Benaulim, Goa and Noida, Uttar Pradesh: Ever since South Africa announced on November 25, 2021 that it had detected the new, highly mutated B.1.1.529 variant of the SARS-CoV-2 virus that causes Covid-19, public health institutions have underscored the importance of vaccination to combat the new variant.

In India, nearly 38% of the total population is fully immunised and 60% have received at least one dose of the vaccination by December 10, 2021. But in this continent-sized country with a population currently greater than that of the entire African continent, vaccine inequities are stark--districts within the same state have a vast gap between their vaccination levels, and rural areas, women and Adivasis lag, an IndiaSpend analysis has found.

In November 2021, our assessment of vaccination data in 700 districts had uncovered geographical and gender imbalances in India's Covid-19 vaccination programme. On November 3, the central government announced the Har Ghar Dastak programme, to focus on vaccinating those who were yet to take the first dose and those due for the second dose, including by vaccinating them at their homes. One month on, there had been a 5.9% increase in first dose coverage and an 11.7% increase in second dose coverage during the campaign, the Ministry of Health and Welfare (MoHFW) said on December 2.

With the Omicron variant now identified in Karnataka, Gujarat, Maharashtra, Delhi and Rajasthan, we took a fresh, district-level look at India's vaccination progress, and found the same inequities persist. People in the wealthier, urban districts are more protected than their counterparts in poorer, more rural districts. The need for vaccination is more pressing in rural areas, where access to health facilities is poorer, public health experts told us.

Every expert IndiaSpend spoke to stressed the importance of vaccinating as many people as possible in light of the looming threat from Omicron. Some suggested that India begin administering booster doses to vulnerable groups, such as healthcare workers, the elderly and those with comorbidities. Others said India's focus must remain on maximising primary vaccination.

Omicron disease severity and immunity evasion

68% of Indians had Covid-19 antibodies from the Delta and earlier variants of Covid-19, per MoHFW's fourth nationwide serosurvey, conducted from June 14 to July 6, 2021, and released in July 2021. A large proportion should also have Covid-19 antibodies from vaccines; 11 months since its vaccination programme began, India has fully immunised over 50% of its eligible population and 85% had received at least one dose, per union health minister Mansukh Mandaviya.

Citing the serosurvey findings and India's immunisation levels by December 2021, the MoHFW on December 3 said the severity of the disease from Omicron is anticipated to be low in India, though further evidence is awaited.

"Based on data from South Africa, it seems that the Intensive Care Unit utilisation rate for the Omicron variant is lower at this point than it was for the Delta variant at a similar point. However, this could be because those infected are the young and healthy, or because the vast majority in South Africa have immunity from a previous infection, and some due to vaccination. We do not know what the situation will be when the virus infects older or less healthy people. So it is too early to say that the Omicron variant is less virulent than the Delta variant, or that disease severity will be lower in elderly individuals or unvaccinated individuals," Swapneil Parikh, internal medicine specialist and author of The Coronavirus: What You Need To Know About The Global Pandemic, told IndiaSpend.

"We do not know if the new strain causes more or less severe disease than the Delta variant, so it would be remiss to make claims about severity right now. We do not want people either panicking or becoming complacent about the disease," Ambarish Dutta, an epidemiologist at the Public Health Foundation of India (PHFI), told IndiaSpend."

Public health experts and vaccine-makers have also expressed concerns about the highly mutated Omicron variant's ability to evade immunity from vaccination and from prior infection by earlier variants. But countries should not wait for evidence on Omicron's transmissibility, immune escape potential and the severity of disease it causes and immediately increase vaccination coverage in those most at risk, the WHO said on December 8. The Har Ghar Dastak programme must redouble efforts to prioritise Adivasis and women for vaccination and expand vaccination efforts in rural districts, which were as affected by Covid-19 as urban India in the second wave, our analysis suggests, and experts confirmed.

