India’s vaccination campaign is unlike any other

In the fall, Devika Chopra, a gynecologist in Mumbai, got a notice from municipal authorities asking to fill out a form with personal information and the number of people who worked at her clinic.

As a health care worker, she and millions of her colleagues in India would be first in line for a Covid-19 vaccine. In January, she got an SMS message saying she had an appointment for her shot. She received her first dose of Covishield, the local name for the Oxford/AstraZeneca vaccine, at the end of last month. This weekend, she received an SMS and a call, and, on Monday, got her second dose.

“It was very systematic, and it was really well organized,” Chopra told me a few weeks after her first shot.

“In fact,” she added, “I think it’s the best vaccination drive that I have seen in the country.”

India still has a long way to go before it can fully appraise its Covid-19 vaccination campaign, a staggering effort that began last month. The nation of more than 1.3 billion is undertaking what may be the world’s largest vaccination push.

India has given out more than 12 million doses of two approved Covid-19 vaccinations since the rollout began January 16. At its start, India had one of the fastest rollouts in the world by sheer number of people who got injections, vaccinating 1 million people in six days. But in a country of its size, it is like the tip of the tip of the pin.

Anshuman Poyrekar/Hindustan Times/Getty Images

The pace has slowed since, driven by a combination of factors, from glitches with the country’s vaccination app to vaccine hesitancy, fueled by what some critics have said was a hasty vaccine approval process that lacked transparency and a dramatic decline in Covid-19 cases in India, after some of the highest infection rates in the world.

The immunization drive has also not yet entered its next phase, in which people over 50 and those with underlying conditions — some 270 million people — will be eligible.

Still, the country has set an ambitious goal of vaccinating about 300 million people by this summer, nearly one United States-worth of inoculations.

“But it’s only one-fourth” of India’s entire population, K. Viswanath, a professor of health communication at the Harvard T. H. Chan School of Public Health, told me. “Just the sheer scale is very daunting.”

If any country could pull it off, though, it might be India. It has undertaken mass vaccination campaigns before, as with polio, though experts say inoculating adults presents different challenges than that effort, which focused on children. India also regularly conducts the world’s biggest elections, and is drawing on that experience and infrastructure to help its Covid-19 immunization push. And India, sometimes known as the world’s medicine cabinet, has the production and manufacturing capabilities to make vaccines — and export them to the rest of the world.

So far, though, the vaccination campaign has been underwhelming. Right now, less than 1 percent of India’s population is vaccinated, an untenable pace if India wants to give two Covid-19 doses to hundreds of millions of people by summer.

Many people I spoke to believe the capacity is there, and that any of India’s early stumbles are just “teething issues,” as a few experts put it. But whatever challenges it might face, India’s campaign is unlike any other, both for its size and the diversity of areas it’s trying to reach.

“The Covid-19 vaccine program in India is one of the most ambitious vaccine campaigns in the world,” Brian Wahl, an India-based epidemiologist with the Johns Hopkins Bloomberg School of Public Health, told me.

India’s experience with mass inoculations and elections is key

Before India launched its vaccination campaign on January 16, it did some dry runs, holding mock vaccination drives across the country to test the logistics of delivering doses and the technology used to track and monitor vaccine appointments. The run-through even included dummy vaccines, to fully train health care workers.

When it comes to mass vaccination programs, these are muscles India has used before, if not at this incredible scale. The country has undertaken large-scale immunization campaigns before, most notably against polio. It also has a strong universal immunization program to deliver vaccines to children and pregnant women across its vast population.

Those undertakings meant that India already had in place a lot of the infrastructure required to deliver Covid-19 vaccines to different states and populations, including rural areas.

The country has established “cold chain” points to safely transport, store, and deliver vaccines that require low temperatures. Indian officials say they have approximately 29,000 cold chain points and 41,000 deep freezers for vaccines (though the country isn’t using the Pfizer/BioNTech or Moderna vaccines, which require extreme cold storage).

“We have an advantage of having a structure in place, with cold chains and deliveries and vaccination centers and trained staff — so that’s the big, big plus point,” said Naveen Thacker, executive director of the International Pediatric Association and former representative to GAVI, the Vaccine Alliance’s board.

T. Narayan/Bloomberg/Getty Images

Vipin Kumar/Hindustan Times/Getty Images

This already-in-place health infrastructure meant that unlike some countries — the United States, for instance — India isn’t really setting up massive vaccination centers in places like sports stadiums. It’s largely relying on a built-in network of hospitals and clinics as the hubs. “It is not an ‘If you build it, they will come’ approach — what they’re doing is actively going to where people are,” Viswanath told me.

India is also drawing from its experience holding elections, the world’s biggest. The democratic process spans weeks, and polling places and election officials go where the people are, no matter how remote — even if it requires airlifting officials up a mountain or into a forested valley to record someone’s vote.

India last voted in 2019, and the country is using its voter rolls to identify people eligible to receive the vaccine. It is also deploying some of the same infrastructure, techniques, and even personnel in the inoculation drive: A security guard who normally stands watch at a voting booth may now instead guard vaccines.

