The Vax Shot Caught Short

13,10,90,370 Doses received by states/UTs

11,43,69,677 Total consumption, including wastage

1,67,20,693 Available doses with states/UTs

2,01,22,960 Doses in supply pipeline to states/UTs

Source: Union health ministry; figures as on April 13

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A  vaccination graph climbing steeply, a cry for vaccine supply, a Tika Utsav, inoculation centres temporarily closed. This was the zigzagging route during India’s expanded vaccination drive including those above 45 years. Amid concerns of a vaccine shortage, a blazing run of inoculation. Can we balance out demand and supply to sustain the marathon? For that elusive HD clarity picture, there are still a lot of pixels missing. But here’s what we know: the country’s vaccination drive has shifted gears since April 1 averaging more than 35 lakh doses most days—even touching 45 lakh on April 5. The data tracker portal Our World in Data shows India surging ahead of the US, which had so far been leading the daily vaccination sprint in terms of major demographies. So far, more than 10 crore citizens have received one dose. But view that in terms of percentage-of-population covered, and India’s large denominator predictably drags the graph down to dismal single digits, lower than most other countries—even neighbouring Bhutan. The tiny Himalayan kingdom has vaccinated nearly 93 per cent of its adult population just 16 days after it began its vaccination campaign on March 27. Overall, Bhutan has vaccinated 62 per cent of its 800,000 people.

India, given its size and volume of people, is a different story. Midweek, however, saw some action on the vaccine policy front. First, Russia’s Sputnik-V vaccine that has completed bridging trials in India was cleared for emergency use. Then, the government decided to fast-track new vaccine opt­ions—essentially by removing the pre-condition of conducting local clinical trials for COVID-19 vaccines that have been granted emergency approval for restricted use by regulators in the US, Europe, UK and Japan, or those in WHO Emergency Use Listing. These will be allowed on the basis of a post-app­roval parallel bridging clinical trial.

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“Yes, a bridging study will continue and the data will be seen by the regulator as per procedure. But the prior need for clinical trials will not be there,” Dr V.K. Paul, who chairs the National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) told reporters. “This therefore compresses the timeline and will increase the access to vaccines that are manufactured in other countries.”

So far, India has been using only two vaccines: Covishield and Covaxin. Even there, the reliance has been skewed. Between January 16 and April 12, Covishield accounted for 91 per cent of the doses administered. What led to this imbalance hasn’t been exp­lained so far. More vaccines, public health experts say, will help ease the current supply constraints.

For a perspective on supply, consider the scenario at the start of the week when the four-day Tika Utsav—aka ‘vaccination festival’—began on April 11. In Odisha, at the same time, nearly 900 out of the 1,452 vaccination centres had to be shut down temporarily because Covishield wasn’t available. By the start of the week 14 of the state’s 30 districts ran out of vaccine stocks. Supplies were indeed trickling in. According to the state health authorities, about 2.5 lakh doses arrived on April 10—but Odisha was averaging 2.5 lakh vaccinations a day by then. “As of now, vaccination is going on at only 579 centres. But even these centres may have to be shut down if stocks don’t arrive soon,” was how Bijay Panigrahi, director, health and family welfare, Odisha, explained the situation at the start of the week. “Priority is being given to districts that are rep­orting more positive cases.”

The situation was marginally better in Bhubaneswar, where people are being vaccinated only with Covaxin, developed by Bharat Biotech. Sources in the Odisha health department say 77,960 doses of Covaxin were available, enough to keep the vaccination drive going in Bhubaneswar through the week.

More states—including worst-hit Maharashtra—have reported shortages as well. But while demand for vaccines has generally shot up, it is also sluggish in several rural pockets where COVID-19 case numbers are still low. Vaccinating officials in far-flung districts tell Outlook that turnout, rather than supply, was an issue they faced. Yet, the bigger picture was that of a high daily nat­ional average. The bottlenecks relate to better planning rather than shortage of doses, Union health secretary Rajesh Bhushan said at the weekly briefing. The larger states typically receive four days’ supply at a time, after which they are rep­lenished, while the smaller states are sent 7-8 days’ supply in one go, he said.

