maharashtra

Chintan Patel and Vivek Kaul

The second wave of coronavirus continues to unleash its horror in India. This crisis has brought in focus the significance of mass vaccinations being carried out at a very quick pace. Without vaccinating a vast majority of our population against Covid-19, there is no pathway to normalcy and achieving herd immunity.

Policy-makers in India have finally awakened to this reality or at least that is what we hope. That they have been found so lacking – in planning, preparation, and priorities – speaks volumes of the caliber of our political and bureaucratic class.

As a piece in The Times of India, dated May 10, points out, at the current rate of vaccination, it will take around 1,000 days to vaccinate the adult population of 94 crore (around 94.3 crore to be precise). But assigning blame will not solve this crisis. Timely, considered action and policies might.

In this article, we try to assess the logistical readiness of a mass vaccination plan by looking at the capabilities and capacities at each step of the vaccination process. Specifically, we look at current and future vaccine supplies and discuss key issues related to vaccine administration.

Vaccine Supply

There are two vaccines available in India currently – Covishield manufactured by the Serum Institute of India (SII) and Covaxin manufactured by Bharat Biotech. In addition, we will be importing Sputnik V from Russia starting this month, with a small amount already having come in, and are likely to receive shipments of Astra-Zeneca vaccines from the United States. Also, Zydus Cadilla has announced that it expects to get emergency authorisation for its 3-dose vaccine shortly.

The table below lists the different vaccine sources and their estimated/committed doses for the next six months. Projections beyond October are subject to too many assumptions which can lead to wide variations in estimates. For now, a six-month planning and estimate window seems appropriate. Even then, these are estimates that may prove to be incorrect.

Expected vaccine Supply (in crore)

Source:

1. Covishield : SII CEO statement reported by Reuters on April 21. India’s Serum Institute to raise output to 100 mln AstraZeneca doses by July, not end-May | Reuters
2. Covaxin: Bharat Biotech statement reported by NDTV on April 21. Bharat Biotech Scales Up Covaxin Production To 700 Million Doses Annually (ndtv.com)
3. Sputnik: India Today report on May 1. First batch of Russia’s Sputnik V Covid vaccine arrives in Hyderabad, to be sent for regulatory approval – Coronavirus Outbreak News (indiatoday.in) and Sputnik V, Covishield, Covaxin: What we know about India’s Covid-19 (BBC). 
4. Astra Zeneca: Press statement by White House, reported by CBS News on April 26. COVID vaccine: U.S. aims to share up to 60 million AstraZeneca doses with other countries after FDA review – CBS News
5. Zydus Cadilla: Press report. Zydus Cadila Likely To Seek Approval For Its COVID-19 Vaccine This Month (moneycontrol.com)

Let’s discus the above table in a little more detail. 

These are broad estimates derived from publicly available information as on May 7, 2021. The intent behind this exercise is to consolidate information emerging from various sources to provide a coherent and a reasonable picture of the vaccine supply scenario.

There might be major changes in either direction, that is, actual supply might increase due to new production or distribution agreements or actual supply might decrease if manufacturers are not able to deliver to their committed/planned volume. As we said earlier, this is a broad estimate.

1) The estimates for Covishield are based on their total production capacity projections given by Adar Poonawalla, the CEO of Serum Institute of India (SII). SII’s current production capacity is between 6 to 7 crore per month. We have assumed it to be at 6.5 crore per month. By July, SII expects to raise its production to 10 crore, as reflected in our estimates starting August. We assume that an increase in production will start hitting the market in the next month. 

On April 28, 2021, the government of India placed an order with SII for 11 crore doses for May, June and July. Over and above this, SII has announced that it has a separate order of 11 crore doses from state governments and private hospitals. But the delivery schedule for those orders is not publicly known.  

To add another layer of ambiguity on the demand side, SII is also obliged to export 20 crore vaccine doses in 2021 as part of its agreement with Astra-Zeneca and World Health Organization. Currently, vaccine exports have been halted due to the domestic crisis in India. It is possible that export of Covishield doses will resume once the crisis abates. In fact, 5 million doses of the Covishield vaccine which were to be exported to the United Kingdom have now been made available for inoculating those in the 18-44 age group.

