Rolling-out a Covid vaccine in India, a journey into ‘uncharted territory’

Despite immunisation programmes for infants and adult vaccination campaigns in select groups, India will be entering uncharted territory when it comes to making available a Covid-19 vaccine across its population.

A nightmare

The roll-out will be a nightmare for healthcare administrators, as they prioritise who gets the vaccine first and who foots the bill, among other things, say medical experts. It will also have to be a staggered roll-out across the country, as administrators would need to procure that many doses of the vaccineto start with.

Assuming there is a vaccine that’s been through the rigours of testing and approval, it should be given to healthcare workers in the field and hospital “because they face recurring risk of exposure to high viral loads”, says Dr K Srinath Reddy, President, Public Health Foundation of India. Then comes the security-forces, including the police, essential workers and the elderly and people with co-morbidities (diabetes, hypertension etc), he adds.

At present, a handful of Covid-19 vaccine candidates are in advanced trials in humans. And the stage is wide open on a final product and its effectiveness in terms of antibody protection and its duration, observes Dr Arun Bhatt, a regulatory expert on clinical research.

Effect on the elderly

Once there is a vaccine, the challenge is the scale of coverage and granular details like giving it to the elderly. Current vaccine candidates are tested in the age group of 18 to 55 years,and its effect on the elderly is being evaluated. “Will they need different dosages, as the elderly have a weaker immune-response,” asks Bhatt. Children, too, are outside the trials, he says, though companies may undertake trials as the adult vaccine is rolled out.

A national expert group is mapping a roll-out plan and has met vaccine makers for this purpose. Indian companies, including Bharat Biotech and Zydus Cadila, are developing Covid-19 vaccines, and Serum Institute has foreign alliances with the OxfordUniversity-AstraZeneca combine and Novavax to make and distribute their vaccines in India.

Cold-chains and cost

Pricing will be a challenge, says Dr Bhatt. Serum Institute’s stated price at not more than $3 a doseis the lowest yet. The expectation is that the Covid vaccine will either be given free or at subsidised prices by governments. Dr Bhatt says even the government may need to seek funding from outside agencies to cover the entire population with two doses possibly.

On the logistics, Dr Suresh Jadhav, Executive Director- Serum Institute, is confident of India’s “well-established” cold-chain system from the Universal Immunisation Programme (UIP). “Vaccines usually need to be stored between 2 to 8 degrees C, and there is a distribution chain, including ice boxes and refrigerators, to ferry and store vaccines right down to the districts and thesil,” he says.

“ASHA or health-workers are trained to give injections to infants and pregnant women, and we have experience of giving MR (Measles -Rubella vaccine) in schools,” says Jadhav, indicating it can be taken to remote locations.

However, the challenge is for adults and the elderly. “Will you go home or call different age-groups to a centre or a camp? The developed world has experience with the adult, flu vaccine given every six months. But the developing world has no such experience,” he says.

“India has a successful house-to-house campaign for polio and an adult vaccination programme against Japanese Encephalitis in Assam and Uttar Pradesh,” observes Dr Vasishtha, former convenor with the Indian Academy of Paediatrics’ (IAP) committee on immunisation. Organising two doses across the population will be a nightmare for administrators, but it should be prioritised based on epidemiology and States that are at higher risk.

Not a hassle

Dr Vashishtha saysintramuscular Covid vaccines can be administered without a problem. “The intradermal BCG vaccine requires more expertise,” he says, of the successfully administered vaccine. On cold-chain requirements, he add that a Covid vaccine’s requirement would be less stringent than the oral polio vaccine.

Currently, States have been told by the Centre to not procure the vaccine independently. Experts also stress the need for surveillance after vaccinationto follow-up for side-effects. Some express concerns on whether the affluent and those with political clout may access a vaccine before those who need it.

And unlike the United States, where some people hesitate to take vaccines, India will see people showing up for it, says Vashishtha, making it all the more necessary to have a plan readybefore the vaccine is ready to roll-out

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