Opinion: Sonalde Desai
The establishment of a national expert group for Covid-19 vaccine distribution and Electronic Vaccine Intelligence Network (eVIN) to track and manage vaccine stocks and storage is welcome. However little attention has been directed towards the last-mile challenges in vaccine distribution. Three challenges deserve particular attention.
Twice is Nice
First cold storage requirements make it impossible to deliver some vaccines directly to people’s doorsteps as has been the case with other vaccination programmes. Second if recipients take one dose of the vaccine but do not follow up with a second dose they will not be fully inoculated. Poor compliance experience for diseases such as diabetes tuberculosis and hypertension do not give us a reason for complacence.
Third a small number of vaccine recipients may either forget not understand the requirement or may choose to take more than two doses with unknown consequences. Fortunately India has a unique experience in delivering vaccines at scale and it would be a pity if we were to overlook this in designing a vaccine delivery system.
The Pulse Polio campaign introduced by the Indian government in 1995 is one of the most successful vaccination programmes in the world. Administration of oral polio vaccine (OPV) faced some of the same challenges that Covid-19 vaccine administration is going to face although at a more limited level. OPV required storage in cold temperatures and required multiple doses.
Nurses transporting vaccines found it difficult to maintain cold chain storage and families were not particularly convinced of the merit of vaccination. As the study by Nizamuddin Khan and Niranjan Saggurti published in the journal Vaccine in May 2020 notes the National Family Health Survey of 1992-93 recorded only 54% of children receiving all three doses of the polio vaccine and 52% of children receiving three doses of DPT (diphtheria pertussis (whooping cough) and tetanus) vaccine.
Pulse Polio campaign set up vaccination booths in central locations such as train station Panchayat Bhawan and parks; arranged cold storage to ensure a steady supply of vaccine to booths; and widely advertised the date and place of vaccination often via popular film actors. The DPT vaccine was not administered in this campaign mode and hence provides an interesting comparison.
Children receiving three doses of OPV increased from 54% in 1992-93 to 60% in 1998-99 and 78% in 2005-06. In contrast full coverage of DPT stagnated and barely grew from 52% to 55% between 1992-93 and 2005-06.
When it comes to delivering the Covid-19 vaccine can we build on this tradition without falling prey to some of the dangers inherent in campaigns? Fortunately we now have an option of combining vaccine administration with Aadhaar-enabled digital infrastructure. Using biometric identification it would be possible to ensure that no one gets more than two doses.
Moreover for individuals who do get one dose of vaccine and do not get the second dose it is possible to send a text message reminding them of the need for a second dose and the location where they can obtain it. Should we choose to restrict vaccination to some priority age groups it would be possible to identify the target population using the Aadhaar database and invite them to the vaccination camp via a text message.
Using vaccination camps as a vehicle would allow us to maximise the number of locations using scarce resources such as freezers and cold-storage vans and provide vaccination in a convenient location across the length and breadth of India since each area will only need to be covered twice. Using Aadhaar-linked vaccination records and text messaging will allow us to reduce attrition and make sure that individuals get both doses. Vaccination camps where a large number of individuals are being vaccinated may also allow us to reduce vaccine resistance by ensuring that people do not feel alone.
The strategy outlined above relies on an adequate supply of vaccines and a relatively open distribution channel where vaccine prioritisation is based largely on the area of residence and age but not restrictive otherwise. As Anup Malani from the University of Chicago notes an India-specific strategy of vaccine delivery would require a focus on areas where the disease has the greatest likelihood of spreading and a focus on the age group that is most likely to be susceptible to serious complication due to Covid-19.
If these are the primary criteria we plan to use then a campaign-like strategy will allow us to efficiently build on our past successes.
The writer Sonalde Desai is professor of sociology University of Maryland US and director National Council of Applied Economic Research (NCAER)-National Data Innovation Centre.