A 3D print of a spike protein of SARS-CoV-2 in front of a print of a SARS-CoV-2 virus particle. The spike protein enables the virus to enter and infect human cells. Caption and photo: niaid/Flickr, CC BY 2.0.
India’s response to the coronavirus pandemic was rapid and decisive. It began with the termination of international travel and public advocacy of mandatory masking and social distancing, at a time when political leaders of many wealthier countries were still dithering on both these issues.
However, the lockdown of all economic activity, cessation of domestic and local travel and curbs on individual mobility that followed – with only four hours’ notice – unleashed an economic crisis as well as the worst humanitarian crisis India has witnessed in recent times. Its impact on the hundreds of millions working in the informal economy, typically suffering from wage exploitation and unacceptable working and living conditions, but largely invisible, was dramatic.
Especially among migrant workers in the cities, the loss of shelter and even access to regular food may have compromised their immunity and increased their susceptibility to infections of all kinds, including COVID-19. Theirs has been a crisis of hope and dignity as well as of physical health.
In much of the world, hope of a return to ‘normalcy’, including economic recovery and relaxation of physical distancing rules, is pinned largely on the development of a vaccine. In India, too, there has been a near-constant and universal refrain from politicians and media alike, amplified by voices from international scientific experts, that ‘normal’ will return once we have a vaccine. Vaccines are possibly the most effective, and cost-effective, public health technology available.
Attempts to develop a vaccine against the novel coronavirus began in earnest and in many places. According to WHO, there are now 17 candidate vaccines already being evaluated clinically, and at least 120 more still in the laboratory (pre-clinical) stage of development. Some of the 17 leading contenders make use of innovative techniques that have not yet been used in a licensed human vaccine.
Others, including one being developed by scientists at Oxford University in collaboration with the pharmaceutical company Astra-Zeneca, use an established technique. This SARS-CoV2 vaccine, now called ChAdOx1-S, is the first to move into the large scale human testing phase, i.e. phase III. Covaxin, developed by Bharat Biotech, Hyderabad, together with the National Institute of Virology and the Indian Council of Medical Research, has been approved for safety testing in humans (phase II).
Responding to past pandemics, most recently the H1N1 flu pandemic in 2009, few doses of the vaccine were available at first. Rich countries had maintained advance purchase agreements with vaccine manufacturers and obtained a large share of what they had ordered this way. Poor countries had to wait at the back of the queue, and by the time production was scaled up sufficiently, the pandemic had ended.
Today, we have learned some lessons. WHO has organised ‘pledging conferences’, and a variety of stakeholders have committed to facilitating an equitable allocation of dosages when a vaccine becomes available. But it remains unclear which vaccine will prove successful, how national interests will play out or how quickly supply will expand to meet demand. These questions have become geopolitical hot topics even as the WHO’s moral authority has been eroded and multilateralism is under attack.
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India begins from a favourable position in what is becoming a global struggle over vaccine supplies, thanks to work being conducted by a number of domestic manufacturers. The Serum Institute of India (SII), Pune, has signed an agreement to produce the Oxford-AstraZeneca vaccine. Preparations are already being made for a vast expansion in the scale of production. Given SII’s experience – it currently supplies some 80% of the world’s vaccines by volume – this may not be a problem, provided of course the vaccine proves effective in either preventing infection by the virus or in preventing the disease.
The considerable commercial risk involved, since these things are not yet known, is partly underwritten by commitment from the Bill & Melinda Gates Foundation. However, access to an adequate supply of vaccine is no guarantee that the COVID-19 pandemic will be quelled. The other issues which will arise, and which demand open discussion, present difficulties specific to the national context.
Efficacy and side effects
One set of issues concerns possible variations in the efficacy of a vaccine. How effective will the vaccine be in people with compromised immune systems? This ‘condition’ is true of many people in India, thanks to poor nutrition, presence of diabetes or heart disease, long-term infections such as TB or leprosy and/or air-pollution-induced respiratory diseases. Many people overuse medication, often obtained informally.
