essay on vaccination drive in india

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• Published: 21 April 2021

Strategy for COVID-19 vaccination in India: the country with the second highest population and number of cases

• Velayudhan Mohan Kumar   ORCID: orcid.org/0000-0002-8477-6679 1 ,
• Seithikurippu R. Pandi-Perumal   ORCID: orcid.org/0000-0002-8686-7259 2 ,
• Ilya Trakht 3 &
• Sadras Panchatcharam Thyagarajan   ORCID: orcid.org/0000-0002-4585-5243 4  

npj Vaccines volume  6 , Article number:  60 ( 2021 ) Cite this article

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Free vaccination against COVID-19 commenced in India on January 16, 2021, and the government is urging all of its citizens to be immunized, in what is expected to be the largest vaccination program in the world. Out of the eight COVID-19 vaccines that are currently under various stages of clinical trials in India, four were developed in the country. India’s drug regulator has approved restricted emergency use of Covishield (the name employed in India for the Oxford-AstraZeneca vaccine) and Covaxin, the home-grown vaccine produced by Bharat Biotech. Indian manufacturers have stated that they have the capacity to meet the country’s future needs for COVID-19 vaccines. The manpower and cold-chain infrastructure established before the pandemic are sufficient for the initial vaccination of 30 million healthcare workers. The Indian government has taken urgent measures to expand the country’s vaccine manufacturing capacity and has also developed an efficient digital system to address and monitor all the aspects of vaccine administration.

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Introduction

A year has passed since the first case of novel coronavirus infections was detected in China’s Wuhan province. During the initial period of the disease, the efforts were concentrated on preventing and slowing down transmission 1 , 2 , 3 , 4 , 5 , 6 . Global analysis of herd immunity in COVID-19 has shown the urgent need for efficacious COVID-19 vaccines 7 . Currently, the vaccine development efforts have started to come to fruition as some of the leading vaccine candidates have shown positive results in the prevention of clinical disease 8 , 9 , 10 , 11 , 12 .

Although not mandatory, India with its estimated population of 1380 million (as of 2020) is planning to administer the vaccine to all its citizens who are willing to take it. Importation of vaccines might not be the best option for India due to its large population. According to the International Air Transport Association (IATA), it would require thousands of flights to transport the vaccine from the production sites abroad to the distribution areas.

India, which has a robust vaccine development program, not only plans for domestic manufacture of COVID-19 vaccine but also for its distribution in countries that cannot afford to buy expensive vaccines from the Western world. In India, the data emanating from clinical trials of different vaccines support their eligibility for emergency authorization, even though some of the final details are not available yet. The emphasis now is on the quality control, quality production, and cost control of these vaccines to make them affordable to even the poorest nations in the world.

COVID-19 vaccine candidates in clinical trials in India

COVID-19 vaccine candidates that are under production and in clinical trials in India are among the leading products internationally. Apart from India’s indigenous COVID-19 vaccines, some local pharmaceutical and biotech companies have signed collaborative agreements with foreign-based vaccine developers. These collaborations range from conducting clinical trials to large-scale manufacturing of vaccines and their distribution. The list of eight vaccine candidates, currently undergoing clinical trials in India, is shown in Table 1 and their technical details are given in Table 2 13 .

Covishield by the Serum Institute of India

Serum Institute of India (SII), Pune, has signed agreements with a few manufacturers such as Oxford-AstraZeneca, Codagenix, and Novavax. It is now producing at a large scale, the Oxford-AstraZeneca Adenovirus vector-based vaccine AZD1222 (which goes under the name “Covishield” in India), and it has stockpiled about 50 million doses 14 . The company will produce 100 million doses per month after January 2021. SII will ramp up its capacity further to produce 2 billion doses per year. Covishield is produced under the “at-risk manufacturing and stockpiling license” from the Drugs Controller General of India (DCGI), and the Indian Council for Medical Research (ICMR). The ICMR funded the clinical trials of the Covishield vaccine developed with the master stock from Oxford-AstraZeneca.

The SII and ICMR have jointly conducted a Phase II/III, observer-blind, randomized, controlled study in healthy adults at 14 centers in India, for comparison of the safety of Covishield (manufactured in India) versus the original Oxford-ChAdOx1 in the prevention of COVID-19 disease. A total of 1600 eligible participants of ≥18 years of age or older were enrolled in the study. Of these, 400 participants were part of the immunogenicity cohort and were randomly assigned in a 3:1 ratio to receive either Covishield or Oxford-ChAdOx1, respectively. The remaining 1200 participants from the safety cohort were randomly assigned in a 3:1 ratio to receive either Covishield or Placebo, respectively. The safety, immunogenicity, and efficacy data of ChAdOx1 administered in two doses containing 5 × 10 10 viral particles on 23,745 participants aged ≥18 years or older from clinical studies outside India showed the vaccine efficacy to be 70.42% 15 . The safety and immunogenicity data generated from the clinical trial in India was found to be comparable with the data from previous trials conducted outside of India.

The SII has applied to DCGI for permission to do clinical trials in India for Covovax (NVX-CoV2373) developed in partnership with Novavax 16 . They are hopeful of launching the vaccine by June 2021. The US-based pharma claims that their Covid jab was found to be 89.3% effective in a UK trial.

Covaxin by Bharat Biotech Ltd

India’s first domestic COVID-19 vaccine, Covaxin TM , developed and manufactured by Bharat Biotech International Limited, in collaboration with the National Institute of Virology of ICMR, is one of the two vaccines of the company, undergoing clinical trials, and is being stockpiled under an “at-risk manufacturing and stockpiling license”.

Covaxin TM is an inactivated-virus vaccine, developed in Vero cells. The inactivated virus is combined with Alhydroxiquim-II (Algel-IMDG), chemosorbed imidazoquinoline onto aluminum hydroxide gel, as an adjuvant to boost immune response and longer-lasting immunity. This technology is being used under a licensing agreement with Kansas-based ViroVax. The use of the Imidazoquinoline class of adjuvants (TLR7/8 agonists), shifts the T-cell response towards Th1, a T-Helper 1 phenotype (which is considered safer than Th2 responses against SARS-CoV-2) and reduces the risk of immunopathologically mediated enhanced disease 17 .

Bharat Biotech Ltd and ICMR began Phase-III trials of Covaxin TM on November 16, 2020, with 26,000 volunteers across 25 centers in India. According to the company, it is the largest clinical trial in India for a COVID-19 vaccine. The firm has generated safety and immunogenicity data in various animal species such as mice, rats, rabbits, Syrian hamster, and also conducted challenge studies on non-human primates (Rhesus macaques) and hamsters. All these data have been shared by the firm with the drug regulatory body of India. Phase-I and Phase-II clinical trials were conducted on approximately 800 subjects and the results have demonstrated that the vaccine is safe and provides a robust immune response and protection. The Phase-III efficacy trial was initiated in India on 25,800 volunteers and to date, ~22,500 participants have been vaccinated across the country. As per the data available currently, the vaccine is safe. Bharat Biotech has stockpiled 10 million doses of Covaxin and will be ready with another 10 million by February 2021. The company will produce 150 million doses by July–August 2021, and they will be ready with 700 million doses by the end of 2021. The firm is also preparing a protocol to expand the testing of its vaccine in children aged 2–15 years.

ZyCoV-D by Cadila Healthcare (Zydus Cadila)

Production of another domestic COVID-19 vaccine, ZyCoV-D by Cadila Healthcare, Ahmedabad, based on the new plasmid DNA vaccine technology, is supported by the Department of Biotechnology, Government of India. Vaccines based on plasmid DNA technology are not licensed for public use. Plasmids are used as vectors to directly deliver the DNA encoding the target antigens into the body of the recipient. Sequence encoding for the pathogen’s antigen is engineered into recombinant plasmid DNA. It is used as the vaccine vector so that the vaccine antigens are directly produced by human cells, thus eliciting an immune response. The Phase-I trials of this vaccine began on July 13, 2020, on volunteers of 18–55 years of age. As ZyCoV-D showed promise in a Phase-I study, and the drugmaker Cadila is currently finishing Phase-II trials on over 1000 volunteers across nine sites. This vaccine is administered intradermally.