Thus, our estimates allocate the entire production of Covishield for domestic use. Please note that if export of Covishield vaccines resumes, the actual supply numbers for India will be lower than estimated numbers.

Currently India faces a supply problem. In May, the supply of vaccine doses is expected to be around 8-9 crore. As one of us had earlier estimated, the total number of vaccine doses needed to vaccinate the remaining part of India’s adult population, stands at around 178-190 crore doses. The gap between what is available as of now and what is needed, explains the prevailing chaos when it comes to vaccines.

2) For Covaxin, once again, our estimates reflect the total monthly capacity. Bharat Biotech, the makers of Covaxin, have announced that they will be able to ramp up their annual production capacity to 70-80 crore vaccine doses by July. In an interview given in late April, Krishan Ella, the CEO of Bharat Biotech had remarked:

“Last month we produced 1.5 crore doses, this month we are reaching 2 crore doses, next month we will be making around 3 crore doses followed by 7 to 7.5 crore doses. We are ramping up the production and by July-August we will be able to reach 70 to 80 crore doses production capacity per annum.”

Using this as a guideline, we have budgeted 2 crore Covaxin doses for May, which ramps up to 3 crore in  June, rising to 6 crore doses per month starting in July (6 crore per month x 12 = 72 crore per year).

3) The first pilot batch of 1,50,000 doses of the Russian Sputnik V vaccine, was shipped to the Hyderabad based Dr Reddy’s Laboratories in early May. We have not counted those since the number is too small for this estimation exercise. As per the agreement between Russian Direct Investment Fund which is marketing the vaccine and Dr Reddy’s, 12.5 crore doses are to be imported to India between April and June 2021 .

We have split that number up from June to September (12.5 crore/4 = 3.13 crore), given that a bulk of these vaccines have not been delivered as yet . For October, we have kept the number at 3.13 crore. It is likely that the Sputnik V dose availability might go up after a few months since six local manufacturers are supposed to manufacture 75 crore doses of the vaccine after the initial batch of imports. The timing of the locally manufactured Sputnik V is difficult to predict. So, as a rough estimate we have retained the 3.13 crore figure for October as well.

4) It is likely that the US might begin to share some of the stockpile it has of the Astra-Zeneca vaccine, with India. We have estimated that to be 1 crore doses a month, starting in June.

5) Zydus Cadilla is expecting to get an approval for its three dose Covid vaccine in May. Their initial production capacity is slated to be 1 crore doses per month, which is expected to rise to two crore doses per month. Given that the vaccine has not yet been approved we stick with the initial capacity of one crore doses.

This vaccine is a three dose vaccine, hence, the “value” of a single dose is two-thirds of the other vaccines – all of which are two dose vaccines. Thus, the equivalent monthly supply estimate for Zydus Cadilla is 0.67 crore (two-thirds of one crore).

6) Another indigenous vaccine made by Biological E based in Hyderabad may become available in August. Since the vaccine hasn’t been approved yet, we have not included it in our supply estimates.

7) During any vaccination drive, some amount of vaccines get wasted due to improper handling, theft and human errors. The following chart shows the rate of vaccine wastage in a few states as of May 10.

Source: Ministry of Health and Family Welfare.

We have not included wastage in our analysis to keep things slightly simple. Having said that, doses lost due to wastage will decrease the available supply for inoculation. 

Finally, with these caveats, we can say that there will be a supply around 102 crore additional vaccine doses between May and October 2021. What this means is that vaccines will continue to be in short supply in the short-term.

The efforts highlighted above to get the various vaccines available in India are all positive steps. But as the numbers indicate, the supply pipeline is not adequate to meet our vaccination needs of close to 180 crore vaccine doses.

The primary reason for this shortage is that the government of India waited too long to place vaccine orders and when it did, it didn’t order enough doses.  This can be seen in the chart below that compares the vaccination order timelines for different countries.

Source: https://epaper.telegraphindia.com/imageview_359302_24528134_4_undefined_19-04-2021_1_i_1_sf.html.

