Road to safety: On the vaccine trail

Tracking the challenge posed by the urgency and sheer scale of giving Covid vaccines to 300 million people in 6 months

NEW DELHI/ PATNA/ MUZAFFARPUR:

The wall is new — so new, in fact, that it is yet to be plastered over. It has been built in the large room of a public health clinic in Bihar’s Dharbanga to create another room. It is secured with a collapsible gate, but as with most walls, it is what lies behind (or will soon lie behind) that’s interesting — an air-conditioned vault that will house 2021’s most precious commodity, Covid-19 vaccines.

In Hathua, in Bihar’s Muzaffarpur district, roughly 60km away as the crow flies from the clinic with the room with the brick wall, the women and children’s ward of the district hospital is empty. That isn’t surprising because it is no longer a women’s and children’s ward. In the ward, a cement platform has been readied. It will support a walk-in cooler that is being installed, a mega-refrigerator that can store vaccines at between 2 and 8 degrees Celsius.

It’s not just Bihar — across India, large cities, nondescript towns, districts big and small, are all scrambling to add critical infrastructure to meet the challenge of vaccinating 300 million people by July 2021, and, if all goes well, hundreds of millions more by the end of the year.

India has recorded in excess of 10 million cases of the viral disease, and suffered 146,163 deaths, and while the per-million statistics are better than most countries (including those in the Organisation for Economic Cooperation and Development, a club of mostly rich nations), and the case fatality rate is among the lowest in the world in such a large country, it is clear that life and work — both have been disrupted radically in 2020 — will return to normal only when enough people have been vaccinated.

This is easier said than done. It requires the government to mobilise millions of workers, significantly augment health infrastructure in a country that spends less than 2% of its GDP on the sector, create a seamless network between states, ministries, agencies and local administrations and, also, a huge outreach effort that, at once, spreads awareness about the benefits of vaccination and quickly quashes malicious rumours of the sort that often circulate over messaging platforms.

To be sure, India is no stranger to mass immunisation measures. It launched a vaccination programme for newborns way back in 1978. Seven years later, it expanded the programme to make it universal and cover all districts. Every year, it gives 11 types of vaccines to close to 26.7 million newborns and 29 million pregnant women. It even boasts two national training centres for cold chains in Pune and Delhi that provide technical training in maintenance of facilities that constitute the backbone of the immunisation outreach.

As an aside, it emerges that one of the vaccines that is part of the universal immunisation programme, the BCG one, may provide people with some form of protection against severe versions of Covid-19, one reason being offered by researchers for India’s better-than-expected Covid-19 metrics.

Magnitude of the task

The addition of vaccines over time to the universal programme, particularly the introduction of the pulse polio vaccine in 1995, has led to a wider and more robust network of better logistics and solid infrastructure, but that is not enough.

The sheer scale and urgency of administering Covid-19 vaccines poses a stiff challenge even to the old hands in India’s success story in vaccination. For India never had to immunise 300 million people in six months.

And states such as Bihar, home to 99 million people (if it were a country, it would be the 15th most populous in the world), are key to meeting this challenge.

The infectiveness of Covid-19 has resulted in its own network effect — no one is safe till everyone is — which means poor and backward states such as Bihar will have to vaccinate people with the same efficiency that richer and more developed states do.

At the heart of Bihar’s effort is a fivestoreyed building in Patna’s Nalanda Medical College and Hospital campus. This is one of India’s largest state vaccine stores—the Centre that stores and supplies vaccines across the state.

Each floor of this building has massive halls packed with containers of different shapes and sizes. There are countless cardboard boxes full of syringes, used cold boxes, Thermocol covers, piles of small plastic ice packs, yellowing from years of use.

This is the centre that fuels the immunisation programme in this part of the Hindi heartland. The ground floor has several rows of mega-sized refrigerators. Then there are three walk-in-freezers (WIF). These supercool white boxes have a temperature range of minus 15 to -25 degrees Celsius. Barring some research facilities or top hospitals such as the All India Institute of Medical Sciences, New Delhi, or the Christian Medical College (CMC), Vellore, where refrigerators with far lower temperature capacities are available, these WIFs offer the lowest temperature vaults in India’s vast health sector network.