How might these health conditions and behaviours interact with the coronavirus and the vaccine? What of side effects emerging in particular population sub-groups? (We already know this to have happened in Scandinavia with the influenza vaccine in 2009.) There is even a controversial theory that unusual responses to the human papillomavirus vaccine reported in India and elsewhere may be due to autoimmune reactions.
Either way, the possibility that vaccine-associated side-effects might emerge in distinctive population groups can’t be discounted. There is also the issue of how they will they become known, given India lacks an efficient system for reporting vaccine-related adverse events. And if they are known to have occurred, who will bear responsibility for the costs of care?
Organisation of vaccination
The focus of vaccination programmes in India has thus far been on infant vaccinations, vital to child survival. Mass vaccination programmes for diphtheria, pertussis, polio and tetanus and, more recently, measles, along with BCG vaccination for tuberculosis have been a key part of the National Family Planning Programme (NFPP), particularly since the mid-1970s.
However, despite the NFPP’s political and financial clout, which for several decades overshadowed India’s other public health goals, national primary vaccination coverage today is only around 61% of the target population. Vaccination programmes have from the start been dogged by organisational problems. Striking successes were of course achieved by the smallpox vaccination and revaccination campaign and, more recently, the polio eradication drive. But they were driven by a war-like approach, and the polio campaign in particular has raised many questions. One concerns the extent to which the drain on resources compromised routine immunisation work. This danger has reared its head during the ongoing pandemic as well.
Moreover, the high prevalence of malnutrition, diarrhoea and coterminus enterovirus infections in certain regions, together with significantly higher numbers of pulse polio rounds conducted there, may have lowered the effectiveness of the vaccine and possibly interacted with the vaccine to produce deleterious effects in many children.
Adult vaccination is an as yet unopened topic in India. How is it to be organised? Perhaps the urgent need to reopen the economy, coupled with suffering among the poor thanks to the lockdown and the fear and stigma surrounding the virus, may facilitate the start of a conversation around this question. While vaccine supply is limited, who should come first? Health and sanitation workers and police personnel, currently among the most vulnerable to infection? Inmates of prisons, refugee camps, and other similar holding institutions whose micro-environments risk the health of their residents and make them infection hotbeds?
Acceptability
The prospect for the uptake of a coronavirus vaccine in India depends mostly on whether the virus is still circulating when the vaccine becomes available and on whether other countries make vaccination a condition for entry visas. Members of the educated urban middle and upper middle classes are likely to be enthusiastically awaiting the vaccine. Mobility is key to their quality of life and they find physical distancing irksome. With ready access to information regarding the vaccine, they will be able to make their own choices.
However, among the less educated generally, willingness to be vaccinated can’t be taken for granted. Their experiences of the public health system have not been universally positive, and doubts and questions often remain unanswered. On the other hand, vaccination may improve their employment prospects, particularly among migrant workers. What if employers were to make vaccination mandatory? This has not as yet been suggested but it raises important social and ethical questions that will need to be discussed in advance.
There are good reasons for not relying exclusively on a single technology. The efficacy of any future vaccine is still unknown, as its effects among different population groups and the duration of its protection. Using masks outdoors, repeated hand-washing, surface hygiene, avoiding overcrowded social and religions events and practising physical distancing to the extent possible will remain important for the foreseeable future.
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Many of these practices are traditional in India – particularly washing hands and feet when reentering homes and traditional forms of greeting – even though their practice has become less common in the rush towards modernity. Perhaps they can be reinvigorated. Equally, the sheer non-availability of water, poor sanitation infrastructure, overcrowded housing conditions and squalid environmental hygiene, which assail most of the urban poor, and religious zeal and rigid adherence to caste and community traditions surrounding socialising could neutralise other benefits such as masking.
The most important reason to avoid an over-commitment, both of emotion and resources, is that the promise of the vaccine may be used to deflect attention from structural factors that affect people’s and communities’ susceptibility to infections of all kinds, and from the continuing failure by both national and state governments to accord adequate priority to health.
Radhika Ramasubban and Stuart Blume are social scientists working on public health technologies. Radhika is based in India and has published widely in the area of public health policy, both historical and contemporary. Stuart is emeritus professor at the University of Amsterdam and author of the book Immunisation: How Vaccines Became Controversial.