaccination of additional sections of the population. These decisions had a domino effect, resulting in a spiral of problems.
It is fairly clear that although the supply of vaccines has improved since May, there is an overall shortage, given the scale of the pandemic. What does the science of epidemiology tell us about prioritising allocation of scarce vaccines?
There are guiding principles, which even the World Health Organisation [WHO] has laid down, which the National Expert Group on Vaccine Administration for COVID-19 [NEGVAC] is also aware of. From an epidemiological perspective, policymakers need to follow two approaches. One is based on the characteristic of the vaccine; in this case, these vaccines can prevent moderate to severe illness and death; they do not stop transmission.
Given its role of preventing hospitalisation and death, one would prioritise vaccinating those at higher risk. This is globally agreed and sanctioned by the WHO. So, we address the high-risk population, front-line workers and then the high-risk population, although most countries follow age-descending order for COVID vaccines. In India, prioritising was definitely the right approach.
The other approach, from a public health perspective, is to reduce transmission of the virus. Vaccinating adults has the purpose of reducing transmission, which is achieved by targeting those who are more likely to transmit the virus, such as officegoers. If we have sufficient vaccines, we could even use a mix of the two approaches. Epidemiology only lays down the principles. What India adopted was a fine approach.
Look at what the latest seroprevalence survey shows. It shows that only about 44 per cent seroprevalence in Kerala, compared with 80 per cent in Madhya Pradesh. If the number of vaccines is limited, I would use the majority of the vaccines for Kerala. Maybe I would even decide that a single shot may be enough for now in States like Madhya Pradesh, given the shortage of vaccines.
Further, if I knew the district-wise seroprevalence rates, I would target scarce vaccines in districts which have low seroprevalence. So, we need to use epidemiology keeping the disease dynamics in mind. People are less likely to complain when the logic is made clear. Even if people complained, it would still be, epidemiologically, the right approach.
Transparency in letting people know the reasoning, logic and intent of the measure upfront is a good way of ensuring support for a particular measure.
Exactly.
Has the prioritising worked well in India?
The NEGVAC, led by Dr V.K. Paul, deliberated on this from September 2020 to January 2021. You may recall that in early April, the Secretary, Ministry of Health, said vaccination is a need, not a want (Addressing a press conference on April 6, 2021, Secretary Rajesh Bhushan said: “The aim is not to administer to those who want it, but to those who need it.”). What he said became controversial. His choice of words may have been wrong, but I agree with him and I have categorically written that I do not support vaccination of the 18-44 age group.
Obviously, everybody is at some risk, but when we have a limited supply of vaccines, we need to use them optimally. I think that is a fair approach. This is an example when technical advice is not listened to and political decisions are made, resulting in a setback.
What implications do the inequities in the distribution of vaccines have on the dynamics of the pandemic?
Inequities are, of course, there. For example, we can address those who are at risk of falling sick or dying if we targeted vaccination. If we vaccinate someone who is not at high risk of hospitalisation or death, it means that scarce vaccines are not being used optimally. Secondly, the allocation of as much as one-fourth of vaccine supplies to the private sector is another kind of promotion of inequity. This is because those who are relatively well-off can access scarce vaccines simply because they have the wherewithal. All this results in suboptimal outcomes. My simple approach would be to ensure availability, accessibility, affordability and quality. Inequity has an impact on all these guiding principles.
What are the potential consequences of leaving a large proportion of the population unvaccinated for the disease dynamics in the pandemic?
For two reasons, from scientific and epidemiological perspectives, the answer to that is slightly more complicated. The epidemiological situation in India is very different. We know that about 67 per cent of people have antibodies. First, vaccines will play an important role, but only a limited role. Second, as the natural infection and immunological effects decline in the population, the vaccines will then play a role that covers this decline. This is one approach to vaccines in halting the pandemic.
But there is another, nuanced, scientific perspective. This is based on the fact that vaccines do not prevent transmission of the virus. Essentially, even a vaccinated individual can have the virus in her nose and throat, but not be sick. This means that transmission will continue as long as the virus is in circulation.