The poorer version of the WIF are the walk-in-coolers (WIC) that can maintain 2 to 8 degrees Celsius temperatures. Both look like mini containers. “These WIFs are 20 cubic metres. But they are enough to store 1.5 to 2 lakh vials. Our total capacity in all WIFs and WICs is 2 million vials,” explained Dr NK Sinha, the state immunisation officer.

“We are encouraging the private sector to contribute in capacity augmentation. We have given the cold chain specifications to the corporate affairs ministry and the heavy industry ministry so that industries can know what they need to build,” said Union health secretary Rajesh Bhushan.

Cold storages, Bhushan points out, are being set up maintaining geographical equity. “Once you plot the 29,000 available cold storages on map, you realise where all we need to have more cold storage facilities. We also don’t require cold storages as long as we can easily transport vaccines to the last point by road,” he adds.

Dry as a cold desert

Nearly all districts in India possess these super stores. But their existing capacities will fall short when the vaccines start arriving.

“We can’t pack these fridges with vaccines; 25% space has to be kept vacant for circulation of the cold air. Also, we need to keep our regular vaccines,” added Dr Sinha.

Indeed, public health systems around India will have to keep the universal vaccination programme going; this is, after all, the lifeline for millions of children and pregnant mothers. But this also means that the Centre and the states can tap only 150,000 out of 239,000 vaccinators.

“If everyone joins the Covid vaccine administration measure, how can we run the regular pulse polio or BCG camps?” a senior official involved in the vaccination drive asked.

Unlike domestic refrigerators, both WIF and WIC have shelves all along their inside walls to store the vaccines. They are as dry as a cold desert, powered by two powerful compressors, and people can walk inside to take out vaccines or add fresh stock.

Stepping inside a WIF is akin to taking a walk outside in Antarctica, albeit in summer and on a good day. There’s a basketful of fat, thermal jackets, trousers and gloves kept beside these vaccine vaults.

Such walk-in refrigerators are easy to install or dismantle but not available at all nodes of the vaccine network. The smaller centres have deep-freezers and ice-lined refrigerators, the mini versions of the WIF and WIC. They offer same range of temperatures as their big brothers, but are easier to install.

And they are easy to identify too — all freezers have blue bodies and all refrigerators, white ones.

The larger vaccination centres, where people will be vaccinated, will have these mini-freezers and refrigerators.

In other sites, especially mobile or pop-up ones, small cold boxes lined with ice packs, will come in handy. These cold boxes are the ones pulse polio vaccinators carry in their doorto-door campaigns.

But states aren’t just counting what they have — they are adding more.

At the seminar room in Patna’s new secretariat, the state’s principal secretary of health Pratyaya Amrit waves a list of additional cold chain infrastructure required for the state.

“We require 8 WICs, 2 WIFs, 432 icelined refrigerators and 549 deep freezers. The Centre has assured us of all help.” And once he gets them, Amrit also has a plan to deal with a quintessential developing-world problem, power cuts.

The temperature tracker app

In the US, United Parcel Service (UPS) and FedEx Corp. have devised systems to track and measure in real-time, for each individual vaccine pallet, metrics such as temperature, light exposure and motion.

India, too, will have a somewhat similar protocol to track the real-time location of delivery vans carrying vaccines, stock positions and the people being vaccinated. The central government will closely monitor all vital data.

But while FedEx and UPS don’t have to face power cuts in Europe or the US, uninterrupted power is not available in every part of India. “We have individual generators attached to each and every WIF and WIC,” said Amrit, “to ensure a steady flow of electricity”.

There’s also a small black box with a digital panel perched on the wall above the deep freezers and ice-lined refrigerators in the room at the Muzaffarpur hospital. The labels suggest these were given by United Nations Development Programme (UNDP) for the national health mission. These black boxes or temperature alert machines, flash the temperature of the refrigerator it is attached to.

But its utility doesn’t end here. Ram Ratan, the AIIMS-educated state programme officer for immunization, summons a hospital employee who takes out his mobile phone, opens an app and shows the details of the realtime temperatures of each one of the vaccine storages.

