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Between ‘Covid is over’ and universal vaccination cheer, India lost sight of strategy

India won't achieve vaccination-assisted herd immunity by July end, the mortalities and serious hospitalisations need to be reduced.

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First wave of optimism, January 2021. The first wave of optimism was universally shared by all Indians — that India beat Covid-19. The world media also ran commentaries on how India beat Covid-19.

Two affirmations in January led to this optimism:

1. India was probably the only country where the infections were reducing when the restrictions were systematically being unlocked. 

2. The fears surrounding the much-heard hypothesis that the infections are likely to rise in winter did not come through.

The result was a nationwide first wave of optimism. It is not an exaggeration that it was shared by most, if not all, because there were hardly any voices raising questions on “what if there is a comeback?” The common folks went complacent, the experts made more theories on why Covid-19 ended. The exports of vaccines coincidentally began in this period.

March 2021. The first wave of optimism was carefully disowned by everyone in a phased manner as the infections started to rise. There were nay-sayers from many other states who were confident that the Covid-19 second wave was not applicable to them, although Maharashtra began reeling under the pressure of the second-wave of infections. Theories about the new variant began, so none of the old predictions of the original virus were wrong. Regardless of what went wrong, who judged it wrong, who was ill prepared — the government or the public or the modellers — the result was that the infections began to rise.

Concerns about vaccine shortage, 1 April 2021. If the transmission chains may be broken, then there is a good chance of containing the virus. This is true regardless of whether it happens by vaccination or by a lockdown. Benefitting from the two wonderful vaccines available in India, Covishield and Covaxin, large vaccination drives began.

April 1 marked two simultaneous occurrences — 

1. the rise of infections and 

2. a roll-down beyond the standard definition of vulnerable (seniors, people with comorbidities) to those above 45.

The latter made many wonder why vaccination should stop at 45, and why not extend it for everyone.

There are a few raising questions about strategy, which was lost in the uproar about stopping exports, opening up imports, allowing free-markets for vaccines. 

Also read: ‘Highly infectious’ double mutant strain was circulating in Uttarakhand even before Kumbh began

Second wave of optimism, 19 April 2021. The government announced that anyone over 18 years of age is eligible for vaccination in the market. The government will ensure vaccination for anyone who cannot afford. Another universal optimism began. From the quarters of the ruling party that made this decision possible, from the quarters of the opposition that was asking for opening up vaccination for all age groups, from the media that was criticising the government in the past month, from the market, from everyone over 18 and desiring a vaccine.

The discussion on strategy is once again lost in the overwhelming cheer for the universal vaccination.

One has to look at the numbers to see what problems this decision solves or it does not. Some of the concerns seem to be about price. But number of doses is another problem. 

Also read: 22 people on a train back from Kumbh found Covid positive at railway station in Ahmedabad

Beyond the optimism, how many vaccines are available

At present, based on publicly available data, about 50 million Covishield doses are made every month, another 5 million of Covaxin. The third entry into the Indian market is Sputnik V, which says the numbers will be low in May, June, and may be in July. And beyond that the production may ramp up from 50–100 million doses depending on how their partnerships work. Also, a Rs 4,500-crore financial support is supposed to help Covishield and Covaxin to ramp up. The market may also open up to other vaccines by Pfizer, Moderna, Johnson & Johnson. Although considering the prior commitments of these companies to US and Europe, whether they will contribute on a large-scale to the Indian market before the Western countries are fully vaccinated remains doubtful.

Assuming there will not be any slowdowns because of the embargo from the US on the export of raw materials needed for vaccine, and assuming a quick turnaround of making the facilities operational, the reality still seems to be about 60 million vaccines per month in May, June, and July. That is about a 180 million doses.

Even if there is a stockpile of another 180 million doses, since all these vaccines are double dose vaccines, it will be realistically possible to vaccinate around 180 or 200 million additional people between now and July.

