By Dr KK Aggarwal
The world’s largest Covid-19 vaccination drive began in India on January 16 this year with a target to vaccinate 300 million people by August. Expectedly and deservedly, the first phase of the drive covered all healthcare (HCWs) and frontline workers (FLWs) engaged in daily battle with the deadly coronavirus. Around one crore frontline health workers and two crore frontline workers were expected to receive the vaccine in the first phase. However, only 50-70% of healthcare workers across various states have been reported to have taken the first dose.
The opening up of the second phase of the vaccination drive, which began on March 1 to include people older than 60 years and those above 45 years with comorbidities, literally gave the vaccination drive a shot in the arm. Senior citizens, in particular, showing great enthusiasm, turned up in large numbers for their vaccine shot.
Dose by dose * India has so far donated eight million doses and sold nearly 52 million doses to 75 countries. * It has administered more than 44 million doses since starting its immunisation campaign in the middle of January. * Around 30 lakh doses were wasted.
Till March 21, 2021, the number of vaccine doses given has crossed 4.4 crore. These include 77,79,985 HCWs (1st dose), 48,77,356 HCWs (2nd dose), 80,84,311 FLWs (1st dose), 26,01,298 FLWs (2nd dose), 36,33,473 beneficiaries aged over 45 years with specific co-morbidities (1st dose) and 1,76,27,418 beneficiaries over 60 years, as per data from the health ministry.
However, the vaccine drive is not moving at the pace envisaged, given the huge population. If the target of vaccinating 300 million beneficiaries by August is to be met, 4-5 million doses, on an average, need to be administered daily. But till March 20, a little over 1.6 million doses were given. This is clearly not enough.
Increasing the reporting of post-vaccination deaths, not only from India but also globally, has raised concerns about their safety and is proving to be a major contributor to vaccine hesitancy. The vaccination drive needs to be speeded up, given the fact that the second wave has come knocking at our door in an ominous sign of things to come. Already, a sharp upsurge in the number of daily new cases is being seen in the country. More than 43,000 new cases have been reported in the last 24 hours (at the time of writing this), the highest since November 26 last year.
In addition to the slow vaccination rate, another important issue is of vaccine wastage. The average Covid-19 vaccine wastage in India so far has been recorded to be 6.5%. Telangana has the highest vaccine wastage rate at 17.6% (i.e. out of every 1,000 doses 176 doses are being wasted), followed by Andhra Pradesh at 11.6%, Uttar Pradesh at 9.4%, Karnataka at 6.9% and J&K at 6.6%.
This is a cause for concern as so far, immunisation has been targeted to priority groups in phases. Millions of citizens who do not fit into either of these categories are awaiting their turn. Vaccine wastage is something India can ill-afford as a larger and bigger second wave could have a potentially devastating impact. “According to the WHO, globally, vaccine wastage is 50%. However, when it comes to vaccination campaigns where vials hold multiples doses of 10 or more, the wastage is 14%.” WHO has defined vaccine wastage as the sum of vaccines discarded, lost, damaged or destroyed. It is a combination of opened and closed vial wastage.
Closed vial wastage is related to suboptimal cold chain systems and improper stock management during storage and transportation. The open vial wastage, on the other hand, is categorised into two: the avoidable open vial wastage (attributed to the practices of healthcare workers assigned to immunisation duties) and unavoidable open vial wastage (includes discarded unused doses from multi-dose vials determined by the vial size and session size). Minimizing wastage without disrupting vaccination coverage is the basis of a successful vaccination programme.
Ironically, the reason for vaccine wastage in the country is not an ineffective transportation system or lack of a proper cold storage system, as would have been generally expected. It is the number of doses in a single vial, though a possibility of their contribution cannot be ruled out.
The vaccine comes in a multi-dose vial, each of which contains 10 or 20 doses. Once the vial is opened for vaccination, all doses need to be used within four hours. There is no open viral policy as there is no vaccine vial monitor and expiry date on the vial of the vaccine. Cold chain maintenance at the session site becomes important in such situations.
If the turnout is low, the unused doses in the vial go waste. Vaccine hesitancy has inarguably played a role in the low uptake of vaccines. Asking beneficiaries to come back the next day or even later in the day might add to the vaccine hesitancy. By failing to draw up the proper required doses, untrained vaccinators may also add to vaccine wastage.
Another reason for wastage is lack of planning at the session site.
Although unrelated to the issue, an important concern is how the wasted doses are disposed of. The health ministry has given directions about their disposal in its Operational Guidelines about Covid-19 vaccine. It states: “The used, unused, partially used vaccine vials should be returned to the cold chain point as per existing Adverse Effects Following Immunisation (AEFI) guidelines for proper disposal. Carry the segregated immunisation waste generated during outreach sessions and hand these over to the PHC for further disposal.”
What needs to be done to avoid vaccine wastage is to open up vaccination to all individuals older than 18 years. More the number of people vaccinated, less will be the wastage. With the numbers of Covid infections again climbing, more people need to take the vaccine. Expanding the eligibility criteria will also increase the probability of breaking the chain of transmission.
The vial should be opened only when the requisite number of beneficiaries is present. Another way to minimise wastage is to open up the vaccination during a fixed time period. If the number of beneficiaries for a certain time slot is less, they can be accommodated in other sessions planned later that day or even the next day.
Targeted vaccination, which focuses on people working in confined spaces such as offices, courts, etc., or in parts of the country where active cases are increasing, may be a better strategy for now. The public, especially in the rural areas, needs to be educated about the benefits of the vaccine and encouraged to come forward to take the required doses.
More vaccination centres can be identified, particularly in smaller cities or rural areas, to scale up the drive.
The reasons for vaccine wastage need to be recorded. This data is essential to identify potential problems so that appropriate course correction can be done. All this requires drawing up a vaccination plan chalked down to the last detail. Vaccines are an invaluable armamentarium in this epic battle against the coronavirus. Vaccines are the only answer to quickly build up herd immunity and to slow down the pandemic, which is proving to be particularly unpredictable. Vaccine wastage of any sort is, therefore, not an option. We need to find easy answers to this conundrum and we need to find them quickly.
The prime minister rightly said: “We have no right to waste a dose which is another person’s right… The more we save, the more eligible people will get both doses.”
—The writer is President, Confederation of Medical Associations of Asia and Oceania, and Heart Care Foundation of India