On May 14, 2021, the Indian government announced that over 2 billion doses of vaccines against SARS-CoV-2 will be produced in India from August to December. The government can be applauded on its intent: vaccinating a billion Indians with two doses each should in theory give India herd immunity. But while the number 2.1 billion doses makes sense, little else does. Vaccines don’t save lives; rapid, mass, repeated vaccinations do.
Vaccinate on a war footing
In the 2019 general election, in just five weeks, about 610 million Indians voted at one million polling stations that were supervised by 10 million election officials. If the nation can be mobilised every five years for the general election, there is no reason why India cannot vaccinate one billion Indians in five weeks. On a war footing, India needs to vaccinate 75% of the population in five weeks, not five months.
Up to May 23, only 10.9% of the population had received one dose and only 3% had been fully vaccinated with two doses. On average 1.5 million Indians have been vaccinated every day since the vaccination programme started on January 16. If in the 150 days between August and December this year, about 2.1 billion doses are produced, India requires not just the production but the administration of at least 14.4 million vaccines per day. But it lacks the infrastructure to administer the produced vaccines at 10 times the current rate. It will fail in this critical task unless it mobilises the armed forces for logistics. Every health worker not working in a hospital and every medical, paramedical, and nursing student will have to be on vaccine administration duty. Unless every Indian is protected either by vaccination or herd immunity, India will remain unprotected.
Spreading viruses mutate. The only way a host can break the cycle of replication and mutation is if the host’s immune system neutralises the virus. Immunity is acquired in only two ways – either by natural infection or vaccine-derived immunity. The problem with the current rate of vaccination is that in the large population groups which remain unvaccinated or under-vaccinated, the virus is spreading, replicating, and mutating. Unless it resorts to mass, rapid vaccinations, India will be condemned to new variant pandemic cycles that will keep surging and receding with cyclical and devastating consequences on lives and livelihoods.
Like influenza, SARS-CoV-2 is here to stay. There is a high possibility of another wave of infections, with another strain if not this. Many more will get infected. The aim is to downregulate the virus with rapid, mass and repeated vaccinations from an epidemic to an endemic infection that has seasonal outbreaks with lower number of cases, morbidity and mortality, allowing us to safely open up and keep the economy open.
Sadly, many decision-makers forget that vaccinating the nation is not a one-off; we will have to repeat this herculean exercise every season with updated and re-engineered booster vaccines to prevent the next pandemic cycle which will be driven by new and emerging variants.
All vaccines are not equally effective – high efficacy equals high economic benefit. The primary driver of the choice of a vaccine manufacturer is not just the ability to produce large quantities in the time frame required; it is the efficacy of the vaccine following peer reviews, publications and rollout. Equally important is the ability of the manufacturer to quickly re-engineer and produce updated vaccines against the prevalent strains and future ‘variants of concern’.
Both the Russian Sputnik V and the Chinese Sinopharm vaccines were rolled out widely and ahead of sufficient phase 3 trial data. Mostly low- and middle-income countries have given emergency use licence to both these vaccines and millions have been vaccinated with them. Both vaccines remain under review by the European Medicines Agency. On May 7, the World Health Organization listed Sinopharm for emergency use and is expected to do the same for Sputnik V shortly. However, absence of transparency in clinical trial protocols and of the data and its analysis have cast doubts on approval of these vaccines in developed countries with access to other vaccines.
Surge in the Seychelles
Policymakers and vaccine manufacturers would be wise to pay close attention to what is happening in the Seychelles with respect to the efficacy of vaccines. Despite being the most vaccinated nation in the world, with more than 60% of its population fully vaccinated, the Seychelles is battling a surge of the virus and has had to reimpose a lockdown. In the fully vaccinated population in the Seychelles, 57% were given Sinopharm (donated by the United Arab Emirates), while 43% were given AstraZeneca (produced by the Serum Institute of India). On a per capita basis of reported cases, the Seychelles outbreak is worse than India’s. All vaccines do not necessarily demonstrate the efficacy that the manufacturers tout. Manufacturers must be held to account not just on their production targets but on efficacy data. Transparency in clinical trials including post-vaccine rollout analysis is mandatory.
The impact of vaccination
Until all Indians are protected, none of us is protected. The government’s announcement that 2.1 billion doses will be provided in five months, without any mention of a central vaccine agency managed by experts to govern the purchase, procurement and production centrally for all States, will create and promote vaccination asymmetry. It will exacerbate the pre-existing healthcare iniquity and inequity in India. To the rich-poor, rural-urban, digital divides we now appear to be adding a new vaccination divide.
India has to learn from its colossal mistakes. It must set aside its hubris and exceptionalism. It must on a war footing coalesce behind the only weapon that works — vaccination. The pandemic cycles have left in their wake incalculable but preventable loss of life, human suffering, financial ruin and economic decrepitude. If we fail, generations of Indians to come will ask why we did not come together and do the right thing.
Joseph Britto is former consultant and honorary senior lecturer in Paediatric Intensive Care at Imperial College at St. Mary’s Hospital, London