Dispatch #36: How did we get here?
In this dispatch I have curated articles on India's botched up Covid-19 vaccination programme
“The vaccine shortage was predictable. It has been clear for some time that the two manufacturers in India, Serum Institute of India and Bharat Biotech, were not going to be able to quickly meet the demand from the groups the government has prioritised for vaccination: those above the age of 45, as well as health care workers and others whose occupation puts them at increased risk. This is estimated to be around 400 million people and immunising them would require 800 million doses of vaccine, plus another 10% more to account for wastage.
The Serum Institute, based on statements made by its CEO, Adar Poonawala, produces around 60-65 million doses a month. Bharat Biotech is estimated to produce around 5 million doses a month, which is expected to double once a new manufacturing facility in Bengaluru is up and running in the summer.
At current production levels this amounts to between 65-70 million doses a month from both manufacturers. At this rate, from April to August, on a best case estimate around 350 million doses will be available to the government. If one adds the 80 million doses that had already been administered from January till 1 April, we get a figure of around 430 million doses from January to July. If we assume that Serum Institute can increase its production to 100 million doses by May (which it has been attempting to do for some time), this figure could go up to over 500 million doses by August. This is still well below the 800 million plus that will be required. The target of 800 million doses by August for 400 million people cannot be met with the existing manufacturing capacity in India.”
That’s Thomas Abraham, in his recent article titled What has Gone Wrong with India’s Vaccination Programme?
If there is one article that you should read to understand India’s vaccination fiasco, then it has to be this one.
He further adds, “The government itself made no moves to indicate how many vaccines it would require. It was only in the first week of January that the government issued a purchase order for 45 million doses, followed by another order in March for 100 million doses. Orders were also placed with Bharat Biotech for amounts that are not publicly available but must be significantly smaller than the quantities from Serum Institute. It was clear that this volume of vaccines was not sufficient for the 400 million odd people who had been prioritised for vaccination.”
Talking about the Indian government’s denial of the shortage of vaccines as the second wave hit the country in March, Thomas writes, “A refusal to acknowledge any shortcomings has been a constant theme in government policy through the pandemic. Official pronouncements whether from ministers or from senior civil servants seem primarily designed to create a portrait of Indian exceptionalism, infallibility, self-reliance and global leadership. (‘India has done better than other countries,’ ‘India is ‘the pharmacy of the world,’ ‘The world is thankful to India for its vaccines.’)”
On the government’s myopic view on funding and procuring vaccines, G S Mudur from The Telegraph writes, “The experts, who have tracked global vaccine efforts, said the Indian government’s lack of investments contrasted with the actions of many countries, including America and Britain, that provided advance funding to vaccine makers and signed purchase pacts with them.
While the policy makers recognised the need for Covid-19 vaccines and acknowledged the Serum Institute and Bharat Biotech as the earliest possible sources of vaccines for India, the
finance to scale up production did not materialise, experts say.
‘This was a botch-up — the government knew the companies’ production capacities and should have foreseen the need to ramp up manufacturing ahead of inoculations.’ Others did exactly this,” the epidemiologist who requested anonymity said.
The US government invested about $6 billion (Rs 44,724 crore), distributed across several vaccine companies including Moderna, Pfizer and Janssen (Johnson and Johnson), in July and August last year on candidate vaccines that were still under evaluation.
The British government had in May last year pledged £65.5 million (Rs 488 crore) to University of Oxford researchers for work on the AstraZeneca vaccine. By October, Australia, Brazil, Canada, Japan, and the European Union had pacts for one or more candidate vaccines.”
Talking about the vaccine manufacturing capacities in India, pharma and health sector analyst Nithya Balasubramanian, in an interview to India Spend said, “Before COVID-19, between the Serum Institute, Bharat Biotech and Biological E, India had about 2.3 billion doses' capacity [to manufacture vaccines of any kind]. Serum Institute has so far struck two manufacturing relationships [to produce COVID-19 vaccines], one with AstraZeneca promising a billion doses, and one with Novavax, again promising a billion doses. I understand that their plan is to repurpose as much of their existing capacities as possible, but they had also announced that they are setting up additional manufacturing capacities for up to another billion doses. That will not materialise overnight; 2022 is possibly when the new capacity can actually see the light of day.
