Finding a vaccine suited to India is the least of the problems the government will face. Storing and transporting them at a certain temperature range can be a logistical nightmare, but India is adept at this.
By Dr KK Aggarwal
Eleven months into the Covid-19 pandemic and the incredible pace of research has already yielded 13 vaccines that are under large scale testing. India’s health minister Dr Harsh Vardhan said on November 22, 2020, that a locally developed vaccine could complete its final trials in a month or two, raising hopes for a rapid roll-out in a country with the world’s second highest number of infections.
It is likely that the government will approve one of the vaccines (looks like the Oxford one, which will be subject to the British drug regulator’s approval) by December with emergency use authorisation. This will give it political mileage across the world for launching a vaccine within a year of the pandemic striking.
In addition, the Indian Council of Medical Research and privately held Bharat Biotech have started third stage trials of Covaxin in a process that would involve 26,000 volunteers. It is the most advanced Indian experimental inactivated vaccine. The other experimental vaccines on trial in India are the one being developed by AstraZeneca and Oxford University that is being manufactured by Serum Institute of India; Russia’s Sputnik V; Zydus Cadila’s ZyCoV-D and lastly one that Biological E. Ltd is developing with Baylor College of Medicine and Dynavax Technologies Corp.
Nevertheless, these vaccines are slated to get approval in several countries and even in India. Yet, the biggest challenge now is the safe storage and transportation of these sensitive vaccines. Most biological functions in living organisms are carried out most effectively at certain fixed temperatures. Similarly, vaccines that use either weakened or inactivated viruses or specific mRNA sequences also need to be stored in cold temperatures so that they are not ripped apart before entering the body.
There are two types of vaccines, one involving the protein part of the virus and the other, its nucleic material. The one with the nucleic acid requires to be stored at -20 to -7 degrees Celsius temperature.
Among all the vaccines in the race, Pfizer and BioNtech vaccine’s storage appears to be the most daunting in terms of requirements. The candidate requires temperatures as low as -70° Celsius equivalent to an Antarctic winter to maintain potency. On the other hand, Moderna’s vaccine requires -20° Celsius and Sputnik needs storage temperature of -18° Celsius. Among all, Oxford-AstraZeneca is the most suited one for tropical countries like India as it requires normal fridge temperatures of 2° Celsius to 8°Celsius.
To know whether India’s cold chain system is efficient and sufficient for the Covid-19 vaccine, we need to understand how it works here. To ensure that potent and safe vaccines are delivered, a network of 27,000 cold chain points has been created across the country where vaccines are stored at recommended temperatures by the Ministry of Health and Family Welfare under the Universal Immunisation Programme (UIP). Under UIP, the first cold chain was established in 1985.
Cold chain is a system of storing and transporting vaccines at the recommended temperature range from the point of manufacture to that of use. India has built a vast cold chain infrastructure to ensure that only potent and effective vaccines reach millions of beneficiaries across the country.
The vaccines are supplied by manufacturers directly to four Government Medical Store Depots (GMSDs) at Karnal, Mumbai, Chennai and Kolkata and state and regional vaccine stores. The GMSDs supply to the states and regional vaccine stores and state and regional vaccine stores supply the vaccines to divisional vaccine stores and districts. The vaccines are further supplied to last cold chain points which are usually situated in primary and community health centres (PHCs and CHCs).
Transportation of vaccines from states/regional stores to divisions and districts is done in cold boxes using insulated vaccine vans. Vaccine carriers with icepacks are used to transport vaccines from PHCs to the outreach sessions in the village.
In addition to the equipment, there are different personnel deployed for cold chain and vaccine handling. In the states, there are state cold chain officers who are in charge of ensuring smooth functioning of all cold chain equipment there. At regional, divisional and district levels, there are cold chain technicians whose responsibility it is to maintain and repair cold chain equipment for maintaining the recommended temperatures for storage of vaccines.
At the PHCs and CHCs, cold chain handlers, who are health personnel (pharmacists, multi-purpose health workers, etc) have been tasked with proper storage and handling of vaccines and daily upkeep of ice lined refrigerators and deep freezers, including temperature charting. Cold chain technicians have been provided with training and tool kits for performing installation, maintenance and repair activities.
For maintenance of cold chain equipment, the government has provided funds to states under the National Rural Health Mission. The performance and efficiency of the cold chain system at different levels is monitored continuously, through supervisory visits and review meetings.
The government procures and supplies all UIP vaccines along with diluents to all states. In addition to vaccines, syringes of different capacities are also procured centrally and supplied to states. The process involves vaccines and logistics forecasting, scheduling, ensuring supplies as per need and so on. It is important to ensure that the cold chain system is not over burdened and supplies don’t fall short. Supplies are made to states on a quarterly basis on receipt of indent. State vaccine stores can store vaccines for three months and so can district vaccine stores. PHCs/CHCs send monthly indents to district stores. PHCs can store vaccines for a maximum of one month only.
Thus, it is a huge well-oiled machinery that will kick in to give over one billion Indians the vaccine that they so desperately need.
—The writer is President, Confederation of Medical Associations in Asia and Oceania, and former National President, IMA
Lead Picture: UNI