Does India Need to Rethink Its Vaccine Policy?
The emergence of a second wave has led to public discussion of whether India's approach to vaccination needs to be changed
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Does India Need to Rethink Its Vaccine Policy?
The emergence of India’s second wave has led to a flurry of op-eds and public debate over whether or not India needs to change its vaccine strategy. To give you a taste of how wide-spread this debate has been, check out these headlines from the past two weeks:
Outlook India: It’s Time To Rethink Our Flawed Strategy To Beat Covid-19
India Today: India needs to change its Covid vaccination strategy now. Here's how it can do it
The Hindu: The second wave: On why new COVID-19 vaccines should be cleared
WION: Why is it time for India to reassess its vaccine strategy
So what has been India’s vaccine strategy so far? What changes have people called for? And which of those changes, if any, can actually blunt the momentum of India’s second wave?
India’s vaccination strategy has, so far, been in line with that of most countries. The first phase of India’s nationwide COVID-19 vaccination campaign saw eligibility limited to healthcare workers and other frontline workers across age groups to protect those working with patients infected with COVID-19 from becoming sick themselves. The second phase focused on vaccinating older citizens (those above the age of 60) as well as those over the age of 45 that had co-morbidities that increase the risk of more serious illness or death from COVID-19.
India has so far delivered 75 million doses of the vaccine (65.7 million people have received only their first dose, while 10.2 million people have received both doses). India also expanded the eligibility of who can get the vaccine to include anyone over the age of 45 from April 1, 2021. While India recorded a high of administering nearly 3.7 million doses in one day, it still averages around 2.2 million doses administered per week.
However, the emergence of a second wave of COVID-19 infections in India has complicated matters, and led to greater pressure on the Indian government to increase the pace of vaccinations in the country.
India registered more than 100,000 new cases of COVID-19 on Sunday, and reports indicate that India’s R0, or reproduction number (which signifies how many people each infected person will infect on average) is above 1.5 and has been steadily increasing over the past two to three weeks. Pressure has, therefore, grown on India’s government to get more shots in arms as soon as possible.
Public health experts have suggested a number of solutions to tweak or rethink India’s overall vaccination policy to cope with the second wave. Some have called for the government to approve additional vaccines, thereby increasing the supply of available vaccines to India’s citizens. India has, so far, only approved two vaccines for use: the Oxford-AstraZeneca vaccine branded in India as “Covishield,” and the indigenously-produced “Covaxin” from Bharat Biotech.
In addition to these two vaccines, three others are in the pipeline that could be approved soon. The first is the Russia-made Sputnik V, which remains closest to approval. The vaccine, which is currently undergoing trials regarding its suitability for India, was earlier denied authorization on April 1, with the Subject Expert Committee of the Drug Controller General of India requesting more data. However, newer reports suggest that Sputnik could be approved in the coming days.
Other vaccines include the single-shot Johnson & Johnson vaccine or the Pfizer-BioNTech vaccine. However, it is unclear whether J&J has begun conducting local trials, or “bridging trials,” that are required by Indian authorities before approval. Pfizer, on the other hand, had withdrawn its application for emergency use in February after Indian authorities had rejected its request to waive the need to conduct local bridging trials, based on its strong efficacy data from around the globe. Pfizer has since offered to domestically produce its vaccine in joint ventures with Indian companies if it can obtain the regulatory clearance and it retains freedom on pricing and exports. However, Indian authorities have not yet taken Pfizer up on its offer.
However, even if these vaccines are approved in short order, there are several steps that need to be taken before they can truly be rolled out nationally at scale to vaccinate citizens in greater numbers. The Sputnik V vaccine needs to be stored at -18°C or colder storage facilities. While a freeze-dried version of the vaccine can be stored in 2-8°C, India will need to establish a cold storage management plan to ensure the vaccine remains effective. Moreover, with Sputnik V not yet approved in India, all production of the vaccine in India is, so far, focused on global markets. Reorienting production towards Indian needs will likely not be immediate.
The second major shift in strategy that has been raised publicly is for India to shift its strategy to mirror that of the United Kingdom, and focus on a “One Jab” strategy. Under such a strategy, India would move to administer as many first doses as possible to people, and delay the administration of the second shot from 4-6 weeks after the first shot, to as much as 12 weeks after the first shot.
While this approach was first criticized, the gamble seems to have paid off for the UK, and it can be a strategy that India considers. Peer reviewed studies published in Lancet, as well as recommendations published by the World Health Organization, supported longer intervals of between 8-12 weeks between the first and second doses. Moreover, the data suggests that “daily number of new Covid cases has fallen by more than 90 percent since peaking in early January,” marking the largest than any other country and despite the emergence of the B.1.1.7 variant in the country.
While India had considered shifting to such a strategy during a meeting of National Expert Group on Vaccine Administration for Covid-19 on February 13, the Chairman of the Expert Group said at the time “As of now, the current recommendation (to start vaccinating after 28 days) stands.” However, with India now in the midst of a second wave, the time is ripe to re-consider whether India should follow its current strategy or shift to a strategy that focuses on administering as many first doses as possible, and increase the interval between the first and second doses.