Adar Poonawalla, CEO of Serum Institute of India last week told a television channel that the firm’s manufacturing capacity is currently about 2 million doses of Covishield a day or roughly 60-65 million doses a month. Pune-based Serum Institute is exploring fin­ancing options—including approaching the government for support—to ramp up production to about 100-110 million doses a month, according to Poonawalla. But that additional capacity will only be up and running by June.

Currently, the CoWIN data dashboard offers real-time, district-wise vaccination figures. But data on supply of vaccines isn’t publicly available, hence the speculation. “We have been vaccinating around 3.5 million on ave­rage each day. The collective production of the two manufacturers, as recent reports suggest, is less than this demand. Unless we have a stockpile, we are running into a short supply,” says former WHO official Rajesh Bhatia. “I guess with the Sputnik-V vaccine and newer vaccines coming in, at least the shortage can be overcome.”

Details of the Sputnik-V manufacturing capacity for India aren’t immediately available. Last October, when the Russian Direct Investment Fund (RDIF) announced its tie-up with Hyderabad-based Dr Reddy’s Laboratories for clinical trials and distribution, the stated aim was to supply 100 million doses of the vaccine to the Indian partner upon getting regulatory approval in the country. Over the past few months, RDIF has ent­ered into manufacturing agreements with Indian companies such as Panacea Biotec, Virchow Biotech and Hetero for a cumulative 400 million doses a year.

The spread of vaccination centres, especially in April, when people aged 45 and over became eligible to receive a shot, has been growing too. Over the past three weeks, the number of vaccination sites increased by 80 per cent to a peak of 71,610 (by April 12). A bulk of this is still government facilities, but private sites too are being added, incl­uding workplace vaccination camps organised by large employers.

The health ministry, which pegs the wastage of COVID-19 vaccines at 6 per cent nationally, has been urging states to bring down the wastage rate to one per cent. Better local management—by consolidating small centres which are delivering small numbers—could help, say authorities. “I think it is necessary to consolidate these centres into larger centres and once that happens, the vaccination wastage will also come down,” R.S. Sharma, chairman of the empowered committee on covid vaccination said at an online event last week.

Currently, as the CoWIN dashboard shows, the daily session trends are typically bunched up around noon. Wastage, explains Bhatia, has both a technical and ethical dilemma. “You can’t avoid it. A vial has 10 doses. Suppose eight people have come to your centre, either you vaccinate those eight and waste two doses or turn them away,” he says. “That’s the reason wastages are built into the demand. These are ground realities.” In comparison to routine immunisation programmes, the current COVID-19 vaccine wastage rates are acc­eptable, he says. But with a pandemic raging on, stepping up vaccination is a key intervention to manage serious disease among the vulnerable groups.

Globally as well, vaccine availability is a key concern. Last week, pharma firm Astrazeneca served a legal notice on partner Serum Institute of India over delays in vaccine shipments for global commitments. In interviews, Poonawalla has pointed to prioritising domestic requirements given the Indian government’s short-term export curbs.

An analysis by the Duke Global Health Innovation Center’s vaccine tracker portal—which collates publicly available inf­ormation—says that vaccine manufacturers worldwide had cumulatively projected a total production of 12 billion doses of COVID-19 vaccines in 2021. In India, vaccines in the pipeline, besides Sputnik-V, include a DNA-based vaccine being developed by Zydus Cadila, which is currently in Phase III trials, and the Serum Inst­itute’s COVOVAX candidate in Phase II/III clinical trials. Meanwhile, this week, the department of biotechnology said it has approved additional funding for clinical studies of a messenger RNA (mRNA) vaccine being  developed in India by Gennova iopharmaceuticals—the vaccine candidate is currently enrolling volunteers for phase I/II trials. Thr­o­ugh trial and error India hopes to overcome its shortcomings and shortages.