India's COVID-19 Vaccination Strategy and Delivery Plan

Strategy

Allocation of Vaccines:  India's strategy was based on the availability of vaccines, which is tempered by cost, cold chain availability, and logistics challenges.  With two India vaccines becoming available—Bharat Biotech's Covaxin and Astra Zeneca's Covisheild—and storage requirement being -2 to -8 degrees, India planned to vaccinate 30 million people in Phase 1.  The first batch would go to about 7 million health care workers, the second to about 17 million armed forces personnel, and the balance 6 million to the elderly (people above 50 with co-morbidities).  The planned time was 6 months (i.e., to July 2021).

Distribution:  The distribution was planned by moving vaccines to four warehouses, one each in north, west, south, and east of India.  From the warehouses the vaccines were to be moved to state headquarters, and from there to hospital government centers, and finally to patients.  The storage and delivery was to be monitored via an app called Co-WIN.  The 30 million people mentioned above needed to be identified and asked to register on Co-Win so that the target delivery of 300,000 daily vaccination could be met.  Further, 200,000 people were to be trained for the actual delivery of the vaccine.

Financing:  India decided to fund vaccinations for most of the population, while allowing private markets for approved vaccines.  Phase 1 was completely government-funded.

Communication: The government used a communication strategy to fortify public confidence and reduce reticence.  The well-crafted communication strategy avoided mixed and contradictory messaging, used simple to comprehend messages, involved regular communication, and utilized community leaders to widen reach and clamp down on the spread of misinformation.

Certification:  The government standardized a globally-recognized certification of immunity. 

Pre-Vaccination Delivery Pain Points

State Health Ministers raised serious concerns five days prior to the vaccine roll-out date (January 16, 20 2021).  They pointed to internet connectivity issues, software glitches (Co-Win) in remote areas, availability of air ambulances to deal with any adverse effects of vaccinations, and infrastructure bottlenecks.  States that only have a 2G network, such as Jammu and Kashmir, would find it difficult to operate the software.  A suggestion for an offline mechanism was well received by the government. States also asked the government to draw up guidelines for common service centers with no internet connectivity, which would double as vaccination centers.  Almost all states needed clarity from the government on the exact dates on when the vaccine would reach them, along with the expected quantities.  The government agreed to the suggestion and allowed states to update inoculation data manually.  States could enter data in Co-win in an offline mode, and as soon as the app could connect to the internet, this data would automatically be uploaded.  Dry runs conducted in several states validated that this was possible. 

A particularly stressful point was raised by the vaccine makers, Bharat Biotech and Serum Institute of India, regarding the government indemnifying them against any future adverse effects.  While the government did not respond immediately to such requests for indemnity, lawyers said that regardless of the government’s stance, there were other legal options available for those suffering from adverse effects of the vaccine.  These options were different for Covaxin and Covisheild as they received different kinds of approvals.  Covaxin was approved in “clinical trial mode,” so recipients may get compensation under new drug rules.  Covisheild got a standard approval, hence recipients may get recourse under traditional litigation. Notwithstanding, the two vaccine companies still pressed the government for indemnification and gave examples from the UK and Australia, who have agreed to indemnify some vaccine makers.  Further, the U.S. already has a statute, known as Public Readiness and Emergency Preparedness Act to promote indemnity to the makers, in a bid to promote research.  However, the government did not accept their demands. 

While the government launched an awareness campaign days before the start of the drive, communication issues still surfaced, as news broke of alleged haste on the government part in granting approvals.  This triggered “vaccine hesitancy” among some beneficiaries. Health experts who were training the vaccinators also reported the same hesitancy.  The government then started making an elaborate credible communication plan, which was to:

• Explain that universal vaccination will reduce chances of Covid-19 infections;
• Suggest that the vaccine is good for everyone rather than getting into a debate about which is the good vaccine;
• Raise awareness particularly in rural areas by involving influencers; and
• Officially disseminate accurate information to curb circulation of fake news and misinformation.

Delivery Drive Day—Roll-Out Plan

The Drive was planned to be kicked off on January 16th, 2021. 

Rules

• Healthcare workers administered Covaxin will need to sign a consent form.
• Active follow up will be done for all Covaxinv recipients.
• Doctors will call every two days to inquire whether they are experiencing any kind of symptoms.
• No signed consent form is necessary for a Covisheild vaccination.

The Drive Plan

• First shots - 300,000 healthcare workers at 3006 sites.
• 200,000 vaccinators, with each vaccination team consisting of five members: one vaccinator and four others.
• Initial Availability - 11 million Covisheild doses and 5.5 million Covaxin doses. Allocated to states in proportion to health care workers.
• States - to organize vaccination sessions consisting of 100 vaccinations per site daily, catering to 10% reserve/wastage.
• Command Centre - Dedicated command centre, no. 1075, will function 24x7.  This will also crack down on misinformation and rumours.
• Delivery Access - two doses with 28 days gap, not interchangeable. Vaccine recipients will need to register on Co-win app.  Details of the vaccination will be provided via SMS.  At the vaccination centre, photo ID will be verified, documents checked with Co-win, the vaccine administered, a 30-minute wait at the centre post for observation, and recipient will be informed about next dose.
• Adverse issues - common to both vaccines.  Could be site tenderness/pain, fever, headache, fatigue, muscle/joint pains, and/or nausea.  Paracetamol advised for symptomatic relief.
• Shots won't be given to pregnant/lactating women, to those below 18 years, or to those with previous histories of allergies.
• Vaccinations will be deferred for active Covid-19 cases, for those who received monoclonal antibodies or convalescent plasma, and for those who are acutely unwell/hospitalized or any other illness.
• Key Challenges identified - logistics of vaccinating millions, identifying and reaching out to beneficiaries, and overcoming vaccine hesitancy.

Actual Delivery

As of January 24th, despite doubts, vaccine hesitancy, and tech issues, India vaccinated close to 1.6 million beneficiaries in nine days, for an average of 177,000 daily vaccinations.  This immunization campaign is perhaps the fastest anywhere in the world.  The government plans to launch a drive to address concerns and scale up daily numbers initially to 300,000, and later to 500,000. The government has added new features to the Covid-19 management app, Co-win, including a way to fill up slots left vacant by those who did not turn up.  Also, new flexibility was provided to enable multiple sessions, increasing the number of sessions, creating a feedback mechanism through SMS, and phone calls.  The platform is based on Amazon Web Services (AWS) servers. 

Through various communication drives, the general public is also being informed (if vaccine hesitancy persists), that vials, once opened, must be consumed in 4 days, otherwise they will go to waste.