In fact, as Satyajit Rath, a veteran biologist formerly associated with the National Institute of Immunology, Delhi, told the Deccan Herald, regarding the government barely stocking up on vaccines: “This was part of a pattern of treating the epidemic as a short-term crisis, somewhat like natural disasters such as an earthquake.”

Now let’s take a look at the possible steps that can be taken to augment the vaccine supply.

A supply of more than 100 crore doses of different vaccines by October, if achieved, will be no mean feat. But even that is not fast enough given our vast population. The following steps can be taken to increase the supply of vaccines. These are medium term solutions and will likely yield results over the 6-12 month horizon. This means that the supply of vaccines will continue to be an issue over the next few months. 

1) The central government should work closely with both SII and Bharat Biotech to enable them to hit maximum production capacity. Additionally, both manufacturers should be asked to furnish a weekly supply schedule for better planning and coordination, if that is not already happening. With multiple buyers in the mix now (with state governments and private hospitals) such a supply schedule assumes even greater significance.

2) India is the vaccine manufacturing headquarters of the world. According to Central Drugs Standard Control Organisation, there are 18 private and three public sector vaccine manufacturers in the country. One potential route to increase vaccine supplies is to leverage spare local vaccination manufacturing capacity to increase supply of Covaxin using licensing and/or royalty agreements with Bharat Biotech.

The intellectual property for Covaxin is jointly owned by Bharat Biotech and the Indian Council of Medical Research (ICMR), a government body. In fact, an arrangement along this line is already in motion where the Mumbai based Haffkine Institute, one of the oldest biomedical research institutes in the country, has been granted permission by the central government and funding by the Maharashtra government to start production of Covaxin.

Vaccines production from this plant is expected to take atleast one year. Other efforts, similar to this could be spawned with other vaccine makers after an assessment of technological and supply chain feasibility. However, based on the Haffkine timeline, it is clear that such efforts will not help in the short term. Having said that, we don’t know if the current wave is the last wave of Covid. 

3) India can import additional vaccines from the United States. The United States has a contract with Astra Zeneca for 30 crore doses of which six crore doses are either in stockpile or will be shortly available. Since the Astra Zeneca vaccine has not been approved in the US, India can apply a concerted effort – both diplomatically and/or financially- to receive a substantive portion of the stockpile.

India should also look at importing additional vaccines directly from vaccine makers. The Municipal Corporation of Greater Mumbai has such plans.

Among the major vaccines approved and in use elsewhere, the Johnson and Johnson (J&J) vaccine is the most attractive given that it is a single-shot vaccine and it does not need extreme cold storage. The J&J vaccine may not be the best use of taxpayer money, but one that private companies could pursue and make available to the general public at a higher cost. 

Vaccine Administration

Vaccine supplies are no good if they don’t translate into inoculation. En-masse administration of vaccines depends on several factors including number of vaccination sites, available personnel, location of sites, and public willingness to get vaccinated. Let’s look at this in some detail. 

The following chart shows weekly vaccination rates in India.

Source: dashboard.cowin.gov.in.

Here are some observations from the above graph.

1) The vaccination rate was quite low till early March. The spread of the second wave of covid clearly catalysed the public into action and the vaccination numbers rose steadily till the first week of April, barring a small dip towards the end of March.

From just over 4 lakh vaccinations in the week of February 27 to March 5, numbers jumped to almost 2.5 crore in the week of April 3 to April 9. After hitting that peak, numbers have dropped down to around 1.15 crore vaccines for first week of May. This is a drop of around 54% over just one month. As covid has spread, our vaccination rates have been dropping.   Vaccine supply shortages are mainly responsible for this drop in inoculation in recent weeks, and the lockdown imposed across large parts of the country may also have contributed to this.

2) The peak rate of around 2.5 crore weekly vaccines is an important statistic. It translates to a monthly rate of 10 crore vaccines – more than the projected supplies for May but about 30% short of the projections for June. What this tells us is that the distribution capacity can handle the imminent vaccination volume, but will need to start ramping up soon to keep up with the projected supply.

