New Delhi: Two months since it rolled out the world's largest vaccination programme, India has given 34.9 million vaccine shots, or about 7% of its initial target of 500 million, up from 3% by February 16. India has 4.5 months to achieve the remaining 93% of this target.

India's capacity to vaccinate every day has fluctuated, rising from 0.22 million shots on the first day of vaccination (January 16, 2021) to 0.13 million shots a month later on February 16 to 1.9 million shots on the third month anniversary (March 16).

India will need to give 3.65 million shots per day for the remaining 137 days until the end of July, in order to achieve its target of vaccinating 250 million people with two doses.

A small number of adverse events, such as hospitalisations and deaths, have been reported following the vaccinations---51 people have been hospitalised and 46 people have died after taking COVID-19 vaccination, according to the government on February 26, 2021. The government has maintained since January 16, 2021, that, "No case of serious/severe AEFI/Death is attributable to vaccination, till date." IndiaSpend reported on the need for more rigorous investigation and transparency on the reporting of these adverse events, which will in turn boost confidence in the vaccination process.

Since our last update on the one-month anniversary of the programme, India has opened up vaccination to senior citizens (aged 60 years and above), and to those aged between 45 and 59 years with preexisting health conditions. For this second edition of the COVID-19 vaccination update, IndiaSpend visited three vaccination centres--one government and two private--in the national capital, and spoke to practitioners and public health specialists on the current criteria for vaccination.

Preference for govt vaccination centres

After initial reports of throngs of people at COVID-19 vaccination centres when it was opened to the private sector on March 1, the footfall appears to have stabilised to a steady pace, we found.

Jeevan Hospital and Nursing Home in south-east Delhi is located in the lower-middle class neighbourhood of Sunlight Colony, on a cramped and potholed road. At 9 a.m. on March 15, when the vaccination drive opened, only three people were waiting inside the building. In two hours, 13 people had been vaccinated. All of them were senior citizens, aged 60 or older.

"I was not able to register online. But I live close to the hospital, so I came over and registered my mother who has been very enthusiastic to get the vaccine," said Amit Arora.

Outside the hospital, brothers Khajan Singh Saini and Dhyanchand Singh Saini, both aged above 60 years, were getting their shoes polished from a cobbler. They live close by, but said they did not want to get vaccinated there. "We don't trust private hospitals, and my son has registered for us to take the vaccine at Safdarjung Hospital," said Dhyanchand.

Khajan Singh Saini and Dhyanchand Singh Saini at a cobbler, near Jeevan Hospital and Nursing Home in Delhi's Sunlight Colony.

In South Delhi's upmarket East of Kailash area, people wait in the sun for their vaccine shot at the National Heart Institute, a private hospital. Rajkumar Jaiswal, a senior citizen who works as office staff serving tea and water at a nearby firm, has come to take his vaccination. Jaiswal said he did not know about the vaccination or how to register, but a woman at his workplace had told him about it and offered to help. "This vaccination centre is close to my house. But I did not know where this place actually is and walked for about an hour trying to find it," said Jaiswal.

In Delhi, there are more vaccination centres in the private sector (136) than the public sector (56). But many people may not know about that, said Debashish Parmar, a doctor at Ram Manohar Lohia (RML) Hospital, a public hospital. RML has three vaccination sites at its campus. Many frontline workers were present for their vaccination, especially from the Delhi Police, on March 15, when IndiaSpend visited. Medical and nursing students were also lined up for their shots.

"Most people don't know where to go for vaccination but assume that RML, being an important government hospital, will definitely be providing the vaccine," said Parmar. "We have so far been able to cater to the inflow of people but it would be good if people went to other vaccination centres also, to decrease the load here."

People wait after taking their COVID-19 vaccination at Delhi's Ram Manohar Lohia Hospital. Recipients are asked to wait 30 minutes after their shot to monitor for adverse reactions.

Expanding the pool of those who can get vaccinated

India's COVID-19 vaccination drive that initially covered only registered health and frontline workers opened up March 1 to all citizens over 60 years of age and those above 45 with 20 specific comorbidities. This is in keeping with the findings of the World Health Organization (WHO) that those with pre-existing health conditions and above 60 are at higher risk of mortality with COVID-19.

Except HIV infection, all the comorbidities included in the government vaccination eligibility list are non-communicable diseases (NCDs) such as heart disease, respiratory disease and diabetes. Up to 73% of India's COVID-19 deaths are linked with comorbidities including diabetes, hypertension, cardiovascular and respiratory disease, according to June 2020 government data.

