India faces a challenge with its mass vaccination efforts
Authors: S V Subramanian
Journal: The Lancet Global Health (2021)

In April, 2021, India recorded more than 48 000 deaths and more than 6·9 million new cases.1COVID-19 IndiaCOVID19-India Ops.https://www.covid19india.org/Date: 2021Date accessed: May 19, 2021Google Scholar This surge, which continued into May, 2021, occurred after a decline in the number of cases and fatalities. Simultaneously, India administered more than 84 million doses of vaccine, averaging 2·8 million doses per day in April, 2021. As of May 19, 2021, an India vaccine tracker reported that more than 186 million doses had been administered; only the USA and China have administered more vaccines. India ranks second in the world for the most vaccine doses given per day, with more than 3·66 million, ahead of the USA, which hit its peak at 3·38 million daily doses. If the Indian administration oversaw the vaccination programme in the UK, it would have vaccinated its entire population twice and have more than 50 million doses to spare. Using the percentage of the population that has been vaccinated as the sole metric, India's performance has been characterised as slow or, at worst, botched.2The LancetIndia's COVID-19 emergency.Lancet. 2021; 3971683Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar Such rhetoric is unwarranted and unfairly blames India for its population size. Unfortunately, the effort to vaccinate hundreds of millions of people could also have contributed to the increase in cases (appendix).3The Times of IndiaMumbai: long waiting time, overcrowding trigger chaos at some vaccine centres.https://timesofindia.indiatimes.com/videos/city/mumbai/mumbai-long-waiting-time-overcrowding-trigger-chaos-at-some-vaccine-centres/videoshow/82449370.cmsDate: 2021Date accessed: May 19, 2021Google Scholar Even day-to-day activities in India can be a super-spreader event, so the mass vaccination exercise in the middle of a pandemic with a highly contagious and evolving virus has the potential to become a super-spreader event. There have been reports of overcrowding in centres administering vaccines.4Sheriff M K Centre extends reach of vaccination: longer sessions, all private hospitals can be roped in. The Indian Express, 2021https://indianexpress.com/article/india/centre-extends-reach-of-vaccination-longer-sessions-all-private-hospitals-can-be-roped-in-7211677/Date accessed: May 19, 2021Google Scholar As of May 6, 2021, more than 144 000 centres have administered at least one dose of the vaccine. However, India's online network for its vaccination efforts (Co-WIN) reports that less than 5% of the total centres have administered almost 50% of the total vaccinations, with an overwhelming number of vaccines administered in urban areas of India. These urban areas, such as Mumbai, Delhi, Pune, and Bengaluru, are also the main sites of the surge in infections and fatalities.1COVID-19 IndiaCOVID19-India Ops.https://www.covid19india.org/Date: 2021Date accessed: May 19, 2021Google Scholar There is also a push from national and international experts, governments, private organisations, and the media to encourage people, especially individuals older than 60 years and those at high risk, to get vaccinated as soon as possible. As of May 19, 2021, more than 56·6 million vaccine doses were administered to people 60 years old and older in India. Individuals face a dilemma: risk a long wait in a crowded vaccination centre or stay at home and delay or avoid vaccination. India needs to urgently take a stock of the places where most of these vaccinations are being administered. Proven non-pharmacological interventions, such as physical distancing, use of appropriate masks (eg, N-95 in hospital and health-care settings), availability of hand sanitisers, and temperature checks, should be strictly enforced at vaccination centres. Co-WIN should limit registration to the number of vaccines that can be administered on that day. Over-booking is only one of the problems with the Co-WIN app.5Bansal V India is betting on glitchy software to inoculate 300 million people by August. MIT Technology Review.https://www.technologyreview.com/2021/02/10/1017860/india-covid-vaccine-cowin-software/Date: 2021Date accessed: May 19, 2021Google Scholar The government should immediately implement the maximum occupancy rule for various vaccination centres. As of May 13, 2021, about 56% of the total registrations to receive a vaccine were walk-in. It might be prudent to pause the walk-in option. In the face of potential reinfection, unknown effectiveness of vaccines in the real-world setting, and the variant of concern B.1.617,6Nebehay S Farge E WHO classifies India variant as being of global concern. Reuters, 2021https://www.reuters.com/business/healthcare-pharmaceuticals/who-designates-india-variant-being-global-concern-2021-05-10/Date accessed: May 19, 2021Google Scholar it is now clear that vaccination does not necessarily equal immunity.6Nebehay S Farge E WHO classifies India variant as being of global concern. Reuters, 2021https://www.reuters.com/business/healthcare-pharmaceuticals/who-designates-india-variant-being-global-concern-2021-05-10/Date accessed: May 19, 2021Google Scholar As per the latest declaration from WHO, mass vaccination is, at best, a mitigating strategy alongside other non-pharmaceutical interventions.7ReutersWHO reviewing Seychelles COVID-19 data after fully vaccinated people test positive.https://www.reuters.com/business/healthcare-pharmaceuticals/who-reviewing-seychelles-covid-19-data-after-fully-vaccinated-people-test-2021-05-11/Date: 2021Date accessed: May 19, 2021Google Scholar The experience of the Seychelles with regard to the potency of vaccination efforts is sobering and should concern all, especially India. Despite fully vaccinating 63% of its population, as of May 15, 2021, the Seychelles reported more COVID-19 cases per 1 million people than India. Between April 30 and May 8, 2021, 37% of individuals who tested positive for COVID-19 had been fully vaccinated. Of concern to India, 43% of the fully vaccinated people in the Seychelles have received the Oxford–AstraZeneca COVID-19 vaccine (ChAdOx1 nCoV-19);8Ministry of Health Seychelles7-day rolling average of new COVID-19 cases reported to PHA.https://www.facebook.com/mohseychellesofficial/photos/pcb.1740768396124284/1740765212791269Date: 2021Date accessed: May 19, 2021Google Scholar currently, 90% of the total doses administered in India are also the Oxford–AstraZeneca COVID-19 vaccine. India needs to immediately rethink its strategy regarding mass vaccination rollout. The country needs to stop people from assembling to get vaccines. Administering vaccines needs to happen systematically with a strict enforcement of proper non-pharmacological guidelines. Taking the vaccines to people might be a safer way for a mass vaccination rollout. Unless essential, mass vaccinations at hospitals and health-care should be avoided. Vaccination should not be rushed because not doing it right can cause more harm than good. For more on India's COVID-19 vaccine rollout see https://geographicinsights.iq.harvard.edu/IndiaVaccine For more on India's COVID-19 vaccine rollout see https://geographicinsights.iq.harvard.edu/IndiaVaccine I declare no competing interests. I am grateful for the excellent research assistance provided by Akhil Kumar. Download .pdf (.24 MB) Help with pdf files Supplementary appendix