3) According to the Cowin dashbord, as of May 7, there were 58,214 vaccination sites (55,822 government sites and 2,292 private sites). Along with using government hospitals in the urban centres, the government has wisely activated the rural healthcare system for vaccine delivery as well. 

The rural healthcare delivery system in India is a three-tier system. The smallest unit, called sub-centres, are health outposts which are meant to be the first contact point between the community and the healthcare system. A group of sub-centres are served by a single primary health centre which has a doctor (medical officer) and nurses on staff. A group of primary health centres feed into a community health centre– which is akin to small hospital with specialist doctors and diagnostic equipment.

A study of the vaccination sites in different states on the Cowin dashboard reveals that many states are using sub-centres, primary health centres and community health centres, as vaccination sites. The rural population is being targeted here.

However, as is often the case, enterprising citizens often outthink policy makers, resulting in unanticipated policy outcomes. In this case, there are reports that urban Mumbaikars, who are digitally more savvy than the rural folks, are showing up in rural areas to get vaccinated. This phenomenon highlights the need to make the registration process more accessible to all.

Now let’s look at state wise vaccination data.  As of May 7, 2021, around 16.75 crore vaccine doses had been given. How do different states compare in this vaccine drive?  The table below provides some insights.

Vaccination Rates (in %)

Source: Author calculations based on data from Cowin dashboard and Unique Identification Authority of India. 

In the above table, we show the five states that are performing the best and five that are performing the worst when it comes to vaccination rates, among states which have a population of over 1 crore. 

Uttar Pradesh has the worst vaccination rate, where only 4.6 % of the population has gotten at least one dose of the Covid vaccine, and just above 1% has been fully vaccinated. It appears that the energy spent by state leadership in image management, has come at the expense of an effective vaccine roll-out strategy.

Bihar, Assam, Tamil Nadu and Jharkand, are the other laggards with no state having fully vaccinated over 2% of their population (except Tamil Nadu which is marginally over 2%). In case of Assam and Tamil Nadu, among other things, the recent state assembly elections may have been responsible for low vaccination rates.

Among states that are doing well, Kerala and Gujarat – with their oft-cited competing models of development – are doing remarkably similar when it comes to vaccinating their people.  Uttarakhand, Jammu and Kashmir, and Rajasthan, are the other vaccination leaders.

The ratio of folks fully vaccinated is not starkly different between the leaders and the laggards – 4.83% for Gujarat vs 1.17% for UP – but the figures for people with one shot taken does show a significant difference (17.28% for Kerala vs 4.59% for UP).

Till the end of April, states were dependent on the centre for getting vaccines. So, the discrepancy in vaccination rates is likely to have been a function of the centre’s distribution decisions, as well. The central government has not released the criteria used for vaccine distribution to the states, something that they should be doing for transparency and efficacy auditing.

Having said that, Gujarat has clearly been a beneficiary of the allotment mechanism, receiving the highest quota of vaccines from the centre after taking its population into account. As an April 19 newsreport on moneycontrol.com points out:

“As on April 8, the supplies to Maharashtra covered just about 8.5 percent of the population. For Delhi, it was 10.4 percent. On the other hand, Gujarat, which can’t be regarded as the most impacted state if one goes by official numbers, had got enough vaccines for 16.4 percent of its population – the highest.”

It appears that when it comes to competition between states, Prime Minister Narendra Modi continues to root for his home state.

Starting  May 1, the state governments can procure vaccines directly from the manufacturers. Having states compete for what is essentially a fixed supply isn’t a great idea since it will not increase the total vaccines available nationwide. Instead, the states and private corporations will fight over the 50% pool that has been de-regulated.

So states that have more leverage with vaccine makers or more financial clout/headroom stand a better chance of pulling ahead in the vaccination race. It will be interesting to see the trajectory of vaccination rates of different states as they begin to place their vaccine orders in the coming weeks and months. Also, this is clearly creating an access problem for the poor.

Vaccine Logistics 

As the supply of vaccines increases in the coming months, the question is do we have enough health care workers and vaccination sites to keep up with supply. 