Inter-state vaccine inequity

Thirteen states and UTs lag the countrywide average of persons fully vaccinated; 12 lag in terms of giving at least one dose to their total population. On both metrics, Bihar, Chhattisgarh, Jharkhand, Manipur, Meghalaya, Nagaland, Maharashtra, Punjab, Tamil Nadu and Uttar Pradesh have to catch up with the rest of the country. Our analysis is based on the total population of districts (read more about our methodology here).

Some states will find it harder than others to close these gaps, say public health experts. "There are districts in Punjab and Maharashtra with low first dose coverage, so there are blind spots in each states' drives. But the literacy rates and awareness about diseases in Bihar and Jharkhand is very poor, so [unwell] people present themselves to doctors much later. In addition, the villages are remote and there are issues of last-mile connectivity in Bihar and Jharkhand. There is a mega vaccination drive underway, and they are trying to get these districts to catch up. But it will be easier for poorly performing districts in Maharashtra to catch up with the country than for districts in Bihar and Jharkhand," said PHFI's Dutta.

Persistent urban-rural divide

The urban-rural gap in vaccination coverage, which was 10 percentage points by late October, remained the same, as of December 5, though some states have slightly reduced this gap. Of 700 districts, 312 exceed the countrywide average of 58% of the total population receiving at least one Covid-19 vaccine dose, and for which socio-economic profile data are available, 38% are urban districts, though their overall share in the 700 districts is 26%.

By late October, among larger states, there were more than 10 percentage point gaps between average vaccinations in urban and rural districts within larger states like West Bengal, Haryana, Uttarakhand, Telangana, Punjab and Jharkhand. By early December, only Jharkhand among these states had reduced its urban-rural gap in vaccination coverage to a single digit, though its overall coverage remained far behind.

Tamil Nadu has joined Karnataka, Andhra Pradesh and Rajasthan among large states with no or negligible urban-rural gaps in vaccination coverage. Kerala remains unique among large states in covering more people in rural districts compared to urban districts, both in terms of partial or full immunisation against Covid-19.

Urban-rural vaccination gaps seen in some northeastern states in late October remain stark. The 29 percentage point gap between people administered at least one dose of a Covid-19 vaccine between Nagaland's urban and rural districts persists. The gap between Manipur's five urban and eight rural districts has reduced only slightly, to 24 percentage points from the 26 seen in late October. In Mizoram, the 19 percentage point gap between six urban and two rural districts in late October had reduced to 15 points in early December.

The urban-rural gap underscores the large percentage point gaps in coverage between most and least vaccinated districts within states. Since late October, only 11 of the 29 states and UTs included in our analysis which have more than two districts, have reduced this gap, even if slightly. In the rest, the gap has remained the same, or worsened. Except for Andhra Pradesh, there are large coverage inequities between districts in all other states and UTs.

Covid-19 spread deep into rural India in the second wave, data show. Mizoram had seen four times and Manipur 1.6 times the average Covid-19 cases per million population for India, by December 7, 2021. Arunachal Pradesh, with 10 districts in the 50 least covered with at least one dose, had 1.2 times more Covid-19 cases per million population than the Indian average.

"People in the northeast believed that they would never get the disease, so when they did, they were caught by surprise. The government acted swiftly by setting up makeshift hospitals, etc., but there was a shortage of medicines. The northeast does not get attention in the media, so this was not covered," Nilanju Datta, a project consultant with the women's rights group North East Network (NEN) in Assam, told IndiaSpend.

Poorer, Tribal-Dominated Districts Among Least Vaccinated

In November, we had reported that India's most vaccinated district, Mahe in Puducherry, has given at least one dose of a Covid-19 vaccine to more than its total usual resident population (including non-residents such as migrant workers), recording 108% coverage. A month later, Mahe is in third place behind South Delhi, now India's most vaccinated district, having administered at least one dose to 112% of its usual resident population.

The least-vaccinated district, Kurung Kumey in Arunachal Pradesh, had covered only 11% of its population by November. Kurung Kumey remained in last place by December, having covered only 12% with at least one dose.

