In Small Doses

India cannot be too ambitious—at least it cannot afford to proceed merely on the basis of numbers that can be more easily expressed in words than actually handled, person by unvaccinated person. Last November, as the health ministry began preparations for India’s Covid vaccination drive, its goal was to give the shots to 30 crore people by August or September this year. By now, at the end of May, about half of that target—15 crore people—have received one shot. As of May 25, cumulatively, 19.84 crore doses have been administered, counting both first and second doses. The speed of vaccination in all these months has been somewhat noticeably—and tragically—parabolic, rising up to a high point in April and then tapering off. Yes, even at last week’s considerably slower pace of about 13 lakh jabs a day, that original milestone is reachable. But the equations on the ground are vastly altered now: those targets were envisaged at a time of relative luxury. Supply constraints have coincided with a brutal second wave of infections in between. The race that has to be entered is both a sprint and a canter that has to be sustained over the long distance. The runner cannot collapse.

But the race track is doubly deceitful. First, the incoherence which has slipped in anew. What was a smooth, orderly, stage-by-stage vaccination programme earlier this year hit a discordant note since it opened up for the entire adult population in May amidst a supply shortage that’s spreading some panic and anger. Many states are now clarifying that first doses for the 18-44 age group are currently on hold while they mop up the seniors with the available stock.

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Take, on top of that, the controversial move to allow states to buy doses directly. Many states and even a couple of municipal corporations (Brihanmumbai Municipal Corporation, for instance) have floated global tenders to buy vaccines—in fact, veterans in public health don’t recall a situation where states have had to step in. It has always been squarely the Centre’s job. Its sudden liking of democratic devolution is creating its own problems. This week, Punjab became the first state to acknowledge a response—Moderna, one of the manufacturers it had approached, declined saying it will only deal with New Delhi. Soon after, Delhi chief minister Arvind Kejriwal too reported that Pfizer has refused to sell directly to the state. “I don’t foresee much interest from manufacturers. Most of them have already committed supplies,” says Dr Chandrakant Lahariya, a public policy and health systems expert. A Union health ministry spokesman too admitted this week that the order books of Pfizer and Moderna are already full and any supplies would depend on their surpluses.

Since vaccine supply is constrained at a global level, it’s not a case of merely buying from the lowest bidder, explains Neeraj Jain, country manager, PATH. “I think the challenge with procurement being opened up is they are all competing for the same stock of vaccines,” says Jain. “That means two things can happen. One is, of course, we can’t find stock. The second option is for some country which has extra stock to start giving out some of that, either directly through aid, or through agents.” That latter scenario could run the risk of creating a bidding competition, leading to unreasonably inflated pricing, he says.

Currently, the Centre is buying vaccines at $4 per dose. Imported vaccines will naturally cost more, experts say. For instance, Pfizer is reported to have supplied vaccines to Israel at $30 per dose, coming in for considerable global criticism earlier this year. Even if states that have issued tenders for import of vaccines are lucky, the guess is they could be looking at $10-12 per dose, according to some experts. Geeta Athreya, who has worked closely with the national immunisation programme in the past, is aghast that India, instead of engaging in this competitive field as a single large entity, has left the individual states to their own devices—a major concern being that a richer state will be able to buy more or pay a higher price.

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It’s not in India’s interest to create such a confusing situation, feels Alok Mukhopadhyay, chairman, Voluntary Health Association of India, and convener of the Independent Commission on Development & Health in India (ICDHI), which works closely with the PMO. “The decision to allow states to import Covid-19 vaccines is disastrous. Everyone in the global market is out to make a profit, and here we are throwing the states, with their fragile economies, to go into the competitive market to bargain, do hard negotiation, and pay in hard currency. It’s a situation that can go astray,” he says. Though both the central and state health ministers are represented in the Central Council of Health, a constitutional body, there has been no deliberation to map out a strategy to tackle the situation, says Mukhopadhyay, who had written to the Union health minister a month back suggesting an action plan.

Supplies will start easing up by July-August because many new vaccines are in multiple stages of trials, says Neeraj Jain. He points to a global study that PATH carried out last year with the Coalition for Epidemic Preparedness Innovations (CEPI), which projected 3-4 billion vaccine doses as becoming available worldwide by the end of 2021. The projections are looking rosier since, but the problem is with the actual global supply.