COVID vaccine (still unnamed) by Biological E. Limited

Biological E. Limited (BE) has initiated a Phase-I/II clinical trial in India of COVID-19 vaccine (RBD219-N1) produced in collaboration with Dynavax Technologies Corporation and Baylor College of Medicine. BE’s COVID-19 vaccine candidate is based on classical vaccine technology of a protein antigen, SARS-CoV-2 Spike RBD, adsorbed to the adjuvant Alhydrogel (Alum), in combination with another approved adjuvant, CpG 1018. The RBD of the S1 subunit binds to the angiotensin-converting enzyme-2 (ACE2) receptor on the host cell membrane and facilitates virus entry. The results of these clinical trials are expected to be available by February 2021. BE’s Phase-I/II clinical trial will evaluate the safety and immunogenicity of the vaccine candidate at three different doses in about 360 healthy subjects in the age group of 18–65 years. The vaccination schedule consists of two doses (of the same strength) for each study participant, administered via intramuscular injection, 28 days apart.

A locally developed, but still unnamed, COVID-19 vaccine of BE has also been given regulatory approval for clinical trials in India. Details of the drug trials have not yet been disclosed.

Sputnik V by Dr. Reddy’s Laboratories

Gam-COVID-Vac, trade-named Sputnik V, is a COVID-19 vaccine developed by the Gamaleya National Center of Epidemiology and Microbiology of Moscow, Russia. Sputnik V is a two-vector viral vaccine based on human adenoviruses. Sputnik V uses adenoviruses Ad5 and Ad26 18 . The recombinant adenovirus types 26 and 5 are biotechnology-derived and contain the SARS-CoV-2 S protein cDNA. Both of them are administered into the deltoid muscle. The Ad26-based vaccine is used on the first day and the Ad5 vaccine is used on the 21st day to boost immune responses. Russia’s Sputnik V vaccine stipulates storage at a temperature not higher than −18 °C.

Dr. Reddy’s Laboratories, located in Hyderabad, have received regulatory approval from the DCGI to conduct mid-to-late-stage human trials for Russia’s Sputnik V vaccine in India. Russia’s RDIF-Gamaleya Institute has signed agreements with more than one Indian company for the large-scale manufacture of their Sputnik V vaccine.

mRNA vaccine (still unnamed) by Gennova Biopharmaceuticals Ltd

The latest COVID-19 vaccine candidate that was granted conditional permission for Phases 1 and 2 of the human clinical trials by DCGI is the mRNA vaccine developed by the Pune-based Gennova Biopharmaceuticals Ltd in collaboration with HDT Biotech Corporation, USA.

COVID-19 vaccination in India

The government of India has constituted a National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) to provide guidance on all aspects of COVID-19 vaccine administration in India 19 . According to NEGVAC, the COVID-19 vaccine will be offered first to healthcare workers, frontline workers, and to persons above 50 years of age (with first preference for those above 60), followed by persons younger than 50 years of age with associated comorbidities. The government has set up a committee comprising experts from various specialties including oncology, nephrology, pulmonology, and cardiology to define the clinical criteria, based on which people with comorbidities should be prioritized for Covid-19 vaccination. Committee has recommended that anyone with a congenital heart disease that leads to pulmonary arterial hypertension, end-stage kidney disease, or cancers such as lymphoma, leukemia, myeloma, decompensated liver cirrhosis, primary immune deficiency conditions, and sickle cell anemia should be included in the priority. The latest electoral roll for the general election will be used to identify the population aged 45 years or more. The cut-off date for determining the age will be January 1, 2021. There will be a provision for self-registration for vaccination, for those eligible persons who have been missed out from the rolls for one reason or other, after giving some proof of identity. After vaccinating nearly 300 million of the population in the first phase, the remaining population will receive the vaccine based on the disease epidemiology and vaccine availability.

The Government of India has arranged to procure 600 million doses of the COVID-19 vaccine from the manufacturers highlighted above and is negotiating for another billion doses. Covishield, produced by SII, and Covaxin produced by Bharat Biotech Ltd were procured by the government, and are administered initially. Nevertheless, the government may alter its strategy, as and when the other vaccines are cleared for administration after the clinical trials. While obtaining the vaccine is the first requirement, distribution, and vaccination of the huge Indian population presents a significant logistic challenge. On November 24, 2020, Indian Prime Minister Shri Narendra Modi discussed the vaccine distribution strategy with the chief ministers and other representatives of states and Union Territories (UTs). He visited the three leading companies on November 28, 2020 to have first-hand information, and to assure them of full support from the government.

The companies SII, Bharat Biotech, and Pfizer India had applied for “emergency use authorization” of their vaccines. All their applications were reviewed by the expert panel at the Central Drugs Standard Control Organization (CDSCO) for their suitability for vaccination in this country. During the second round of discussions, Covishield, the vaccine candidate from Pune-based SII, was approved for emergency use by the Subject Expert Committee (SEC) of DCGI on January 1, 2021. They have approved the vaccine to be given in two doses 4–12 weeks apart. This time interval is similar to that employed by the UK, and the company is allowed to deploy its vaccines to priority groups, even though a full safety assessment has not been completed. Bharat Biotech was asked to furnish more data demonstrating the efficacy of its candidate, Covaxin. On January 2, 2021, the SEC gave its approval to Bharat Biotech’s Covaxin coronavirus vaccine also for emergency use. These recommendations, along with rollout modalities, were taken up by the DCGI. In a major development, on January 3, 2021, DCGI approved two COVID-19 vaccines for restricted emergency use in the country 20 . Bharat Biotech’s Covid-19 vaccine Covaxin has been recommended for conditional approval (i.e., to be administered under clinical trial mode) by the DCGI based on Phase 3 immunogenicity data for 24,000 volunteers after the first dose, and for 10,000 volunteers after the second dose. Conditional approval of Covaxin was based on incomplete Phase 3 trial data, in the context of a possible emergency, especially infection by mutant strains. On behalf of SEC, Director, All India Institute of Medical Sciences (AIIMS) Dr. Randeep Guleria explained that the Bharat Biotech vaccine will be used in an emergency when there is a sudden increase in cases and need for vaccination. Covaxin can also be used as a backup if questions arise on the efficacy of the SII’s vaccine. According to Dr. Harsh Vardhan, the Health Minister, Covaxin has immunogens (epitopes) from other proteins, in addition to those from Spike proteins. This makes it more likely to work against variants like the N501Y variant (UK variant) 21 . Moreover, Covaxin data showed that it not only produced antibodies in all the participants but it also sensitized CD4 T lymphocytes that impart a durable immune response. The technology used for Covaxin production allows it to target various components of the virus, like the membrane glycoprotein and nucleoprotein, in addition to the spike protein. Managing Director of Bharat Biotech Dr. Krishna Ella said that they will be able to establish Covaxin’s ability to protect against mutant strains of the novel coronavirus, detected in the UK and 30 other countries. Dr. Ella explained that the approval of the SEC of DCGI only means that the firm will no longer require to have a placebo group in its ongoing clinical trial, and will vaccinate people in an open-label format. The safety and efficacy of the drug was to be closely monitored. However, Bharat Biotech announced on March 3, 2021, the results of the third round of clinicals trials showed that Covaxin was 80.7% effective in preventing COVID-19. After going through Covaxin’s Phase 3 trial data, the subject expert committee gave emergency use authorization for this vaccine, and so Covaxin is no longer administered under clinical trial mode.

Pfizer India has reportedly sought more time, but the company’s mRNA vaccine has already been approved, under emergency use conditions, in a number of countries including the USA and UK, and by the World Health Organisation (WHO). Though the extremely low temperature of −70 °C required for storing the Pfizer vaccine poses a big challenge for its delivery in India, the company has hinted at making the necessary arrangements for the same. However, the present laws in India do not normally permit the usage of any vaccine (like the Pfizer vaccine) that has not undergone proper clinical trials in India. Though people above 50 years of age have been prioritized for vaccination by the government, a decision on the administration of Covishield to those above 60 and below 18 had to wait, as clinical trials have not been carried out yet on these age groups of the population. However, the government had relaxed the rules for marketing drugs in India by introducing the “New Drugs and Clinical Trials Rules, 2019”. The need for local clinical trials was also waived in the new rules if the drug is already been approved by any of the DCGI- approved countries, which the DCGI can decide on a case-to-case basis. Approvals by USA, UK, and WHO can be taken into consideration and DCGI may give approval for mRNA vaccine and also for the administration of Covishield and Covaxin to other age groups.

