Arun Kumar
Vaccinating the entire population of the country against COVID-19 is a hard feat to achieve given the weak health infrastructure of the country and various other factors like confusion and vaccine hesitancy. A strict lockdown and safety measures are the only way to deal with the second wave of the deadly disease.
COVID-19 was declared as a pandemic by the World Health Organization (WHO) on 11 March 2020. For a while it appeared that the disease had abated in India but suddenly it is in the midst of a crisis due to the massive surge of cases and a breakdown of its medical system in many parts of the country.
Controlling the disease has thrown up a conundrum. While vaccination is proceeding in the country new mutants of the virus have emerged and it is speculated that they may be able to evade the presently available vaccines. While some of the advanced countries have managed to vaccinate a significant percentage of their population by mid-April 2021, some countries have barely started and that would enable the virus to persist and mutate.
The rich countries had ordered 3 billion doses of the vaccine. Canada had ordered enough to vaccinate its population five times over. WHO had cautioned against such actions and had initiated the COVAX program for equitable sharing of the vaccines. It proposed distribution of 2 billion doses to 190 countries.
Caseload and Vaccination Strategy
India started its vaccination on 16 January when its case count was low (15,144) compared to its peak (97,894) in mid-September 2020. On 15 February, cases were down to 9,121 and the country was seemingly in a comfortable situation. Vaccination was proceeding slowly but hospitalization and deaths were dropping almost all over the country. Further, India was in the comfortable position of having the Serum Institute of India (SII), the largest producer of vaccines in the world, which claims that it can annually produce a billion doses and more if needed.
The situation has turned adverse since February. New cases have risen fast in most states, notably Maharashtra, Kerala, Uttar Pradesh, Karnataka, Tamil Nadu and Delhi. Districts in Maharashtra have seen a rapid rise in positivity rates and deaths. There are reports of a new mutant affecting India, which may be the reason for the increase in the number of cases and deaths. This strain is apparently different from the highly contagious South African, United Kingdom and Brazilian variants.
The vaccination program is unfortunately proceeding slowly. In the first month of vaccination, barely one crore people were vaccinated. Not even all the frontline workers had got one dose and many did not come forward for the second one. One crore in a month means only 0.6% of the population had been vaccinated. In Israel, about 50% of the population got vaccinated by mid-February. The pace of vaccination has picked up and by mid-April more than 100 million had been vaccinated with at least one dose, but that is still about 7% of the population.
This contrast between India and Israel is not just due to the latter’s small population but due to differing administrative capacities. India’s weak administration is again in focus. It was known since mid-2020 that vaccination would have to start soon, but adequate protocols and logistics had not been worked out in advance to roll out a massive program.
Vaccines were ordered in January, whereas the United States and Europe had booked massive number of doses six months earlier. There was complacency; officials were assuring the nation that we are used to rapid inoculation and if India can conduct massive elections, it can also vaccinate rapidly. But recently, the country has faced the twin problem of shortage of vaccines and vaccination. This is due to weak infrastructure and people’s skepticism about the disease and vaccination.
At the present rate of vaccination of 30 million per month, if two doses are to be administered to 1.4 billion people it would take 93 months or 7.8 years to vaccinate the entire population. Since children below the age of 18 are not to be vaccinated at present, about 70% are to be vaccinated.
That would still mean 5.5 years. Further, since the immunity due to vaccination may not last more than one or two years, people would need to be vaccinated, say every two years. So, much before everyone gets vaccinated, several booster rounds of vaccination would be needed by those already vaccinated. So, a substantial portion of the population will never get covered.
Alternatively, to achieve herd immunity, 60% of the population has to be vaccinated according to some experts. This number can change with circumstances, but assuming this to be correct, at the current rate of vaccination, it would take 3.3 years. So, even this will not happen and the full benefit of vaccination would not be available.
To achieve herd immunity in one year and if only those above 16 years of age are vaccinated, 14 crore vaccinations per month are needed—an exponential increase is needed within a short period of time. Further, decentralization in vaccination (and not supply of vaccines) is needed so that the states can take their own decisions since they know their administrative and health infrastructure better.
Vaccination Strategies: The Issues
As long as the virus continues to circulate, it can mutate and become more virulent and reinfect the vaccinated population and/or those who have had the disease earlier. Of course, those already vaccinated may get a milder attack but we cannot be sure given the limited knowledge of the virus.
So, along with vaccination, physical distancing and use of masks, etc, remain essential. The fight has to be global since the virus does not respect class or borders—it has spread to the Antarctica and infected Presidents, Prime Ministers and home ministers.
One is still learning about the virus and different nations are adopting different strategies to deal with it. Issues being grappled with are:
- Whether those who have had the disease develop immunity and do they need the vaccine?
- Whether one dose is good enough for people who have been infected?
- What should be the gap between the two doses?
- Which vaccine works better for the elderly?
- Should children be vaccinated now or later?
- How long does the immunity last?
- Can those who are vaccinated still spread the disease?
- Which vaccines can take care of the new mutants?
While initially it was felt that the second dose of the vaccine should be administered after four weeks of the first dose, new research suggests that a longer
interval of up to 12 weeks may be more efficacious. This also enables more people to get the first dose which provides some protection to the population and also speeds up vaccination.
Some feel that those who have had the disease would have developed antibodies and immunity against the disease so they need not be vaccinated. This is one reason for vaccine hesitancy. France had decided to give only one dose of the vaccine to those who have had the disease earlier believing that the antibodies already developed by the infection only need to be boosted.
