More than a third of all vaccinations done in the world each day are in India . With over 40,000 sites, it is heartening to see how India is shaping the COVID-19 vaccination programme. Yet, these are baby steps, and there is a long way ahead in covering the vulnerable. Here is why (https://bit.ly/3lxRN5m).
So far, India has vaccinated only 3.2% of the adult population . Although the country covered 2.6 million doses per day on March 15, the seven-day rolling average hovers only around 0.11 per 100 people . This slow pace, which is also cause for concern, does not constitute an appropriate response when compared to India’s true potential in scaling up vaccination.
Steps to scale up
India has identified a target of 300 million vulnerable population , but there is neither a definitive time frame attached to it nor any specifics on the process. With COVID-19 cases on the rise again in different parts of the country, time is running out. If India can vaccinate 10 million people per day, the vulnerable can be protected over the next two to three months. However, this requires speeding up the pace by five times. Given that India has 300,000 trained vaccinators (217780 auxiliary nurse midwives and over one lakh nurses ), nearly three million people can be covered each day by the public health workforce. They are trained in vaccinating millions of children routinely through outreach sessions. Thus, they can easily cover two million doses per day routinely. By expanding participation by private health facilities, it would be possible to cover more than seven to 10 million doses per day.
India-Russia template
To have a sustained campaign of 10 million doses per day, India will need to have a reasonable stockpile and production line of vaccines. Several other vaccines are available internationally with established efficacy and safety, and can be approved under emergency use authorisation (EUA). The bridging study can be done while vaccines are rolled out under the EUA before access to the market. The government may proactively seek supplies from other manufacturers while rapid studies can assess safety and immunogenicity in the Indian context. The ongoing arrangement with Russia for the local production of Sputnik while the vaccine is already undergoing clinical trials in India is an excellent template of using Indian companies to roll out other vaccines. India has to balance compassion to supply vaccines to other countries with the compulsion to save the lives of millions of Indians, who are at risk of death due to serial waves hitting different parts of the country. Regulated sales in the private market should be used as a careful option to accelerate the vaccination campaign. The government should act as the assurer of quality and regulate the prices of all the vaccines in the country. Any person who is 18 years should be permitted to get any vaccine approved by India, at any designated place, and at a fixed price regulated by the government. This will scale up vaccination in the workplace settings across the country and for all others who can afford them. While this happens, the inequities in the health system, which systematically neglect the poor and the marginalised, should be looked into on priority. This can be done with the government as the sole provider of free vaccines and care for all Indians below the poverty line or who cannot afford to buy vaccines. Vaccinating people in impoverished communities is a mandatory social responsibility.
Make it simple
Public health programmes should be as simple as possible to ensure scalability. Simple age-based criteria should be used to expand vaccination without restrictive criteria such as insisting on a medical certification of comorbidities. The preregistration and over-reliance on the CoWIN app through the entire process needs immediate remedy. Simple, offline, walk-in vaccination should be done with paper-based collection of details. This can be followed by uploading the details onto CoWIN. In addition to this, the authorities should use the opportunity to identify people with comorbidities. More than half the people in India with comorbidities are unaware of their condition. By opportunistic screening using simple digital measuring devices for blood pressure and blood glucose, the otherwise ‘missed persons’ from routine health-care provision can receive treatment for their non-communicable diseases, or NCDs. This is a non-negotiable service element that no government can afford to neglect.
A ‘3M’ road map
Microplanning is a process that is followed in India’s vaccination programmes, that captures the population details by identifying and mapping them. It has details for workforce and logistic arrangement, and tags for people to clearly identify vaccination sites. The micro plans are the blueprints of the vaccination programme, which connect houses, migrant population and institutions such as old age homes and dementia care centres with vaccination teams. This is not just the fixed sites; the micro plans also provide details of mobile teams and outreach sessions to cover a population. The central government can work with the States in strengthening micro plans so that the vaccination pace picks up and is sustained.
Mobilising identified persons can be done by the accredited social health activists (ASHAs) in rural areas and other volunteers in urban areas. There is one ASHA for 1,000 population in rural areas . Based on the micro planning done, people should be mobilised to designated vaccination sites on a designated day. The strategy for mobilisation in urban areas can include innovative technological solutions. Role models can influence many peers to get vaccinated as well.
Monitoring and mentoring of each step of the process are essential. The activities that need structured support include preparing micro plans, ensuring that all the necessary inter-sectoral coordination is done, and that the necessary logistical and transport supplies are provided. Task forces can coordinate these at the district and sub-district levels.
By coordinating with the World Health Organization, India has an irrefutable track record of designing and updating micro plans, which have been used as templates in the global polio eradication programme. India’s reputation as a world leader in vaccination programmes needs to be strengthened further by addressing these issues swiftly. We are making good progress in COVID-19 vaccination efforts, but it is not sufficient to achieve what is necessary. Doing the best that we are capable of is the only option. And, we can do it.
Giridhara R. Babu is Professor and Head, Lifecourse Epidemiology at the Indian Institute of Public Health, Public Health Foundation of India, Bengaluru