Regional Director, WHO South–East Asia Region, Dr. Poonam Khetrapal Singh, welcomed the first emergency use authorization given to the COVID-19 vaccine. According to her, this decision taken by India will help to intensify and strengthen the fight against the COVID-19 pandemic in the region. The use of the vaccine in prioritized populations, along with the continued implementation of other public health measures and community participation will be important in reducing the impact of COVID-19.

COVID-19 vaccine distribution: functional cold chain

India has sufficient manufacturing capability for the vaccine (more than 2.4 billion doses annually) and various medical and surgical disposables such as vials, stoppers, syringes, gauze, and alcohol swabs. However, the first bottleneck was the storage and transportation of the vaccines, as this requires very specific temperature regimens. Some of the vaccines under development and production in other parts of the world require storage temperatures as low as −80 °C. Fortunately, the vaccines that India has introduced first for distribution in the country require a storage temperature of 2–8 °C only. The government has been working on measures for the quick and effective distribution of the COVID-19 vaccine. Vaccine manufacturers have started airlifting the vaccines in cold boxes with digital temperature tags to four major depots at Karnal (Haryana), Mumbai, Chennai, and Kolkata, where they are stored in walk-in coolers. From there, planes or insulated vans would transport the vaccines to the designated stores in 37 States/UTs. From these 41 centers, they are further transported to temperature-controlled facilities at the district-level vaccine stores by the State/UT governments. The vaccines are stored in ice-lined refrigerators (ILRs) in districts, from where they are transported to distribution centers in cold boxes and then in ice-packed vaccine carriers to vaccination sites. Real-time remote temperature monitoring of 29,000 cold-chain points is already done through COVID Vaccine Intelligence Network (Co-WIN) vaccine delivery management system, which is a cloud-based digitalized platform. Co-WIN platform was developed by India, but any country can use it. The Indian government will extend assistance for the same.

The initial batches of COVID-19 vaccines are administered through the Universal Immunization Program (UIP) mechanism already operational in India, and it will recruit private cold-chain operators to boost up the capacity. Through UIP, the government is currently, immunizing 26 million children and 30 million pregnant women annually. As UIP has over 26,250 functional cold-chain points at subdistrict or rural level centers (out of its total 28,932 points), vaccines can be stored at facilities not far from the vaccination sites. With the 85,622 cold-chain equipment that UIP has, and the other cold chain infrastructure of the immunization program, the government of India can manage 600 million doses and the private sector can manage 250–300 million doses annually. It could be surmised that with the present capacity, about 400 to 450 million people can be vaccinated in India annually. It indicates that vaccination in India that started from January 2021 would be able to vaccinate only about one-third of the population, by the beginning of 2022, even if it uses the present capacity of the immunization program entirely for COVID-19 vaccination. This is only a theoretical assumption, as India cannot afford to neglect all other vaccination programs under UIP, for the sake of COVID-19. Thus, there is an urgent need to expand the cold-chain infrastructure for storage and transport, as India, the world’s second-most populous nation, moves into the next stage of managing the COVID-19 pandemic. On October 15, 2020 itself, Dr. Harsh Vardhan, the Health Minister of India had directed the states to make a robust plan for vaccine storage and distribution.

The government of India would look for companies, including private ones in each city, which have cold storage facilities and which can take care of distribution, under the regulatory control of the government. Synergistic use of the food cold chain is what the government can use during this time of health emergency. Their facilities would require some minor redesign of storage and transportation. The food cold chain normally has the necessary infrastructure facilities and a complex supply of chain logistics and management.

Manpower requirement

India’s UIP currently has 55,000 cold-chain staff, and 2.5 million health workers. It will be the health workers, as first-line responders who are getting the vaccination initially. According to government officials, the current healthcare infrastructure may not require additional manpower for administering the vaccine to the healthcare workers. For the second round of vaccination of the priority groups such as the elderly population, persons with comorbidities, pregnant women, and children, a much larger number of trained medical and paramedical staff experienced in vaccine administration will be in place to handle the workload. Understandably, these newly recruited staff will receive the vaccination before they become members of the workforce. Vaccination of people above 60 years and those above 45 with comorbidities have already started from March 1, 2021.

The government of India had asked the states to start training the additional personnel. The orientation of vaccinators through a virtual platform had started on December 5, 2020. The government of India has launched ‘Integrated Govt. Online training’ (iGOT) portal on the Ministry of Human Resources and Development (HRD)’s Digital Infrastructure for Knowledge Sharing (DIKSHA) platform for the capacity building of frontline workers on COVID-19. This platform has training resources that may be accessed by health staff in case they are unable to access the training session or if they want to revisit the training resources. The identified manpower from all the states has been trained in handling the Co-WIN system. COVID-19 vaccine is now introduced only after all training is completed in the district/block/planning unit levels.

Though virtual training methods were used wherever possible, the majority of the training was conducted through the classroom platform. The newer training modalities emphasized “the new normal”, i.e., mitigation of the risk of transmission. For this purpose, 49,604 Medical Officers (in 681 districts) were trained on operational guidelines. The government has already trained 2360 trainers, who would, in turn, train immunization officers, cold-chain officers, IEC (Information, education, and communication) officials, and development partners. As we are reporting, more than 7000 of them have already completed their training, though the number of people required will be several times more than that. More than 18,000 new blocks have been created for vaccination. Trained vaccination teams have already been deployed at 1400 blocks. Each vaccination team will have five members consisting of qualified and trained vaccinators, support staff, and security staff.

As India is planning to have COVID-19 vaccination programs in the urban and rural areas simultaneously, midwives and auxiliary nurse midwives, who have a far greater reach in the interiors and rural areas, were included in the first group of health workers trained in vaccination skills. These trained resources will play a crucial role in the health care of people in rural India. In order to expand a vaccination campaign, the government is planning to engage the allied healthcare workforce including pharmacists and public health workers. Pharmacists may be able to do a better job as a second line of “vaccination warriors” as they have a professional knowledge of maintaining the cold chain and keeping the vaccine intact. It is suggested that the 0.8 million-strong pharmacists in the country could play an important role in this endeavor. At the same time, the existing laws and regulations need to be amended to permit pharmacists to administer vaccines.

The majority of vaccines currently under clinical evaluation need to be administered through the intramuscular route. Later, the vaccinators can be trained adequately to have first-hand experience for administering all modes of injections namely intramuscular, subcutaneous, and intradermal modes. In addition, they should be able to handle different brands of COVID-19 vaccine that will become available in the country in the future. Those vaccines may require a different set of norms for storage and administration. After all this training (e.g., train-the-trainer), the trained personnel can be employed in other places and for other vaccination programs even after this pandemic subsides. They are also trained to monitor and manage common adverse reactions to the injection.

A large number of private clinical laboratories, including diagnostic laboratories, have been established, not only in urban areas but also in the rural areas in India. Most of them have good infrastructural and manpower support. If they become part of the COVID-19 vaccination program, it would be beneficial to both the government and the private clinical laboratories. All these ventures will be executed under strict regulatory control, following standard protocol established by the government agencies, with a standard operating procedure (SOP) to guide the trained workforce. States are augmenting the state helpline 104 (which will be used in addition to 1075) for any vaccine/software-related query. Orientation and capacity building of the call center executives have taken place in the states and UTs.

