In vaccine race last lap, the key steps for India

HEALTH/ GOVERNANCE

Topic: General Studies 2, 3:

• Issues relating to development and management of Social Sector/Services relating to Health 
• Government policies and interventions for development in various sectors and issues arising out of their design and implementation. 

In vaccine race last lap, the key steps for India

Context: Nearly unparalleled efforts in science over the past few months have yielded at least two COVID-19 vaccines (from major pharma companies, Pfizer and Moderna) with promise (above 90% efficacy), in a historically short span of time.

Oxford University and its partner AstraZeneca are expecting the results of their phase-3 trials by December end, and have reportedly seen a good immune response in earlier trials among senior citizens

What should be the evaluation criteria for COVID-19 vaccine?

Evaluation of candidate vaccines for COVID-19 should be done on technical parameters and programmatic suitability. An ideal vaccine would provide all of these — 

1. A vaccine that provides immunity of high degree (90% + protective especially against severe illness), broad scale (against different variants) and durable (at least five years if not lifelong)
2. A vaccine that is safe (little or no side-effects and definitely no serious adverse effects)
3. A vaccine that is cheap (similar to current childhood vaccines); 
4. A vaccine that is programmatically suitable (single dose, can be kept at room temperature or at worst needs simple refrigeration between 2°C and 4°C, needle-free delivery.
5. A vaccine that is available in multidose vials, has long shelf life and is amenable to rapid production.

A difficult vaccine to develop

Historically, we have faced difficulties in the development of coronavirus vaccines. 

• No Reference Vaccines: Although there were some attempts at development of vaccines against Severe Acute Respiratory Syndrome (SARS) and the Middle East Respiratory Syndrome (MERS), there are no licensed vaccines for any coronavirus yet. 
• Danger of Re-infection: Previous coronavirus vaccines were found to be immunogenic (generate antibodies as in phase II) but did not effectively prevent acquisition of disease (phase III) fuelling a concern that re-infection may be possible
• Inadequate Long term experience: There are also safety concerns due to immunological consequences of the vaccine as these vaccines use newer techniques with which we do not have long term or large population experience.
• Need of post-licensure surveillance system: About the safety of vaccines, there are always possibilities of rare (one in million) or delayed (by months or years) serious adverse events which will come to light only after mass vaccination has started; this requires a good post-licensure surveillance system to be in place. 

Given various candidate COVID-19 vaccines, what should the government strategy be while choosing a vaccine and for vaccination?

• Ranking by risk category: The first rule would be to not to put all your eggs in one basket. We already know that government has planned for vaccine supply from different sources

• The second rule would be to prioritise: WHO has issued guidelines for prioritisation for vaccine recipients. For this, we need to rank population sub-groups by risk category and by programmatic ease of vaccination. Vaccination should start with where these two criteria intersect — health-care workers followed by policemen

• The third rule is use multiple channels to immunise the population. Other important considerations would be of equity and cost. 

Challenges Ahead

1. Vaccinating the general population

• Vaccinating the frontline workers like healthcare workers (& policemen) by utilizing the cold storage requirements at their own facility, including in private sector or district hospitals
• The problem arises in vaccinating general population especially the high-risk groups (the elderly and those with co-morbidity) 
• It might be easier to vaccinate the institutionalised elderly as compared to community-dwelling ones. 
• Solution: The only orderly option is to create some sort of a technological solution of a queuing system based on an earlier registration process for age and presence of co-morbidity and allotment of appointment in a nearest booth

2. Ensuring Equity in Vaccine Distribution

• The greatest challenge would be to immunise the poorest and the most vulnerable (slums/migrants/refugees/people with disabilities). 
• Solution: Because of access issues, this must be by an outreach or camp approach (booths along with web-enabled appointments facilitated by civil society)
• Leveraging Institutional Experience: India has learnt major lessons through social mobilisation efforts during the Pulse Polio campaigns, Aadhaar card enrolment and elections, which will serve as good models
• Strategic Usage:  It is expected that the pandemic would start receding once we protect about 60% of the population (in terms of coverage x effectiveness). However, we should ensure that this coverage is well-spread out, else focal outbreaks will keep occurring in areas with poor vaccine coverage. 
• This also raises the possibility of using a ring immunisation strategy (immunising the population around reported cases), even earlier.

3. Issue of Market forces

• One major challenge would be that many people would be willing to pay for the vaccine and ask for expedited access. 
• Obviously, till we cover a bulk of phase 1 beneficiaries, the government should not concern itself with other groups. 
• However, government can and should allow the vaccine to be available in the private sector at a market-driven price for such people. 
• It will be ethical as well as cost-saving for the government, if it does not divert vaccines from the government-driven programme.
• Let the decision to wait for a government-delivered vaccine or one from the private sector be made by individuals, and not the government. It will also free the government to focus more on “needy” people.

Conclusion

• Many countries have already published their prioritisation policy, therefore it is critical that the government has a fair, transparent and published policy in this regard even if it results in heartburn in some quarters.