Narendra Kumar Arora, executive director of INCLEN Trust International, an international clinical epidemiology network, and chair of the working group on Covid-19 vaccines under India’s National Technical Advisory Group on Immunization, said India is relying on this critical combination of health and election infrastructure to deliver vaccines to its population.

“The location of the immunization center is driven by the map used for election booths, and the other requirement is driven by health systems’ previous experience,” Arora told me.

Right now, India is targeting front-line workers for vaccination: about 10 million or so doctors, nurses, and other health care professionals, and about 20 million others like police officers and sanitation workers.

India hasn’t fully deployed its vaccination infrastructure, though it is picking up the pace, or “getting warmed up,” as Arora put it. India launched its drive with about 3,000 immunization centers. As of last week, it was up to about 10,000. Over the coming weeks it will scale up to between 50,000 and 100,000 immunization centers.

But the warming-up period does look disappointing on paper — especially when taking into account India’s vaccination know-how. To reach its goal of vaccinating 300 million people by summer, India will have to succeed at inoculating around 1.5 million people daily. In a little more than a month since the campaign started, the country had just cracked 12 million doses total.

And a question right now is whether India really is just warming up for this undertaking, or if the sluggish start is a warning of bigger problems ahead.

Want a vaccine? India has an app for that. But does it work?

As much as India is relying on its long-built expertise on immunizations, the government is also launching a new system: its Covid-19 Vaccine Intelligence Network, or CoWIN, app.

CoWIN is a digital platform for the vaccination campaign. People will register with the app, and through that they’ll receive communication when they’re eligible to get their first, and second, shot. CoWIN will also help India track the vaccinations, keep track of vials in cold storage, and figure out how many doses to allocate to different places. It’s meant to provide real-time monitoring of the immunization campaign.

But the system has had its fair share of glitches, some of which may be stalling the vaccination drive.

Technical problems meant people weren’t getting messages about their appointments to get vaccinated. The MIT Technology Review spoke to one physician who got a message intended for someone else. The system itself was slow in loading information required to verify who was getting a vaccine.

It also wasn’t particularly nimble: If someone didn’t show up for their appointment, it was difficult to fill those slots, or have people sign up for cancellations. Hospitals had to adjust and allow for walk-ins to overcome some of the issues. The app has been crashing, too.

Health officials in several Indian states faced problems when trying to schedule second-dose appointments using the app, as the software didn’t recognize that people had already gotten their first shots. According to the Times of India, because of issues with the app last week, only 25 percent of those eligible for a second dose were able to get a shot in Maharashtra; in Mumbai, only 4 percent of a little more than 1,900 people got their second shot.

And this is all before CoWIN has been made available to the general public. Right now, the app is relying on ready-made lists of health care and front-line workers, who are the only ones getting a shot. This is a manageable number of people whose credentials are pretty easy to verify and who probably know better than most how and where to get a vaccine.

The goal of the CoWIN app is to get the general public to register for vaccinations, and “that facility will be opened up once the program is more confident about the performance,” Arora said, about resolving some of those “last-mile glitches.”

But even then, there are concerns about how well the app will work for a mass vaccination campaign. In the United States, seniors in particular have struggled with using some of the digital vaccine appointment platforms, and some experts fear that could be replicated in India. People may not be able to navigate the app, or become frustrated with it if it is glitchy, and those people may give up altogether.

Health officials will still use other sources to identify those eligible including voter rolls, medical records, and other documentation. Door-knocking — a tried-and-true method for vaccination campaigns, especially in India — will also supplement CoWIN’s self-registration. Such a massive campaign requires a wide range of strategies, but a lot does seem to hinge on this technology.

Beyond that, there are privacy concerns, since the CoWIN app will include identifying documents, including India’s equivalent of a Social Security number. Fake CoWIN apps have also cropped up in various app stores, raising fears of scams and misinformation.

And all of this may contribute to India’s other major problem with its vaccine rollout so far: vaccine hesitancy.

The biggest hurdle may be vaccine hesitancy, and India may take some of the blame

Ritika Aggarwal, a psychologist in Mumbai, got her first dose of the Covishield vaccine in February, a little less than a month after India began its vaccination campaign.

She didn’t want to get the shot immediately, and said she was a little nervous. Some of her worry was over having tuned out the news a little bit, and her desire to get more information.

“I waited for a lot of the doctors to take it and give me their feedback,” Aggarwal told me. “Then a lot of discussion with family in terms of whether should I go, or should I not?”

Aggarwal did go. She was anxious up until she received the injection at the local hospital. After her dose, she saw the informational posters and the reading material that explained the process and the potential side effects. Once she left the hospital, she said, “I was perfectly fine. I think once it was just in motion, the anxiety completely settled.”

Anshuman Poyrekar/Hindustan Times/Getty Images

Aggarwal is relieved to have gotten at least one dose of the vaccine — even if, as she points out, she’ll still have to be vigilant. But her anxiety isn’t unusual for India’s front-line workers, many of whom, like her, want the vaccine but have concerns about which ones are available.