Implementation of the program

COVID-19 vaccination, at least in the initial phase, will be totally under government control. High-level coordination at national, state, and district levels have been established for effective cooperation and collaboration among the key departments involved in COVID-19 vaccination. Twenty-three ministries/departments and numerous developmental partners are involved in planning for the COVID-19 vaccine introduction. Their roles have been described in the operational guidelines issued by the Ministry of Health and Family Welfare, Government of India 19 . Co-WIN system will be linked to existing UIP programs and it will meticulously monitor and follow up on the immunized individuals. The Co-WIN system will be used not only to track enlisted beneficiaries but it will also to ensure that only pre-registered beneficiaries will be vaccinated in accordance with the prioritization. Enlisted beneficiaries can select vaccination sites nearest to their home. Autogenerated SMS/email intimations are sent to the beneficiaries, vaccinators, mobilizers, and supervisors about the date, time, and place of the session. To observe the staggered approach, beneficiaries are advised by mobilizers to come to the session as per the staggered time slot to prevent overcrowding at the session site. As per the guidelines issued by the Centre for the COVID-19 inoculation drive, 100 people will be injected in each session per day. People will be monitored for 30 min after administering the shots for any adverse event. On the basis of the initial experience, some vaccination sites have been permitted to work for 24 h every day and the number of people to be injected in each session has been increased up to 200, to speed up the vaccination. Experience gained in the vaccination of the first round would be helpful for the improvement of the second and subsequent cycles.

The purpose of this perspective was to highlight the overall crux of the vaccine development and vaccination strategies that were implemented during a pandemic in a densely populated country (India). This report can be viewed as a baseline document for future pandemic preparedness, and to effectively tailor and refine the strategies that will help the population at large 22 , 23 .

India is in a privileged position in producing affordable medical, surgical, and essential generic medicines for the world. It is also well-known that India is the world’s largest manufacturer and worldwide distributor of vaccines. The current COVID-19 pandemic has triggered rapid development, emergency use authorization, and unprecedented collaborative efforts from various stakeholders. Although vaccination might be a cost-effective strategy for survival and a better quality of life for the people as well as for the revival of the economy of India, questions remain. For example, vaccination might not work for some individuals. This, in turn, requires a periodic re-evaluation of the vaccine platforms. Owing to these barriers and gaps in our understanding, the efficacy and safety of COVID-19 vaccination through post-marketing surveillance is of paramount importance and requires long-term follow-up. This should account for both successes and failures, outstanding benefits, and/or its superiority over other types of pharmacological and non-pharmacological treatment regimens. Studies are needed nationally and globally, along with transparent sharing of data and reports among all participating companies, institutions, and nations. This is mandatory for periodic evaluation and re-strategizing COVID-19 management plans. These data analyses can hold the keys to the future effective public health management of COVID-19. India’s experience in immunization for COVID-19 offers tips for strategy preparation, not only for countries with similar economic strength and health facilities but also for the world at large.

Data availability

No datasets were generated or analyzed during this study.

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Kumar, V.M., Pandi-Perumal, S.R., Trakht, I. et al. Strategy for COVID-19 vaccination in India: the country with the second highest population and number of cases. npj Vaccines 6 , 60 (2021). https://doi.org/10.1038/s41541-021-00327-2

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Guest Essay

How India Can Survive the Virus

Vaccines alone won’t save the country.

By Shahid Jameel

Dr. Jameel is a virologist.

NEW DELHI — As of Tuesday, India had over 23 million reported cases of Covid-19 and more than 254,000 deaths. The real numbers may be much higher , as the country reported an average of more than 380,000 new cases per day in the past week.

As a virologist, I have closely followed the outbreak and vaccine development over the past year. I also chair the Scientific Advisory Group for the Indian SARS-CoV2 Consortium on Genomics , set up by the Indian government in January as a grouping of national laboratories that use genetic sequencing to track the emergence and circulation of viral variants. My observations are that more infectious variants have been spreading, and to mitigate future waves, India should vaccinate with far more than the two million daily doses now.

In India the virus was mutating around the new year to become more infectious, more transmissible and better able to evade pre-existing immunity. Sequencing data now tells us that two variants that fueled the second wave are B.1.617, first found in India in December, which spread through mass events; and B.1.1.7, first identified in Britain, which arrived in India with international travelers starting in January. The B.1.617 variant has now become the most widespread in India.

On Monday the World Health Organization designated B.1.617 a variant of concern . When tested in hamsters , which are reasonable models for human infection and disease, B.1.617 produced higher amounts of virus and more lung lesions compared with the parent B.1 virus. Global data shows the B.1.617 variant to be diversifying into three sub-lineages. In a preliminary report posted on Sunday, British and Indian scientists found the B.1.617.2 variant in vaccine breakthrough infections in a Delhi hospital.

On Monday, American researchers reported the B.1.617.1 variant to be neutralized with reduced efficiency by serums from recovered Covid-19 patients and those vaccinated with the Pfizer and Moderna vaccines. Indian researchers reported similar findings in a preliminary report on April 23.

With these variants circulating through India’s still mostly unvaccinated population, public health officials here are trying to determine when the second wave might peak, how big it will be and when it will end.

The estimates vary widely. The Supermodel Group , preferred by the Indian government, estimated cases to have peaked at about 380,000 cases per day in the first week of May. The simulation model by the Indian Scientists Response to COVID-19 , a voluntary group of scientists, predicts that daily cases will reach a peak sometime in mid-May, but it forecasts a much higher peak, about 500,000 to 600,000 daily cases. The COV-IND-19 Study Group at the University of Michigan predicts a peak by mid-May with about 800,000 to one million daily cases.

All models predict India’s second wave to last until July or August, ending with about 35 million confirmed cases and possibly 500 million estimated infections. That would still leave millions of susceptible people in India. The timing and scale of the third wave would depend on the proportion of vaccinated people, whether newer variants emerge and whether India can avoid additional superspreader events, like large weddings and religious festivals.

What worries me is that we may not even be able to measure the peak cases accurately. Data show that testing is increasing at a far slower rate than cases. In this scenario, numbers will reach a plateau — not because case numbers have stopped rising but because testing capacity will be tapped out. The national average test positivity rate is over 22 percent, but several states have rates that are, alarmingly, even higher — including Goa at 46.3 percent and Uttarakhand, which hosted the Kumbh festival, at 36.5 percent. “India will have a manufactured peak of about 500,000 daily cases by mid-May,” argued Rijo M. John, a health economist.

Vaccines remain one of the most effective public health tools, and vaccination with speed is shown to significantly reduce the spread of the coronavirus. India started its vaccination drive in mid-January with a sensible plan to vaccinate 300 million people in phases — health care workers, frontline workers and then people above 60 years of age or above 45 years with comorbidities. And as a leading supplier of vaccines worldwide — India supplies about 40 percent of all the world’s vaccines — two Indian companies, Serum Institute of India and Bharat Biotech, were well positioned to execute.

But by mid-March only 15 million doses had been delivered, covering a mere 1 percent of India’s population. The vaccination drive was hobbled by messages from Indian leadership that the country had conquered the virus and by news from Europe associating fatal blood clots with the AstraZeneca vaccine, which remains the mainstay of India’s vaccination rollout.

When the second wave arrived, only 33 million people, about 2.4 percent of the population, had received one dose and seven million people had received both doses. On May 1, vaccination opened for everyone older than 18 years, but many states have reported shortages and the pace of vaccination has slowed down . Local supplies are expected to stabilize by July, but their low penetration cannot reverse the current wave of infection and death in India.

Covid-19 vaccines mitigate disease, but they may not prevent infection, especially when transmission rates are as high as they are now. Though good data is lacking, variant viruses with evasion potential may also have a role in “breakthrough” infections in vaccinated people.

The immediate need is to reduce spread by increased testing and isolation of people who test positive. Several Indian states are under lockdown. This would “flatten the curve,” allowing health care facilities and supplies to regroup. Rapidly enhancing the health care infrastructure will also save lives. India should increase available hospital beds by setting up temporary facilities, mobilize retired doctors and nurses, and strengthen the supply chain for critical medicines and oxygen.

At the same time, India cannot allow the pace of vaccinations to slow. It must vaccinate at scale now, aiming to deliver 7.5 million to 10 million doses every day. This will require enhancing vaccine supplies and doubling delivery points. There are only about 50,000 sites where Indians can get vaccines right now; we need many more. Since only 3 percent of these delivery points are in the private sector, this is where capacity can be added.