This will add to the 108 million already administered with at least one dose, and 16 million with two doses. Even assuming there is an additional 90 million stock that will account for this second dose, a reasonable target that may be reached is 300 million. This will still be a much smaller number compared to the about 900 million population over 18 years of age, and definitely not enough to reach a “vaccine assisted herd immunity” anytime soon.

Also read: Decentralise Covid fight, don’t bury head in sand like ostrich. Be like a peacock

Critical three months

Vaccination-assisted herd immunity will not be achieved in the next three–four months, the mortalities and serious hospitalisations need to be reduced. Why should one have short-sighted fear of next three–four months when many more vaccines will be available beyond that? Because the second wave of the pandemic is already overwhelming the health-care system in many places.

How to reduce the hospitalisations and deaths is the concern of now, and the next few months. Vaccination is supposed to reduce serious hospitalisations and mortality. It is also supposed to break the transmission chain, as would a lockdown, but clearly without hurting the economy as a lockdown would.

Unless the vaccination is either scaled or strategically administered to the high risk groups, the battle between vaccines and lockdown in breaking the transmission chain will tilt in favour of the latter.

Also read: ‘Fearing Covid’, Indians are popping ivermectin, HCQ, dexamethasone — all self-prescribed

‘High risk equivalents’ — the lockdown math

From the perspective of the nation, all people are equal, and everyone deserves a vaccine. But from a public health point of view, not everyone is at the same risk due to Covid-19. Eighty-eight per cent of the fatalities in the first wave were from ages 45 or above (55% above 60, 33% between 45 to 60). Of course, risks may be higher with the variants in the 2nd wave, but hopefully will not be drastically different. Compared to the Seniors, the younger groups of ages 25 have a much lower mortality risk 15 to 100 times lower based on different estimates.

Source: Captured from the tweet of @VincentRK

To interpret it literally, purely in terms of mortality risk-mitigation, vaccinating 15 to 100 around the age of 25 is equivalent to vaccinating 1 Senior person over 60.

While we most agree on the merits of universal vaccinations, the age group (>60) which has a mortality of 1% or higher is less than 30% vaccinated in some states, and 50% or so in many others. Just a couple of states crossed 80% coverage of the Seniors. There is still 50–70% of seniors, and similar number of people between 45–60 to be vaccinated.

Encouraging seniors and 45+ group.

The government has endorsed a universal vaccination. It is a welcome measure. The aim is not to defy, judge or question the government. But it is to listen to the numbers, as numbers speak. Then wise steps may be taken by the governments, population, or families.

The goal is not to leave behind the younger ones, but remembering that a rapid and near 100% coverage of the seniors and possibly those over 45 should be simultaneously aimed for. A near 100% coverage sounds unreasonably high, but even large states like Rajasthan around 90% vaccination coverage for the Seniors. So it is possible.

Whether it happens by suggestion, recommendation or education, it will be nice to see the States ensure a maximal coverage of vaccines among the most deserving as soon as possible.

This last sentence most deserving may be interpreted in two ways, from the perspective of lives and economy. Purely by considering the risk of mortality at an individual level, one may ensure coverage among the 45+ group. And secondly, if hospitalisations and deaths continue, lockdowns will become inevitable and longer. Completing the vaccination of the vulnerable is the key both for saving lives and economy.

The younger ones, especially those living with parents and grandparents should understand the compounded effect of protecting themselves as shown schematically below (based on the efficacy of AstraZeneca Covishield).

B. Saraswat, S. Ansumali, MK. Prakash, medRxiv

The author is Faculty Fellow, Jawaharlal Nehru Centre for Advanced Scientific Research (JNCASR). Views are personal.

This article first appeared on Medium.

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  1. It is opposition ruled states have lost the site. We are suffering being in Maharashtra.
    They want vasooli and vasooli only. Bruk was selling remdesiver at 1100 by intervention of opposition party leader and BMC buys at 1600. This was issue why bruk MD was picked up Maharashtra police.

    No local media or MSM are asking right questions.

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