First, let’s look at the manpower question. As per the Fifteenth Finance Commission Report tabled in February 2021, there were a total of around 27 lakh healthcare workers in India in December 2017. These include registered nurses (RN), registered midwives(RM), lady health visitors (LHV) and auxiliary nurse midwives (ANM). Specifically, there were 20,48,979 RNs and RMs, 56,469 LHVs and 8,60,927 ANMs, serving in the country. All these healthcare workers are capable of administering a vaccine.

Now, consider a full-throttle vaccination campaign with 1 crore doses/day. Assuming that a healthcare worker administers 50 doses a day, we would need 2 lakh healthcare workers which is less than 8% of the total available personnel. Thus, it is evident that labour won’t be a bottle-neck to ramp up the vaccine drive. 

Next, let us look at how many potential vaccination sites are available. Recall that currently, around 61,000 sites are being used. As per the Rural Health Survey of 2019, there are 1,57,411 sub-centres, 24,855  primary healthcare centres and 5,335 community health centres, across the country.

Thus, even without counting government hospitals and private clinics, there are over 1,87,000 potential vaccination sites, almost three times than are being currently used. Thus, vaccination sites also are not limiting factors in scaling up vaccine delivery.

One potential hindrance in getting maximum number of people to sign up for the vaccines is the current vaccination registration process. A huge rush for vaccines has made the signing up process a bit of a lottery. In fact, techies have resorted to writing scripts to alert them when an elusive spot opens up. For everyone else, the process consists of repeated tries on loop.

One major problem experienced by folks trying to sign-up for a vaccine is the non-receipt of a one-time password (OTP). The OTP is a pre-requisite to move ahead in the registration process, and many folks have been unable get past the OTP step. Technical glitches in the early stages of an app/website roll-out are not unheard of, but given the importance of this issue, one would have expected the “routine” bugs to have been ironed out before mass adoption.

That such glitches are so widespread indicates that the en-masse registration was not planned with adequate lead time. Here too, like most aspects of the Covid response, the government’s lack of readiness is being exposed.

The online registration will likely smoothen out over time, but currently it only caters to the internet-savvy comfortable in English. Online sign-ups may not totally work for all folks, both rural and urban. Systems that allow a registration method that is appropriate and accessible for those not comfortable with the current digital setup, need to be created. .As a start, the Cowin registration website needs to become multi-lingual.

The language barrier automatically excludes the majority of the country. As per the 2011 Census, only around 13 crore people identified English as first, second, or a third language. It is mind-boggling that the government decided to offer the registration process only in a language that the vast majority does not understand. That the registration process cannot support the major Indian languages, is again a sign of a system put together in haste.

Vaccine Hesitancy 

Vaccine hesitancy can also potentially derail the entire vaccination drive. If too many adults choose not to sign up for the vaccine, it won’t be possible to reach herd immunity quickly. In some ways, the severity of the second wave makes the most compelling argument for the need to vaccinate. Yet, for a variety of reasons, people tend to be hesitant.

Safety concerns, efficacy concerns, and ignorance (wilful or genuine) about the seriousness of Covid-19, are prime reasons that drive this hesitancy. WhatsApp messages and fake news exacerbate the psyche of suspicion and distrust. The best anti-dote to that is positive messaging and increased awareness about the benefits of vaccination. Given this administration’s core competence of narrative management, mass communication to encourage vaccine enlistment should not be a big hurdle.

As a more directed policy step to incentivise vaccinations, especially in rural areas, the central government could consider linking a Public Distribution Service (PDS)-based benefit with a vaccination dose. For example, for each vaccine dose a voucher for a few kgs of rice/wheat, which can be redeemed at the local ration shop, can be given.

This should not cost the central government much (other than perhaps transport and administration) since the Food Corporation of India storehouses are overflowing with way more grain than the strategic and operational buffer that needs to be maintained.

The pathway to a fully vaccinated Covid free India is not easy and won’t happen overnight. But, with proper planning and execution, we can make significant progress over the next several months. We all need to do our bit to succeed in this effort.

All, including Nero.