The cold chain infrastructure in the country is skewed towards richer, urbanized centres. Roughly 4 cold chain points serve 100,000 population in Gujarat, whereas there is just one cold chain point for the same number of people in Jharkhand.
When the covid-19 pandemic began spreading, India, like most other countries, was left scrambling for protective gear and medical equipment to manage the crisis. As the world prepares itself for the launch of vaccines that are expected to bring the pandemic to an end, India may be better prepared at least on one count. As the world’s leading vaccine manufacturer, India may have better access to vaccines than many other parts of the developing world. Serum Institute of India (SII) alone is a producer of more than 1.5 billion vaccine doses every year and is expected to produce 1 billion doses of the Novavax vaccine by 2021.
Yet, distributing the vaccines in India’s first mass adult vaccination drive might prove to be a daunting task. It will require expansion of India’s existing cold chain capacity at a break-neck speed, especially in some of the more densely populated parts of the country, where such infrastructure is severely limited. It will also require addressing gaps in India’s existing vaccine distribution network, which a health ministry report flagged a couple of years ago.
India’s health minister has said that the government aims to inoculate 300 million most vulnerable people by August 2021. This translates to 600 million doses till August, a target that may be hard to attain, given India’s state of cold storage infrastructure such as depots and refrigerated vans.
It may be possible to administer 550-600 million doses only over the course of 2021, given the bottlenecks in India’s cold chain infrastructure, wrote Anubhav Aggarwal and Sayantan Maji of Credit Suisse in a report on India’s vaccination plan last month.
The estimates are based on the assumption that the infrastructure for the current immunization programme in the country will be leveraged for the covid vaccination plan even while keeping the regular immunization program going. In addition, private cold chain companies will be tapped to distribute roughly half of the required doses (300 million over the course of the next year). These estimates appear reasonable, said Sunil Nair, CEO, Snowman Logistics, the largest private cold chain firm in India. Snowman itself could arrange for storage of 100 million doses, he added.
India’s vaccine distribution network is operated through four government medical store depots (GMSDs) in Karnal, Mumbai, Chennai and Kolkata, which procure vaccines from the manufacturers. About 53 state vaccine stores get their supplies either from these GMSDs or directly from manufacturers. The state vaccine stores then distribute the vaccines to regional, district and sub-district level cold chain points via insulated vans.
India currently has about 27,000 cold chain points, 76,000 cold chain equipment, 700 reefer vans, 55,000 cold chain handlers, and 2.5 million health workers as part of its vaccine logistics network.
To meet the target for the first phase of the covid vaccination drive, the public sector distribution capacity will need to be expanded 2-3 times. Augmenting this capacity is not the only challenge. Gaps in the existing supply chain are an equally big challenge. India’s vaccine management has improved over the years thanks to a real-time supply chain management system known as the electronic vaccine intelligence network (eVIN). As of August 2020, it had been implemented in 32 states and union territories, and it will come in handy during the covid vaccination drive.
Yet, the latest available audit of the vaccine chain conducted by the health ministry in 2017-18 shows that bottlenecks still exist. 26% of eVIN cold chain points reported instances of stock out during the period of assessment. More than a fifth of facilities reported wastage of vaccines.
India ranked within the 51-75 percentile range among 89 countries on effective vaccine management as per a global analysis by WHO-UNICEF in 2018.. Its performance was relatively poor when it came to following the required vaccine arrival procedures and using the MIS system for estimating demand of vaccine, syringe, etc.
What adds to the vaccination challenge is the inter-state disparity in the distribution of cold chain points across the country. For instance, roughly 4 cold chain points serve 100,000 population in Gujarat, whereas there is just one cold chain for the same number of people in Jharkhand. Jharkhand, Uttar Pradesh, and Bihar are among the least served states when it comes to cold chain infrastructure.
It won’t be easy to fill such deficits given that most of the private sector cold chain network is concentrated in the bigger cities and towns, said Gagandeep Kang, a virologist at the Christian Medical Centre, Vellore.
A union health ministry official responsible for managing the vaccine management drive declined to comment on this issue. A senior health ministry official from Jharkhand said that the state has identified 30 new cold chain points for expanding its distribution network. It also expects to receive 148 ice-lined refrigerators and 57 deep freezers from the central government later this month, the official said, on condition of anonymity. The government plans to allocate its existing resources from the universal immunization programme as much as possible towards covid vaccination drive, but without disrupting the regular immunization drive, he said. Despite this expansion, Jharkhand will still lag behind more urbanized states such as Gujarat, and will have to manage with its limited resources.
Uttar Pradesh, another state with cold chain limitations, is planning to increase storage capacity by 2.5 times, according to Rakesh Dubey, director general of the state’s family welfare department. The central government has arranged for cold chain equipment such as walk-in freezers, walk-in coolers, ice-lined refrigerators, deep freezers, etc. and they are being installed, he said. The state government is examining the feasibility of using repurposed refrigerated vans from other industries, he added.
The unique requirements of the upcoming immunization drive pose another layer to the distribution challenge. Identifying beneficiaries, ensuring they show up on the day of vaccination, and administering a second dose after a month would require a lot of micro-level planning, said Neeraj Jain, country director India at PATH, a global non-profit that works with countries across the world in boosting immunization and public health.
Apart from distribution and delivery challenges, two key issues would be vaccine uptake and monitoring, said Kang.
“Vaccine uptake requires confidence in the vaccines and the delivery system, and we seem to sway from vaccines being the ultimate solution (which they may not be) to vaccines being developed so rapidly and with many short-cuts so they must necessarily be unsafe and untested (which is not true)," said Kang. “Also, documentation of vaccination and the tracking and investigation of vaccine safety events are essential components of monitoring which have traditionally not been done well. So thinking through the external monitoring or support mechanisms would be helpful."