India has now approved the vaccines developed by Astra-Zeneca and Bharat Biotech. Several more will likely be available later in 2021. Deploying these vaccines effectively will be crucial. India and other developing countries have to keep their specific circumstances in mind while formulating vaccine strategies.
India will not need to vaccinate 1.35 billion people, but just beyond the point where the reproductive rate is under control even without suppression. If India had, for example, 60% of people already infected and we knew who they were, we would have to vaccinate at most 40% or ~560 million persons. This requires approximately 1.1 billion doses, given that most vaccines need a booster dose. Actual targets will be higher if India cannot identify who already has natural immunity. The choice of vaccines will be constrained by cost, cold-chain availability and so on. There are five key issues that vaccine strategies must consider.
The first is allocation. Most nations will vaccinate healthcare workers first. They treat those who are infected with Covid-19 and vaccinate the remaining population. After that, it seems logical to prioritise the elderly, who have a higher infection fatality rate. However, premature death costs a young person more years of life than an old person. The balancing of risk and harm may have convinced Indonesia to buck the global consensus and vaccinate working age persons first. It is worth considering in India. Even if the elderly are prioritised, that will not exhaust the vaccine supply: 80% of India’s population is below 50.
Allocation among the working age population should consider two factors. First, the additional protective benefit from vaccination is much lower if one has immunity from a prior infection. Thus, areas with a large susceptible population and a higher reproductive rate obtain greater benefits from vaccination. Indeed, with severely limited doses of vaccine available, it may be prudent to screen people for Covid-19 antibodies and prioritise vaccination of those without antibodies.
There may also be greater benefits to fully vaccinating one area fully than to giving a small number of doses to multiple areas. Adequate vaccination in an area will permit relaxation of suppression in that area; spreading vaccination across areas may not result in release of any of those areas. Areas that are closest to herd immunity even without suppression require the least number of doses to return to normal economic activity and have higher returns from vaccination. Areas that suffered the greatest economically will have the greatest benefit from relaxing suppression after vaccination. These twin considerations should guide prioritisation.
The second issue is distribution. Moving vaccines from companies to warehouses will be relatively easy but moving it from warehouses to distributors to end-users will be tricky, given the difficulties with cold chains and storage facilities. Digitally monitoring storage and transportation facilities will be critical. Second, 600 million or so vaccine recipients need to be identified, and then re-identified three-four weeks later for a second dose. As Nandan Nilekani has suggested, we may need to build a bespoke, vaccine-agnostic digital platform to enable this. Third, administering 30-40 million immunisations a year is a different kettle of fish from vaccinating 600 million people in a year. Sourcing the trained human resources necessary to deliver intramuscular shots, without diverting from existing priorities, will not be easy. Perhaps medical students, phlebotomists, paramedics and pharmacists can be rapidly and reliably trained to administer vaccines.
The third issue is financing. The choice here is whether to finance vaccinations publicly or privately. In the United States, United Kingdom and Europe, vaccines are likely to be entirely free and administered publicly. However, India will need a hybrid strategy, where the majority of the population is vaccinated for free publicly, while allowing private markets for approved vaccines. Cost alone will necessitate this. The cheapest vaccine India is considering — Covaxin — will cost over $1.1 billion at $1 per dose. Other vaccines will cost from three times as much (Astra) to 30 times as much (Moderna). Given the tight fiscal situation, the government will be well-advised to have as much private sector involvement as possible.
The fourth issue is communication. It’s vitally important for the government to have a well thought out communications strategy to fortify public confidence and reduce vaccine reticence in the population. A good strategy will avoid mixed and contradictory messaging, be simple to comprehend, be science-led, involve regular communication, utilise respected community leaders to widen reach, and clamp down on the spread of misinformation.
And the final issue is certification. Resumption of normalcy will require standardisation on certification of immunity, whether by vaccination or prior infection. Every country will need an internal set of protocols regarding proof of vaccination, but also standards that are interoperable with norms elsewhere. In other words, proof of vaccination in India or Tanzania must be acceptable to a Singapore Airlines or Qantas. This will also require multilateral bodies to play an active role in creating frameworks, around which digital platforms can be created.
India is embarking on a monumental mission, not just in terms of vaccinating its own population, but also vaccinating a large part of the world thanks to its position as the world’s leading vaccine producer. Addressing these five issues will augment the effort to efficiently get vaccines to hundreds of millions in the shortest period of time.
Reuben Abraham is CEO, IDFC Institute in Mumbai, and Dr Anup Malani is professor , University of Chicago Medical School
The views expressed are personal