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This is the InFocus podcast from The Hindu. Good afternoon and welcome to the Hindus InFocus podcast, Emslie, the media host for today. Last week, Prime Minister Modi chaired an all party meet at which he said that experts believe the covid-19 vaccine will be ready in a few weeks. Eight vaccine candidates at different stages of preparedness in the country. On Wednesday, the Serum Institute of India and Bharat Biotech's requests for emergency use authorization of their vaccine candidates in India were put on hold pending more evidence.


The vaccine will have to reach thousands of health care workers, frontline workers and elderly persons with comorbidities who have been prioritized to get it. How prepared, though, is India for the vaccine rollout? What is emergency use authorization? And what does it mean for the vaccine as new as the covid-19 vaccine? Are people ready to take a vaccine or are there worries that may have to be combated? And what are the challenges astate healthcare system will face in what may be a vast program that lasts for months?


Talking to us about these issues is Dr. Rajiv Dasgupta, chairperson Center of Social Medicine and Community Health, Jawaharlal Nehru University.


Good afternoon, ductility Dasgupta, and welcome to the Hindus InFocus podcast. Hello.


Thank you, Doctor. There seems to be some hope with regards to the pandemic now with vaccines around the corner. The prime minister and orebody meet on Friday has said that a vaccine will be ready in the next few weeks and also indicated that India has the best capacity and expertise in vaccine distribution, given the country annually targets around fifty six million pregnant women and children as part of its universal immunization program.


Could you give us an idea about how this program could be harnessed for the way that 19 vaccination drives?


As you rightly said, India does have very deep strengths in the immunization program, in fact, among all the national health programs. This is one of the finest programs with strong supply side as well as demand side factors. In other words, India is capable of and very regularly immunizes very large numbers of children and pregnant women, as well as some other vaccine vaccinations in very specific areas such as the Japanese encephalitis. So overall, India's strength is both in program delivery as well as vaccine manufacturing.


And the current optimism and confidence essentially stems from that. Those are the strengths and that's what any government would really play on.


Dr., could you give us an idea about the people and the logistics involved in achieving this?


So this program, as you know, the routine immunization program, as we call it, it works through a very wide network of frontline health workers who are backed by a cascade of program managers that goes right up to the district, state and central levels. Vaccines, by the very nature required very strong, robust and timely logistic support and very critical to this is both vaccine movement moving it from the factories, from the production units to the storage units. The storage units are also at state levels, at regional levels, down to district and subdistrict levels, plus the fact that the coalition has to be maintained, which means right from the manufacturing point to the delivery point, refrigerated refrigeration specifications have to be met with.


So vaccine movement always gets priority. There are a number of vaccines that is in the program, including the eradication elimination program, such as polio and measles, rubella, which means that those campaigns have to be conducted on a regular basis. Plus there are catch up around. It would be familiar with the terminology such as the transition, the mission and the and the intensified mission introduced, which are fairly recent initiatives. And all these have gone on to strengthen both the program as well as the confidence in the program.


Dukkha, the 19 vaccination program, once it begins, will be unprecedented in scale, primarily in our country because of our population. And it's going to stretch the state's capacity in a way that not many things have. How ready to face this? And do we have the resources, the logistics in place? We just spoke about how we are going to harness what we learned from the universal immunization program. But how did we, in terms of other resources and facilities to be able to vaccinate?


There is an enormous effort that's going on in the background, whether it's in terms of the regulatory decisions to be made, the whole issue of numbers, the prioritization strategy, who would be announced first and in what sequence the the calculation of the computation of demand, how much vaccine is going to be required there. Now, these mechanisms exist from much before the immunization program, particularly around the polio and measles. Rubella initiatives have undergone a whole range of strengthening.


That is, there's a whole lot of digitalization that has happened in terms of tracking vaccine logistics, in terms of tracking storage spaces and so on and so forth. In other words, these strengths certainly exist on the ground, plus the fact that enormous background work is on even as we speak. And it will continue to work because as we just discussed, a greater degree of surveillance will be required once the actual vaccine usage. So the preparation is really on a giant scale.


It's about some of the issues that will really begin to crop up once licensing is done, once decision for use is made and one's expectations really rise.


What what are some of those issues that may crop up after? One issue, of course, is if I may, on a lighter note, expectation management. Yes. Who what what exactly is an ideal prioritization strategy? There are no foolproof answers to that. There are ethical issues woven around that. All countries are going through intense discussion processes. Each country would certainly like to maximize benefit for its entire population to the extent possible. As far as prioritization strategies go, there are arguments made on both sides in the sense that there are countries who feel that the the the the minorities, minorities, in the sense the the more marginalized groups who really actually need to be in front line work.


In other words, those kinds of work, which you cannot do from home and who would necessarily need to be in public spaces, who need to travel long distances for work, who who can be compensated, at least otherwise, and therefore would need to be at their workplaces should that be a priority? Other countries have argued that the elderly with comorbidities, they are a priority. And the one category on which there has been complete consensus is those who are at the frontline of health and health related care.