All of these measures have wide support among my fellow scientists in India. But they are facing stubborn resistance to evidence-based policymaking. On April 30, over 800 Indian scientists appealed to the prime minister, demanding access to the data that could help them further study, predict and curb this virus.

Decision-making based on data is yet another casualty, as the pandemic in India has spun out of control. The human cost we are enduring will leave a permanent scar.

Shahid Jameel is a virologist and director of the Trivedi School of Biosciences at Ashoka University in Sonipat, India.

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India’s Covid-19 vaccination drive, one year on | Recap

On january 16, 2021, india administered its first dose of a covid-19 vaccine. it has been one eventful year since the country’s vaccination drive began. here’s a look back at all the highlights..

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One year ago, India set out on the challenging journey of vaccinating its massive 1.38 billion-strong population against Covid-19.

In the year since the country’s vaccination drive began, 90 per cent of the eligible population has received the first dose and 60 per cent has got their second dose too. Additionally, precautionary doses, commonly known as booster shots, are now being given to frontline workers and vulnerable individuals above the age of 60 years.

A lot has happened since the first vaccine dose was administered on January 16, 2021. The country has battled both vaccine hesitancy and vaccine shortage to arrive at the current plateau in vaccine demand. "The vaccination drive has been a success because there has been very little vaccine hesitancy compared to the rest of the world," said Dr Monica Mahajan, director of internal medicine, at Max Healthcare.

HOW MANY DOSES HAVE BEEN ADMINISTERED?

More than 156 crore vaccine doses have been administered in India so far under the national vaccination drive. Of these, more than 90 crore are given as first doses, 65 crore as second doses and 42 lakh as ‘precautionary doses’.

#LargestVaccineDrive India’s cumulative vaccination coverage achieves 156 crore landmark milestone More than 57 lakh Vaccine doses administered today till 7 pm https://t.co/5Up0q2tBHb pic.twitter.com/bdjdi4e1P7 — Ministry of Health (@MoHFW_INDIA) January 15, 2022

PHASES OF VACCINATION DRIVE

The Indian vaccination drive has been carried out in phases.

January 16, 2021: Vaccination drive began for frontline and healthcare workers

March 1, 2021: Vaccination drive began for those above the age of 60 years and those with co-morbidities in the 45-60 year age group

April 1, 2021: All above the age of 45 years became eligible for Covid vaccination

May 1, 2021: All adults (18+) became eligible for Covid vaccination

November, 2021: Government launched Har Ghar Dastak (door-to-door) vaccination campaign to achieve 100 per cent first dose coverage

January 3, 2022: Adolescent population (15-18 years) began receiving Covid-19 vaccine

VACCINES APPROVED IN INDIA

Over the last one year, eight Covid-19 vaccines were approved for emergency use in India. These are Serum Institute of India’s Covishield, Bharat Biotech’s Covaxin, Russia’s Sputnik V, Moderna, Johnson and Johnson’s single-dose vaccine, Zydus Cadila’s ZyCoV-D, Serum Institute of India’s Covovax and Biological E’s Corbevax.

However, Covishield and indigenously developed Covaxin have been the backbone of India’s vaccination drive. While Sputnik V failed to take off in India, ZyCoV-D has not been rolled out yet. Meanwhile, Moderna has not been able to enter the Indian market as an agreement has not yet been reached.

Bharat Biotech’s Covaxin has faced manufacturing challenges, facilities like bio-safety level 3 (BSL-3) laboratories have been improved with aid from the government. At present, Covaxin is the only vaccine being administered to children.

CHALLENGES FACED

India’s vaccination drive has not proceeded without its fair share of hurdles along the way. The government was criticised over a delay in ordering vaccines.

"We should've booked our vaccines in June 2020 when the initial vaccine candidates were ready and field trials were beginning. This would've helped us gain lot of months," said Professor Dileep Mavalankar, director at Indian Institute of Public Health, Gandhinagar.

Additionally, the country’s decision to export vaccines to other countries attracted ire, especially as the devastating second wave struck India. The initiative, called Vaccine Maitri, was suspended temporarily in April 2021. Critics claimed that Vaccine Maitri was an “image-building exercise” for the prime minister.

As India faces a third wave of Covid-19 led by the Omicron variant, the vaccination drive will continue to play a decisive role in the battle against the pandemic. "It is because of the people of India who have got themselves vaccinated that we are seeing minuscule fatalities and less hospitalities even during this severe wave of the pandemic," said Dr Vikramjeet Singh, senior consultant at Aakash Healthcare in Delhi.

ALSO READ: Why Corbevax, Covovax haven’t made the cut for the third dose yet?

ALSO READ: 'Bed-ridden' man in Jharkhand starts walking after receiving Covid vaccine Published By: Tarini Mehta Published On: Jan 16, 2022 --- ENDS ---

• MyGov Updates

World’s Largest Vaccine Drive Reading Time : 7 minutes -->

The National COVID-19 vaccination drive of India is world’s largest vaccination drive and has been unprecedented in both scale and reach.

As India crosses 1,35,99,96,267 vaccine doses and closes in on a historic milestone of administering 200 cr Covid vaccination doses in record time, the sheer speed, scale and safety with which the drive has been conducted, has made the entire world take notice. We have now vaccinated more than 50% of the adult population with both doses of vaccine, and approximately 85% have received one or two doses.

The vaccines developed by the Astra Zeneca with Oxford University and local firm Bharat Biotech is the part of the drive that could inoculate about 300 million people on priority basis this year (2021).

The online platform being used to monitor vaccination stocks, storage temperature and individual tracking of beneficiaries for COVID 19 is Co-WIN. A dedicated 24/7 call center -1075 has been established to address all queries related to the software, vaccine roll-out and the COVID 19 pandemic. The website Co- WIN has performed exceptionally.

These are not small or insignificant achievements especially given the enormity of challenges that India faced. In the past, it took decades for vaccines that had been developed globally to be introduced in India. This could not have been possible without the planning and administrative vision of the Central government, coordination and implementation by the states, execution and dedication of the lakhs of health care workers but most importantly the full-fledged participation of the people of India, who at a time when social distancing has been prescribed, have understood the value to unite under the leadership of PM Modi to defeat this foreign enemy that has caused tremendous damage to India and the world. It also proves that, when it is a cause in the national interest or Jan Hit, the people of India, never shy away from uniting in a Jan Abhiyan.

[This Blog is written by Pranjali Kumari, MyGov Saathi]

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Building confidence in the covid-19 vaccine in india, unicef india insights for impact project with facebook.

As the coronavirus pandemic continues to unfold, billions of people across the globe are still waiting to receive their first dose of the COVID-19 vaccine. To meet this need, UNICEF is leading the global distribution of lifesaving COVID-19 vaccines as the key delivery partner of the COVAX Facility — a groundbreaking partnership between the World Health Organization (WHO), the Global Alliance for Vaccines and Immunizations (GAVI), UNICEF, and Coalition for Epidemic Preparedness Innovations (CEPI) to address the multiple facets of the pandemic. To date, COVAX has secured more than 5 billion vaccine doses and, of these, UNICEF has already shipped over 236 million across 138 countries. However, significant challenges in vaccine distribution remain. Not only does vaccine hesitancy continue to grow around the world, the pandemic has also disrupted routine vaccination services that are critical for protecting children against preventable diseases in more than 70 countries.

To better understand constraints to vaccine adoption, Facebook’s Data for Good team is leveraging its Insights for Impact program to help equip UNICEF and its key partners with information and tools to build public confidence in both routine and COVID-19 vaccines. Beginning as an eight-country pilot in 2020, this collaboration has expanded to include broader support for UNICEF’s vaccine messaging efforts in more than 100 countries with the help of Facebook’s Health Partnerships team. This case study explores how Facebook worked with UNICEF India to address vaccine hesitancy and increase COVID19 vaccine adoption in India.

Defining the Problem

Official statistics in India have counted over 34 million COVID19 cases since the onset of the pandemic and over 450,000 deaths from the disease. [1] At the same time, the number of tests conducted per capita in India remains low and only 30% of the eligible population has been vaccinated from COVID19. [2] Alongside the operational challenges in delivering vaccines to a country of 1.38 billion people, vaccine hesitancy remains a barrier, with health workers facing resistance from people who believe that vaccines aren’t effective, and cause serious side effects.

