One billion doses delivered; but a long road ahead

As of today, India has delivered more than 100 crore doses of the COVID-19 vaccine. This achievement is reason to celebrate and applaud the government and its immunization partners. Festivities are underway at the Red Fort in Delhi and the milestone has been announced on planes, trains, and in public hospitals. But it is not a time to be complacent.

By Brian Wahl, 21 Oct 2021

Approximately 20% of the total population is now fully immunized and more than 50% have received at least one dose of the vaccine. There are two specific challenges—supply and demand—that lie ahead for the “world’s largest immunization campaign”. But luckily, there are steps that can be taken to avert these challenges and end the current phase of the epidemic.

The first challenge India will have to face is related to supply. Thankfully, production shortages in recent months have been addressed and around 6-8 million doses are regularly being administered daily. This is encouraging. However, the number of required doses might not be static for two reasons.

First, officials have indicated that exports of COVID-19 vaccines could resume before the end of the year. The second reason is that children could become eligible for vaccination soon. Currently, only those older than 18 years are eligible.

However, an expert panel of the Drugs Controller General of India (DCGI) recently recommended emergency use authorization for Covaxin in children 2-18 years of age. Another new vaccine called ZyCoV-D recently received emergency use authorization for individuals older than 12 years.

Many countries and global COVID-19 vaccine financing mechanisms rely on India due to its strong vaccine manufacturing sector. Exports of COVID-19 vaccines were halted in April as cases increased during the devastating second wave. That India will allow exports once more in the near future is encouraging.

The Serum Institute of India and Bharat Biotech have both announced that they are increasing manufacturing capacity. Several other indigenously developed vaccines could also help strengthen supply if they are found to be safe and effective.

Like with the development of other COVID-19 vaccines, there are risks associated with the initiation of manufacturing while clinical development is ongoing, especially for unproven approaches, like COVID-19 vaccines delivered through nasal spray.

The government has supported COVID-19 vaccine development in India through the 900 crore Covid Suraksha Fund in an effort to reduce the risk associated with vaccine development. India is a very young country—approximately 40% of the population is less than the age of 20.

Opening eligibility for children and teenagers would dramatically increase demand for vaccine doses. As schools begin reopening in many parts of the country, many parents have indicated they would want their children vaccinated before they go back to school. Children are at much lower risk of severe outcomes compared to adults.

With current supply, older adults and those with comorbidities, should remain the priority for vaccination. As randomized controlled trials of COVID-19 vaccines continue, we will know more soon about their safety and efficacy in children. Even though children are at much lower risk of severe disease and death, there could be a time in the coming months when vaccinating them could reduce the risk even further and prevent transmission for disease.

The second potential challenge is related to vaccine acceptance and enthusiasm. As more and more people are immunized, making incremental gains in vaccination coverage will be increasingly difficult.

We have seen this phenomenon occur with routine immunization programs in India and around the world. Luckily, multiple studies suggest that COVID-19 vaccine acceptance in India is among the highest in the world.

According to data from multiple sources, more than 80% of eligible Indians have already or plan to get the vaccine. This is encouraging. But it is important to note that vaccine confidence is not static.

As cases remain very low, vaccine enthusiasm, including for second doses, could wane.

The gap between those who have received at least one dose (50%) and those with two doses (20%) is likely due to several factors, including the dose interval for Covishield.

However, some of this disparity could be attributable to low enthusiasm—those who have said, “I already had COVID, why do I need both doses?” or “There are so few cases these days, isn’t one dose enough?” In addition, misinformation and disinformation about the COVID-19 vaccines can undermine high levels of acceptance. Facilitated by social media, fake rumors about the vaccines can spread fast.

There are several things that can be done to further strengthen vaccine confidence. The government has been working with several partners to communicate the importance of COVID-19 vaccination even before vaccines were available in early 2020.

This has contributed to strong confidence throughout the country. Continued communication efforts will certainly help. In addition, the center recently and rightfully communicated to states that efforts to ensure individuals receive their second doses should be ramped up.

The celebrations today marking the important milestone will hopefully bring renewed enthusiasm to the immunization program. We know from global evidence that the best approach to communicating around vaccines is to respect, empathy, and understanding. This helps build trust among those who are perhaps on the fence.

Creatives and public health experts can also work together on this front. Last week, my institution, the Johns Hopkins India Institute, and the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh launched a campaign to further strengthen confidence in India.

The campaign focuses on everyday Indians who have worked to get their families, friends, and communities immunized. The campaign was designed to set normative behaviors for immunization by asking the question, “Teeka Lagwaya, Na?” Working with several community-based groups, we hope this campaign will help This is our small contribution to several ongoing effort. We know other groups are doing their part as well.

India has achieved a tremendous milestone today in exceeding 1 billion doses of COVID-19 vaccine administered. It is important to thank the numerous individuals who have made this achievement possible. We owe a debt of gratitude to the health workers, especially doctors and nurses, who have worked tirelessly from the very beginning of the pandemic.

The frontline community workers—the ASHA and Anganwadi workers—who have worked tirelessly to protect their villages and communities. And those who make sure that vaccines reach those who need them, even if that means traversing treacherous river and mountains.

We have a long way to go before we immunize the entire population and there will be challenges along the way. So, it is important to continue efforts and maintain COVID appropriate behaviors. But today we can and should celebrate an important milestone.

Brian Wahl, PhD, MPH is an epidemiologist and faculty member at the Johns Hopkins Bloomberg School of Public Health