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Why India simply may pull off ‘the arena’s greatest vaccination program’

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India will launch its nationwide COVID-19 vaccination program on Saturday. Within eight months, it plans to vaccinate 300 million people—nearly equivalent to the entire U.S. population. And that’s just the first phase of the country’s coronavirus vaccination drive that will eventually extend to India’s nearly 1.4 billion people.

India is the second most populous country in the world, and after the U.S. it has the second-most coronavirus cases in the world. A successful COVID-19 vaccine rollout will be crucial to lowering India’s daily new coronavirus cases and deaths.

The sheer magnitude of the effortthe government is aiming to administer 1.3 million shots per daywill pose a challenge, as will wrinkles that are somewhat unique to India. The country of nearly 1.4 billion, for instance, has 900 million citizens without regular access to the Internet.

Still, a December report by Fitch Solutions said India is well suited to pull off the feat—”The world’s largest vaccination program,” as Prime Minister Narendra Modi has called it—even with the weak spots in its health care infrastructure. The report cited India’s “good track record” of mass vaccination drives as evidence that it can succeed.

Who will get India’s vaccine first?

India’s 10 million health care workers will receive the vaccine first, followed by 20 million frontline workers like police and sanitation staff. Next in line are people over 50 and people under 50 with co-morbidities—diabetes, heart disease, and other conditions that put them at increased risk for a severe case of COVID-19—who number around 270 million. After that, vaccines will become available to the broader population on a voluntary basis.

In December, India’s government released guidelines for states on how to vaccinate their residents in order to reach the 300 million target—around 20% of India’s population—by late summer. The instructions provided training modules for the health care workers administering the vaccines and handling the cold storage technology. The government will be using a digital platform called Co-WIN to track vaccine stocks, storage information, and who gets the doses.

Indian passengers wait in a queue for a temperature check at Bandra train station in Mumbai on Dec. 19, 2020.
Imtiyaz Shaikh—Anadolu Agency/Getty Images

Last week, India carried out the last of three vaccination “dry runs.” It administered dummy vaccines to health care workers at nearly 5,000 sites across the country to catch any blips before the real rollout starts.

After health care and other frontline workers receive the vaccine, the next high-risk group—people over 50—can register online with their phone number and some form of ID, then receive a text message telling them when and where they will get vaccinated. On the day of vaccination, they need to bring their ID for proof of identity. They can verify their identity with a range of proof, including driver’s licenses, passports, pension documents, and Aadhaar cards, India’s 12-digit national identification system that pulls an individual’s biometric data like fingerprints, irises, and photographs.

Once an individual is vaccinated, he or she will receive a QR code certificate to indicate so. The government hasn’t released information on how it plans to reach the hundreds of millions of Indians who don’t have Internet access.

State governments will be in charge of vaccinations within their state, but the central government will bear the cost of the vaccinations, Modi said on Monday.

Which vaccines has India approved?

Modi has attached the “Made in India” label to both of the vaccines that will be distributed in the government’s campaign. One of them, Covaxin, is a homegrown vaccine from Indian pharmaceutical firm Bharat Biotech. The other was developed in the U.K. by Oxford University and pharma multinational AstraZeneca, but it’s being made in India by the Serum Institute of India, the largest manufacturer of vaccines by volume in the world, so Modi has hailed it as India’s own.

Both vaccines are administered in two separate doses, 28 days apart, and both can be stored at a normal fridge temperature of 2 degrees to 8 degrees Celsius, which India’s vaccine transport and storage network can sustain. (Other COVID-19 vaccines, like those made by Pfizer and Moderna, require ultracold storage technology that is more scarce in India.)

Other countries, like the U.K., have approved and are rolling out the AstraZeneca vaccine, but India’s decision to give the green light to the Bharat vaccine has raised a few red flags.

A woman reacts while a health worker takes a nasal swab
A woman in New Delhi reacts while a health worker takes a nasal swab sample during the rapid antigen COVID-19 test drive in October 2020.
Pradeep Gaur—SOPA Images/LightRocket via Getty Images

India’s drug regulator approved Bharat’s vaccine for emergency use on Jan. 4 but didn’t publish data about the vaccine’s efficacy. (Bharat said it would release its Phase III trial efficacy data by March.) One day earlier, the regulatory panel had asked Bharat for more efficacy data before it approved the shot. The quick reversal prompted criticism from some health experts and groups, including the All India Drug Action Network (AIDAN), a health watchdog.

