Who must get it next?
Dr Anu Grover, Dy General Manager – Medical, Affairs, Ipca laboratories; Dr Manish Grover, Pharm R & D Expert, Ex Global Director; Meenu G Sharma, Principal Consultant, Businessassociar
The day of 16 January 2021 was a much-awaited day when the vaccination drive against deadly pandemic COVID-19 began in India. While the approval of two vaccines, under emergency use clauses, has brought lots of hope, there were reports in media raising concerns about their efficacy and safety. There has also been a bit of confusion on one vaccine being released in ‘clinical trial mode’ which was not clear in its meaning and intent, so created some sort of initial vaccine hesitancy.
At the current juncture, while we still do not know everything about the COVID-19 virus and its cures, we already have two vaccines approved for emergency use by the regulatory bodies in our country. It is definitely commendable progress in a very short time. We must realise that this is humanity’s war against a deadly virus. In war, one does not have the luxury of time. Therefore, these vaccines have been approved with abridged trials, meaning they have adequate data to say that they are safe for human use and that they have sufficient positive response in a majority of the population that these were tested on. This is a very good starting point for all of us.
Most people have basically two questions in their mind: First, whether to opt for vaccination or not and the second connected question for those who answer the above question with a yes, is which of the two available vaccines one should opt for? The situation reminds one of the popular Shakespearean dilemmas, “To be (vaccinated) or not to be.”
For the government, with two vaccines in hand to possibly combat the virus, the next thought is how to select the sections of the population who get it first and how to prioritise its usage for the whole nation.
Since supply in the initial phases is going to be limited, various countries are handling prioritisation and distributions using different approaches:
- The UK sets out tiers of prioritisation and strategies to start with getting the vaccine to the very old and to those working in care homes before moving down the age brackets. Prioritising the most vulnerable members of society is a common/conventional approach.
Joint Committee on Vaccination and Immunisation (JCVI) advised that the first priority should be the prevention of mortality, and to do this they have opted for immediate protection of very vulnerable, elderly people, rather than general prevention of mortality by using the vaccine to reduce the reproduction rate (R-number) of the virus and slow down transmission.
- Germany’s strategise to vaccinate at-risk groups first, along with nurses and doctors. An estimated 40 per cent of the population gets first dibs on a vaccine under the German plan.
- China has put citizens with overseas travel plans among the groups prioritised for emergency-use vaccines. Aside from preventing its citizens from bringing the virus back home, it also reduces the risk of Chinese nationals becoming carriers of the virus overseas.
- The Advisory Committee on Immunization Practices (ACIP) in the US has recommended that healthcare personnel along with long-term care residents be offered COVID-19 vaccination first (Phase 1a) followed by persons aged ≥75 years and non–health care frontline essential workers (Phase 1b) and then to persons aged 65–74 years, persons aged 16–64 years with high-risk medical conditions (Phase 1c)
- A recently published model from Khalifa University supports this. Authors suggest that priority should be accorded to groups with the highest number of daily in-person interactions. This amplifies the vaccine’s effectiveness by reducing infections (and mortality) both among the vaccinated group and those they come into contact with. According to their model, proper prioritisation can reduce total fatalities by up to 70%. How to weigh other risk groups? Obesity is a comorbidity for serious complications from COVID-19. Do overweight people get to jump the queue?
Are these models the best way to minimise fatalities due to COVID?
Let us focus on India. With a population exceeding 1.3 billion, we do carry a very high risk of the rapid spread of the virus. So far, infection rates per million of the population is reported to be one of the lowest in our country when compared with the developed world. Nevertheless, we do need a logical strategy to prioritise the vaccination of residents of this country. This must include the answer to at least two questions; first being how to prioritise population and second how to cover the whole population of this vast country.
For the first part of the strategy, we need to first understand who is at a higher risk. We know that the virus spreads by people to people contact. Hence, the best approach would be to stratify the population on the basis of people-to-people interaction frequency.
- High interactions – People who travel using public transport or have interactions with large number of unknown people, like hospitals, shopkeepers, restaurants etc.
- Moderate interactions – people who go to work, but travel in their own vehicles and meet a set number of known people on a daily basis.
- Minimal interactions – People who have a sedentary life. This population mostly stays at home and has minimal interaction with other people. It is group 1, who will have the highest probability of catching the virus and by corollary the highest probability of spreading it too. Hence, this set of population needs to be targeted on priority. In addition to this risk group, it is also important that we minimise probability of getting the virus from outside India and sending virus out of India. Hence, everyone travelling in and out of the country – irrespective of their interaction frequency, must compulsorily be vaccinated.
Covering a population exceeding 1.3 billion is going to be a big task. In the first phase which is currently underway, 30 million healthcare workers are being vaccinated, being at the highest risk. However, with the current pace, experts estimate it could take about 3 years to vaccinate 300 million high-risk people targeted in the next phase of the rollout. The government infrastructure alone may not be adequate to quickly vaccinate the large population of our country and we would need private setups to support the effort. Once vaccines are granted full approval for mass use, the government should de-control vaccination and use a more flexible model. For example, a set percentage of available supply, say 30-40 per cent, could be allocated to be applied through the private sector along with sufficient safeguards to prevent black-marketing and also ensure safe usage. This will speed up vaccination of larger population size in a much shorter period of time, without compromising access for the highest-risk subgroups.
And now to the question, “to be (vaccinated) or not to be”. It’s too early to know if the vaccines will provide long-term protection. Additional research, which is time-consuming, is needed to answer this question.
However, available data indicates that vaccines are designed for the body’s immune system to safely recognise and block the virus that causes COVID-19.
Of course, the final choice will be up to the individual. We must remember that we have two weapons in the form of promising vaccines that will help us fight the disease. Those who will take it will not only help reduce the burden of disease but will also help us in charting a further strategy to fight the scourge for the long term.