The Covid-19 vaccine has finally arrived. Some 50 countries around the world have already started vaccinating their citizens, barely a year after the first alert was issued by China signalled the start of the epidemic.
Britain led the way in the Western world, authorising the vaccine made by US-German pharma alliance Pfizer-BioNTech. Its vaccination campaign started on December 8. Canada and the United States started their vaccination drives on December 14, Switzerland on the 23, Serbia the 24 and the vast majority of the European Union on December 27. All of them are using the Pfizer-BioNTech vaccine. The United States and Canada are also the first two countries to have authorised the vaccine by the American pharma company Moderna.
In early January, the EU authorised Moderna’s vaccine. The green light for the Moderna vaccine from the European Medicines Authority (EMA) and later by the European Commission, was a big boost for European hopes of containing the disease. With the Moderna vaccine, the second one now authorised in the EU, more vaccines would come.
The EU had granted conditional marketing approval earlier for a similar vaccine from the US company Pfizer Inc and German partner BioNTech SE. The Pfizer/BioNTech vaccine has been given to hundreds of thousands of Europeans since the roll-out began though officials in Germany and France were unhappy at the slow rate of progress.
The Moderna vaccine was expected to accelerate the vaccination campaigns in Europe as concerns grow about two more infectious variants of the virus detected in South Africa and Britain.
India begins vaccination drive
A cautious India took time to look into the pros and cons of the effectiveness of different vaccines available and began its vaccination drive from January 16 by inoculating health workers in what is likely to be the world’s largest Covid-19 vaccination campaign.
The world’s largest vaccination programme began at a total of 3006 session sites across the country, which will be connected virtually throughout the exercise. Around 100 beneficiaries will be vaccinated at each of the session sites. A dedicated 24x7 call centre — 1075 — has also been established for addressing the queries related to the pandemic and the vaccination process.
India plans to vaccinate around 300 million people with two doses in the next six to eight months including 26 million infants. The recipients include 30 million doctors, nurses and other front-line workers, to be followed by 270 million people who are either over 50 or have illnesses that make them vulnerable to Covid-19.
As India launches an ambitious effort to vaccinate 300 million people against Covid-19 within six months, it is employing two vaccines — both manufactured domestically but approved under very different circumstances.
One is Covishield, the vaccine developed by Britain’s AstraZeneca and Oxford University, which is being manufactured in India by the Serum Institute, the country’s largest drug-maker. The other is Covaxin, developed by an Indian firm Bharat Biotech in partnership with the Indian Council of Medical Research (ICMR) and the National Institute of Virology (NIV). Covaxin is a whole-virion, inactivated SARS-CoV-2 vaccine with two adjuvants – Algel (alum) and Algel-IMDG.
Government health officials promise that both drugs are effective and say that Indians who line up for the first phase of shots will not be able to choose which drug they receive. The establishing of efficacy of the vaccines on final analysis of phase-3 trials and full licensure may take some more time but India has decided to go with the drive based on the results till date. Given India’s experience with childhood immunisation and administering millions of doses in extremely diverse geographical and socio-economic conditions, there is confidence that the country has the executive ability to fulfil the demand of the vaccination challenges.
There seems to be some divisions among scientists and doctors in India on the sagacity of the government promoting both Covishield and Covaxin as being equivalent to one another. They are not. Covaxin is being administered as part of a clinical trial and its efficacy is not established. But then all the vaccines on offer in the United States or the United Kingdom have some insufficient efficacy. This inspires greater confidence in India about Covaxin.
Even otherwise, candidates chosen for early vaccination are adults — and a significant fraction of them are far more medically literate than the average Indian. It is their experience that is expected to percolate down and influence adoption of the vaccines among the larger population.
Logistics for the vaccination drive were worked out during several trial runs conducted by government staff throughout the country. However, India's weak public health system and low transport connectivity to some parts of the country have raised concerns over how to carry out this mammoth task. The vaccines need to be stored at low temperatures at all times - which will be more challenging as the summer months are approaching. India has readied cooling apparatus for storage, including 45,000 ice-lined refrigerators, 41,000 deep freezers and 300 solar refrigerators.
India's drug regulating authority says Covishield is 72% effective while the results of Covaxin's trials are expected in March. No wonder that India’s Covid-19 vaccination programme, billed by the government as the world’s biggest immunisation campaign, has got off to a tepid start. Hesitancy among frontline health workers, who are being inoculated on priority, glitches in the functioning of the Co-WIN app, and doubts about the safety of the ‘prematurely approved’ Covaxin vaccine are the main reasons for the lower-than-expected turnout at the majority of vaccination centres across the country in the early days of the vaccination programme. Most states and UTs fell short of their targets, with Punjab, Tamil Nadu and Puducherry being the prominent laggards. The far-from-encouraging numbers have prompted NITI Aayog member (health) Dr VK Paul to remind healthcare workers, especially doctors and nurses, of their societal responsibility. Asserting that both Covishield and Covaxin are safe, he has dismissed concerns about adverse effects as ‘unfounded, negligible and insignificant’.