Finally, some has called for India to shift who its prioritizes to receive the vaccine entirely, suggesting that rather than vaccinating by age nationally, India look to vaccinate as many people as possible in areas where transmission of the virus is highest, thereby building up a local version of herd immunity. Prof. Dileep Mavalankar, Director of Institute of Public Health, Gandhinagar, sums up the strategy in a recent op-ed in the Indian Express. He writes:
Herd immunity is a local concept, not a national concept. For example, if city A has 80 per cent vaccine coverage and city B has only 10 per cent vaccine coverage then disease transmission in city A will stop but not in city B even if the country’s average immunisation is 70 per cent.
Immunisation is needed where the disease transmission is high. We give Japanese Encephalitis (JE) vaccine in eastern Uttar Pradesh and Bihar where the risk of the transmission is high, not in rest of India as the risk of transmission is low there. The same principle has to be followed in the COVID vaccination drive.
Here’s how the strategy would play out:
Take, for example, a hypothetical country where there are 100 districts of one million population each. In this country, the COVID disease distribution is such that five districts have 60 per cent of the total COVID cases, another 10 districts have 20 per cent of the cases, and the remaining 85 districts have 20 per cent of the case count. Now, you have a limited number of vaccine doses available, say 30 million. In such a situation there could be two ways to distribute this vaccine quantity. Model A where each of the 100 districts gets the vaccine to cover 15 per cent of its population with two doses. This is a fair and equitable distribution. Model B where we give all the 30 million vaccine doses to cover fully the 15 districts (two doses for the 15 million people) which are producing 80 per cent of the COVID cases. This implies no vaccination in the remaining 85 districts which accounted for 20 per cent of the cases. This model is highly inequitable and many political objections are likely to be raised. From an epidemiological point of view, however, Model B is much more superior than Model A as it will rapidly achieve herd immunity in the 15 districts which will reduce the cases by 80 per cent. In the next phase, when more vaccines are available the rest of the country (85 districts) can be covered in phased manner.
Adopting such a strategy would be a major shift away from not only what India has done so far, but the strategies that all major countries have adopted so far. Prof. Mavalankar is right to point out that such a strategy is also likely to attract political objections.
However, there are one major additional factor that needs to be considered. While the long-term goal of any vaccine strategy is build up immunity among the population, the desire to focus on healthcare workers, older citizens, and those with co-morbidities is also to ensure that vaccines can prevent serious illness and death. Shifting to a strategy that focuses on creating immunity at a district level means that, in districts where the virus is spreading at a lower rate but certainly still spreading, the risks of death or hospitalization increase as vaccinations in those districts are de-prioritized.
The emergence of India’s second wave has led to lots of public thinking about whether India’s vaccine strategy needs reorientation, and if so, in what ways should it change. There is no magic bullet, however, and each of these options have trade-offs. Moreover, a vaccine strategy alone may not be enough if mass gatherings, such as political rallies for the ongoing state assembly elections or mass religious gatherings continue to take place. However, these suggestions of how to adapt India’s vaccine strategy to tackle its fast-rising second wave of COVID-19 infections are important conversations to have as we continue to think about how to most effectively use the best tool we have against the virus at this precarious and important stage.
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News Roundup
The Union Cabinet approved a Production Linked Incentive (PLI) scheme for India’s Food Processing industry in order to “support creation of global food manufacturing champions commensurate with India's natural resource endowment and support Indian brands of food products in the international markets.” The initial financial outlay for this scheme will be Rs. 10,900 crore ($1.49 billion) in order to implement the scheme over a six year period from 2021-22 to 2026-27.
Chief Minister of Maharashtra Uddhav Thackeray announced new restrictions to slow down the spread of COVID-19 in the state after cases rose to 49,447 cases in the state this past Sunday, April 4. The new restrictions include a night curfew on weeknights from 8pm to 7am, a complete lockdown on weekends from Friday at 8pm to Monday at 7pm, and a continued ban on public gatherings. The full order is available here.
The United States Special Presidential Envoy for Climate John Kerry announced that he would visit India from April 5-8 as part of a broader trip that will see Envoy Kerry visit the United Arab Emirates, India, and Bangladesh from April 1-9. The trip comes in advance of the planned international climate summit involving 40 countries, including India, that President Biden is hosting in May.
External Affairs Minister Dr. S. Jaishankar participated in the 17th Ministerial meeting of the Bay of Bengal Initiative for Multi-Sectoral Technical and Economic Cooperation (BIMSTEC) countries on April 1, 2021.
Finance Minister Nirmala Sitharaman participated in the 6th Annual Meeting of Board of Governors of New Development Bank, held via videoconference on March 30, 2021, alongside representatives from Brazil, Russia, China, and South Africa. The theme of this year’s annual meeting was on the evolution of infrastructure, and the Finance Minister highlighted India’s decision to set up a new Development Finance Institution.