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The government’s own projections point to 2 billion (200 crore) doses being available in India by December (see graphic), accounting for a production ramp-up by both the Serum Institute of India (which makes Covishield) and Bharat Biotech (Covaxin) and a slew of new vaccines in advanced trials. Hyderabad-based Dr Reddy’s Laboratories, which has already soft-launched Sputnik V, says it will import the initial doses from Russia until July or August. Then local manufacturing will kick in, potentially trimming the price from the current Rs 995 per dose, according to the company.

Extending that projection a bit further, India could be looking at 3 billion doses by the first quarter of 2022, said Dr V.K. Paul, who chairs the National Expert Group on Vaccine Administration for Covid-19 (NEGVAC), at a briefing on May 13. Sudarshan Jain, secretary general of the Indian Pharmaceutical Alliance (IPA), too reckons domestic supplies will be streamlined within a few months. “Between August to December, the pharma sector is confident of being able to supply 1.5 billion doses which should be enough for India. Already, production in the country has been ramped up to around 75 million doses a month,” he says.

But vaccine manufacturing is a complex process, says Dr Lahariya. “Projections are projections. Many vaccines are in Phase 1 or 2 or 3 clinical trials…we really don’t know what the final outcomes will be. Scaling up production is going to be a separate process. So all of those should be taken as extremely optimistic projections,” he says. “We need to be ready with plan B.”

Even with the available supply, the first step is to vaccinate the high priority groups, he says. “So, let’s not be emotional and say it’s opened up for everyone and we can’t do anything now. In my opinion, states should be bold and should categorically decide, based on the advice of technical experts, how best they want to prioritise. If that means halting vaccination for a few younger age groups until sufficient and assured supply, so be it.”

“Comfortable numbers will come by December. We need to do some smart planning,” says Prof N.K. Ganguly, former dir­ector, Indian Council of Medical Research. That involves reaching rural India, where the chances of mortality are higher because of the poor health infrastructure—luckily, the immunisation network covers rural areas because of India’s strength in infant vaccination, Ganguly points out. “We have to go to those villages and put supplies there.”

The second strategy, he says, is to place advance orders right away because the pandemic ‘is not going to go away’ anytime soon. “We have to immunise, maybe every year we may have to give a booster. So if there are 2-3 other companies, we need to give them advance orders,” he tells Outlook. This means being ready to absorb the risks involved: outcomes will hinge on clinical trials and approvals. That’s how Operation WarpSpeed in the US went about it, he points out. “We really need to do the same…place advance orders so they can start manufacturing. And those who have got authorisation, we need to help them to build infrastructure,” says Ganguly.

A former health secretary who had once headed the national immunisation programme says India has the wherewithal to handle vaccination on a large scale and an adequate cold chain capacity for storing vaccines. He ass­umes most states will not be importing vaccines that need to be stored at below minus 4 degrees Celsius—that leaves little choice besides Covishield, Covaxin and Sputnik V (the Moderna and Pfizer vaccines need upto -70 degrees Celsius). “States will have to draft strategies to vaccinate people in the 18-45 age group,” says the former bureaucrat. “Beyond acquiring vaccines, there are challenges of cold storage, logistics, supply chain, having trained people for administering and maintaining records. This is an evolving process and cannot be hastened,” he says.

Supply crunches are not unique to India. Various other countries too are in a similar situation. But what we probably need, given our iniquitous social landscape, is a more well-thought-through approach, says Dr Anant Bhan, who specialises in global health, bioethics and health policy. He points to the multiple price points in the current procurement policy. “Right now, there’s a potential issue around equity. People with resources, either financial resources or access to technology, are much better placed,” he says.

Neeraj Jain of PATH says a coordinated approach will be the way ahead, given that private organisations too are ready to put in money. “Not just for their employees but even communities around their factories or communities at large. There are a lot of conversations going on in that direction,” he says. “I’m just hopeful we get a single-window procurement process going. Once that happens, everything else can be easily brought into place. If we go into a bidding war, we’ll get into a challenge of increased inequity of access.” Not good news for a country like India.

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Vaccine Production/Availability August-December

• 75 Covishield

• 55 Covaxin

• 30 Biological E Subunit vaccine

• 5 Zydus Cadila DNA vaccine

• 20 Serum Institute of India—Novavax

• 10 Bharat Biotech nasal vaccine

• 6 Gennova mRNA vaccine

• 15 Sputnik V

Doses (in crores)

216 Total

Source: Government of India