World approves India’s vaccine
After India began its vaccination programme with Covishield developed by Britain’s AstraZeneca and Oxford University and Covaxin, both manufactured domestically, the country has been receiving numerous requests from other countries for vaccines. The requests came both as grant assistance and commercial supplies and these have increased since New Delhi rolled out nearly five million doses of Covishield. Several countries that have been offered or purchased Chinese Covid-19 vaccines, including Brazil and Cambodia, have turned to India for supplies of the AstraZeneca vaccine amid questions about the efficacy of some of the Chinese vaccines.
There is a clear preference for multiple options and India is the preferred option for potential beneficiary countries because of its global reputation as a vaccine manufacturer. Besides, the Serum Institute has the Oxford-AstraZeneca connection. This is good for Indian diplomacy in both South Asia and the extended neighbourhood.
Although India needs a huge number of vaccines to immunise its own people, it is hopeful that with its massive vaccine manufacturing capacity, it will be able to serve the world as well. The Serum Institute of India, which is manufacturing Covishield with Britain’s AstraZeneca and Oxford University, is the world's largest vaccine manufacturer.
In the first week after it began the vaccination programme at home, India has gifted vaccines to seven countries in the region as part of its neighbourhood first policy. It sent to Bhutan 150,000 doses, to Maldives 100,000 doses, to Nepal about 1 million doses, to Bangladesh about 2 million doses, to Myanmar 1.5 million doses, to Seychelles 50,000 doses and to Mauritius 100,000 doses of vaccine. India has also announced to send 500,000 doses of the "made-in-India" Covishield vaccine to Sri Lanka as gift by the end of January.
India’s operational challenges
The most important challenge the vaccination programme is facing is the lack of the trust quotient. In spite of the government’s repeated assurances, the fact that Covaxin was given emergency use authorization in the clinical trial mode is weighing heavily on the minds of some of the intended recipients. The fear of being treated like a guinea pig is probably making them shy away from the early jab. The delay in releasing the efficacy data for the vaccine’s Phase 3 trials has aggravated the trust deficit.
India has begun its vaccination drive but the biggest challenge is how to vaccinate 1.3 billion people and that too urgently. With more than 10 million confirmed coronavirus cases and a battered economy, it is going to be a long task.
The timeline for delivering the universal vaccine programme and the Covid-19 vaccine is very different. Vaccines for pregnant women and children are staggered over an entire year whereas the coronavirus vaccination programme attempts to vaccinate 300 million people (600 doses) in the first six months.
Transporting the vaccine across the sprawling country where the summer starts in March will be a huge problem. Given the summer heat, it will be a big problem to go with Covaxin that needs to be stored at -70 C temperature.
Distributing the vaccines in India’s first mass adult vaccination drive might prove to be a daunting task. It will require expansion of India’s existing cold chain capacity at a break-neck speed, especially in some of the more densely populated parts of the country, where such infrastructure is severely limited. It will also require addressing gaps in India’s existing vaccine distribution network, which a health ministry report flagged a couple of years ago. To meet the target for the first phase of the Covid vaccination drive, the public sector distribution capacity will need to be expanded BY 2-3 times. Can India do it?
What adds to the vaccination challenge is the inter-state disparity in the distribution of cold chain points across the country. For instance, roughly four cold chain points serve a 100,000 population in Gujarat, whereas there is just one cold chain for the same number of people in Jharkhand. Jharkhand, Uttar Pradesh, and Bihar are among the least served states when it comes to cold chain infrastructure. The unique requirements of the upcoming immunisation drive pose another layer to the distribution challenge. Identifying beneficiaries, ensuring they show up on the day of vaccination and administering a second dose after a month would require a lot of micro-level planning.
Even as India conducts the world’s largest vaccination drive, the active coronavirus infection tally in the country has continued to decline. The country reported a net reduction of 1,254 cases on January 24 to take its count of active coronavirus cases to 1.84 lakh, the lowest since June 24 and 81.9% lower than the September 18 peak of 1,017,754. India’s share of global active coronavirus cases has declined to 0.72% (one in 141). In the week ended on January 24, India recorded 96,025 fresh cases; the lowest weekly figure in seven months. The country is now 13th among the most affected countries by active cases.
Maybe, the sharp decline in new infection cases and the fatality rate are weighing upon the people and the government. While the decline in fatality rate is making people hesitant to take vaccines, the government officials too feel that everybody is not required to be immunised – 50-60% would be enough.
But these are simple inferences, for the newly discovered Brazilian coronavirus variant is feared to be far more infectious. Experts from Germany's Robert Koch Institute say the Brazilian mutation is similar to the South African variant, which is seen as more contagious than the original virus. A third mutation that has emerged in the UK has added to fears about the pandemic, with scientists worrying that these more transmissible variants could step up the outbreaks across the globe.
There are several Covid vaccines under development including many with new mechanisms of action that could hopefully prove effective for the new mutants.