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On 1 May, India will move into uncharted territory. An additional 600 million people in the 18-45 age group will become eligible for vaccination. This will happen without any corresponding immediate increase in India’s vaccine production capacity, which currently stands at about 75 million doses per month. So far, one dose has been administered to about a 100 million Indians who are above the age of 45, or roughly 40% of the estimated eligible population.

Thus, by this weekend, we will be tripling the vaccine requirement, even as 60% of the currently eligible population remains to be vaccinated. There are already multiple reports of serious vaccine shortage, with many unable to get their second dose.

The vaccination drive is not merely about attaining herd immunity.
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The vaccination drive is not merely about attaining herd immunity.


Consequently, India now needs to quickly determine not just who to vaccinate, but where to vaccinate in order to secure the maximum public health benefit in an atmosphere of shortage. Obviously, everybody cannot be vaccinated simultaneously. Beyond the market-determined allocation—those who can pay more will get vaccinated first—the country needs a broader plan to prioritise.

The vaccination drive is not merely about attaining herd immunity. While that is indeed the medium-term goal, vaccines can also be used in a targeted fashion to mitigate the epidemic over the next few months. Full protection from vaccination is attained only about 3 weeks after the second dose, but partial individual protection from severe illness may be obtained just a few weeks after the first dose. So, it is possible to affect the severity of the second surge and limit the spread of the illness by having a viable, well-thought-out plan.

Here, the pandemic’s concentration in a few districts could and should be exploited. For example, in mid-April, 25 districts (less than 5% of India’s districts) were responsible for 50% of the total infections. The disease is spreading beyond these districts, but experience from the first wave in August and September of 2020 offers valuable clues.

Has the geography of covid-19 infections changed between September 2020 and April 2021? Can the settlement structure of the infection-intensive districts—whether city, semi-urban periphery or village—offer further insight? Our analysis suggests that India needs to worry about a much smaller, more manageable subset of the population than 600-700 million people, at least in May and June. The key question for the upcoming vaccination drive in the midst of an acute second wave is ‘where’ rather than ‘who’.

Geography of covid

To analyse the geographic spread of covid-19, we grouped districts into four categories according to the caseload intensity: districts that comprise 50% of the cases, those comprising the next 25%, the next 15% and, finally, the other districts.

Chart 1a maps districts that were pandemic hotspots in the August to September 2020 period. The pandemic was relatively concentrated in Maharashtra and in the southern states, with major urban centres in the north, east and west also affected. In September 2020, about 45 districts accounted for 50% of the cases (marked in dark brown) and another 100 districts added 25% more cases. Essentially, the disease was largely confined to 145 districts. Comparing the first and second wave is instructive.

Chart 1b attempts to do just that, showing the spread of the disease in the March to April 2021 period. Interestingly, the current surge started out even more concentrated, with only 10 districts accounting for 50% of the cases and a further 37 districts taking that figure up to 75% of cases in March. By 17 April, covid-19 had spread substantially in at least 105 districts, which were responsible for 75% of all detected cases.

The initial concentration of cases in fewer districts resulted in the visible overwhelming of the healthcare system in the surge zones. Further, and of great importance for the predictability of this surge, the pandemic is revisiting its old haunts. As of 17 April, 89 of 105 districts that were the hotspots at that point also figured in the list of 145 districts from September 2020, and accounted for 91% of the population of the hotspot districts.

But is the pandemic becoming more rural? And is it affecting the semi-urban and rural pockets of the districts which were hotspots in the first wave? Chart 2 looks at the settlement structure of the hotspot districts at different periods during the pandemic. It shows that the current surge started out in areas that are much more urban than in August-September 2020. By April, the pandemic is moving beyond the megacities into districts with million-plus cities and large towns. As such, the peripheries of these cities—though they may be administratively classified as villages—are also likely to have a significant number of infections.

Since the location of the cases is not known publicly (but known to the administration), the analysis is circumstantial, but there have been relatively few reports of cases in rural areas. It was feared that this might occur last year, especially after migrant workers started returning to their villages. This is a possibility this year too due to similar migrant movements and also due to recent large gatherings like the Kumbh Mela and election campaigns. But it hasn’t happened yet. If things play out similar to last year, the worst of covid may remain concentrated in urban areas and their peripheries.

The vaccine plan

India started vaccinating those above 60 (and those above 45 with co-morbidities) from 1 March, and then, all those above 45 from 1 April. The first dose has been administered to about a 100 million people from this eligible category as on date.

The spread of vaccination has been largely proportional to the eligible population across states, with some states like Rajasthan doing exceedingly well. But while states have battled each other for vaccine doses, the district-level story has gotten very little attention.

If we dig deeper and look at the district-level vaccination coverage, the most affected districts do have a higher share of the eligible population who have received at least one dose, but this ratio is still less than half. In other districts, it is only around a third. What’s worse is that the pace of vaccinations has slowed down considerably since mid-April—either because people are scared of vising vaccination centres or because of supply issues. The missed opportunity is this: If we had focused on the districts previously affected by the surge in September, we could have vaccinated the entire vulnerable population above 45 in these areas by now.

This was clearly a mistake. In the next month or two, when vaccine supplies are likely to remain very constrained, how can we use the vaccination drive to save lives? The best option appears to be to focus the drive on increasing vaccination among the existing 45+ category beginning with urban areas by using pop up vaccination camps closer to the people. This needs to be done while simultaneously phasing in younger people with co-morbidities in the districts which currently comprise the top 50% of reported cases. This will protect the most vulnerable in precisely the areas where they are most at risk.

As more doses become available, one can then extend the vaccination to other areas in a phased manner, with 18-20-year-olds in districts that have rarely seen covid cases being the last to be vaccinated. People need to be convinced that the prioritisation process is based on an assessment of risk exposure, and that the people who are most in danger are being prioritised first. This will also save lives by decreasing the need for hospitalization among those infected, preserving scarce healthcare capacity in these perilous times.

Beyond vaccination centres

To do this, we must go beyond the current approach of expecting people to come to the vaccination centre. The low share of vaccinations till now shows that there are many vulnerable and eligible people who are finding it hard to access vaccination centres or are hesitant. It would be important to address these issues. We must focus on taking vaccine doses to the people in high-risk areas, rather than merely expanding the eligible population.

Second, in a raging pandemic situation, a number of vaccinated people will be infected, especially those that have received only one dose. To ensure this does not increase vaccine hesitancy, it is important to convey that this does not indicate that the vaccine is ineffective and that even if infected, the illness is more likely to be mild if the person has been vaccinated.

There is a risk that saturation vaccination in certain areas can make the virus move to new areas which are currently not very highly infected. Also, the virus can mutate as the share of infectable people goes down after vaccination. One must be careful to watch out for both these possibilities, by closely monitoring the spread of the disease in new areas and by extensively increasing sequencing and observing the nature of mutations that are taking place.

The fact remains that by expanding vaccination drive to all adults, the government has done away with the question of whom to vaccinate. The states are now tasked with the onerous responsibility of sequencing vaccination in a situation of high scarcity.

In this situation, a good way to prioritise may be a geographic criterion that targets particular districts. In the districts that accounted for 75% of all cases on 17 April, 34 million had received their first dose out of an eligible 45+ population of about 100 million. We can give at least one dose to most of this remaining high-priority, vulnerable group in May if we try. We must.

Partha Mukhopadhyay and Shamindra Roy are researchers at the Centre for Policy Research

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