|Ahead of print publication
Vaccination in controlling COVID pandemic in India: A SWOT analysis
Arvind Singh Kushwaha, Sitikantha Banerjee
Department of Community Medicine, AIIMS, Nagpur, Maharashtra, India
|Date of Submission||01-Feb-2021|
|Date of Decision||06-Feb-2021|
|Date of Acceptance||06-Feb-2021|
Arvind Singh Kushwaha,
Department of Community Medicine, AIIMS, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
The ongoing COVID-19 pandemic has been unstoppable across the globe and India. The application of strategy “test, track and treat” has not been sufficient in halting the pandemic. Arrival of vaccines on the horizon has raised hopes of termination of pandemic in the near future. It should be emphasized that epidemiological relevance, efficacy, safety, operational feasibility, and social acceptance are minimum prerequisites for successful implementation of a new vaccination campaign. The ambitious launch of COVID vaccination by India at the juncture of a declining pandemic needs to be discussed in relation to its timing, economic implications, and ramifications on public health. This article aims to analyze this vaccination strategy.
Keywords: COVID vaccination, pandemic, strategy
| Introduction|| |
The novel coronavirus SARS-CoV-2 (coronavirus disease 2019) pandemic, epicentered in Hubei Province of the People's Republic of China, has spread worldwide and has become a global threat. The application of strategy “test, track and treat” has not been sufficient in halting the pandemic. Arrival of vaccines on the horizon has raised hopes of termination of pandemic in the near future.
Immunization is one of the most cost-effective and successful global health interventions to save lives and prevent disease globally. Centers for Disease Control and Prevention reported vaccine as one of the 10 greatest public health achievements of the past century (1900–1999). Evidence shows that vaccine is an effective measure to control communicable diseases and has been used previously in controlling epidemics.
Considering the global burden of COVID-19, attempts have been initiated to launch a suitable vaccine against it. The World Health Organization (WHO) with partners around the world is supporting vaccine development by coordinating the key steps and monitoring progress. Based on the tracker developed by the Vaccine Centre, London School of Hygiene and Tropical Medicine (updated January 8, 2021), 68 of 291 total vaccine candidates are under clinical testing. In December 2020, two COVID vaccines have been authorized by the US Food and Drug Administration for emergency use-Pfizer-BioNTech and Moderna. In India, two vaccines got approval of the Central Drug Standards Control Organization (CDSCO) for restricted use in an emergency situation – Covishield and Covaxin. Immunization against COVID-19 was initiated in India on January 16, 2021, using the above two vaccines. Initially, health-care providers (HCWs) and frontline workers are being vaccinated, followed by general population. A total of 37, 58,843 HCWs have been vaccinated in India as on February 1, 2021.
It should be emphasized that epidemiological relevance, efficacy, safety, operational feasibility and social acceptance are minimum prerequisites for successful implementation of a new vaccination campaign. In this context, it was attempted to carry out a SWOT analysis of COVID vaccination campaign in Indian perspective, with a special focus on the critical issues that need to be taken into consideration during its extension in the general population.
| Situation Analysis|| |
Till January 29, 2021, there have been 101,053,721 confirmed cases including 2,182,867 deaths of COVID-19 globally, as reported to the WHO. Being a third world country harboring the second-largest population in the world, India is suffering severely from COVID-19 disease as evident from its high absolute number of confirmed cases and death (10,734,026 and 154,184 respectively, on January 30, 2021). A declining trend in active COVID cases and COVID-19 related death has been observed globally. In the Indian context, there is a declining trend of cases since September 2020 despite easing of lockdown and a considerable number of large public gatherings (election rally, festival, farmer's protest etc.) in the recent past. It clinches toward the hypothesis that herd immunity may be playing a significant role, which can be proved by results of serosurveys carried out in different parts of the country. It is pertinent to mention that case fatality and infection fatality rates were much lower in India compared to most of the other high burden countries, the reasons for which need to be explored.
