As world waits for COVID-19 vaccine, India must use time to build robust immunisation plan, delivery system for last-mile reach

Right from selecting the strategy for delivery of COVID-19 vaccine to recruiting a large volunteer staff, every tool must be analysed from the perspective of India’s unique public health system and its capabilities

As world waits for COVID-19 vaccine, India must use time to build robust immunisation plan, delivery system for last-mile reach

The world has been embroiled in a fight against the novel coronavirus for over 6 months now with only one end-point in sight — a COVID-19 vaccine. An invisible army of scientists are working across the world hoping to achieve what usually takes decades in just a few months. As of 20 June, 169 vaccines were in development and 11 were undergoing clinical testing.

Even though the success of the steroid drug Dexamethasone in COVID-19 treatment is a promising development, the true victory against the viral disease will be when 60-70 percent of the world’s population has been immune to the virus (known as herd immunity). The vaccine can catalyse this in a way that is considered safe and truly enable a realistic return out of lockdowns and into the normal status quo.

As per WHO’s chief scientist Dr Soumya Swaminathan, nearly 200 crore doses of the vaccine could be available for public use by the close of 2021. When a vaccine is touted ready for use, the first priority of all governments is to ensure that they are able to produce or source it in adequate quantities at affordable prices. However, that is only half the battle.

Adequate supply doesn’t ensure that every citizen in need has real and effective access to it, neither does it secure near universal demand for the vaccine to further herd immunity. It is imperative on the Indian government, therefore, to create well in advance of the vaccine becoming available, a robust vaccination plan and commensurate systems around its delivery to one of the largest and densest populations in the world.

Strategic starting points

Of course, a pandemic of this scale and proliferation needs a targeted campaign-styled mass vaccination strategy as relying on routine immunisation methodology will be time consuming and inadequate. India’s routine system is primarily targeted at children below five years and needs a complete overhaul to cater to all ages.

As world waits for COVID19 vaccine India must use time to build robust immunisation plan delivery system for lastmile reach

Representational image. AP

Polio’s experience has also shown that a campaign-styled approach is more immunogenic and demonstrates a dramatic and immediate impact. Campaign use enhances coverage substantially due to its ability to reach out to those that routine strategies cannot, and also because of its ability to enhance immunity in close contacts of those vaccinated through secondary spread. The latter claim of course depends upon the specifics of the infection and proved to be immensely useful in controlling polio. Such an effect can have immense potential for India’s dense population but needs to be subject to more research.

Ideally, India should target both an ‘attack’ strategy through a campaign to attain enough coverage and a ‘maintain’ strategy to ensure all newborns and infants are vaccinated through routine channels. An attack-contain strategy might be unsuccessful in interrupting transmission in India’s rapidly exploding population alone. During India’s tête-à-tête with smallpox eradication, therefore, the government had to supplement it by adequate surveillance and containment as well.

Key planning priorities

Administering a campaign of this scale necessitates intricate planning. Right from selecting the strategy for delivery (door to door, community-led, hospital administered, etc) to recruiting a large volunteer staff, every tool must be analysed from the perspective of India’s unique public health system and its capabilities.

Another critical choice is the method of administration of the vaccine, which is intrinsically related to its success. Administration through a needle or syringe, while traditionally prevalent, has its own drawbacks such as providing training to volunteers, social acceptability, and logistical costs. Oral vaccines (eg, cholera, polio, and rotavirus) and intranasal influenza vaccines have been used globally for mass vaccination during outbreaks.

In any case, these need to be supported by a robust and well functioning logistical backbone of a fail-safe cold chain network. India’s Electronic Vaccine Intelligence Network (eVIN) is already a best practice in logistics management for vaccines. However, the priority of the government should be to ensure that the cold-chain transport and delivery network is adequately prepared to not get overwhelmed by the pressures of the COVID-19 mass campaign.

Thinking in the 21st century

All our experience with campaign-styled vaccination has been from an era devoid of modern-day advanced and emerging technologies. Effectively combating the pandemic through vaccination needs to optimise the integration of technology and innovation in planning.

As world waits for COVID19 vaccine India must use time to build robust immunisation plan delivery system for lastmile reach

Representational image. AP

Outside the box thinking early on can help weave innovations into the organic design of interventions. For instance, thinking beyond oral and needle-based administration into next-generation technologies like microneedle array patches, oral gels, jet injectors, etc. can exponentially enhance outcomes. However, this needs to be evaluated further based on epidemiologic and economic modeling and social and behavioral health perspectives.

At the same time, innovations in cooling technologies like sustainable solar direct drive refrigerators and those not requiring constant power can propel uninterrupted vaccination to all the corners of the nation. Bold thinking would require investing in research of refrigeration-free vaccines altogether like the MenAfriVac that was largely successful for tackling meningitis in Africa. Disruptive ideas like self and home administered oral tablets or skin patches can be potential game-changers, but it depends upon how far the Indian jugaad and creativity will allow us to go in this fight.

Suryaprabha Sadasivan is vice-president and healthcare policy lead at Chase India and Abhinav Verma is a lawyer and policy consultant working on health systems strengthening

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