Covid: How do you vaccinate a billion people?

When it comes to vaccine manufacturing, India is a powerhouse.

It runs a massive immunization program, manufactures 60% of the world’s vaccines, and is home to half a dozen major manufacturers, including the Serum Institute of India – the world’s largest.

Unsurprisingly, there is no shortage of ambition when it comes to vaccinating a billion people against Covid-19. India plans to receive and use some 500 million doses of the vaccine against the disease and immunize up to 250 million people by July next year.

This confidence is bolstered by his history of immunizing a large number of people each year. India’s 42-year-old immunization program, one of the largest health programs in the world, targets 55 million people – mostly newborns and pregnant women who receive some 390 million free doses of the vaccine against a dozen diseases every year. The country also has a well-oiled electronic system to store and track these vaccines.

Yet vaccinating one billion people, including hundreds of millions of adults for the first time, against Covid-19 is going to be a formidable and unprecedented challenge, experts say.

Five of the 30 vaccine candidates under development in India are in clinical trials. They include the Oxford-AstraZeneca vaccine which is being tested by Serum and a local vaccine under development by Bharat BioTech. “Having a local vaccine is a top priority,” Dr Renu Swarup, secretary of the Indian Department of Biotechnology, told me.

From choosing a bouquet of vaccines to controlling distribution to identifying groups for the first jabs, “everything is a challenge,” says Dr Gagandeep Kang, microbiologist and first Indian elected Fellow of the Royal Society of London.

“We underestimate the complexity of the exercise. It will take at least two years to vaccinate half of the Indians.”

Here are some of the main challenges:

India has about 37,000 “

The cold chain stores from which stored vaccines can reach more than eight million sites. (Almost all vaccines must be transported and distributed between 2 ° C and 8 ° C in what is called the cold chain.) Will this be enough?

India will also need enough auto-deactivated syringes to prevent reuse and possible re-infection. The country’s largest syringe maker has said it will manufacture a billion such syringes by next year to meet growing demand.

Then there are questions about the regular supply of medical glass vials. And what about the disposal of the huge amount of medical waste that will be generated by this mass vaccination campaign?

Nearly four million doctors and nurses are fueling India’s vaccination program, but India will need more to perform Covid vaccinations.

“I worry about how we can [extend all the resources] in rural India, ”Kiran Mazumdar Shaw, founder of Biocon, the country’s leading biotechnology company, told me.

The vaccine supply will be tight next year and it will be difficult to decide who gets the vaccines first.

Health Minister Harsh Vardhan said private and government health workers and frontline workers “from other ministries” will receive the first doses.

Experts believe it won’t be easy.

“We will never have a sufficient supply of vaccines. The prioritization of recipients will be a considerable challenge, ”says epidemiologist Dr Chandrakant Lahariya.

Consider this. In a country where the majority of health care is private, will a private health worker have priority over a public worker? Will permanent workers have priority over people working under contract?

If older people with underlying diseases are eligible for early injections, how will the different co-morbidities be prioritized?

India, for example, has more than 70 million diabetics, the second highest in the world. Will they all have a coverage preference?

Deployment of the vaccine in all 30 states will not be possible. Will the first supplies therefore go to the states most affected by the pandemic?

Questions of fairness and partisan impartiality are inevitable.

According to Prashant Yadav, who studies healthcare supply chains at the Washington-based Center for Global Development, entering into manufacturing contracts with vaccine manufacturers with a “reasonably good portfolio” of vaccines should help India get enough doses to people fairly quickly.

But the success of routine vaccination does not guarantee the success of Covid-19 vaccines, he says.

“Routine immunization infrastructure has a huge footprint, but is primarily aimed at clinics run by the government. There is no large-scale adult immunization program and adults do not routinely seek primary care at public government health centers, ”says Dr Yadav. A well-regulated public-private partnership is the only way out this time, he adds.

People like Ms Shaw and Nandan Nilekani, co-founder of Infosys, one of India’s largest IT service companies, suggest India should use Aadhaar, the 12-digit unique identification number that more than one billion Indians use it to access social assistance and pay taxes. , to record and track each dose.

“We need to design a system capable of doing 10 million vaccinations a day across the length and breadth of the country, but all unified by a digital backbone,” Nilekani told a newspaper.

Some of the concerns relate to corruption in access to vaccines.

How do the authorities prevent frauds such as people who get false papers to get on the lists of people selected for the first shots? And how do you prevent the sale of fake vaccines in distant markets?

Vaccines have side effects for some people. India has a 34-year-old surveillance program to monitor these “adverse events” after vaccination.

But the researchers found that the benchmarks for reporting side effects are still low, and the number of serious adverse events is still well below expected numbers.

Failure to report side effects transparently could easily lead to vaccine concerns.

This is perhaps the biggest question. Will the government acquire all doses and roll out a free or subsidized state-run vaccination program? Or will the rich pay their doses at market prices through private distribution and sale?

Experts like Dr Lahariya believe the government should foot the bill for immunizing all Indians until the pandemic is over. Others like Dr Shaw say private companies could pay to vaccinate their employees.

Mr Nilekani estimates that with vaccines costing between $ 3 and $ 5 (£ 2.24 and £ 3.74) to start with, a double-dose vaccine could cost as much as $ 10 for each Indian and $ 13 billion for the ‘India. It would be very expensive.

That’s why, says Gagandeep Kang, a good vaccine for India should cost less than 50 cents a shot, be plentifully available, and administered in a single dose.