Overcoming hesitancy key to vaccine success
Jha himself took the vaccine on January 16, the day the rollout began, along with his mother, a guard in the hospital. But many others have demurred, including his uncle, a lab technician in RML. The reasons for the low turnout are varied, from genuine health issues to lack of trust in Bharat Biotech’s Covaxin, whose Phase III trials are still under way, to anxiety about adverse reactions. Glitches in the CoWIN app, the tech platform supporting the vaccination rollout, have also hampered efforts. The net result is a lacklustre response — by Thursday evening, despite Jha’s best efforts, the numbers did not cross 31.
RML’s experience of vaccination is not an exception. A week into the launch of the much-awaited vaccination drive against Covid-19 in India, the rollout is progressing far slower than anticipated. Though the country crossed the 1 million vaccination mark by Friday, a milestone the Union Health Ministry was eager to underline, that does not conceal the fact that the targets the country set for itself were more ambitious. On the inaugural day, for instance, 3 lakh healthcare workers were expected to get their first shot, but the final number was off by a third. If India is to inoculate 30 crore people, or 300 million, by July, as the government had initially announced, that would translate into 3.3 million shots a day on average, considering the vaccines require two doses.
Getting Cold Feet
Conversations with healthcare workers, government officials and public health experts reveal a host of reasons for the low numbers, starting with vaccine hesitancy. That’s a situation the World Health Organization describes as a delay in the acceptance of or refusal of vaccines despite the availability of vaccine services, which different factors influence.
In the case of Covid vaccination, the fact that one of the vaccines being used — Covaxin — has not yet cleared Phase III trials is preying on the minds of at least some of the intended recipients, particularly doctors. In RML Hospital, where only Covaxin is available, 1,000 resident doctors shot off a letter to the Union health ministry, expressing their reservations about Covaxin. “The hallmark of authenticity is data. Covishield data is superior hence it is a safer option now. Those who are saying that nothing has happened to them after taking Covaxin are showing casual bravado, not informed choice,” says Dr Nirmalya Mohapatra, vice-president of RML’s Resident Doctors Association and a signatory to the letter.
The reservations about Covaxin, as compared with Serum Institute’s Covishield, are hardly confined to RML. In Karnataka, which otherwise has been reporting one of the highest daily vaccination numbers, the state’s resident doctors association has lodged a protest with the government about the lack of option to take Covishield in some hospitals. “The consent form for Covaxin says we are being enrolled in Phase 3 trial — that’s wrong. The vaccine should have passed Phase 3 trial. They cannot run a trial on us, no?” says Dr Dayanand Sagar, president of the Karnataka Association of Resident Doctors. He says doctors feel they are being treated like guinea pigs. “With the peak of the pandemic now over, we could have waited for another month for the trial to be complete. When there are other vaccines with proven efficacy, why push us to take this?”
Indeed, the fact that Covid cases in India are well below the peaks in August and September, when daily cases of close to a lakh were being reported, is influencing the decision to delay getting the vaccine. “The old fear of Covid has receded. There is also a certain degree of anxiety about what will happen if we take the vaccine as there has been some amount of fake news and a general lack of clarity,” says Jibin TC, state president of United Nurses Association in Maharashtra.
Globally, vaccine hesitation is an issue immunisation drives have to grapple with, and Covid vaccination is no exception. “People take a vaccine depending on their threat perception, their belief in the need for urgency and their belief in the vaccine efficacy,” says K Srinath Reddy, president, Public Health Foundation of India. A sharp fall in cases and deaths, for instance, makes people feel there is no urgency. But at present, since vaccination is confined to healthcare workers, Dr Reddy says the hesitancy is more likely to do with doubts about the efficacy of one of the vaccines.