A substantial number of Indians have NCDs, according to the 2015 India State Level Disease Burden Initiative. Cardiovascular disease accounted for 28% of deaths in India in 2016, up from 15% in 1990. Ischaemic heart disease was the leading cause of health-loss in India in 2016, and stroke the fifth. Also, the prevalence of chronic obstructive lung disease increased to 55 million in 2016, from 28 million in 1990.

As of 2019, India had 77 million diabetics--second only to China (116 million)--according to the International Diabetes Federation's Diabetes Atlas 2019. Up to 75% of India's diabetics face higher COVID-19 mortality risk, as IndiaSpend reported in June 2020. Hypertension affects nearly three in 10 Indians and is responsible for 17.5% of all deaths and 9.7% of disability-adjusted life years or DALYS in India, IndiaSpend reported in May 2018.

Some comorbidities have to coexist with others for eligibility in this round. For example, those who have had diabetes should also be hypertensive to get vaccinated, and their diabetes should have existed for over 10 years, or should have other complications associated with it.

Given this high prevalence of diabetes and hypertension in India, some health experts are of the view such comorbidities should be sufficient conditions for being on the priority list. The current list of eligibility criteria is "pretty good", said Anoop Misra, chairperson of the National Diabetes, Obesity and Cholesterol Foundation, but some of the conditions are restrictive.

"It needs to expand to include even younger people who also have these chronic diseases," said Misra. "In my practice, I can see that chronic diseases are occurring in younger people too. Some of the cut-offs also don't make sense. For example, asking that people who have had diabetes for 10 years get the vaccine first. Diabetes, whether one has had it for such a long period or less, remains a risk factor for COVID-19."

Prabhakaran Dorairaj, cardiologist and vice president (research and policy) at the Public Health Foundation of India, pointed out that the eligibility list is dynamic and will start to embrace a wide group of comorbidities in the future. "One can argue that the list should have simply said that anyone with diabetes or hypertension should get the vaccine, but the volume of people would have been staggering for the system to manage it initially," he said.

"As the ability to vaccinate increases, as the availability of vaccines increases, as more vaccines get approved, more people can also be vaccinated and the list of eligible people can increase," said Dorairaj.

How the world is deciding on vaccine eligibility

In November 2020, WHO offered advice on how countries can prioritise vaccine eligibility for COVID-19. If those with all kinds of comorbidities are included in the early months of the vaccination drive, demand could outstrip supply. The organisation also pointed out that those with multiple comorbidities are at a higher risk than others.

WHO asked countries to use local data to figure out their prioritisation strategy. As an example, it said, one approach could be "to prioritize individuals who have two or more relevant comorbidities". India's vaccination criteria so far, has been in line with this advice.

NCDs have been on the mind of policy-makers around the world even before the pandemic. In 2011, global leaders met at the United Nations to put together an agenda to tackle disease such as cardiovascular problems, cancer, chronic respiratory disease and diabetes that cause 60% of all deaths globally.

In the UK, the priority list for vaccination is divided into nine groups, and "will include around 99% of people at risk of dying from the disease". The first group is of residents in care homes for the elderly, the second, of those older than 80 and also frontline health and social workers. The remaining groups are largely age-based and of those who are "clinically extremely vulnerable".

The US government's vaccination prioritisation has been divided into phases. In the first, vaccination is being offered to healthcare personnel and residents of long-term care facilities. In the second, it is opened to frontline workers and those older than 75. In the third phase, it is open to those between 65-74 years of age and also 16 to 64 years of age with underlying medical conditions that increase the risk of severe COVID-19. "As vaccine availability increases, vaccination recommendations will expand to include more groups," said the US-based Centers for Disease Control and Prevention.

What is the status of the vaccines so far?

So far, the Indian government has approved two vaccines for COVID-19--COVISHIELD and COVAXIN. The former is manufactured by Serum Institute in Pune, developed by pharmaceutical company AstraZeneca. The latter is manufactured by Bharat Biotech in India.

COVAXIN's approval was based on interim safety and immunogenicity data from phase 1 and 2 clinical trials, and safety data from phase 3. COVISHIELD's approval was based on safety, immunogenicity and efficacy data from phase 2 and 3 of clinical trials abroad, and some ongoing data on safety and immunogenicity from the same phases in India.

Currently, several countries including Germany, Italy, France, Sweden and Norway have suspended the AstraZeneca COVID-19 vaccine after reports or recipients experiencing blood clots following the vaccination. The WHO has said that there is no link yet between the vaccine and the blood clots that people are experiencing, and that people should continue to take the vaccine.

This month, COVAXIN's efficacy results have been published in The Lancet medical journal. The Indian Council of Medical Research said that these results put COVAXIN "at par with other global-front runner vaccines".

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