Insights from Public Posts and COVID19 Trends and Impacts Survey in India

To better understand trends in vaccine hesitancy in India, Facebook’s Data for Good team analyzed thousands of public posts about the topic on Facebook. The research team also included insights on hesitancy from Facebook’s COVID19 Trends and Impact Survey (CTIS), which tracks information on vaccine acceptance at a local level in over 200 countries and territories worldwide.

At the time of analysis, the COVID19 Trends and Impact Survey found that India had one of the highest rates of vaccine acceptance in the world with almost 77% of respondents indicating that they would like to receive the vaccine. While concerns about side effects are typically the main reason for hesitancy, the top factor contributing to hesitancy in India was that people stated that they want “to wait and see if [the COVID19 vaccine] is safe and get it later” which was indicated by 45% of respondents who said they did not want a COVID-19 vaccine. The second most common reason for not wanting the vaccine was “I think other people need it more than I do right now,” which was indicated by 37% of respondents.

Qualitative assessment of the public posts around the COVID19 vaccine in India demonstrated generally positive feelings, with many posts expressing national pride that India produced its own vaccine and, at the time, was distributing its vaccine to other countries. The posts included undertones of social cohesion and a strong national momentum to vaccinate. Many users also shared personal stories of being vaccinated, encouraged others to get vaccinated and showed appreciation for health workers. Lastly, public posts about the vaccine revealed that many people had questions about their availability, about potential side effects and when/how they would be eligible to receive their first dose.

The Importance of Message Testing

Using these insights, the Yale Institute for Global Health, UNICEF and Facebook worked to develop a series of eight campaigns -- four in English and four in Hindi -- all of which targeted both men and women aged 18 years and older in India and had the goal of increasing the public’s confidence in the COVID-19 vaccine. With content designed by the Public Good Projects , the campaigns linked out to the Government of India’s COWIN website which provided more information on vaccines, registration for appointments, and getting their vaccination certificate.

[1] https://www.worldometers.info/coronavirus/?utm_campaign=homeAdvegas1?

[2] https://www.bbc.com/news/world-asia-india-56345591.

Campaign Messages

1. Filling Information Gaps with Emphasis on Safety and Efficacy [English/Hindi]: Given that the CTIS and public post data indicated a mostly positive attitude about vaccination, this campaign approach aimed to fill the information deficit and answer people’s questions about vaccine safety and efficacy. This campaign emphasized vaccine safety by outlining the rigorous testing by scientists and promoted efficacy by outlining that vaccines are the best way to limit the spread of COVID-19.

2. Countering the “Wait and See” Approach [English/Hindi]: Given the high proportion of hesitancy being driven by those choosing to “wait and see” if the vaccine was safe, this campaign sought to counter this position with fact-based messaging highlighting the urgency of vaccination using messages like, “Every day you wait to get vaccinated is another day that you could be spreading COVID-19 in your family and community.” This campaign aimed to reassure people, despite the perceived rush to develop and distribute vaccines, that the time for them to be vaccinated is now.

3. National Pride [English/Hindi]: This campaign also sought to capitalize on the social approval expressed in public posts, as well as the national pride that people were expressing at India’s ability to develop its own vaccine and share with other countries ( deploying messages like, “Make India #1 in COVID-19 vaccination” and “Don’t let India down, get vaccinated against COVID-19.” This messaging positioned India as a leader in the global fight against COVID-19 and motivated Indians to join the fight by getting vaccinated.

4. Testimonials/Messengers [English/Hindi]: The analysis of public posts revealed that many people were sharing vaccination testimonies and encouraging their friends to get the vaccine and explaining why they chose to get it. Moreover, public posts often expressed appreciation for healthcare workers. Leveraging these insights, this campaign focused on personal stories of successful vaccination through trusted peers, family members and healthcare workers. The content emphasized minimal side effects and desire to return to normal life.

UNICEF, Yale and Facebook tested the effectiveness of these four approaches, in both languages, over a three week period in July-August 2021. Viewers of each ad set were randomly divided into two groups – those that saw the ads and those that did not. Upon completion of the campaign, viewers from both groups were randomly surveyed to help determine whether the ads had successfully influenced attitudes on vaccination. The post-campaign survey for all eight campaigns tested five different messaging elements, including recall of the campaign itself, the perceived importance of vaccination to prevent COVID-19, and likelihood of advising others to get vaccinated against COVID-19. Of the five questions asked, we asked two custom questions for each campaign.

The eight campaigns reached a combined total of over 98 million people in India. A statistically significant lift was observed in ad recall for four of the eight campaigns, three of which were in English, which indicates that the content was engaging and memorable for English-speaking audiences. Overall, the most successful campaign was the “National Pride” campaign that attained a statistically significant lift for four out of the five awareness and attitude questions for both English and Hindi campaigns. This campaign was particularly effective in increasing the likelihood that Hindi-speakers would advise a close friend or relative to get vaccinated against COVID-19. Meanwhile, the “Testimonials/Messengers” campaign attained an especially strong lift around perceived social approval for COVID-19 vaccination and the “Filling Information Gaps with Emphasis on Safety and Efficacy” worked particularly well in shifting attitudes on the perceived effectiveness of COVID-19 vaccines among English-speaking audiences. The “Countering the “Wait and See” Approach” campaign was the only campaign that did not attain a statistically significant lift for any of the non-ad recall questions.

In terms of language performance, results were mixed across Hindi and English campaigns, with English campaigns achieving higher recall, but Hindi campaigns moved attitudes more significantly. The research team also examined the campaign click-through rates to the India COWIN website and found that the Hindi campaigns had higher click-through rates than the English campaign, indicating this content was more effective in getting people to seek more information.

Overall, the campaigns improved attitudes among the Indian public towards COVID-19 vaccines, including their effectiveness and whether people would recommend COVID-19 vaccines to friends or family. Campaigns emphasizing social norms such as national momentum and content depicting testimonials with diverse messengers including health care workers and parents achieved the greatest lift in attitudes, showcasing the importance of leveraging credible voices in the quest to address vaccine hesitancy.

Influencing Vaccine Decision-making Moving Forward

Vaccine decision-making is complex and influenced by individual observations, experiences, knowledge, and even values and beliefs. Changing vaccine attitudes and behaviors often requires multiple nudges at multiple levels to be effective, including programs that target individuals, communities and even the policy landscape.

Observing statistically significant outcomes as a result of a digital campaign is a substantial accomplishment, showcasing how online outreach can influence complex decision-making at a low cost per person reached, as well as providing valuable insights to UNICEF that can be applied to future vaccine outreach.

Learnings that can be applied to future vaccination campaigns include:

• Consider content leveraging national momentum to vaccinate. In the India context, highlighting social norms and promoting cohesion can be a powerful strategy for building confidence in vaccines. This campaign worked particularly well for increasing the likelihood that Hindi-speaking audience members would advise a close friend or relative to get vaccinated against COVID-19.
• Use Trusted Messengers and Testimonials. Campaign results confirmed that doctors continue to be trusted and effective messengers in the Indian context, aligning with broader research and consensus within the field of vaccine acceptance and behavior change. Furthermore, the campaign results also demonstrated that personal stories about why people chose to vaccinate may be compelling.
• Share practical information and answer common questions. Given the high vaccine acceptance in India and generally positive sentiment from public posts, a campaign may link people to online resources for vaccination information (including safety and efficacy), registration and site locations may be an effective strategy to make it easier for people to get their shot and alleviate their concerns.
• Consider content in local and/or multiple languages. In a country as large and diverse as India, it is important to consider content in the language which will resonate with local populations. Our research found that results were mixed across Hindi and English campaigns, however, the Hindi campaigns had higher click-through rates and were more likely to move attitudes.

Yale and UNICEF plan to leverage these insights in a number of additional countries to increase vaccine acceptance across the many countries in which they work.