Reports suggest that Tata Sons Ltd. is the front-runner to buy the government-owned Air India airlines, and is discussions with the government to finalize the terms of purchase, including hammering out differences on issues such as pension liabilities, real estate assets and debt. The reports also suggest that Tata could submit its financial bid as soon as this month should talks continue to progress.
Indian authorities have reportedly blocked at least two bank accounts belonging to ByteDance, the company that developed the social media platform TikTok. Per reports, “authorities ordered two of ByteDance India’s bank accounts in Citibank and HSBC to be blocked because of alleged evasion of certain taxes in online advertising dealings between the ByteDance unit in India and its parent entity in Singapore, TikTok Pte Ltd.”
Petroleum minister Dharmendra Pradhan and US energy secretary Jennifer Granholm will update the terms of the India-US Strategic Energy Partnership in order “to focus more on clean energy keeping advanced American technology and the rapidly growing Indian energy market.” The move comes as the Biden administration in the U.S. focuses on new priorities and shifts away from the focus on on supply of fossil fuels from America that dominated the U.S.-India energy relationship under President Trump.
India’s Chief of Defense Staff announced the creation of a Joint Logistics Node (JLN) in Mumbai, aimed at providing “integrated logistics cover to the Armed Forces for their small arms ammunition, rations, fuel, general stores, civil hired transport, aviation clothing, spares” as well as “engineering support in an effort to synergise their operational efforts.” The announcement comes as part of the Indian Armed Forces’ effort to create joint theatre commands to enhanced jointness and integrated warfighting between the various branches of the Indian Armed Forces.
India and Australia held the 6th round of their bilateral India-Australia Dialogue on disarmament, non-proliferation and export control. The talks are aimed at facilitating mutual understanding on topics such as nuclear, chemical, biological disarmament and non-proliferation, conventional weapons, outer space security and strategic export control.
The United States and India concluded the 11th edition of their bilateral joint special forces exercise “Vajra Prahar,” which was held in Himachal Pradesh in March 2021.
Four to Read
From cogent analysis to potentially big news that you should keep an eye on, here are a few commentaries and other pieces of writing that I found particularly enlightening:
Dr. Avinash Paliwal, Senior Lecturer at SOAS, University of London, argues: “In 1988, Rajiv Gandhi made the error of conflating tactics with strategy when India supported anti-junta outfits based on a miscalculation that the junta was collapsing. Since then, India went to the other extreme of courting the generals at the expense of other actors. Instead, what is needed is in-depth diversification of relations with EAOs and CRPH, without cutting channels with Naypyidaw. Myanmar is a neighbour, and this is where one would expect India to be bold, creative, and undertake diplomatic heavy-lifting—precisely because China requires countering, regional economies need oxygen, and because it’s worth trying to save lives.”
Darshana Baruah, an associate fellow at the Carnegie Endowment for International Peace, where she leads the Indian Ocean Initiative, writes: “Washington is not alone in engaging the Indian Ocean in silos; Delhi’s political class, too, has divided the ocean into many sub-regions. Traditionally, India draws a line with Mauritius and Seychelles as its areas of strategic collaboration in the Indian Ocean. In terms of sub-regions, the priority is in the northern (Arabian Sea and Bay of Bengal), and eastern Indian Ocean (Andaman Sea and Straits of Malacca). The Indian Navy, on the other hand, defines the region in its entirety as its area of responsibility from the coast of Malacca to the eastern coast of Africa. While India has begun to rectify this division of the Indian Ocean, especially with the establishment of the Indian Ocean division in the ministry of external affairs (MEA) in 2016, the western Indian Ocean and the eastern coast of Africa still continue to be in the maritime periphery in Delhi’s official worldview.”
Richard Rossow, Senior Adviser and the Wadhwani Chair in U.S.- India Policy Studies at the Center for Strategic and International Studies, writes: “India’s startup scene has received a substantial boost in recent years due to specific policy interventions by the government. This focused effort is helping create a stronger ecosystem for emerging entrepreneurs to see their ideas take flight. The US is the envy of the world due to its renowned startup hubs like Silicon Valley, Boston-Cambridge, Seattle, the Virginia Tech Corridor, among others. Many organizations in the US are looking at ways to partner with Indian institutions and startups for mutual success. Such initiatives can set in motion a new, deeper phase of US-India commercial ties in the future—unburdened by the distances and tensions of the past.”
Rita Sharma, former secretary, ministry of rural development and former secretary to the National Advisory Council, argues: “While the Mahatma Gandhi National Rural Employment Guarantee Scheme (MGNREGS) has been a valuable employment tool and safety net, as seen in the migrant crisis, its role in building ecosystems resilient to the climate crisis is being increasingly recognised. There is now an urgent need to bring upfront the scheme’s potential in addressing matters of lives and livelihoods while combating the climate emergency.”
Thanks for reading this latest edition of Indialogue. Please let me know if you have any thoughts or feedback by emailing me at aman@amanthakker.com.