Vaccines have to be equitable: Jacob John
Home Health Vaccines have to be equitable: Jacob John
Health - April 29, 2021

Vaccines have to be equitable: Jacob John

You can’t have two companies holding the country to ransom, says the professor at the Department of Community Health, CMC, Vellore

As this goes to print, the number of COVID-19 deaths in India has crossed 200,000 amid an acute shortage of oxygen. Jacob John, professor at the Department of Community Health, Christian Medical College, Vellore, says it is ironic that just when vaccine hesitancy is abating, the country may be running out of vaccines as we universalise inoculation for everyone who is 18 years and older. Excerpts from an interview:

When vaccine manufacturers set the price of COVID-19 shots, and States are asked to take on the financial burden of inoculation, are we ignoring vital lessons from many parts of the world where the vaccines are universal and free?

Absolutely. Vaccines have to be equitable. People have been hit by a pandemic and those who need these vaccines the most should not face barriers to receiving them. Vaccines by nature are expected to be equitable and supposed to reach people who cannot afford them.

Now, the responsibility for vaccinating the 18-44 age group has been devolved to the States; some State governments have said they will provide the vaccine free but not all have committed to doing so. If the poor between 18 and 44 are not assured the vaccine for free, they will not take it. And that is an equity issue.

I also feel it’s extremely unfair that companies are attempting to make such large profits. I have no idea how they justify a pricing of ₹300 or ₹600. It’s absolutely unacceptable because they have not had to bear the research costs. The government has enough leverage, and if it wants to, it can decrease the pricing to below the ₹200 threshold. You can’t have two companies holding the country to ransom.

We run one of the world’s largest universal vaccination programmes involving millions of people. What are the lessons we can draw from our past experience? What are the unique challenges posed today?

India’s Universal Immunisation Programme is about children, and it has a good system of delivering vaccines to them. We are not particularly good at vaccinating adults; we haven’t ever done it on a large-scale, except in some States. So I think drawing parallels is challenging. But I’ll explain what I’m worried about.

Currently, there are three things that matter. One is the vaccine supply chain. Then, the physical infrastructure to deliver vaccines. And finally, the cost of trying to vaccinate the entire population. If resources permit, and infrastructure exists, you could vaccinate everybody at one go. But clearly, we don’t have enough vaccines. And vaccinating 700 million people is not something that’s going to be possible overnight.

So, from our experience with vaccination as a programme, one, you should have a system by which you forecast how many vaccines you have, and prioritise people who have the largest burden of disease; these, clearly, are people older than 45 years. Scaling up vaccination is not easy because you don’t have the product and you also don’t have the capacity to deliver this at one go. We haven’t really thought through this process, and we are not going to be able to offer this vaccine to everybody.

Under 2% of Indians have received both doses of the vaccine since the roll-out. How much of this can be attributed to vaccine hesitancy? How can this fear be combated and quickly?

So, I think a lot of the initial problem was the way the vaccine was introduced; there was hesitancy because of how the vaccines were tested, how they were pushed. And there was also a temporary decline in the disease. So in India, on one hand, we had a message saying the country is special, we are not seeing fatality, this is a mild disease, nothing to worry about. And on the other, people were anxious about the vaccine’s efficacy and safety.

But then at the beginning of this year, when the numbers started increasing, and the second wave came, a lot of these people turned around. The number of cases and deaths in the last few months have been so high that people who had refused vaccines earlier are now looking forward to it. Unfortunately, as this tide changes, the supply is going to crash.

Why is India, the world’s largest producer of vaccines, facing such an acute shortage? Where did we go wrong?

Clearly, all of us had a sense of complacency. We thought we were past the pandemic and didn’t move fast enough. So, we had two vaccines that were good and we started both those vaccines without a licensure programme (these two vaccines are still on emergency use authorisation). There were multiple other sources of vaccines we should have tapped into, and licensed quickly enough, knowing how large our population is. We did not move fast enough to tap into the global resources we have. And now, it’s a little too late. You can’t start planting trees in the middle of a forest fire. By the time we get the vaccines, it’s only going to help us for wave three and four, not for this particular wave, unfortunately.

What are the challenges in systematically tracking the spread of the virus in real-time in a country as vast as this?

Tracking viruses — both the trend in increase in infections as well as genomic variant tracking — costs resources. And we don’t have unlimited resources. When we talk about testing a proportion of the population, it’s only practical from a public health perspective if it’s going to result in public health action. For instance, if we are going to test, trace and isolate people — and that’s not when you have this kind of community transmission going on — you won’t be able to invest enough. Do the math: if it costs ₹1,500 for a PCR test, think how much it will cost to test the majority in a population of a billion.

The way to approach this would be to start sampling country-wide, look at sequence variations, trends in increase in disease, and increase in reinfections. Reinfections are the key. So, if we find evidence of multiple reinfections with a particular variant, that changes the entire dynamic of this pandemic. Our strategy should be to set up facilities across the country to look at sequences. We are interested in knowing if there is a dominant variant. And how that translates in terms of reinfection or severity of disease. We need to be able to understand that, not just in one geography, but across the country.

What do we know about the many new variants that have emerged, their transmissibility and the potential vaccine-escape mutants?

We know very little at this point, because we are so limited in the sequencing that we have done. However, we know broadly that there are certain variants in certain parts of the country (there are different mutations that dominate in different geographies) that are now dominating. The point is, viruses mutate all the time. That is natural. These are random stochastic events, but they also are a response to a survival need. So, the variants that we are seeing may have been first identified elsewhere, but they have emerged here or have been imported here.

We see the B.1.1.7 in the North, in Punjab and Delhi clearly, and in the West, we see the B.1.618, the B.1.617 clearly dominates in Maharashtra, and in the South, we are seeing multiple variants. The question is, what is the consequence of these? One thing seems clear: certain variants like the B.1.617 appear more infectious.

What is not very clear is, having picked up an infection, is it more virulent? That is, is it causing more disease?

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