In his address to the nation on October 20, Prime Minister Narendra Modi assured that every citizen of India will be administered a COVID-19 vaccine. Modi wants to make use of India's experience of disaster management and conducting elections across the length and breadth of the country to put in place an efficient system for vaccine delivery and administration.
Modi's assurances also gave a glimpse into how India intends to vaccinate its 130 crore citizens. It's going to be a massive, months (if not years) long exercise that will see states and union territories, district level functionaries, civil society organisations, volunteers, citizens, and experts from all necessary domains join hands. The entire process is expected to have a strong IT backbone, with the system designed to leave a lasting positive impact on Indian healthcare system.
But what's the level of planning so far?
The National Expert Group on Vaccine Administration for COVID-19 (NEGVAC) in consultation with state governments and relevant stakeholders have readied a detailed blueprint of vaccine storage, distribution, and administration. NEGVAC is also working actively on vaccine prioritisation and distribution.
India's health authorities have experience of reaching 2.9 crore pregnant women and 2.67 crore newborns under its universal immunisation programme (UIP). India's UIP is functioning with 29,000 vaccine storage points, 83,000 deep freezers and other equipment, 736 district vaccine stores and 258 cold and freezer rooms to store vaccines.
Health Secretary Rajesh Bhushan says India has the technology and cold storages capacity. The technology includes temperature trackers that provide real time information to centralised server. It tracks vaccine procurement, storage, temperature, and transportation. The movement of vaccines is done on refrigerated vehicles. "If the vehicles are not refrigerated, there will be temperature controlled boxes. We are discussing how to augment this infrastructure. There is a national committee doing that," he says.
THE REAL TASK
But the scaling up is easier said than done. India immunises 3 crore infants and women through injections (polio is given as oral doses) a year against vaccine-preventable illnesses like TB, meningitis, pneumonia, diphtheria, pertussis, tetanus. But the COVID-19 vaccination challenge is much tougher. In fact, it is approximately 10 times larger in scale compared to UIP. Doctors, paramedics, hospital staff, senior citizens, persons with specific chronic illnesses are expected to be vaccinated first since they belong to high risk groups.
According to the health secretary, the vaccine expert committee has readied a draft prioritisation plan, and has tried to calculate the number of high priority people versus the number of doses that will be available from January to July. "If the present clinical trials proceed, and succeed, then the number of doses will be sufficient to vaccinate the priority list of people," he says without giving an estimate of the total number.
The number is believed to be as high as 30 crore, say sources. But it is not the size of the numbers alone which is a problem. The vaccination drive must take into stock the geographical expanse of the country. Every step in the logistics, delivery, and administration need to be put in place. The prime minister in his speech also said: "It must include advanced planning of cold storage chains, distribution network, monitoring mechanism, advance assessment, and preparation of ancillary equipment required, such as vials, syringes."
In its monthly report, Delhi-based Council for Healthcare and Pharma (CHP) says that private sector is already gearing up to provide ancillary support to ensure that the vaccine reaches people.
"Makers of vials and syringes have started building up capacity in anticipation of a surge in demand if and when a successful COVID-19 vaccine is launched in India. Schott Kaisha a joint venture between German pharma packaging firm Schott and Indian glass tube maker Kaisha which supplies four to five million vials (mostly multi-dose vials) a month to vaccine makers in India and abroad has the capacity to manufacture 1 billion vials per year and the company can ramp up production quickly to meet demand," the CHP report says.
It adds: "Borosil is presently utilising 45 percent of its vial making capacity as it recently added additional capacity. It can easily double capacity without further capex. Vial maker Gerresheimer India is planning to scale up capacity by 30 percent. Hindustan Syringes and Medical Devices Ltd, the world's largest manufacturer of auto-disable syringes that are used for vaccination, plans to scale up production to 1 billion syringes a year in the first half of 2021 from 700 million currently."
Indian cold chain operators have also started work to prepare an efficient logistics network to ensure the smooth and safe delivery of COVID-19 vaccines. "Snowman Logistics, India's largest cold-chain network and a subsidiary of Gateway Distriparks Ltd, plans to set aside one chamber each across its 31 facilities in India and deploy refrigerated trucks for vaccine distribution. Gati Ltd's cold chain business, Gati Kausar, will use its fleet of 120 trucks for delivering vaccines. India's UIP is supported by more than 27,000 cold chain facilities, of which 3 percent are at the district level and above, and the rest at the local level, according to the government's comprehensive multiyear UIP plan for 2018-22," the report adds.
In terms of cold storages, the government is likely to put on alert every possible storage facility in the country - medical and non-medical - to be converted into vaccine storage points if need be.
Even if every other piece falls in place, there will be a tough task of training people to administer vaccines. And this is where the role of two government institutions - National Cold Chain Resource Centre, Pune and National Cold Chain and Vaccine Management Resource Centre, New Delhi - becomes pivotal. Both institutions, established for the very purpose of capacity building by imparting training to programme managers on immunisation supply chain system and technical training to cold chain technicians in repair and maintenance will have to work overtime now.
What the government needs to do is to decide early enough who are going to be part of the vaccination mission and once that is done, allow them to undergo training by using cascade mechanism. The centres should be able to train online master trainers, who in turn can train state trainers, who will train district trainers. The cascading effect should result in trained personnel getting added at every public health centre level before the roll out of the vaccination programme.
Besides the preparations, first you need COVID-19 vaccine. Also, health authorities must get a sense of which type of vaccine will be administered and what type of training, arrangements need to be made. For instance, a lot depends on the temperature that is required to be maintained to store and transport the vaccines. If it is within the 2-8 degree centigrade temperature range, India can heave a sigh of relief. The UIP vaccination infrastructure follows the same range. Also, most of the cold storages including the ones for storing horticulture products and cold chains can operate in that temperature range. If it is negative, say -15 to -25 degree centigrade, India only needs to augment its infrastructure. But, if the COVID-19 vaccine that finally clears the regulatory tests is in the range of -60 to -80 degree centigrade, the ultra freezing temperature, the challenge will be enormous. That's one of the reasons why the government is perhaps waiting to act despite a ready blue print. It wants greater clarity about the temperature and other requirements.
Once the temperature requirements for the vaccine are confirmed, the government is certain to augment its cold chain capabilities. Facilities - both private as well as government - will be made part of the national mission. Similarly, once the administration method (which can vary from vaccine to vaccine) is known, the government will have to initiate massive training in vaccine handling, distribution, administration, at every level - primary centre, district, state, national - almost instantaneously to have a battle ready team when the vaccine arrives.