India is presently battling an aggressive second wave of the COVID-19 pandemic. India launched its vaccination drive in mid-January, starting with the vaccination of priority groups. The central government has announced a slew of policy measures to expand the eligibility bracket of vaccinees and to deploy more vaccines for domestic use. These policy interventions coupled with the availability of vaccines in the open market are expected to further intensify India’s anti-COVID-19 battle.
Interventions into action
The decision to open up vaccination for all individuals above 18 years of age and to make available vaccines in the open market and vaccines approved in other countries is a welcome move, especially when the country is facing a surge in COVID-19 cases. With more than 300,000 cases being reported across the country on a daily basis over the last three to four days, with health facilities getting overwhelmed, and with vaccine shortages, the new policy interventions for accelerating the vaccination drive need to be quickly translated into action.
India is presently vaccinating more than three million people per day and has administered more than 140 million doses of the vaccine as of April 25, 2021. What is important, however, is the vaccinated versus total population ratio. Only about 22.3 million people, which is roughly 1.63% of India’s population, have been fully vaccinated, against a requirement of 70%-75% for achieving herd immunity. The corresponding figures for the United States and the United Kingdom are 28% and 18%, respectively, while it is 55% for Israel (https://bit.ly/3aEPVDP). By realistic estimates, India may need to administer about two billion doses of vaccines to reach herd immunity levels. India’s current daily vaccination figure, although impressive in itself, may not be adequate to reach the target in the quickest possible time. The need of the hour is, therefore, an uninterrupted supply of vaccines for the proposed accelerated and augmented vaccination drive.
The import relaxations announced for COVID-19 vaccines and the recent guidelines issued by India’s drug regulatory authority for restricted use in emergency situation of vaccines which are already approved for restricted use by the U.S. Food and Drug Administration, the U.K. Medicines and Healthcare products Regulatory Agency, the European Medicines Agency, and the Pharmaceuticals and Medical Devices Agency Japan have eased the introduction into India of the newer generation mRNA vaccines and other vaccines effective against the variants and mutant strains of the virus. Despite the regulatory nod, the full-fledged roll-out of these vaccines may be delayed in view of the time requirements for the mandatory bridging trials and safety assessments of the first 100 recipients of these vaccines. As time is of the essence, can some of these requirements be short-circuited, with weightage given to data from the trials conducted abroad? Would it not be possible to extrapolate data pertaining to Indian-origin recipients of the Pfizer or Moderna or other vaccines and determine the suitability of these vaccines for domestic use in India?
Issue of ethics
The ethics in prioritising target populations for vaccination were hotly debated globally, prior to the launch of the vaccination campaign. Prioritisation was done based on the number of infections that could be prevented, the number of lives that could be saved, the probability of survival, the length of survival and the ‘utility’ of the lives saved (in terms of life years gained and in quality of life improved). Top priority was assigned to health care and other front-line health workers, which satisfied the doctrine of benefit maximisation. While choosing 60-plus and those with co-morbidities as the third priority group, the guiding principle was the protection of the most vulnerable.
Relaxation of age-limit for deciding on the eligibility for vaccination has twin advantages, the first being the expansion of the vaccination net and the second being the freedom of the individual to exercise options for selecting the vaccine of her choice. The younger lot of the economically active population group and students attending college and university can get themselves vaccinated from May 1. This has the widest impact from the health economics point of view, as the Disability-Adjusted Life Years (DALYs) saved through vaccination of the 18-plus age-group would be the highest.
Allowing students of the outgoing and incoming Class XII into the vaccination net, sooner than later, seems prudent, although with DALY as the sole criterion, they may not qualify. Class XII is the gateway to higher education. These students have already had one academic year of online studies, which too had been dogged by equity and accessibility concerns, besides psychological stress and tensions. A comprehensive strategy to vaccinate students in the 16-plus age-group, in the next phase merits consideration, as has been approved by the United States Centers for Disease Control and Prevention.
The decision to keep the 18 to 44-year age-bracket under the ‘other than Government of India channel’ may discourage the socially and economically disadvantaged people such as labourers and daily wage workers from seeking vaccination, as they may not be able to procure the vaccines at determined prices.
The silver lining, nevertheless, is that State governments can take a call on providing the vaccine to this age-group free of cost. This may perhaps be a financial strain on cash-strapped State governments. Despite the financial burden, States such as Kerala have already committed to providing vaccines free of charge to all eligible people. The differential pricing regime announced by the Serum Institute of India and Bharat Biotech for supply of their vaccines to the central government and State governments and the private sector is, however, a matter of concern. A rethink on the pricing strategies of these companies is called for. Furthermore, it would be equitable if those who can afford to pay for their own doses opt to do so.
Flattening the COVID-19-curve and its downward trajectory eventually rest on judicious vaccination deployment plans and the pace of vaccination. The proposed augmented and fast-tracked vaccination drive with a wider population base and a bigger basket of vaccines should facilitate the health system in this ongoing battle against COVID-19.
Dr. Sharmila Mary Joseph is an IAS officer of the Kerala cadre. The views expressed are personal