Willingness to accept COVID-19 vaccine among HCWs- A situational update:
Although national-level data on vaccine acceptance is not available in the public domain, information obtained from newspaper reports is pointing toward limited acceptance in different parts of the country and high level of vaccine hesitancy among HCWs., Newspaper reports reflect low vaccine coverage (around 20%) in some states. Low coverage on HCWs is also found in other countries after initiating COVID-19 vaccine.,
A cross-sectional study is being carried out among HCWs working in Nagpur city, Maharashtra, to find out the proportion of them willing to accept COVID-19 vaccine and the reasons of acceptance and nonacceptance of vaccine among them. Participants are being approached online and data are being collected using a semi-structured Google Form. Interim analysis of 83 responses as obtained by January 15, 2021, revealed that 48 (57.8%) were willing to take vaccine, others being either indecisive or unwilling. Majority of HCWs who were indecisive opined that current knowledge on vaccine was too limited to take a decision. Major causes of unwillingness were the perception that herd immunity has been achieved and past history of COVID infection. The facilitators for taking the COVID vaccine included they consider themselves as high-risk group, they think that their vaccination will also protect their family members, and vaccination will decrease their stress level. This reluctance of vaccine acceptance among HCWs can have a snowballing effect on high-risk population whenever offered the vaccine.
| COVID Vaccination Strategy by India|| |
The massive vaccination drive initially targeting HCWs, then frontline workers followed by high-risk population is being undertaken targeting around 300 million people in next 6 months. There is a need to analyze the rationale for this strategy whether the economics, epidemiology, and ethics support this strategy. The same is discussed below.
| Strength|| |
- Safe vaccine: Evidence available till date based on findings of a clinical trial reflected favorable safety and efficacy data of both the currently available COVID vaccines. Moreover, they are expected to significantly decrease serious infection and mortality, which would be immensely beneficial in managing the pandemic
- Cold chain and other resources: The storage temperature for both the vaccines currently used in India is between 2°C and 8°C. The vaccines used in routine immunization in India are also stored in this temperature, so maintaining a cold chain for COVID vaccines will not be much challenging. India has a considerable number of vaccinators, other helping staffs, and logistics for running universal immunization program, the same machinery could be utilized for COVID19 vaccination, which seems to enhance operational feasibility. The Indian health system has experience of planning and executing similar mass vaccination campaigns in selected areas (i.e., Adult Japanese Encephalitis vaccination), which could be helpful in this context
- Building trust of HCWs: As in the first phase, all the health-care workers are being vaccinated in India, it is expected to motivate them to continue the herculean task of managing this pandemic which they are doing for the last 1 year. This may also be done to see that the HCWs are in a position to handle “second wave” scare due to the present or newer strain of SARS-CoV-2 that is being played in the public domain.
| Weakness|| |
Effectiveness and safety
Decision to introduce any vaccine to a large segment of population should be taken after ensuring its safety beyond reasonable doubt. History has revealed adverse consequences of the 1976 swine flu mass vaccination program in the USA which had to be halted, which was criticized as being overenthusiastic decision, resulting in a large number of adverse event following immunization (AEFI) in the form of Guillain–Barre syndrome. Till date, enough evidence is not available on the efficacy and safety of COVID-19 vaccines when introduced to a large population. Certain subpopulation were exempted from the trial, such as pregnant and lactation women, children <18 years, immunocompromised population, and >65-year-old population. Hence, safety and efficacy related information are absent for this subpopulation. Unfortunately, they are major vulnerable population in relation to mortality and morbidity due to COVID-19. Further, CDSCO has given permission of two COVID 19 vaccines for restricted use on emergency situation in India, but more clarity is expected as to what are the “restrictions”. The data related to trials are still not available in the public domain.
AEFIs need to be stringently monitored and reported in Co-WIN app so that single adverse event should not get missed. The pooled information on safety obtained from the first phase of vaccination should be made available in the public domain, which could guide decision-making by future beneficiaries. Further, as HCWs and Frontline workers are being vaccinated in the first phase in India, and they are predominately in working age group, data on AEFI obtained from them may not represent that of the general population. Rare but serious adverse events are not known till date, as they could only be exposed when the vaccine is being administered to a large population. There should be transparency in reporting AEFI and that should be made available in a public forum at a regular interval.
The costs and benefits of adding the COVID19 vaccine as well as its potential short- and long-term impact on national health budgets need to be considered before taking a decision. A standardized economic evaluation should include affordability of operational cost, potential funding gap, and prospects of financial sustainability. A cost-effectiveness analyses need to be carried out to ensure that cost-effectiveness ratio is low enough to introduce it. As per the WHO's Commission on Macroeconomics and Health considers, a cost/disability-adjusted life year averted of less than three times the gross national income per capita of the country is “cost-effective” – that is, a worthwhile investment. This criterion could be useful for taking a decision. No such information is made available by the authority in this respect. A huge cost is being incurred for this vaccination drive, which may possibly be better utilized for health system strengthening.
