BackThe country’s big conundrum of vaccination priority and equity
A well-aimed vaccination strategy in the face of a shortage can help us emerge from this pandemic
PremiumHailed as the world’s largest vaccine producer, India is struggling to vaccinate its waiting population during a deadly second wave of covid, which is costing us both lives and livelihoods, severely impacting our economy that was showing strong signs of recovery only a few months ago. From a promising start to the year 2021, which saw two vaccines being approved and covid caseloads at an all-time low, we are now battling the world’s highest number of cases, and more importantly, deaths. Unlike the first wave, when the virus mostly hit the elderly and those with comorbidities, this time it has taken young lives: 20% are below the age of 45, which is challenging our vaccination strategy. When India initiated vaccination in mid-January, we followed an age-tiered strategy, coupled with inoculating our frontline health workers. Starting with over 60-year-olds from 1 February, we moved to 45 years and above by 1 March, and announced 18 years and above starting 1 May. However, we soon realized that this was untenable, as we didn’t have the quantum of vaccines necessary to vaccinate our adult population. The government has shared an estimate of over 2.2 billion doses of vaccines that can be produced between now and December, but many have called this aspirational and unrealistic. Another private sector estimate puts this at half or about 1.2 billion doses between Covishield, Covaxin, Sputnik, ZyCov-D, Novavax and J&J’s until December 2021. Imported vaccines from Pfizer, Sputnik and Moderna could possibly add another 100-200 million doses, but no more.
Vaccination rationale: The country’s challenge is to formulate a vaccination strategy that protects the vulnerable whilst stopping transmission.
Based on the latest census, approximately 63% of our population are over 18 years of age and hence eligible for vaccination. This would mean we need to vaccinate about 820 million across the country. If we assume that 180 million have received at least one jab, we are now down to 640 million. Factoring in the need to cover 70% of our population to gain wide-scale protection for all, we are down to 450 million vaccinations, or 900 million double doses. Current production, therefore, could help us reach a very safe place by the end of the year and avert a third wave. Starting January 2022, we can start giving booster doses at 200 million doses per month.
Vaccination prioritization: In order to ensure that every vial and every dose of vaccine is used efficiently, we need highly streamlined logistics, which can only happen with decentralization at the state level. Today, the central government has announced a model that is split 50% between central procurement and the balance between state governments and the private sector. In my view, a public private partnership model at the state level of pooled vaccine procurement and deployment with shared responsibilities will allow us to vaccinate ourselves out of this pandemic.
We also need the science of epidemiology to lead our vaccination strategies. At a time of vaccine inadequacy, effective impact rather than equitable access ought to drive our decision-making. For example, we must prioritize vaccination on a formula of district-wise population density, case load, fatality rate and doubling rates, followed by occupation- based prioritization depending on risk of exposure and infection.
If we use Karnataka as an example, then Bengaluru would be the obvious place to start, followed by Mysuru, Bellari, Dakshin Kannada, Dharwad, Hassan Tumakuru, Shivamogga, Belgavi, Gulbarga, etc. Maharashtra would have a graded weightage starting with Mumbai, Pune, Nashik, Aurangabad, etc. Punjab would prioritize Ludhiana, Amritsar, Jalandhar, Patiala, and so on.
In Karnataka, it makes eminent sense to deploy 50% of vaccines in Bengaluru and the other half in high-load districts. We could theoretically stop the spread within 3 months by deploying 5 million doses per month with at least one jab per person. In order to vaccinate 5 million per month, we would need to vaccinate about 150,000 per day across the state. If Bangalore has to vaccinate 2.5 million per month, approximately 500 vaccination centres would be required, each delivering 100-250 doses per day, or, better still, organize camps for mass vaccination of 1,000 per day in slums, local markets and construction sites that would accelerate the pace of vaccination as well as tackle vaccine hesitancy.
As for occupation-based prioritization, those most at risk would be delivery service personnel, cab drivers, market vendors, provision shop staff, slum-dwellers, construction workers, and on-site employees, followed by residents of high-rise buildings, gated communities and then single dwellings.
Once urban centres are secure, perimeter protection can be deployed through entry-exit protocols, and the focus can then shift to vaccinating the rest of the state. Such a strategy could stop the spread of viral infection in Karnataka with as few as 15 million doses over three months, and the entire state could be got under control with an additional 30 million doses thereafter, which would include second jabs, and by which time vaccine supplies would increase. This model may be worth adopting across the country. A strategy of dealing with vaccine inadequacy through well-targeted priority inoculation is the way forward.
Kiran Mazumdar-Shaw is chairperson, Biocon, and co-chair, Lancet Citizens Commission on Reimaging India’s Health System
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