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Insights into Editorial: Salvaging strategy: On scaling up COVID-19 vaccinations

 

 

Context:

The precarious second wave of COVID-19 infections has hit India with greater ferocity than the first. Despite a year to prepare, we have been caught woefully off guard again.

Multiple reports of the scarcity of COVID-19 vaccines and drugs have surfaced from different parts of the country.

According to the Observer Research Foundation, till the end of March, India had produced 316 million doses of Covishield and Covaxin the two COVID-19 vaccines in use in India.

Of this, 64.5 million doses have been exported. This suggests that the issue isn’t vaccine production. Perhaps, the problem has more to do with centralised procurement, distribution, and coordination with different State governments and local authorities.

 

Second wave of coronavirus infections:

  1. India’s aggressive second wave of coronavirus infections marked by over 1,50,000 cases a day and many deaths is clearly the result of irrational exuberance early in the new year.
  2. After prematurely assuming that COVID-19 was virtually over, governments made rash decisions to allow large religious gatherings and political campaigns with little regard for disease control.
  3. The lapse is now threatening a nascent economic recovery.
  4. Rather than view the crisis as a political setback, the government should focus on a mitigation strategy that will not hobble the economy, while stopping the wildfire spread of the virus.
  5. The National Vaccination Strategy, however, remains inscrutable and non-transparent, since more vaccines, including WHO-approved ones, remain unavailable to Indians for unspecified reasons.

 

First step in health services is decentralisation:

  1. Decentralise the response to district level. Knowledge of existing and evolving local conditions matters, for the design and the delivery of an effective response. Local data gathering and analysis provide real time intelligence for rapid response.
  2. Local community networks are important channels for information dissemination and for partnering the administration in implementation.
  3. We need consultative policymaking at the national level, inter-departmental planning at the State level and data-driven decentralised decision making for situation adaptive implementation at the district level.
  4. The district collector must coordinate health-care services across all facilities in the district and be empowered to commandeer hospitals, hotels and transport facilities as needed.
  5. Prevent super spreader events and mandate masks. Testing numbers are again being projected as the best measure of an efficient and effective response. This is incorrect.
  6. While tests are indeed an important component of the strategy, we cannot test asymptomatically infected persons and mildly symptomatic persons who do not report themselves.
  7. These constitute a very large number at any time, as we know from antibody surveys.
  8. We cannot randomly and repeatedly test large proportions of the population to detect virus presence in such potentially infective persons.
  9. Masks, if worn well and regularly in public and even in indoor gatherings, will greatly reduce risk of transmission from any infected person, known or unknown.
  10. Even the more infectious variants will be blocked by effective masks, even where physical distancing is not possible.

 

Better solutions to avoid the spread of COVID-19:

What is absolutely essential is preventing super spreader events.

  1. Crowding, whether indoor or outdoor, offers the virus an opportunity to seed itself among many exposed persons who then carry it elsewhere to perpetuate the chain of transmission.
  2. There should be a ban on large gatherings, for at least the next eight weeks. Travel restrictions too must be imposed during this period.
  3. The notion that all of India has acquired or will soon acquire herd immunity must be dispelled with clear messaging for some months to come.
  4. Use smart testing and tracing, but case detection needs more. The past year has taught us that viral tests are useful but have limitations.
  5. A single RT-PCR test can miss between 30%-40% cases, due to limitations posed by swab collection, transport efficiency and laboratory competency apart from testing too early or too late during the infection when a replicating virus is not detectable.
  6. We need to detect possible cases through household surveillance of symptomatic individuals by primary health-care teams supported by citizen volunteers. All suspect cases and household contacts must be tested.
  7. Positive cases must be isolated and provided home or hospital care depending on severity.
  8. Symptomatic but negative persons and household contacts should be re-tested three to five days later but wear masks and observe distance even at home till the re-test result too is negative and the infected person has recovered.
  9. Genomic analyses must be performed in at least 5% of test positive samples.
  10. Contact tracing, for persons from whom the case may have acquired the infection and to whom the case may have passed it on, needs to be conducted with speed and efficiency.

Local networks help in early case detection and contact tracing. The use of just apps will not do.

 

Social support is key to win over COVID-19:

  1. Involve people, not just instruct. Citizen engagement is critical for a successful pandemic response.
  2. Formal and informal networks that exist at the local level must be activated and supported to educate people and motivate them for adopting COVID-19-appropriate behaviours, symptom reporting, providing contact information and registering for vaccination, while providing social support to affected families.
  3. Masks can be produced at the State or district level, for free distribution to households by community-based organisations.
  4. People partnered public health must become the credo and lasting legacy of the COVID-19 campaign.
  5. Provide empathetic social support. District authorities must identify vulnerable persons and families who may suffer hardships due to loss of income, shelter or incur high health-care costs.
  6. Proactive support must be provided from public financing, as state policy, even as philanthropy is mobilised to supplement.
  7. Children must be supported for education at home or in the neighbourhood, through voluntary agencies, to overcome the digital divide of online teaching.
  8. Social solidarity must become the soul of our pandemic response.

 

Way Ahead: Step up vaccine rollout:

  1. Speed up vaccine rollout, recognising value and limitations. The benefit of currently available vaccines is to provide protection against severe disease, not infection per se.
  2. This information must be clearly conveyed to the public, politicians and the media so that wrong expectations of complete protection against infection do not lead to laxity in behaviour or an outcry of vaccine failure.
  3. Given this objective, available vaccines must be prioritised for vulnerable persons.
  4. Initially, the aim must be to immunise all persons above 35 years of age and all younger persons with at-risk health disorders.
  5. We must get more vaccines quickly into the supply chain by incentivising greater production volumes of already approved vaccines and waiving the requirement of a bridging trial for domestic manufacture of vaccines approved by credible international regulators, subject to submissions of full trial data to our regulators.
  6. We must train more vaccinators for delivery closer to home, stepping up daily administration rates at more centres.

 

Conclusion:

Nonetheless, as India aims to inoculate more and more people it is imperative to ramp up vaccine production.

It is important for the government, therefore, to come up with rational activity curbs, keep them stable and incentivise people, including through financial rewards.

These initiatives can lower the perception of lost opportunities and compensate workers in the affected sectors such as the travel, food and hospitality industries.

This road map can be reviewed when vaccines become widely available and cases decline, although a return to a carefree past is a long way off.

Political communication on the state of the pandemic lacked a clear sense of purpose during festivals and poll campaigns.

Now, the COVID-19 strategy can avert costly partial or full lockdowns only with public cooperation, and that calls for building credibility and trust.