India’s fight against COVID-19: Virus to vaccine and beyond

As a past practitioner of medicine primarily and an inquisitive business system analyst by profession, I remember being equal parts curious and nervous while comparing the stark contrast in the administrative pandemic response and surprisingly common public apathy across both countries. The pandemic shone a bright spotlight on some blind spots in healthcare systems across countries. I nervously agreed with everyone who predicted an impending public health disaster given India’s weak and under-resourced healthcare infrastructure.

A year later, with its astonishingly low case positivity and COVID-19 related mortality as compared to some star healthcare systems abroad, India (pleasantly) proved many of us wrong.

With a population of 1.3 billion people that is 4x that of the United States, India’s total confirmed cases just about cross 10.9 million with the official death toll for India hitting 155,771 at the time of writing this.

While experts have hypothesized a younger demographic, vitamin D levels, BCG vaccination and higher temperatures as factors responsible for lowering the death rate in India, it is of note that India was among the first countries to adopt a flexible national lockdown, with decisive leaders leading and advocating social distancing and masks from the front. India also saw a markedly less severe version of the disease with major cities having reached 40-50% seroprevalence months ago.

Some of the possible reasons for India’s success in controlling the pandemic could be:

1. Enforced lockdowns limiting both internal and external travel thereby restricting community transmission. Interstate travel required e-Pass to cross state borders and is still not entirely de-regulated. Additionally, shutting down schools and colleges for almost an entire year now, thereby ensuring the super-spreaders stay home.
2. Immediate quarantining of individuals and localities along with stringent contact tracing.
3. Atmanirbhar Bharat with indigenous production and supply chain of personal protective equipment (PPE) and increased laboratory testing capacity.

Hitherto an importer of PPE kits, in March 2020², India’s Niti Aayog had estimated that the country would need 20 million PPE kits and 40 million N-95 masks per day by July. Responding to PM Modi’s clarion call for an Atmanirbhar Bharat or a self-reliant India, the domestic industry responded with a massive scale and speed such that by July 2020, India’s indigenous supply of PPE kits had exceeded the domestic demand and it exported 2,300,000 PPE to the US, the UK, Senegal, Slovenia and UAE. The country also increased its laboratory testing capacity under the same call for self-reliance, from 14 COVID-19 testing laboratories in February 2020 to more than 1,300 Virus Research & Diagnostic Laboratories (VRDLs) by August 2020.

4. Citizen awareness/mass advocacy drives were enforced, and non-compliance was penalized by law. For months on end, citizen telephone caller tunes played COVID-19 educational messages by default.

However, India cannot afford to get complacent in its fight against the virus. After months of steady decline, India is now reporting growth of active cases, with the states of Maharashtra, Kerala, Punjab and Gujarat leading the national upswing.

Vaccine versus virus: the race

While more than 200 million shots³ have been given worldwide to date, the vaccination rollout has been much slower than anticipated With an average daily vaccination rate of 6.3 million doses per day globally⁴, it will take an estimated 4.9 years to cover 75% of the population with a two-dose vaccine at the current pace.

Having authorized two vaccines, Pfizer and Moderna, the U.S. is currently administering 1.3 million doses a day⁵, constrained by a supply of about 10 million to 15 million doses a week. Attributable causes of note for the delayed rollout include planning and executing a mass vaccination program with an unpredictable supply against a humongous demand, the complex supply chain requirements across multiple products, a mutating virus, unprecedented winter storms (like in the USA) and a hesitant populace.

With a target of inoculating some 250 million people over six-to-eight months, India commenced her ambitious COVID-19 vaccination journey on 16th January this year with two vaccines, the SII-Oxford-Astra Zeneca Covishield vaccine and Bharat Biotech-ICMR Covaxin vaccine.

Despite having the world’s largest vaccine manufacturing capacity, including the largest vaccine producer (Serum Institute India) and a strong track record running colossal immunization programs for almost four decades now, India has a daunting uphill task to vaccinate hundreds of millions of adults against COVID-19.

So far, India appears to have excelled on its vaccination strategy, scoring high across checkpoints: manufacturing, evangelization, case index - public prioritization and scaling production to the extent of enabling vaccine diplomacy by sharing vaccines with other countries. India’s next challenge will be around how she executes the vaccination administration management to ensure last-mile delivery compliance for both doses.

Public health survives on the breath of public trust

Indians⁶ showed the highest level of trust in coronavirus vaccination, with 80% of them saying they are willing to get vaccinated, according to a worldwide survey.

Some of the risks threatening to disrupt the pace of the rollout include the sheer scale of the project, relatively fragile healthcare infrastructure, shortage of medical personnel throttling the delivery capacity and the government’s (flawed?) strategy of excluding the private sector in the rollout. Logistical challenges like insufficient cold-chain facilities or building a priority case index of population at higher risk (in the absence of standardized, harmonized digital national registries) add to the problem statement. Not surprisingly, Prime Minister Modi promoted technology⁷ assisting epidemiology to prevent future pandemics in his recent address to neighboring countries.

At the time of writing this, the implementation of the second phase of vaccinations for the elderly and high-risk individuals (Day 1 today ) appears to be facing some operational challenges. On the technology front, its COWIN app and portal have been facing multiple glitches, adding to the confusion at the vaccination centers regarding prioritization indices, lists missing from the app and senior citizens being turned away from vaccine centers for vague reasons. A grim reminder that if technology cannot solve a problem, it better not add on or create new problems. It also doesn’t reflect well on India's self-proclaimed image of being the global information technology brain and brawn.

Hopefully, the recently announced National Digital Health Mission will address some of the base underlying issues and enable the government to leverage technology for public care delivery — ushering in an era of digital healthcare in the country and hope for more than a billion people waiting to exhale.

Notes:

1. Tale of Two Countries and a Virus (medicinegirls.blogspot.com)
2. India’s successful journey to self-sufficiency in PPE kits - The Economic Times (indiatimes.com)
3. (More Than 202 Million Shots Given: Covid-19 Vaccine Tracker (bloomberg.com)
4. (More Than 202 Million Shots Given: Covid-19 Vaccine Tracker (bloomberg.com)
5. (https://www.bloombergquint.com/coronavirus-outbreak/eu-wins-vaccine-deal-doses-go-unused-in-germany-virus-update)
6. 2021-edelman-trust-barometer.pdf
7. ( PM addresses a workshop on “Covid-19 Management: Experience, Good Practices and Way Forward” | DD News)

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