States Confront Question Of Who Gets The Vaccine Shot First
India’s Covid-19 vaccination drive has been able to cover just over a tenth of its target population between January and May. With the country facing a severe shortage of doses, many states are now identifying priority groups that need to be inoculated first.
And on top of their lists are street vendors, transport workers, bank staff, journalists, judicial workers, teachers and persons with disabilities, and lactating mothers, among others.
What is driving the prioritisation strategy? Age, comorbidities, higher risk of infection due to professional or economic concerns?
Till April, the country prioritised age and comorbidities. Health care workers, frontline workers and those above 60 years of age were the first target groups, based on the experience of the first wave that affected senior citizens the most. The age eligibility was then lowered to 45 years on the same principle.
Risk should be the guiding principle, epidemiologists and public health experts told BloombergQuint. And priority should be given to those facing the highest risk of death—the older population, those with comorbidities, and healthcare workers, they said.
Since May, however, as a brutal second-wave attacked even younger people, the central government threw open vaccinations for all adults and put the onus of procuring doses and inoculating the 18-44 age group on states.
With only 15% of the older cohort fully vaccinated yet, this was not a prudent strategy, say some experts. Opening up vaccinations for the younger cohort before completely immunising the more vulnerable population is at odds with epidemiological evidence.
A paper by Brian Wahl of the Johns Hopkins Bloomberg School of Public Health last year demonstrated that in case of limited supply, the best strategy for India to reduce deaths would be to fully vaccinate the older people first. Even the World Health Organization recommends it.
"You don't have to be a genius to figure that out,” said Jayaprakash Muliyil, chairperson of Scientific Advisory Committee, National Institute of Epidemiology. “Sure, when enough vaccines became available you should’ve expanded it to younger people."
Yet, the second wave may have forced the government's hand. Though, no explanation is forthcoming as to why it chose to expand the vaccine program without assured vaccine supply. Now that the drive has been widened, the focus should be on ensuring all groups get at least one shot, Muliyil said.
But age can’t be the sole determining factor, said Rajib Dasgupta, chairperson of the Centre of Social Medicine and Community Health at Jawaharlal Nehru University. States also need to consider the wider array of risks factors and expand their scope of what they consider essential workers, he said.
When Work-From-Home Is Not An Option
About 92% of India’s labour force works in the informal sector. So, while many companies and industry bodies are taking on the responsibility of inoculating their employees, states must focus on those who have no one to fall back on.
"I think this group covers a lot of individuals. This includes people who are selling us vegetables, those who are delivering our food, those who are driving buses and cabs and autos," Wahl said. "These are the people who are keeping society running even in the midst of a lockdown."
In their vaccine priority lists, states like Chhattisgarh, Madhya Pradesh, Tamil Nadu, Jharkhand, Goa, Punjab, Karnataka and West Bengal have focused on those facing occupational risk, albeit with some differences.
Jammu & Kashmir has included shikhara drivers and horticulture workers. Goa and Kerala have listed seafarers. Karnataka has put film industry workers on its priority list.
Common to many states' lists are electricity and water department workers, railways staff, construction workers, court staff, teachers, cab and auto drivers, security and housekeeping staff, street vendors, grocery shopkeepers, fuel pump employees, salon staff and Covid-relief volunteers.
According to Antony Kollannur, a former director at the State Health Resource Centre in Chhattisgarh, states should tap into their massive network of community health workers to identify such groups. “ASHA, AWW, and ANM jointly can do this enumeration without any discrimination in the inclusion or exclusion.”
Next Step: Curb The Spread
Once the top priority groups are covered, the next phase should be for states to identify and prioritise certain districts over others to reduce mortality rates and severe disease outcomes.
India’s former health secretary K. Sujatha Rao suggests that states must:
- Conduct seroprevalence studies to see the level of antibodies in different regions.
- Analyse the socio-economic characteristics of individuals in these areas.
- Recognise the at-risk population from these groups.
- Prioritise regions that have more share of at-risk population.
States must also focus on areas of higher population density first to limit the case count and deaths, said K Srinath Reddy of the Public Health Foundation of India. “Areas of high urban density tend to have more vaccination centres also so they must be recognised as a strategic priority.”
However, Kollannur cautioned that this “mosaic pattern” of geographic targeting should be undertaken only after the priority groups are covered.
Challenge Of Fair Access
Vaccine equity, not equality, is of paramount importance to ensure that everyone has fair access to getting a shot, Muliyil said.
States are likely to run into that question while prioritising vaccines. According to the WHO, the burden of the pandemic has been the worst on certain disadvantaged demographics that cut across social and economic lines. It has called on countries to recognise these groups and make sure they get an equal chance at getting the vaccine shot.
“Certain disadvantaged groups may genuinely have a more difficult time obtaining vaccines, either because of lack of knowledge, less access to facilities, or some such hurdle,” said Anup Malani, a health economist and law professor with the University of Chicago Law School. “We should equalise access as long as it doesn’t slow down vaccinations a lot.”
States, for instance, could reckon that perhaps the poorest need protection first as they don’t have a financial safety net. That is what Chhattisgarh has done as it is diverting a third of the vaccine quota to prioritise those below the poverty line.
Multiple states have also identified jail inmates and inmates of correctional homes as priority groups that may be vulnerable due to the overcrowding in India’s prisons. And persons with disabilities find a mention in some priority lists as they may find conventional means of booking and getting a shot inaccessible. West Bengal and Assam have also identified transgenders as a socially disadvantaged group in need of a shot first.
But prioritisation of disadvantaged groups, especially amid a shortage, can be a double-edged sword, Malani said, "Adding in certain subpopulations for political reasons—as opposed to genuine lack of access to vaccination on an equal basis—risks politicising and slowing down the vaccination process."
Wahl also cautioned states against getting overly specific with vaccine priority groups.
"The more targeted you get with how you want to roll out your vaccine, the more complicated it will be," he said. "There's a balance to strike between the public health perspective and the practical perspective. It is difficult. But it is something states will have to grapple with."