“There will be an alert if the temperature rises. We will know immediately and take appropriate steps,” said the employee. Ratan added that he can “monitor all vaccine vaults across Bihar with the help of this, sitting in Patna.” But to store the vaccines, states have to get them first.

The supply chain

At the crowded Basant Vihar restaurant (a favourite of Bihar chief minister Nitish Kumar), Dr NK Sinha, the state immunisation officer, recalls how the premier Rajdhani Express had to be requisitioned to deliver polio vaccines to the state in 1995.

India already has a detailed plan on the supply chain for Covid-19 vaccines even though no vaccines have got approval from the Indian drug regulators so far.

To be sure, transporting vaccines will be easier than storing them. All possible vaccine candidates for India, from Serum Institute of India’s Covishield to Pfizer Inc.’s mRNA vaccine will require 2 degrees to 8 degrees Celsius temperature for transportation.

Covishield, developed by the University of Oxford/AstraZeneca Plc., can be stored, transported and handled at 2 degrees to 8 degrees, BioNTech SE and Pfizer’s vaccines need to be stored at minus 70 degrees Celsius, but can be kept for up to five days at 2 degrees to 8 degrees.

The same temperature can keep Moderna’s product stable for 30 days but if it needs to be stored for longer, the vaccine requires a temperature of minus 20 degrees Celsius. The Gamaleya vaccine can be stored at 2 degrees to 8 degrees.

Much of the long-distance movement of the vaccines in India will be by air. The last mile transport is likely to be over the road.

Today’s India boasts of 137 airports covering all 28 states and eight Union territories and as of March 2017 the road network runs over 5.8 million kilometres, a significant expansion of the country’s transport capacity from the early years of economic liberalization. Indian Railways, too, has nine refrigerated parcel vans but they are unlikely to be used, according to officials.

From airports, refrigerated vans and insulated vaccine cars will take the quickest possible route and maintain strict temperature controls to deliver the vials at designated points.

The vaccines will be treated like VIPs and will receive police protection during transportation. The centre’s guideline to this effect to the states says: “Vaccine safety needs to be ensured during storage, transportation and delivery of vaccine with sufficient police arrangements so that there are no leakages in the delivery system.”

Every state has made elaborate preparations already. Bihar, according to a power point presentation by the principal secretary of health Amrit, has one that details every part of the plan — from picking up the vials at the airport, sending them to storage, then moving them across the state.

“The vaccine pallets will come to the state vaccine store in refrigerated vaccine vans. The same vehicle will be used to send them to regional vaccine stores (Bihar has 10 such stores),” said Amrit.

“The regional centres will send the consignment to all the district vaccine stores in insulated vaccine vans (smaller vans that carry the vials in cold boxes).”

These vans will take the vaccines to designated cold chain points, the final storage destination before the vaccine pallets are sent to vaccination sites.

At every level, right from the production lines to the jabs, the Union government will keep a close eye. Union health secretary Rajesh Bhushan described the transportation model as the hub and spoke method and said, “the entire programme will be monitored by the central government.

The discussions and debate

For Bhushan and other officials involved in Covid-19 management at the Centre, weekend breaks have become a rare luxury. According to an official, “for the past five months, there are at least five-six meetings daily related to Covid management over different echelons of the central government”. Reviews with states, inter-ministerial or intra-ministerial discussions, meetings with cabinet secretary or the Prime Minister’s Office dominate the long days of the Covid-19 managers of the Narendra Modi government.

India is yet to sanction emergency authorisation to any vaccine at the time of writing this article, but way back in July, when Covid-19 vaccine trials entered a defining stage worldwide, Indian authorities started preliminary discussions on a wide range of issues, from logistics to ethics, to set the stage for a smooth supply and effective use of a vaccine when it is ready.

A month later, On August 8, the cabinet secretariat formed an expert committee comprising representatives of a host of ministries and institutions to oversee all aspects of its Covid-19 vaccine plan, from identification of the vaccine to buying to financing the purchase to distribution and administration.