A Bharat representative and India’s Ministry of Health didn’t respond to requests for comment.

Malini Aisola, co-convener of AIDAN, wants more transparency into the panel’s decision and the efficacy data, and she also wants the government to establish a publicly available monitoring system to track any adverse events that occur during the vaccine rollout.

India’s vaccine advantages

Chandrakant Lahariya, a vaccinologist and public health expert who has researched the history of vaccines in India, says that as far as logistics are concerned, India’s goal of inoculating 300 million people in the next six to eight months is “very much feasible.”

He points to India’s universal immunization program, which according to Unicef is the largest public health program in the world. India vaccinates 26.5 million infants per year for a number of diseases, as well as annual tetanus shots for 29 million pregnant women. The centers used for these vaccinations offer cross-country storage facilities and distribution points for the COVID-19 vaccine, including 29,000 cold-chain points offering precise temperature customization for the doses.

“A majority of the existing facilities will be used, but a smaller number of makeshift facilities will also be created,” Lahariya says.

India also is known as the “pharmacy of the world” since it produces half the world’s total vaccine supply. India’s vaccine manufacturing ecosystem means that India is unlikely to suffer a shortage of essentials like glass vaccine vials, as the U.K. did. Unlike the U.S., India won’t have to import such materials from other countries.

India’s pharmaceutical manufacturing strength also helped it ramp up COVID-19 testing capacity last year. The government shepherded domestic test-makers into an online marketplace to more efficiently distribute testing supplies across the country. Indian manufacturers also helped the country move from a reliance on imported tests at the start of the outbreak to producing 75% of its COVID-19 tests domestically by May.

India established new high-throughput testing facilities that focused on shorter turnaround times for test results and limited exposure to infectious material for lab workers. The efforts helped India accelerate from 75,000 tests per day in May to 1 million tests a day in August. The testing capacity scale-up suggests India will be able to carry out a similar increase in vaccination capacity. If India can ramp up COVID-19 vaccinations at the same rate it did testing, it will be able to inoculate 250 million people by June, according to the Fitch report.

India is also launching its vaccination campaign as its daily COVID-19 caseload declines.

In the last week, India reported an average of 17,000 new infections per day, down from a peak of almost 98,000 in mid-September. It had recorded 10.5 million cases in total as of Friday. The government credits its nationwide lockdowns and public awareness campaigns for the dropoff, but health experts caution that people shouldn’t let their guard down because a new wave could come at any time.

Some scientists argue the actual number of people who’ve contracted the virus is around 200 million people, much higher than India’s official tally. One government-backed study used mathematical projections to estimate that almost one-third of people in India had contracted COVID-19.

Economist Ajay Shah, who researches economic policy and public administration in India, says that pockets of the Indian population may already have achieved herd immunity, which is the aim of the vaccination drive.

Seroprevalence tests in some parts of India last year found that a majority of the population in some areas tested positive for coronavirus antibodies—the proteins a person’s body produces in response to infection—indicating that those people had contracted and recovered from the virus and were, at least temporarily, immune to it.

“There is more population-scale seroprevalence in India than probably anywhere else in the world, and the role of immunization at best is to tip the system over into herd immunity if it has not already gone,” Shah says.

Lessons from the past?

India has marshaled its resources for a nationwide vaccination drive in the past, successfully eradicating polio in 2014 and for its smallpox eradication campaign in the 1970s.

In the 1960s, around 60% of the world’s smallpox cases were reported in India.

India worked with the World Health Organization in the following decade to train medical staff, organize publicity campaigns, and vaccinate huge numbers of people. The critical technological breakthrough was the development of a smallpox vaccine that remained stable at room temperature, says Shah. Room temperature vaccines could be transported to people in rural areas who lived far from the cold-chain storage facilities that the vaccine previously required.

In late 1974, 133,000 health workers visited 100 million households across 2,641 cities and more than half a million villages, isolating smallpox patients as well as their family members and neighbors and vaccinating all of them. The last smallpox case in India was recorded in May 1975, four years before smallpox was officially eradicated from the planet.

While the eradication of smallpox is an example of what Shah calls a “population-scale success story” of vaccination in India, its lessons hardly apply to the COVID-19 crisis. Smallpox infections were easy to spot, plus India’s population has more than doubled since then.

What’s more, Shah says, “the smallpox vaccine was rolled out in India over a total period of six years, and today nobody is going to accept a six-year rollout [of the COVID-19 vaccine].”

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