“We knew from our social listening reports that there was a high level of vaccine hesitancy amongst the public. There were concerns about the safety and efficacy of the vaccines being given in India, on their availability and lack of access to getting vaccinated. After the second wave in India, there was an urgency and necessity to vaccinate the public. This campaign allowed us to reach a significant audience with important messages, encouraging the public to get vaccinated as soon as possible and measure the impact of our messaging on the audience.” said Brian Alfred Boye, Communication Officer, Communication, Advocacy and Partnerships at UNICEF India.

"This is an incredible opportunity to learn from the power of social media for health promotion. In recent years, my research group and others have found promising leads on how to influence people’s health behavior and these insights provided us the opportunity to evaluate at scale.

The major strength of this effort is the collaboration - particularly with Facebook, UNICEF country offices, and other partners - where we bring together all our unique strengths to address one of the most pressing issues facing global health, vaccine confidence,” said Dr. Saad Omer, Director of the Yale Institute for Global Health.

"Being able to use insights from public posts on Facebook to inform outreach in India showcases the power of digital platforms to increase vaccine awareness and uptake," said Steve Satterfield, VP of Privacy and Public Policy at Meta. "We look forward to continuing the partnership with UNICEF to increase adoption of both childhood immunizations and the COVID-19 vaccine across countries."

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India begins world's biggest Covid vaccination programme

Country of 1.3 billion people hopes to vaccinate 300 million citizens by August

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India has begun one of the world’s biggest Covid-19 vaccination programmes, the first major developing country to roll out the vaccine, marking the beginning of an effort to immunise more than 1.3 billion people.

The first dose was administered to a health worker at All India Institute of Medical Sciences in Delhi, after the prime minister, Narendra Modi , kickstarted the campaign with a national televised speech.

“We are launching the world’s biggest vaccination drive and it shows the world our capability,” Modi said. He implored citizens to keep their guard up and not to believe any “rumours about the safety of the vaccines”.

It is not clear if Modi, 70, has been given the vaccine like other world leaders as an example of its safety. His government has said politicians will not be considered priority groups in the first phase of the rollout.

India has registered more than 10.5m coronavirus cases, the second highest in the world, and 151,000 deaths. The government has been preparing for the vaccine rollout for weeks, and over the past few days shipments were sent to more than 3,000 sites set up for injections.

The Indian health ministry has drawn up plans for 300 million people, almost the equivalent to the population of the US, to be vaccinated by August. Frontline healthcare workers, police and the army have been given priority, with those over 50 and with co-morbidity conditions to follow, all free of cost. Maharashtra, home to Mumbai and the state worst hit by coronavirus, plans to vaccinate 50,000 healthcare workers on the first day of the vaccine rollout.

Across the vast country, more than 200,000 vaccinators and 370,000 team members have been trained for the rollout. Large-scale trial runs have been conducted in at least four states and authorities have readied 29,000 cold storage units to transport and hold the vaccine safely.

Two vaccines have been given emergency approval for India’s immunisation programme; the Oxford/AstraZeneca vaccine, known in India as Covishield, and a domestic product, Covaxin, developed by the pharmaceutical company Bharat Biotech.

The approval of Bharat Biotech’s vaccine, which was co-sponsored by an Indian government body, has proved controversial. Covaxin is still in phase 3 human trials and a full dataset on its efficacy has not been released or peer-reviewed, unlike the Oxford/AstraZeneca vaccine or the Pfizer and Moderna vaccines which have been authorised in the UK and the US.

India’s drugs controller general, VG Somani, insisted Covaxin was “100% safe”.

The government has ordered 5.5m doses of Covaxin and 11m doses of Covishield. Boxes of Covishield were dispatched bearing the message “may all be free from disease”.

Significantly for ease of availability and low cost, both vaccines will be produced domestically. The Serum Institute of India, one of the world’s biggest vaccine makers, has already produced and stockpiled around 50m doses of Covishield.

The institute has billions in pre-orders from countries around the world also desperate for the vaccine. The Indian government is negotiating how much stock to release for export, given fears that it could lead to a domestic shortage.

The government faces another challenge of growing vaccine opposition in India. According to a survey of more than 8,000 people carried out by Local Circles, 69% of Indians are hesitant about receiving the vaccine.

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Challenges facing COVID-19 vaccination in India: Lessons from the initial vaccine rollout

Abhishek pandey.

1 Center for Infectious Disease Modeling and Analysis (CIDMA), Yale School of Public Health, New Haven, Connecticut, USA

Seyed M Moghadas

2 Agent-Based Modelling Laboratory, York University, Toronto, Ontario, Canada

Sandip Mandal

3 Indian Council of Medical Research, New Delhi, India

Sandip Banerjee

4 Department of Mathematics, Indian Institute of Technology Roorkee, Uttarakhand, India

Peter J Hotez

5 National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, USA

Alison P Galvani

With more than 28 million reported cases as of June 5, 2021, India continues to be one of the countries worst hit by the COVID-19 pandemic. After months of steady decline in cases since September 2020, India is now battling a devastating second wave, reaching a global record of more than 400 000 reported cases in a single day at the peak. The resurgence coincides with the emergence of the Delta variant that may be more transmissible [ 1 ]. In an attempt to control the COVID-19 pandemic, India initially authorized the emergency use of two vaccines, each requiring two doses – Covishield developed by Oxford/AstraZeneca and Covaxin developed by Bharat Biotech in collaboration with Indian Council for Medical Research (ICMR) and the National Institute of Virology The vaccination drive in India started on January 16, 2021 with an ultimate target of vaccinating 300 million people by August 2021 [ 2 ]. The first phase of vaccine roll-out prioritized 30 million health care and frontline workers. Vaccine rollout however has been slower than expected and the country is now facing shortages due to an inadequate scale-up of vaccine production so far. Here we discuss the challenges facing COVID-19 vaccination in India using state-level vaccination data during the initial stage of vaccine rollout.

Out of the 30 million individuals prioritized for the first phase, 18 million registered for vaccination and 11.1 million received their first dose. Only 2.46 million people received the second vaccine dose, translating to an uptake rate of 8% nationally. As public health management in India is decentralized, the state governments are primarily responsible for vaccine distribution. We calculated the rate of vaccine uptake for each state by estimating the percentage of eligible individuals registered for vaccination and using data of those receiving at least the first dose of vaccine by the end of the first vaccination phase. We found stark differences in vaccine rollout across states ( Figure 1 ) . Registration of eligible individuals ranged from over 80% in Andhra Pradesh and West Bengal to less than 40% in Nagaland, Punjab, Goa, Mizoram and Tamil Nadu. By the end of February 2021, only four states (Gujarat, Rajasthan, Chhattisgarh and Uttarakhand) were able to vaccinate at least half of those eligible with the first dose. Less than 20% of eligible individuals were vaccinated in the states of Nagaland, Punjab, Tamil Nadu, Mizoram, Goa, and Manipur. In contrast, states of Gujarat, Madhya Pradesh and Rajasthan vaccinated over 80% of those registered ( Figure 1 , Panel C ) . The states of Maharashtra, Kerala, Karnataka, Punjab and Tamil Nadu accounted for more than 80% of all active cases in India by the end of February. Except for Karnataka, vaccination coverage during the initial phase was less than the national average of 35% in each of these high burden states ( Figure 1 , Panel C ) .

Phase 1 vaccine rollout in India. Percentage of eligible individuals that ( A ) registered for vaccination and ( B ) received at least the first dose of vaccine by February 28, 2021. We chose February 28, 2021 as the end time point because Phase II vaccinations started on March 1, 2021. We calculated the state-level number of eligible individuals by using data on the number of health care and frontline workers [ 3 - 5 ], and normalizing the total eligible across states so that the national total added up to the target of 30 million. ( C ) Comparison of percentage registered and vaccinated across states. Dashed lines indicate national averages – 35.44% vaccinated (horizontal dashed line) and 58.06% registered (vertical dashed line) of those eligible for Phase I vaccination by February 28, 2021. Point size is proportional to the number of active COVID-19 cases in the state on February 27, 2021.