“The expert group or Negvac led by member Niti Aayog Dr VK Paul doesn’t have any fixed schedule for meeting. It summons a meeting as and when required. It doesn’t even have a WhatsApp group for members to keep in touch daily. For them, landlines and webinars are the most effective medium of interactions,” a member of the panel said on condition of anonymity. Negvac is short for the National Expert Group on Vaccine Administration

Prime Minister Narendra Modi held a series of meetings with the chief ministers and two all-party meetings over the last six months.

He is also regularly briefed on the Covid-19 situation and all aspects of the vaccine plan. On November 28, Modi visited the facilities of Bharat Biotech International Limited, Serum Institute of India and Zydus Cadila Limited to see first hand how these companies were getting along with their vaccine development and manufacturing. But all plans eventually arrive at the same point — administration of the vaccine.

The final challenge

Sitting next to his supervisor at a small office in Patna’s state vaccine store, a middle-aged official says that neither he nor any of his family members will take the vaccine.

His supervisor, who holds a key position in the immunisation programme in the state, looked visibly embarrassed. But there are many who are worried about two unknown enemies that can seriously hamper the prospects of the vaccine plan: misconceptions and rumours.

“In rural Bihar, people think Covid is an urban illness. They refuse to believe that it has spread across rural India too,” said Onkar Chand, the social mobilization coordinator in Darbhanga.

“And as a result, a large part of the rural population might flatly refuse to take vaccines. Any refusal to take vaccines not only dampens the campaign but also make others sceptical about the vaccine programme” added Dr NK Sinha.

The local administration is aware of this.

Muzaffarpur district collector Chandrasekhar Singh accepts that false rumours resulting in a boycott of vaccines is a risk factor that he has thought about a lot. “We plan to do a door-to-door campaign. We will involve influential political leaders as well as religious heads to campaign for us. The information and communication plan is one of the critical areas of the overall Covid programme,” Singh adds.

In his last few meetings, apart from reiterating the importance of mask and social distancing to combat Covid-19, the Prime Minister himself has spoken of the need to collectively counter the menace of rumours. Similar rumours in 2018, usually speared through WhatsApp, caused concerns about child-lifting in many parts of the country and resulted in many innocent people being lynched.

“There is always a possibility that a recipient might die due to natural causes after taking jabs. But even that can be fuel for the gossip mills,” said a Union government official who asked not to be named.

As Prataya Amrit returns for a quick lunch at home, a family member shows a forwarded message in WhatsApp that says, “vaccination will start from tomorrow.”

“Just imagine. No vaccine has been decided yet but such rumours have already started spreading.”

The Centre’s guideline for the states too, acknowledges the challenge of “ensuring over 1.3 billion people in India receive factual and timely information and updates on vaccine rollout progress and benefits.”

It adds that outreach efforts need to address “public’s anxiety and queries regarding government’s decision for prioritisation of vaccine administration, apprehension about the vaccines introduced after a short trial, and fear of adverse events, misconception about vaccine efficacy, rumours and negative narrative in the media / social media space.”

But far away from the world of rumours, on a bright December morning, a group of auxiliary nurses at a vaccination centre in Muzaffarpur say they are not worried about false rumours. “We are ready to push Covid vaccines (likely to be intramuscular one, one adds helpfully) when the time comes.”

Another demonstrates how the vaccines will be delivered with single-use syringes that automatically disable themselves once used.

A third explains how ice boxes must sweat for a few minutes before the vaccines can be kept in them for use at the inoculation centre.

India’s Covid-19 managers have many things to worry about, but if these nurses in Bihar are any indication, the administration of the shots isn’t one of them.

“When a newborn arrives for BCG or pulse polio, we feel as if its our own child. When people come for Covid vaccines to use, they will be treated like our family members,” smiles Sunita Kumari, one of the nurses, as she prepares a vaccine for a pregnant woman.

In rural Bihar, people think Covid is an urban illness. They refuse to believe that it has spread across rural India too... a large part of the rural population might flatly refuse to take vaccines.

ONKAR CHAND,

Social mobilisation coordinator (Darbhanga)