Vaccine to Vaccination: Lessons from Spanish Flu pandemic in dealing with COVID-19 crisis

“They say it starts right in your head: You begin to sneeze
and your eyes turn red.
You then have a tight feeling in your chest, And you cough
at night and you just can’t rest.
Your head feels dizzy when you are on your feet; You go to
your table and you just can’t eat.
And if this ever happens to you, You can just say you got
the Spanish Flu”

~ Joe Bogle, October 1918

As we achieve the undistinguishable milestone of a million cases in 10 days, it is time to pause, introspect, analyse, and most importantly, accept, that every single attempt against the dreaded onslaught has come to naught.

While epidemiologists and world leaders endeavour to do their best, there were admonitions in history from the Spanish Flu that forewarned the onslaught of the second wave of the contagion. As we stand at the advent of the second wave of in India, it is worth mentioning that while the first wave of the Spanish Flu led to approximately 5,000 fatalities in India, the second wave which appeared in September 1918 ravaged the population of western India,  and the death toll is estimated at anywhere between 12 million to 18 million Indians.

The present recorded death toll is close to 1,70,000, which to many of us is nothing more than a number. To put it into perspective, the total number of Indian soldiers martyred in the 1962 war with China, and the three wars against Pakistan in 1965, 1971 and 1999 (Kargil), was under 10,000. As the ‘pandemic fatigue’ sets in, 1,70,000 deaths thanks to do not evoke a corresponding reaction as do the deaths of our soldiers. Part of our silence is on account of the human tendency to pay more attention to some deaths than to others. Perhaps survivors don’t much want to talk about an experience that seems to have neither restrain nor remedy.

As we hear news of vaccine shortages, and mobs at vaccine centres, let us try and understand the distinction between manufacturing a vaccine, and vaccinating over 100 crore (one billion) people (about 75 percent of the population) to achieve any measure of herd immunity. To understand the enormity of the challenge, this number would equal the cumulative number of children that are administered the polio vaccine in five years in India!

Each year nearly 2.3 million vaccinators under the direction of 1,55,000 supervisors visit 209 million houses to administer Oral Polio Vaccine to just under 20 crore (200 million) children under five years of age, across the country. With the individual nuances of each of the vaccines, temperature constraints, and the logistical difference between administering an OPV drop versus an injectable potion, we are probably looking well past 2022 before life can go back to “pre-Covid normal” under an umbrella of immunity to the contagion. It makes it all the more prudent to taper down the celebration at the launch of the vaccine, extend safety protocols such as social distancing, wearing a mask, and resolutely work towards vaccination.

To its credit, the government has established the National Expert Group on Vaccine Administration for , a three-tier administrative architecture with committees and task forces at the state, district and block level to address this challenge on a similar footing to conducting a general election. App-based digital tools will speed up the process and the race between the vaccine and the virus has begun. Unfortunately, it is the virus that has taken the lead, as we go past the first bend.

Vaccine and Spanish Flu (1918-19)

There may be some lessons and inspiration that we and our scientific community can draw from the horrors of the Spanish Flu, which felled anywhere between 1.2 to 1.8 crore (12 to 18 million) Indian lives. While we have followed the progress of vaccine development across the world on a daily basis over the past six months, it is noteworthy that Indian scientists made great progress in developing a vaccine for the Spanish Flu influenza. 

When the second wave appeared in September 1918 with attended high mortality, investigations were begun at the Bombay Bacteriological Laboratory, established under WM Haffkine in 1896 and at the Central Research Institute, Kasauli, founded in 1903, to develop a vaccine.

The efforts of Indian researchers Dr Soparkar and Dr Gore of the Bombay Laboratory are particularly noteworthy. They worked independently and produced results similar to those in Europe. Remarkable work was also carried out in Karachi. As a consequence of the efforts of these scientists, it was felt that there was enough evidence to justify a vaccine.

Information was sought from South Africa regarding the constitution of the vaccine in use there, which was then prepared at Kasauli and issued for use to the military only. Later the formula adopted by the War Office Conference of Bacteriologists was cabled to India, and vaccine was prepared on those lines at the CRI, Kasauli.