In terms of fully vaccinated persons, Mahe still leads at 97%. Kurung Kumey is in last place even on this metric, having fully vaccinated just 8%. Urban districts like Mahe and South Delhi dominate the upper-end of the vaccine coverage rankings; tribal-dominated districts like Kurung Kumey fill the least-vaccinated end of the spectrum.

India's wealthier, more urban districts rank higher both in terms of fully vaccinating their population and in administering at least one dose of a Covid-19 vaccine. To categorise districts as poor, we used Niti Aayog's assessment of the proportion of population in 641 of India's 736 districts that are multi-dimensionally poor. This assessment incorporates levels of deprivation in health, education and living standards when measuring poverty, and not just income.

In the 25 districts with the highest fully vaccinated population, the proportion of the poor population is lower than the India average of 17.65%. Conversely, the 25 districts with the lowest fully vaccinated population, except for Mansa in Punjab, have larger multi-dimensionally poor populations than the India average. Of these 25, 19 are tribal-dominated, or have larger than average Scheduled Tribe populations. Three are in Telangana.

The picture is similar for districts ranked by at least one Covid-19 vaccine dose. More people in India's wealthier state capitals and big cities are protected with at least one dose than their counterparts in the tribal-dominated districts of Arunachal Pradesh, Nagaland, Manipur and Mizoram.

The districts of Jharkhand and Chhattisgarh which feature in the bottom 25, are also tribal-dominated. Every district in the bottom 25, except Meghalaya's South Garo Hills, has a multi-dimensionally poor population higher than the Indian average, per the Niti Aayog rankings.

There were 29 districts with less than 50% of their eligible population covered with at least one dose, the MoHFW told Parliament on December 3. Most of the districts in the bottom 25 of IndiaSpend's rankings also feature in the MoHFW's list, which also has mostly tribal-dominated districts in the North East.

As recent official, age-wise district-level population data are not publicly available with the decennial census delayed due to the Covid-19 pandemic, IndiaSpend has asked the MoHFW for the district-level population data it has used to calculate vaccination coverage. We will update the article when they respond.

IndiaSpend has also asked the state governments of Arunachal Pradesh, Manipur, Nagaland, Mizoram, Jharkhand, Chhattisgarh, Gujarat, Himachal Pradesh, Haryana, Delhi, Punjab, Uttar Pradesh, Bihar and Maharashtra for reasons behind lower vaccination coverage in some districts and the steps being taken to increase vaccine uptake in these areas, with the Omicron variant now in India. We will update the article when they respond.

Women lag men in many districts with better vaccination coverage

India's vaccination sex ratio at 949 females receiving a dose for every 1,000 males, is below India's normal sex ratio of 1,020, but close to 952, the average sex ratio at birth of any population. Only 14 of 36 states and UTs have a better vaccination sex ratio than India's, led by the southern region.

Outside the south, Bihar, West Bengal, Assam, Odisha and Chhattisgarh are among large states that have performed better in ensuring vaccination of women. Maharashtra, Gujarat, Himachal Pradesh, Punjab, Haryana and Delhi are among the worst performers on this metric.

Of the 700 districts in our analysis, 318 (45%) have equal or greater than the countrywide average of 58% of the total population covered with at least one vaccine dose. Among these 318 districts, 149 (47%) have a vaccine sex ratio worse than India's average.

As in November, we found that women are behind men by substantial margins in some of India's biggest urban districts: Delhi, Mumbai, major cities of Gujarat, Punjab and Haryana.

Public health experts had told us in November that the vaccination program needs to be taken to women's doorsteps. IndiaSpend has asked the ministries for women and child development and health and family welfare for reasons for lower vaccination coverage of women compared to men in several states, and for details of steps being taken to increase vaccine uptake among women, with the Omicron variant now in India. We will update the article when they respond.

Address vaccine hesitancy, incentivise vaccination

The government has to work on last-mile delivery, public health experts said. The central government's Har Ghar Dastak program is a good effort in this direction, they added.