Not everyone is surprised by the slow start to the rollout. In a nationwide survey of 1,400 healthcare workers in December, conducted by Dr Abdul Ghafur — a consultant in infectious diseases with Apollo Hospitals, Chennai — in his personal capacity, the majority preferred to delay taking the jab or to decide later. “Only 45% of healthcare workers, majority of them doctors, said they were willing to take the vaccine as soon as it was available,” says Ghafur. Those who were hesitant were concerned about the safety and efficacy of vaccines — this was independent of the concerns around Covaxin, since the survey was conducted in December. But he adds that the hesitancy also appeared to be a temporary phenomenon. “Those surveyed said they would consider it after three-six months. Only 8% said they would not take it at all.” In Bengaluru, Dr H Sudarshan Ballal, chairman of Manipal Hospitals, was also told by people that they did not want to be the first in line. “Right now, there has to be confidence-building through mass awareness campaigns,” says Ballal, who took the vaccine on the inaugural day.
Need the Needle
Aware of the less-than-optimal response in the first week of the rollout, the government has launched an awareness campaign to assuage concerns and improve uptake. As part of this, Prime Minister Narendra Modi held a video conference with healthcare workers in his constituency, Varanasi, on Friday afternoon, asking them about their experience of getting immunised, in a bid to dispel fears.
Measures to broaden the outreach should have been done a fortnight ago, says Dr Shahid Jameel, virologist and director of the Trivedi School of Biosciences at Ashoka University. “When you are transparent, there is trust in the system; when you are not, people start thinking about all sorts of possibilities — that we are being used as guinea pigs. The government should have been transparent from Day 1 when the approvals were made.”
The health ministry has also made changes to the CoWIN app to allow the entry of the names of beneficiaries other than those registered at a session site for a particular day. “Earlier, if there were 100 people to be vaccinated and only 80 turned up, there was no way to add the extra 20. Now, that flexibility has been made,” says Rathan U Kelkar, Kerala’s mission director for the National Health Mission. Kelkar is not perturbed by the pace of the vaccination. “At this point, as advised by the Centre, we have to ensure that people are taken care of after the vaccination — that management is the priority for us. Since this is a new vaccine, it’s always better to go a little slow and ensure that there is confidence-building among everybody.”
Jameel, too, believes the hesitancy is a temporary bump and concerns will dissipate in the days ahead: “We started from less than 50% turnout to more than 70% now.” In Delhi, for instance, Sir Ganga Ram Hospital, with 100% turnout at its sessions, is a stark contrast to RML. “Since CoWIN opened for on-the-spot registration, we are seeing a huge interest among our doctors and staff. Many of our senior consultants had to go back as the slots got filled fast,” says Dr Shalini Chawla, Covid nodal officer at Sir Ganga Ram Hospital, where Covishield is being given.
Other countries, too, have grappled with a slow rollout in the beginning, like the US, which aimed to vaccinate 20 million by the end of 2020 but had to make do with 6 million instead. Last week, around 939,973 doses a day were administered in the US, according to Bloomberg. “The numbers in India are not as high as we would have liked them to be — but even with testing, we got off to a really slow start. Also, all the countries got off to a slow start. In fact, the top 20 countries have much better resources. That way, we are punching above our weight,” says Oommen C Kurian head of the health initiative at Observer Research Foundation.
On Saturday morning, the health ministry announced that India had vaccinated 3.47 lakh beneficiaries in the last 24 hours, the highest so far.
One option to improve the numbers of those getting vaccinated, Ghafur suggests, would be to open up the drive beyond healthcare workers immediately. “We should bring forward the next group of 2 crore frontline workers. This is the perfect time to change strategy. That way, those who are hesitant will also shed their hesitancy,” he says.
The bigger challenge to tackle hesitancy, though, might well be when the vaccine drive is opened to those beyond frontline workers. “All these months, we were saying, when will we see a vaccine?” says Dr SC Bharija, senior dermatologist at Sir Ganga Ram, who turned up to take the shot on Thursday, after an unsuccessful attempt on Tuesday when he was too late. “Now that we have it and we know that there is no line of treatment available, no one should say no.”