To understand the heterogeneities in vaccine distribution in India, we examined the association between vaccination efforts across states with respect to the number of eligible individuals per 1000 population and vaccine delivery infrastructure. We estimated individuals eligible for the initial vaccination phase using state-level data on the number of health care workers [ 3 ], police strength [ 4 ] and prison staff [ 5 ] and normalized the data to match 30 million eligible individuals nationally. State-level vaccination data was obtained from the governments' website CoWin [ 6 ]. We found that lower vaccination coverage was associated with a higher number of individuals eligible for vaccinations per capita ( Figure 2 , Panel A, P  < 0.010). Northeastern states of Nagaland, Mizoram and Manipur, for instance, had more than 75 eligible individuals per 1000 population, but vaccinated less than 20% of those eligible, whereas Uttar Pradesh and Bihar with less than 20 eligible individuals per 1000 population, vaccinated more than 40% of those eligible. Vaccination uptake was positively correlated with vaccine delivery infrastructure such that the states that had a higher number of vaccination clinics per 1000 eligible individuals were able to achieve higher vaccination coverage by the end of the initial phase of vaccination ( Figure 2 , Panel B, P  < 0.010). For example, Gujarat with more than 3 vaccination clinics per 1000 eligible individuals achieved a vaccination coverage of 64%; whereas with less than 1 vaccination clinic per 1000 eligible individuals, Maharashtra was only able to achieve vaccination coverage of 28%.

Association between percentage vaccinated with at least one dose and ( A ) number of eligible individuals per capita and ( B ) number of vaccination sites per eligible individual. The solid line is the regression line and the shaded area represents the 95% confidence interval. Point size is proportional to the number of active COVID-19 cases in the state on February 27, 2021.

India grappled with low rates of both registration and vaccine administration during the initial stages of the vaccination campaign, likely because of vaccine hesitancy, misinformation propagated by social media, and technical glitches in the online registration platform. Vaccine hesitancy in India was fuelled by concerns about vaccine safety and skepticism about the efficacy of the Covaxin vaccine that was approved before the completion of the Phase III clinical trial [ 7 ]. Ensuing suspension of Covishield in multiple European and African countries due to safety concerns, together with rising anti-COVID-19 vaccine sentiments [ 8 ] may have elevated distrust. The steady decline in cases for months in India may have encouraged people to adopt a wait and watch approach, contributing to vaccine indifference. Moreover, the requirement to register online for receiving vaccines may have contributed to low vaccination rates as more than half of the Indian population does not have access to the internet. Our results showed large differences in the pace of vaccination across states likely reflecting the local budgetary constraints and disparity in health care infrastructure.

Despite the slow start, the vaccination campaign in India improved in pace as the country addressed some of the challenges. Initial glitches in the online registration platform have largely been resolved, allowing public health officials to effectively track and plan logistics for the vaccination campaign. Along with online registrations, eligible individuals aged 45 or more can now receive vaccines without pre-registration. Interim results for the Covaxin clinical trials have demonstrated a vaccine efficacy of 81% against symptomatic infections [ 9 ] alleviating concerns about its efficacy. Unlike the initial stage of the campaign, during which vaccines were available only at government clinics, states are now utilizing private hospitals to vaccinate individuals. Given that more than 80% of health care services in India are provided by the private sector [ 10 ], private hospitals can greatly accelerate vaccination rollout.

The devastating second COVID-19 wave in India has overwhelmed an already strained health care infrastructure. The country is now facing a shortage of essential medical supplies and battling a multi-pronged war to contain the second wave as well as to continue vaccination. The resurgence of cases, coinciding with the spread of highly transmissible SARS-CoV-2 variants underscores the urgency to accelerate the vaccine rollout. Although India has emerged as a COVID-19 vaccine development and manufacturing hub providing the country an edge for procurement of vaccines for domestic use, the scale of production has been inadequate. Indian vaccine manufacturers have struggled to ramp up production due to financial constraints as well as due to embargo on the export of raw materials needed for vaccine production by the United States. Extension of eligibility criteria to include all individuals above 18 years of age on May 1st would inevitably require expansion of vaccine supply and vaccination centers to accommodate the substantial increase in individuals targeted for vaccination.

To facilitate the importation of vaccines with emergency use authorization from elsewhere in the world, India has removed the requirement of a local bridging trial. The state governments and Indian corporates can now supplement their vaccine supply by importing doses directly from both domestic and international manufacturers. Efforts to procure and locally manufacture single-dose vaccines, such as those produced by Johnson & Johnson, would facilitate efforts in rapidly expanding vaccine coverage. To alleviate the financial strain and boost domestic capacity, the Government of India is making advance payments to the local manufacturers. Moreover, the United States has agreed to supply raw materials critical for scaling up production of Covishield. The United States has also decided to provide up to 60 million vaccine doses of the AstraZeneca vaccine to other countries, including India [ 11 ]. These ready-to-use vaccines can help bolster the vaccination drive in India.

Photo: From the collection of Ashish Jain, used with permission.

The ongoing humanitarian crisis posed by the second wave of COVID-19 in India could threaten the progress made in other countries and underscores the vulnerability of countries with weak health care infrastructure. Elevated community transmission provides more opportunities for vaccine escape variants to arise, which could prolong the pandemic. Moreover, the halt of COVID-19 vaccine exports from India has impacted the already slow pace of the vaccination drives in many low-income countries. A concerted international effort is therefore imperative to assist India to curtail the transmission effectively and save millions of lives.

Achieving the ambitious target of vaccinating 300 million individuals by August 2021, while challenging, is both feasible and essential to avert an exacerbation of COVID-19 outbreak in the country. As of April 22, 2021, a total of 118. 45 million doses have been administered since the initial vaccine rollout ended, corresponding to a national average of 2.2 million doses per day, which is over 6 times higher than the average daily vaccination rate of 325 000 during the initial phase [ 12 ]. On April 22, 2.7 million doses were administered. At this rate, the goal of vaccinating 300 million people could only be achieved by early October 2021. If the vaccination rate is increased to 3.37 million doses per day, the goal could be reached by August 2021. Going forward, India’s ability to achieve its objectives of vaccination campaigns will depend on boosting vaccine supply, expanding health care capacity, staffing more health care professionals to administer COVID-19 vaccines, overcoming vaccine hesitancy and misinformation, and ensuring an equitable distribution of vaccines.

Funding: APG acknowledges funding from NSF Expeditions grant 1918784, NIH grant 1R01AI151176-01, National Science Foundation grant RAPID-2027755, Centers for Infectious Disease Control and Prevention grant U01IP001136 and the Notsew Orm Sands Foundation. SMM, SM, and SB acknowledge support from the Canadian Institutes of Health Research [OV4 – 170643, COVID-19 Rapid Research].

Authorship contributions: AP and PS conducted literature review and performed data analysis. SMM, SB and PJH provided their insights regarding the evolving pandemic situation in India. All authors contributed to interpretation of data analysis. AP, PS and APG wrote the first draft of the manuscript. All authors edited the manuscript for final submission.

Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest.

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“The COVID-19 vaccination drive demonstrates that India has become Atmanirbhar in vaccination against infectious diseases”, Elucidate.

Topic: Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources.

3.  “The COVID-19 vaccination drive demonstrates that India has become Atmanirbhar in vaccination against infectious diseases”, Elucidate. (250 words)

Reference:  The Hindu

Why the question: The question talks about the vaccination drive and the journey India has taken so far. Key Demand of the question: Discuss in what way finally now India has reached the stage of Atmanirbharta in the journey of vaccination. Directive: Elucidate – Give a detailed account as to how and why it occurred, or what is the particular context. You must be defining key terms where ever appropriate, and substantiate with relevant associated facts. Structure of the answer: Introduction: Start by highlighting the vaccination journey so far travelled by India. Body: Although India will not need to vaccinate its entire population, it would have to vaccinate at least 30-40% of the people to develop herd immunity fully. Even at a minimum scale, approximately 1 billion doses of Covid-19 vaccines will be required, given that most vaccines need a booster dose. Discuss the challenges before it in achieving the set targets. Explain in what way it is finally achieving Atmanirbharta in vaccination against covid-19. Conclusion: Suggest upon the efforts made by government of India and conclude with way forward.

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