Prioritization for vaccination
Enough vaccine for the entire population may not be possible in the near future, and a prioritization system is required to decide who should be vaccinated at the earliest. A scoring system may be developed and used, considering age, area of residence, comorbidity, and immunity level into consideration. The vaccination drive is not being guided by results of seroprevalence studies which have been done. Vulnerable people residing in low prevalence regions could be prioritized for vaccination. A prototype scoring system developed by brainstorming of specialists has been described in [Table 1]. Further research is warranted in this respect by data analysis and using suitable statistical techniques.
Natural infection is known to induce robust immunity that may last years. Cross immunity due to prior exposure to related coronaviruses has also been known to exist. As health-care workers and frontline workers have been maximally exposed to COVID19, it is expected that a large proportion could have been infected as well (symptomatic/asymptomatic). History of infection and antibody testing could have been used to guide whether they require vaccination or not to optimize resources. HCWs recovered from COVID19 are also included for vaccination. They could be left out to economize the campaign. If the vaccine acceptance rate among HCWs is found to be poor (as observed in the interim analysis of the ongoing study in Nagpur), it could impact acceptance among the general population which are still susceptible.
| Opportunity|| |
- Political commitment and felt demand: The COVID19 vaccines currently introduced in India for HCWs are being produced indigenously, so it will be economically beneficial for the country to administer it to a large segment of population. The resources available for vaccine production and administration seem to be sufficient because there is a strong political will. Moreover, there is a strong demand from the provider side for vaccines
- Innovation and improvisation: India's success in developing and implementing COVID19 vaccination will showcase India's global leadership in health. Use of digital platforms like Co-WIN application for web-based monitoring of the vaccination drive is commanding. The vaccination and AEFI can be strictly monitored through this app, thereby enhancing transparency of the campaign. It will generate a robust database, which will guide future decision making
- Vaccine diplomacy: As India is helping other countries in supplying vaccines it will create an opportunity for the country to enrich the international relationship and assume global leadership in this crisis.
| Threat|| |
Fast-track vaccine development
Vaccine must be introduced after ascertaining its foolproof safety and effectiveness. Based on the recent report of the World Economic Forum, vaccine development starts with discovery research followed by stages of preclinical and clinical development (including Phase 1, II, and III clinical trial), regulatory review and approval followed by manufacturing and delivery, and the complete process usually take more than 10 years. Plotkin et al. also pointed in their review article that estimates of the time required from a research phase to bring a product to the international market range from 5 to 18 years. It is the first time in the history of vaccine development that it is being developed within a very short period of time (6–9 months). It is of utmost importance to check its efficacy and safety before rolling it out for mass vaccination across millions of people. ProVac/TriVac models can be used for calculating cost-effectiveness. Till date, no such analysis report is made available by the government for public.
A false sense of security
The vaccination itself may lead to a false sense of security among the beneficiaries and it could increase their complacency and affect their compliance of wearing a mask and social distancing. In this respect, it needs to be reinforced the comment of the WHO chief – “vaccine will not be enough to stop the pandemic.”
Efficacy of vaccine against a new strain of COVID-19
New strains/subtypes of COVID19 have been reported from the UK, USA, and some other countries. Existing evidence is insufficient to comment whether the currently used vaccines are effective against those strains.
Distribution of vaccines
Equitable distribution of vaccines needs to be ensured so that the most vulnerable population could get the vaccine at the earliest. Inequity in distribution among nations, states, and territories could lead to adverse consequences, which is pointed out by the WHO in a recent press report.
Poor social mobilization, risk communications, and advocacy activities
From the beginning of this COVID-19 pandemic, it has been witnessed that very less attention has been paid on risk communication, leading to social isolation and discrimination of COVID patients, community resistance toward testing, etc., It is of utmost importance to carry out intensive risk communication and advisory activities to make people aware who actually require it and how much protection it can give. In due course of time, the demand of vaccine might keep on decreasing. Further, acceptability of vaccine for the general population is also questionable. History revealed poor utilization of flu vaccine introduced after H1N1 pandemic. Hence, a preintroduction acceptability survey among the general population is recommended. Underutilized vaccines may create an economic burden for the society.
Although vaccination against COVID19 is voluntary, generating a certificate after vaccination may point to a purported design to force people to adopt vaccines as it may be mandated for travel and other businesses.
| Conclusion|| |
From the above discussion, it can be commented that rollout of COVID-19 vaccination campaign needs to be guided by the evidence generated by the existing surveillance system. Defining and enlisting the target population, confirming safety and effectiveness, and ensuring adequate supply and cold chain are essential prerequisites before taking this vital decision of vaccine rollout for the general population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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