This is what happened in the United Kingdom and the United States; vaccination coverage was high, but the vaccine only offered partial protection against transmission. As long as there is transmission of the virus in any part of the world, the risk of new variants will be there. That is why in addition to vaccines we need to continue with other measures like wearing face masks and social distancing norms.
An even more nuanced issue is that most of the vaccines used in India and the U.K. are essentially the same (adenoviral vector vaccines). There is only limited evidence on the extent to which these vaccines curtail transmission of the virus. But there is some evidence that the mRNA [messenger RNA] vaccines do far better in limiting transmission. That is perhaps the reason why some of the countries using mRNA vaccines are reporting lower transmission rates.
To prevent new variants from emerging we require two things to happen: one, every part of the world must be vaccinated, and two, people need to follow COVID-appropriate behaviour. Reducing transmission is a must. Not all vaccines have a proven role in reducing transmission. I do not want to complicate this further.
Vaccinating children
When do you think we have to consider vaccinating children?
I do not think children may need to be vaccinated, at least not the vaccines that are currently being administered. The purpose of vaccinating children would be to reduce transmission because children rarely develop serious illness. Vaccines are safe but they come with a different kind of risk. All of them come with one or another kind of risk; it is just that in adults the benefits far outweigh risks. Because children do not generally develop serious illness following infection, I am not sure whether the existing vaccines should be used on children. But children will continue to aid transmission of the virus, which means we need a vaccine that is effective against transmission.
My sense is that vaccines for children below 12 years may not be universally needed. Maybe we need to target only those with high risk. I guess some of the next generation vaccines, or a nasal vaccine that reduces transmission, may be good options.
I am not very sure that vaccinating those in the 12-17 age group is right. Of course, vaccination is not always based purely on scientific principles because there are apprehensions among people. In some situations, vaccines are a reassurance to people, especially for parents who are wondering whether it is safe to send children to school. This age group may get vaccinated because they carry a higher level of risk than those younger.
In my opinion, the case for vaccinating children below 12 requires more evidence. The U.K. has assured supplies of licensed vaccines, but even it is not vaccinating all those in the 12-17 age group, only those at high risk. More science is required. The U.K. is different from the U.S.
Why is the situation in the U.K. so different from that in the U.S.?
The U.S. and Canada are different in that they are “medicalised” systems. Obviously, vaccines have a cultural context. Both these societies are highly commerce-driven. Vaccines are also seen as a product, where companies want to prove they are ahead of the others. There are also other dimensions, such as vaccine nationalism, and the anti-science attitudes at play, but I do not want to be commenting excessively on things I am not an expert on. But obviously, you cannot take politics out of health.
Vaccine hesitancy
What is the nature of vaccine hesitancy in India?
The nature of vaccine hesitancy in India is very different from that in the West. There is organised opposition to vaccination. In the U.S., for instance, you will find educated people, doctors, parliamentarians, all of them are taking a strong position against vaccines. I understand that a group of 12 people are responsible for something like 70 per cent of all anti-vaccine information in the U.S. They are clearly well organised.
In India, much of the hesitancy is related to apprehension or poor availability of information. People here do not have a pathological opposition to vaccines. In my opinion, the majority of the people are indecisive or undecided; they would rather wait for others to get vaccinated, see who else gets vaccinated before they do. Many of them are fence-sitters. Surveys show that 50-60 per cent of people are willing to accept the vaccine; 25-30 per cent are fence-sitters, who may be willing if their queries are addressed; and then there is the remaining which may be unwilling to change their mind against getting vaccinated. But since most of the vaccination programmes are meant for 90 per cent coverage, the last section is not too important.
But the reactions to vaccines also vary, as is revealed by several surveys. Generally, those under 40, or even parents under 60, are more likely to agree to getting vaccinated because they have experienced the universal immunisation programme. In India, the hesitancy is mainly information-related or a question of taking advice from a trusted source.
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