Serum Institute's existing capacity is around 1.3-1.5 billion doses, total. So, based on all the reports that we have seen, their current manufacturing capacity of the AstraZeneca vaccine [called Covishield in India] is about 70-odd million doses per month [Editor's note: the capacity is between 70 and 100 million per month, as per a Rajya Sabha committee report]. Bharat Biotech, unfortunately, is much lower than that, at around 5-10 million doses [Editor's note: 12.5 million per month, per the Rajya Sabha report].
If you add all of that up, it's at the run rate [the current rate of COVID-19 immunisations per day]--that is, however much they are producing, we are actually consuming. [Editor's note: On April 9, India administered 3.6 million doses; the past week's average has been 3.1 million daily doses]. We really need them to step up so that we can actually get ahead of the game. We are talking about annual capacities and we are also talking about capacities for different types of vaccines. Every capacity can't be repurposed to suddenly start making COVID-19 vaccines. Different vaccines are based on very different technologies, so repurposing doesn't happen overnight.”
In the same interview, PHFI professor Dr Giridhar Babu added, “We have reached nearly 4 million doses per day, but what we really require is at least 7-10 million doses per day, just to cover the vulnerable population in the next 2-3 months. That is, if we want to make a dent in terms of reducing mortality, which is the ultimate goal. I don't see that happening with the current availability of only two vaccines.”
Nithya agreed to what Prof Babu said by adding, “At 10 million shots per day, India needs 300 million doses a month. Hopefully Serum Institute can scale up. I think I saw an announcement that they have requested some monies from the government to scale up the capacities. [Editor's note: As noted above, SI is producing between 70 and 100 million doses of Covishield per month, as per a Rajya Sabha committee report]. Bharat Biotech has been working on trying to scale up their capacities to 50-60 million doses. So that takes us to 150-160 a day.We will, for sure, need Zydus and Sputnik V's capacities to kick in if we want to hit that 300 million run-rate.”
“It's not day 5 of a test match; we are still very much in the middle of the match. In fact, we started playing this game not as a test match but as though it's a T20, and thought the game was over. That was the big mistake we made. It's very clear that by January 2021, COVID-19 cases had come down in India after the big rise up to the middle of September 2020, for several reasons. We now know that laxity set in at different levels after that. At the individual level, COVID-19 precautions were abandoned, in terms of masks not being worn, crowding, moving around, celebrating whether in outdoor places or, particularly problematically, in enclosed places. That has been a major issue. The resumption of economic activity also brings a large number of people together for a long period of time, in offices, factories and in public transport. But even enforcement by authorities has slackened. We have seen that in the number of political meetings and rallies being organised, with elections being held at the block, local body and assembly levels. Large political and religious gatherings have been permitted.
There was also a feeling that herd immunity is already upon us. I have been cautioning against this for quite some time. Don't think of herd immunity as some Nirvana; it's not yet here and we don't know when it will arrive. Yet that feeling took hold of the political class and industrialists and then percolated, to some extent, into the public health community, with some sections propagating the idea that herd immunity is already here in India. They are also partly responsible.
There is also the challenge of mutant strains of COVID-19. With international travel now increasing, mutants that developed elsewhere are already in India. We, however, don't know the extent to which these are responsible, or not, for the rise in cases, because the genomic screening of various positive tests is not at that level.”
To make matters worse, the export embargo on the vaccine raw materials by the US, forced Adar Poonawala, the CEO of Serum Institute to took to Twitter to request Biden to remove the embargo.
“That was shortly after the Biden administration announced, on February 5th, plans to use the Defence Production Act (DPA)—legislation that grants the president broad industrial-mobilisation powers—to bolster vaccine-making. This legislation has helped American pharmaceutical companies to secure raw materials and equipment needed to make more vaccines. But American firms that supply products essential to vaccine production say the DPA hinders their ability to export them. They must seek permission before exporting goods, which requires time and paperwork, and if America’s government decides they need the goods, firms may be barred from exporting them at all. Some are also concerned about pharma companies outside of America stockpiling goods because of concerns about delays caused by American export controls. Together, export controls and stockpiling risk gumming up the global supply chain.
Vaccine production requires an array of special materials, including plastic tubing, raw goods, filters and even paper. Because all these items have to be specially approved by regulators to be used in medicine production, finding substitutes quickly can be impossible.”
The Development Data Lab has been compiling the data on infections, health infrastructure and vaccinations since last year.
The chart below shows the state-wise number of vaccinations per 1000 population up till 12th April.