On June 21, India administered 8.6 million shots of COVID-19 vaccines, the highest daily doses since the start of the drive on January 16. With an officially projected supply of around 210 million doses of COVID-19 in the period from June 21 to July 31, India should be able to administer 5 million shots a day (6 million shots a day, if we exclude holidays) and sustain the tempo for the coming weeks. Yet, this would not be enough to achieve the stated target of jabs for the entire adult population by the end of 2021. To achieve that, India needs to conduct at least 10 million jabs a day, now onwards.
Even with the ongoing vaccination drive, there are many ground reports about two challenges, which demand urgent attention and intervention.
The first is vaccine inequity. There is low uptake of COVID-19 vaccine among groups such as slum dwellers and urban poor as well as in rural population. Some of these inequities have their origin in supply side aspects, as most vaccination centres are in urban settings, and the need for prior and, for some, mandatory, registration on the digital platform.
The second challenge is vaccine hesitancy. Misinformation on social media has further aggravated this. However, we need to remember that this is not an India-specific or COVID-19 vaccine specific phenomenon.
Way back in 2014, World Health Organization (WHO) constituted an expert group to study vaccine hesitancy. The group recognised that when it comes to vaccines, there is a spectrum from people who accept all vaccines at one end to those who refuse all vaccines, and the majority falling in between. The expert group suggested the need for a timely, transparent and effective communication strategy to tackle vaccine hesitancy. In 2019, WHO had identified vaccine hesitancy as top 10 global public health challenges.
Telephonic survey
In India, a telephonic survey amongst over 3,000 urban and rural respondents from Delhi-NCR (Haryana, Rajasthan and Uttar Pradesh), done by National Council for Applied Economic Research, between December 23, 2020 and January 4, 2021, noted that while 61% were willing, there was hesitancy among 39%.
In April 2021, another survey in 14 slum clusters of Delhi and Ghaziabad, amongst 2,097 families and 4,774 respondents, only 7% of respondents were willing to get COVID-19 vaccine. Many thought that since they were healthy they did not need vaccines and nearly one-third of respondents were afraid of vaccines.
In Madhya Pradesh State, reportedly, 270 COVID-19 vaccination sessions in rural areas ended up as zero sessions, where nobody turned up.
In the four months since the opening up of COVID-19 vaccination for 45+ populations; only 48% of the 60+ population has received at least one dose. That is a reminder that merely availability of vaccines does not translate into increased coverage. Vaccine hesitancy seems to be playing a role in keeping the coverage low.
In the last few weeks, the Indian government has taken some corrective measures to rejig the COVID-19 vaccination strategy, resolve a few policy issues, streamline vaccine procurement and supply. However, there seems relatively less attention on the challenges related to implementation and delivery.
By end of June, India’s vaccination drive is at an early stage with nearly 4.5% of the total population receiving both shots. The demand seems high, however, once India achieves approximately 50% to 60% coverage of adult vaccination with at least a single dose, hopefully by early October 2021, then there could be a situation of sufficient vaccine supply but not enough takers due to vaccine hesitancy. Also, there is risk that while aggregate coverage may appear high, some population groups, especially the most vulnerable, may have relatively low coverage.
Therefore, early identification of the excluded population sub-groups and the vaccine hesitant group is an urgent need. We need to plan and prepare for such eventualities to achieve coverage as close to 100%, to halt the march of the virus.
Addressing inequity
First, analyse vaccine coverage data by every possible equity stratifiers such as rural urban, rich and poor, religion, deprivation status, tribal and other population sub-groups. The government needs to use more granular data by equity stratifiers and develop appropriate strategies to scale vaccination coverage in those settings and areas. Special mobile-based vaccination sessions should be conducted in those areas and population groups.
Second, generate scientific evidence to understand vaccine hesitancy. The government needs to engage academic institutions to conduct primary research to understand the concerns of people who have any form of hesitancy. Alongside, professional agencies, with experience in social marketing should be engaged in developing vaccine communication campaigns. Instead of newspaper advertisement, science and evidence-based communication for vaccination drives need to be implemented. In rural and urban slums and tribal areas, the communication strategy should be done with the help of frontline workers, Panchayat and local influencers.
Third, implement the evidence informed COVID-19 vaccine communication strategy adapted for local context: the Indian ministry of health & family welfare had formulated a COVID-19 vaccine communication strategy, in Dec 2020. However, many of the health functionaries are not even aware about various communication strategies. Some of the good practices including financial and non-financial incentives (both at individual and community/village levels) implemented by various districts and Indian states should be explored for further expansion.
Science-based strategies
The Indian government aims to achieve COVID-19 vaccination of the entire adult population in India by end of 2021. However, it will be a naive to assume vaccine coverage is simply a function of vaccine availability. It is sine-qua-non that the challenges of vaccine inequity and hesitancy are identified in advance and evidence and science-based strategies and communication plans are drafted and implemented to tackle this with immediate priority.
(Dr. Chandrakant Lahariya, a physician-epidemiologist, is a public policy and health systems expert and co-author of ‘Till We Win: India’s Fight Against The COVID-19 Pandemic’).