"Supply of Covid-19 vaccines is not a constraint at the moment, but we do have to consider issues of last-mile connectivity," said PHFI's Dutta. "There are enough vaccines to cover the entire adult population of the country. We need to ensure that the supply reaches all areas while also improving demand in areas with low uptake. This can be done by giving positive incentives like cash to people to get vaccinated and negative incentives like requiring vaccination for entry to public spaces or gatherings. We should also improve communication, awareness and community engagement," said Parikh.

States and UTs had Covid-19 vaccine supplies totalling nearly a quarter of a billion doses as of November 29, the MoHFW informed Parliament on December 3.

Women's health activists working on the ground in north-eastern states told us that past issues of supply of vaccines have been resolved, and attributed the low vaccine uptake in some districts in these states partly to vaccine hesitancy.

"Speaking from the context of Nagaland, I can say that the low uptake of vaccines is due to several reasons. One is religious beliefs that people hold on to. Unfounded rumours have been going around that vaccination is the mark of the devil. Many believe that if one has strong faith in God, then we will be protected by God," Wekoweu Tsuhah of the North East Network who works in Phek district, Nagaland told IndiaSpend.

"When the state government began an aggressive campaign for mandatory vaccination, starting with government employees, with conditions like holding back salaries if they are not vaccinated or coming to office without an RT-PCR test etc, there was a backlash. People started believing conspiracy theories about Covid-19. Many people I have interacted with have said that they got vaccinated not because they believe in the efficacy of vaccines, but because it has become necessary for carrying out activities, especially travel," said Tsuhah.

"Initially, there was a shortage of vaccines, and some of the primary and community health centres were not functional or did not have personnel manning them, but the government took efforts to remedy this," said NEN's Datta. "In Assam, in the communities that we work with, there was a rumour that if you take the vaccine, you will die in two years. Given the lack of trust, the ASHA workers approached our community mobilisers to organise health camps. I know that in Dhemaji and Darrang districts, it took a lot of convincing to get the women to take the vaccine," she said.

IndiaSpend has asked the ministries for tribal affairs and health for reasons for lower vaccination coverage in tribal-dominated areas and for details of steps such as door-to-door vaccination being taken to increase vaccine uptake in these areas, with the Omicron variant now in India. We will update the article when they respond.

Vaccine inequity can give rise to new variants, say experts

Concerns on Omicron's ability to evade previous immunity have led to a renewed focus in countries including the United States, United Kingdom and the European Union on vaccination booster dose programs, in response to Omicron. After Omicron cases were found in India, calls for booster doses have emerged in India too.

Reduced protection in vaccinated persons against infection and mild disease with Omicron, however, does not necessarily mean reduced protection against severe illness and death, other experts have said. The WHO on December 9 reportedly said it was more important to vaccinate people with first and second doses, and broad-based administration of booster doses risked exacerbating inequities in vaccine access.

Given the inequities in India's vaccination coverage, the focus must remain on full vaccination, said PHFI's Dutta. India's government aims to fully vaccinate all adults by December 2021. "The new [Omicron] strain is more infectious. The priority should be to vaccinate as many adults as possible before December 31 because this will protect the vulnerable. Once we have covered the adult population, we can give booster doses to the elderly and the immunocompromised," he said. "If the virus spreads very fast in districts [where vaccination coverage is low], we can expect mutations and newer variants. Therefore we need to get as many people vaccinated as quickly as possible," said Dutta.

"Of course, we should maximise two-dose coverage, but a third dose for an 85-year-old or immune-compromised individual may reduce their risk of death due to Covid-19 by a greater amount than a second dose for an 18-year-old who has already had Covid-19," said Parikh. "Variants can emerge when there are long term infections in immunocompromised individuals in remote areas, where people have little access to healthcare facilities. It's in our interest to ensure vaccination in all areas; it's also the right thing to do.".

(Nileena Suresh contributed to this article.)

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