Meanwhile, Lieutenant Colonel Liston, Director of the Bombay Laboratory had prepared a vaccine consisting only of Influenza ‘bacilli’ (250 million) which was issued for use in selected communities. Finally, in December 1918 at a conference of Bacteriology held in Delhi, the constitution of the vaccine was decided upon.

It had the following constitutes: 500 million influenza and hundred million ‘bacilli’ for the first dose, and double this for the second dose. It was prepared at both the above-mentioned Laboratories and at the King’s Institute of Preventive Medicine established in Madras in 1903. The vaccine was distributed free of charge. A different pandemic, a century apart, a different strain of the pathogen, the parallels are incredible. Similar to the Spanish Flu vaccine we have a twin-dose vaccine for and the majority of the world distributing it free of cost.

Public bust, private boom

Over the past weeks, a controversy has erupted over the efficacy of the vaccine candidates, side effects such as deep vein thrombosis ( blood clots), the submission of test data, and the debate between free vaccination versus vaccination at a cost to the vaccinee.

Privatisation of the research and development in the field of immunology has opened doors to conglomerates, and names like Pfizer, Moderna, AstraZeneca, Biocon, Serum Institute of India, Bharat Biotech, and Zeydus Cadila have become household names, and are riding the crest of the wave.

Traditionally, manufacturers were able to sell vaccines to developing countries at a lower cost because they could get a higher price from industrialized countries. But industrialized and developed countries no longer use the same vaccines for communicable epidemics such as polio, yellow fever, or smallpox.

In addition, manufacturers no longer maintain excess production capacity: supply must be equivalent to demand. Finally, with the exception of the hepatitis B vaccine, there is no longer enough competition among suppliers to keep prices down. The key factors that in the past decades have kept vaccine prices relatively low “have evaporated”, and the vaccine boom is here for everyone to enjoy.

India revelled in the unique advantage with Vaccine production restricted mainly to public sector undertakings, prior to 2008. Vaccine prices were low, and the government was able to successfully initiate immunisation programmes such as Small Pox and Polio eradication.  In its edition of May 2008, The Lancet, among the world's oldest and best-known peer-reviewed general medical journals, condemned the decisions made by the Government of India in 2008 to suspend the production of some vaccines.

Public-health experts questioned the closure of three major Indian vaccine facilities which produced the bulk of essential vaccines for infants in India including BCG and diphtheria, pertussis, and tetanus (DPT). Licences for the production of vaccines at the three centres -- the Central Research Institute in Kasauli, the Pasteur Institute of India in Coonoor, and the BCG Vaccine Laboratory in Chennai were suspended in 2008. In all fairness to the government of the day, immunisation levels had achieved decades of verifiable success, and there was possibly no need to expend resources into Vaccine development in the absence of a looming threat. Who could have predicted a pandemic on the scale of a dozen years ago? Who would have believed it?

Ironically, the commercial boom that private enterprises such as the Serum Institute, Biotech and other private sector companies will now reap from sales of the vaccine, may have been shared in some measure with the public sector institutes that had over a century of experience. Would we have had an exponential production capacity, and no threat of a Vaccine shortage that stares us in the face today, had this been a public-private sector joint effort?

While we may never have the answer to that question, should our private sector manufacturers fall short of the mammoth task of producing the required number of vials or be domineered by commercial motivations, we may still rue the suspension of vaccine production facilities, and ensuing research, at the CRI, Kasauli, Pasteur Institute, and the BCG Vaccine Laboratory.

As we ride the crest of the current wave, we are faced with the challenges of vaccine production, dissemination, and eventual vaccination of nearly a billion people. The journey is just beginning, and the path is strewn with blockades such as lack of faith in the vaccine itself, incomplete data available in the public domain, supply logistics, pricing, and diversion of the vaccine for purposes such as ‘vaccine diplomacy’ and commercial profit, among others. What we must not forget, is that the vaccine is just that, a jab in the arm in our fight against the contagion.

The vaccine syringe is only one of the many arrows in our quiver in the battle against , and must not be celebrated as an end to the pandemic.