An elderly woman at a vaccination centre in India (File image: AP)
After a brief lull, COVID-19 has come back with vengeance, and the numbers are rising dramatically. The rate at which COVID-19 cases are increasing is worrying the public health community and the policy-makers, as it is defying all the expectations of the severity of a second wave.
From around 11,000 odd new cases a day in mid-February, we have reached 131,000 test positives on April 8. The peak is nowhere in sight, and as a country we seem to be on uneven ground regarding the immediate containment measures.
This comes immediately after India received applauds for the way it rolled out vaccines; and ensured that health and frontline workers receive them within a short span of time.
India, being a powerhouse in vaccine production, has been able to administer 94 million vaccine doses till April 8. The daily number of vaccines administered now stands at around 3.4 million and has been slowly inching up over time.
Though the absolute numbers look fabulous, when we convert these to proportion of population who has received at least one dose of the vaccine, India’s performance looks a bit dicey. According to the popular data tracking portal OurWorldinData, India has given at least one shot to 5.71 percent of its population. Compare that figure with countries such the United Kingdom (46.71 percent) and the United States (32.89 percent), and then we realise that we are lagging behind.
Even Bhutan (61.04 percent) and Brazil (8.87 percent), which relies on other countries for their vaccine needs, have better vaccination statistics. This is a problem with the huge population to be vaccinated, which makes even large vaccine consignments feel like a drop in the ocean.
At present, our regulatory agencies have permitted two vaccines — Covishield and Covaxin. Covishield, manufactured by the Serum Institute of India (SII), is the Indian version of the COVID-19 vaccine developed by Astra Zeneca and Oxford University. It is a non-replicating viral vector vaccine, which does not require stringent storage and transportation requirements as the Pfizer vaccine. The cost of production is also lower, making it the ideal candidate for the poorer regions of the world. Though it has been plagued with several issues like lower-than-expected efficacy and reports of adverse effects, several studies have shown that it is good enough and that the vaccine can possibly prevent disease transmission.
Covaxin, developed by a group which includes Indian Council for Medical Research (ICMR) and manufactured by Bharat Biotech, is an inactivated vaccine using a time-tested methodology. It raised a lot of questions when the vaccine was rolled out before peer reviewed data on its efficacy was available in the public domain. Since then, it has had a good run with Phase 2 trial results published in the Lancet Infectious Diseases showing that it is “safe, immunogenic, with no serious side effects”.
Covishield has done all the heavy-lifting, in terms of making the COVID-19 vaccine available widely in India. So far, the company has supplied more than 100 million doses to the government and exported 60 million. According to public disclosures by the SII, their current production capacity stands at 60 million per month. Bharat Biotech has a reported production capacity of less than 10 million a month and has provided only around 10 percent to the total number of vaccine doses administered in India.
The difference between production and demand is growing; and can possibly result in severe shortages when India is going through a second wave. If the demand stabilises around 3.5 million a day and if we are vaccinating people on all days of a month, the total number of doses required may be around 105 million a month. Considering the existing production capacity of both the vaccines, it is 70 million at most; and we don’t have publicly available data on any kind of a vaccine stockpile in India.
We have to remember that the vaccines, especially Covishield, has export commitments too. Besides, the demand for vaccination will pick up as we are going through a second wave and when more people get vaccinated with few adverse events.
If we apply the diffusion of innovation theory here, we should anticipate a large section of ‘early majority’ and ‘late majority’ to turn up for vaccination soon. Also, we are a young nation with a median age below 30 years. So when we open up vaccination for the more bulky regions of the population pyramid, the shortfall may be even starker. Already some states are complaining of vaccine shortages and the political mud-slinging has started.
Complicating things further, there are reports that Astra Zeneca has sent legal notices to the SII for the delay in sending the promised vaccines and the COVAX facility (an ad-hoc vaccine procurement and sharing system for COVID-19) is insisting that the SII is legally bound to supply the promised vaccine doses.
A multimodal strategy is needed to overcome this looming crisis, before it snowballs into something larger which can derail the entire process of COVID-19 containment. We need to ramp up the production capacity for the two licensed vaccines, even if it means using public money to augment private infrastructure. SII’s Adar Poonawalla has asked for Rs 3,000 crore to boost production capacity to more than 100 million a month. Apparently, they don’t see value in investing more money to increase production, as the pricing strategy don’t allow them to cover for the additional investment.
Another strategy may be to use the existing capacity for vaccine manufacturing in India, to produce COVID-19 vaccines. The Central Drug Standards Control Organization (CDSCO) website lists 25 such facilities managed by 18 private organisations, some of them can possibly be used for COVID-19. The licensed manufacturing route is the most likely option in this case, and there are reports that Bharat Biotech is in talks with several other smaller companies to use their facilities.
Authorising newer vaccine candidates, which has shown acceptable efficacy and safety in trials, should also be considered as an option in this country. Dr Reddy’s laboratories has asked for clearance of the Sputnik-V, a vaccine initially made by Gamaleya National Research Centre in Russia. Smaller trials have been conducted in India and several countries are already using it. The single-shot COVID-19 vaccine from Johnson & Johnson and the Novovax COVID-19 vaccine has shown adequate safety and effectiveness profile in studies conducted elsewhere; and they are good options for India too.
India should not try to cater to the internal demand by defaulting on its international commitments, especially those given to the COVAX facility which aims to share vaccines with the regions of the world who may not have any other way to access them. Many countries of the global north have been accused of ‘vaccine nationalism’, and it would set a bad precedent if a country such as India, which is aiming for a leadership position on the global high-table, sets out on the same course.
There are no standard solutions on the table and our problems are quite unique. So there needs to be an atmosphere to facilitate dialogue between the government, industry and civil society. Decision-making has to be fast and transparent; and in the best interests of the public. Every single person in India should remember that we cannot afford the economic consequences of a third or fourth COVID-19 wave!