India has approved two vaccines for emergency use. One, Covishield, is the AstraZeneca/Oxford vaccine being produced by the Serum Institute of India (which is also producing that vaccine for much of the rest of the world).

The other is Covaxin, developed by the Indian pharmaceutical company Bharat Biotech along with the Indian Council of Medical Research and National Institute of Virology. But Covaxin was approved before it completed its phase 3 clinical trials, so it lacks full efficacy and safety data — a dearth of transparency criticized by many prominent Indian experts and physicians.

“This vaccine, when it received the regulatory emergency approval, was still and continues to be in the phase 3 stage. So there were no data for efficacy. So that was the primary concern,” Malini Aisola, co-convener of the All India Drug Action Network (AIDAN), an organization that promotes equitable access to medicines, told me. Aisola said experts and scientists have also questioned the basis on which the vaccine was given the emergency approval.

As Aggarwal told me, she wasn’t sure she wanted to get a vaccine that was still in the study phase, though she ended up being able to get Covishield, the AstraZeneca vaccine. Indian media have reported similar phenomena, with health care workers more reluctant to get Covaxin and overall turnout for the vaccine much lower than anticipated.

According to the Guardian, a few days after the vaccination drive began, overall turnout was about 64 percent of what was initially expected, with attendance much lower in certain states, like Punjab, which only had 22 percent of expected turnout. All of that has dragged down India’s vaccination numbers.

“One of the factors in the early vaccine hesitancy or resistance that some health care workers had could have been that some felt they could hold out for a few months more, by which time perhaps efficacy data would become available,” Aisola said.

As Aisola explained, Indian regulators have imposed certain safeguards around the use of Covaxin, and there is close monitoring of anyone who receives the dose. Recipients also get follow-up phone calls and have to keep a diary for several days — all of which makes sense, but may be, as she pointed out, “another source of anxiety.”

More transparency would help build public confidence in the vaccines, whether it is Covaxin or Covishield. “It would also really help the government in its own objective of trying to have a successful vaccination drive, because people will be able to see that the government is really in their corner in terms of protecting their safety by sharing the information transparently,” Aisola said.

And she and other experts pointed out it will help squash the inevitable rumors and anti-vaccination conspiracy theories. Otherwise, the worst-case scenario might occur, where legitimate concerns about transparency around vaccines merge with outright misinformation, confusing people and deterring them from taking any vaccine.

Uptake among front-line workers has increased, with about two-thirds of all health care workers now vaccinated, according to Arora. He credits additional outreach around safety and efficacy.

But the struggles for turnout also could be a warning sign, if the very people who’ll be delivering the vaccines to everyone else are themselves hesitant to get the injection. After all, the health care workers are the advocates, the examples for everyone in the vaccination drive. They’re also very likely to be the ones vaccinating others.

Sanchit Khanna/Hindustan Times/Getty Images

Sanchit Khanna/Hindustan Times/Getty Images

India is also struggling with the same viral misinformation around Covid-19 and the vaccines that other countries are dealing with. India, in particular, has seen disinformation spread across social media channels, particularly through WhatsApp.

“You can prepare everything, but you can never judge people’s minds,” the International Pediatric Association’s Thacker said. “And we live in a very small world, so whatever happens in South Africa, US, UK, Spain, Italy, immediately reaches to India.”

Another element possibly contributing to vaccine hesitancy: India’s relative good fortune of having a more manageable pandemic right now. India has recorded the most Covid-19 cases of any country behind the United States, with more than 150,000 deaths. But cases began falling since a peak in September, swiftly and somewhat perplexingly, and have remained comparatively low since.

That’s a great thing overall, of course. But experts worry that low case counts, combined with vaccine questions, might make it much harder to convince Indians that it’s urgent they get a shot.

“When you don’t see cases on a daily basis, it makes demand-generation that much more difficult,” said Wahl, the India-based epidemiologist. And vaccination is “still critical — no country is out of the weeds yet — and having the greatest proportion of your population protected is super important.”

All of this is going to make it harder for India to achieve the goals of its vaccination drive — though Thacker told me the country still has the capacity to hit that goal of vaccinating 300 million by summer. “If we are able to tackle this infodemic and communication challenge,” he said, “India can deliver.”

Health workers I spoke to in India said they’ve heard from patients that they have concerns — they want to get the vaccine, but they are concerned about side effects. Chopra, the doctor who now is fully vaccinated, said that when talking to patients, she acknowledges that there are uncertainties, but she encourages people to trust the process. She is direct about the possibility of side effects. She posted a detailed account of her own vaccination experience, documenting the exact symptoms she felt in the hours after each dose. A sore arm, she posted, was the worst of her second shot.

And, of course, not everyone needs convincing to get the Covid-19 vaccine. They are eager for the next phase of India’s campaign to begin.

“Most of my in-laws, and my parents, friends — everyone’s only question is, when are they going to roll it out for us?” Aggarwal said. “They’re all just waiting for the vaccine.”

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