Children (aged below 16 years) have not been part of the testing, so vaccinating them is not advised at present. Similarly, in the trials for AstraZeneca vaccine, very few of the elderly (above 65 years of age) were included, so the test results are not robust. Consequently, Denmark and Germany are not giving this vaccine to those above 65 while Belgium, Spain and Italy will not give it to those above 55 and Switzerland has not used this vaccine at all. France has recently decided to give this vaccine to the elderly as well. Now with the scare of blood clots in some people below the age of 50, this vaccine is not being recommended for the young in some countries.
However, WHO has advised, considering everything, that it is safe. Actually, the rich countries have an alternative to AstraZeneca but that is not true for the poor countries since the alternatives are expensive and need deep cold storage. Further, it is the older people who are more at risk and need vaccine first. Yes, vaccines have side effects. While only a small percentage of the vaccinated are showing severe side effects, the long-term effects, if any, are not yet known.
Vaccinating children has become crucial since they are usually asymptomatic but spreaders of the disease. In India schools that had started classes for senior children have been found to be spreading the disease. However, many parents cannot go to work if children are at home and not in schools. Tests on children are being sped up so that they can also be vaccinated soon. This is especially so since it is speculated that in the second wave, the young and the children are being affected in larger numbers.
People also ask which is a better vaccine? Pfizer and Moderna are mRNA vaccines which offer greater protection even against the mutant strains. But these are expensive and difficult to handle. South Africa is reported to have returned the AstraZeneca vaccine since it was found to be less effective against the variant spreading there. It is also said that the mRNA vaccine can be programmed reasonably quickly to tackle the newer strains of the virus.
Vaccine Hesitancy
The confused picture has also led to misconceptions about the vaccines. They were developed in record time and approved for emergency use. So, some feel that the vaccines are under-tested and may cause problems. Some believe in conspiracy theories, namely some pharma companies and some rich businesspersons are pushing vaccination for their own profits.
The rapid approval of Bharat Biotech’s Covaxin in India without completion of various phases of trials was criticized by the experts and many of them said that they would not take it. The government initially did not offer a choice of the vaccine to people, so many frontline and health workers did not come forward to take their jabs. This added further to the skepticism.
The picture gets complicated due to misconceptions. Many people believe that vaccines are being pushed for controlling population. Further, certain religious beliefs have militated against vaccination. Earlier also, there has been resistance against polio and measles inoculation.
Has India’s Luck Run Out?
Due to the caseload coming down rapidly in India since mid-September, people had started going about their lives as if the disease had abated. Reports suggested that actually the number of people infected could be more than 30 times the 11 million who had tested positive till March 2021.
That would imply that 23% of the population may have already been infected—way below the level at which herd immunity would kick in. So, the decline in daily cases was not due to herd immunity. It was not even due to heat or young population or measles inoculation, etc. If any of these factors mattered, why did India have a surge till mid-September?
Research does point to lack of hygiene and better immunity among the poor as a possible cause but again why did that not matter earlier? It is also worth pondering why daily cases had come down by mid- February in spite of festivals, farmers’ movement and elections since October. Could it be that a milder mutant was circulating in India? But such luck has run out with a more virulent version circulating and leading to the second wave. So, rapid vaccination is crucial to deal with the virus before it mutates further.
Vaccination is proving to be difficult because of the sequencing which has to be done round by round. One cannot simply go house by house. Prioritization is needed—frontline workers, health staff, those above 50, those with comorbidities and finally the rest of the population. But, initially vaccine hesitancy was in the way with reports of doses being wasted. But, now with the disease surging, many more are coming forward for vaccination. Opening up to everyone in such a situation will lead to chaos and black marketing. Sequencing has to be practiced.
Public–Private Partnership Needed
Administering 14 crore doses per month at the earliest cannot be handled by the public sector alone. The private sector, which has a majority of doctors and
hospital beds, has to shoulder a large part of the burden. But given the overall shortages, central coordination is needed in vaccination, prioritising creation of beds in critical areas, oxygen supply and so on. Lessons from the second and third waves experienced by various countries are that a lockdown becomes necessary. India today needs to slow down the chain of transmission.
Reports of profiteering in testing, equipment, oxygen, etc, have appeared. This is likely to increase with the entry of the private sector in vaccination. A tight check would be required so that the already distressed public does not suffer further. The price of vaccine is another cause of worry as it is being opened up for the private sector. It is likely that the well-off will get the shots quickly, leaving the poor to fend for themselves. In the government centres, there is likely to be overcrowding and chaos.
Testing and vaccination should be treated as a public good and must be given free to everyone with the government paying a fixed rate for vaccination to the private sector. A cess can be levied on transactions in the booming stock markets to fund the vaccination and testing. Only those who trade in the stock market and are well off will pay.
Conclusions
Vaccination remains crucial for protection from COVID-19 but it is not the solution to the immediate problem of the second wave. Only a short and sharp lockdown can slow down the transmission of the disease among people. Further, if the virus is not eliminated everywhere, it can keep mutating and posing a challenge to the vaccines which will have to be tweaked to take care of the mutations. So, a global perspective and continuous research and development are required.
The virus has taught us that we are a collectivity. If the poorer nations are not able to eliminate the virus and if the poor everywhere remain vulnerable, the disease will persist. So, globally, health has to be treated as a public good with governments playing a crucial role.
India faces a stupendous task which can only be tackled effectively if the centre follows a decentralized strategy with states allowed greater role in key aspects of tackling the disease. They understand the local situation better and can better ramp up the health infrastructure to face the huge challenge but for that the centre must provide the funding urgently.
Article first appeared in The Economic & Political Weekly as The Unresolved Issues in Controlling Covid-19: No Time to Lose on May 09, 2021.
About the Author
Dr. Arun Kumar, Malcolm S Adiseshiah Chair Professor, Institute of Social Sciences, New Delhi.
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