That's actually the most non-negotiable category. The point is, what exactly are governments going to promise and the extent to which those promises will be feasible and possible, given that there is intense demand globally in the vaccine market and and clearly much of the supplies that is going to be available has been, in a sense, provoked by the more affluent countries, a term which increasingly news call vaccine nationalism that will also be in play. This is in addition to managing side effects, managing very serious adverse events that go with any vaccination program, the actual efficacy, whether it will be at 50 percent efficacy, whether it were 90 percent efficacy, which means that even among those who will receive the vaccine, all will not be for the entire.


One hundred percent of those who received the vaccine will not be protected because that in itself is a function of the efficacy of the vaccine. Right.


Doctor, the prime minister said at your own party, meet that priority will be given to, as you pointed out, health care workers, frontline workers and the elderly with comorbidities. Do we have the mechanisms in place to be able to identify one of these categories, say the elderly across our country, across states and districts? Will we be able to do that? That in itself is one of the major challenges. One of the key mechanisms that's going to be used is using existing databases, such as either for identification, which means that any existing database that one uses would have certain inclusion, exclusion issues that go with it.


But the other more tricky problem is identifying those with comorbidities, and that that's where this whole digital health initiative is being pitched. But these systems can't really be put into foolproof action overnight. And that's why I say that expectation management is really going to be a very difficult thing for any government, whether it's at the central level, at the state level or at a relatively local level. Therefore, identification of the vulnerable, whatever the vulnerable, characterization, vulnerability, characterization maybe is going to be a very big challenge except for, of course, health workers.


But there's a catch there. Also, there's a there's an enormous amount of health workers who are in the private sector, many of which is not so well regulated or even completely outside the net. There's also this issue of and as we have seen very sadly, with some of the covid related deaths among health providers, that those who are on private contractual terms haven't received the benefits, that the government, those in government are in full government employee employment actually received.


So in other words, there are these fuzzy areas. There are what's known as wicked problems.


Which really needs to be solved both with empathy as well as as close to real time as possible, talking about the problems in other countries, the skewed nature of health infrastructure, some of our states perform better than others when it comes to health indicators. How how would this work in terms of vaccine distribution? And is there anything from the success and the failure of the universal immunisation program? Are there any lessons or takeaways from it that we can focus vaccinate?


The immunisation program, as it stands, is very centrally rooted in the government provided system. However, now we are having a situation where we are catering to a completely unprecedented number of beneficiaries, which is over and above the ongoing program because the ongoing program is not going to be shut down for any period because yes, I think that's cool, but are going to be born children.


Those children have to be protected. Women will be in their pregnancies. They have to be protected. Certain issues like Japanese encephalitis is seasonal. In other words, none of them you can't put a pause button to those ongoing activities. So whatever is going to be taken up is going to be over and above those. And that brings to the discussion the extent to which non-government providers will be reached out to how they will be rolled out, how will they be trained.


There's this whole question of data systems, of these data systems being able to talk to each other. If you are in the private, private overnight's organization that's providing service, it's not that these are insurmountable, but these are practical issues to consider. And finally, which is really going to be a gigantic effort, is tracking adverse events, because earlier I mean, not earlier in the routine program, there is a defined number of children and they're defined in geographic terms vis a vis the frontline health worker.


So she exactly knows how many villages she caters to or the urban areas she caters to, who the children are, who the households are, and those those factors and therefore the adverse events following immunization or what's called the fight that system. It's also a relatively decent system, but it's now reasonably well-established system. But here is a situation where with a whole new pool of those immunized across age groups, these efforts need to be checked and plus the fact that it's a new vaccine.


So all adverse effects that may follow, particularly the serious ones, need not necessarily be known or predictable. And therefore, a very high index of suspicion will need to be maintained. And it's not that the system is unaware of it. So the preparations are on to recruit a much wider network, in other words, to cast the net wider than the standard yafai system. But these are very new challenges. And all of this has to be have to be done over and above all other activities, both immunization as well as other health services.


Doctor, we were talking about frontline health workers who know exactly how many children they need to immunize these ASHA workers and other health care workers who are already overburdened by the pandemic. Are they going to face multiple challenges in the coming days? That goes without saying that they are going to face multiple challenges. One will one will really have to put a lot of faith into the systems that exist at state and district levels. The fact is that each state and as we have seen with the covid pandemic itself during its worst months, each state or district or municipal body have really put their best foot forward.


They have made all kinds of innovations or or really designed practical interventions within their own settings. And the the the total covid management experience in India is a tribute to that. And therefore, I believe states and districts will also rise to the occasion. But yes, it is a new vaccine. It is a new program, and it will come with its own challenges. But I do have a faith in the district and state systems.


Do we need to scale up human resources for this doctor? The only mechanism of scaling up human resources is, as I said, the existing immunization program is, for all practical purposes, a heavily government state dependent program, including including advocacy even. It's monitoring, but here is a situation where the governments are reaching out to the private sector and I'm sure this this this collaboration will work out. But yes, this is a new demand on human resources, both in terms of numbers as well as capabilities.


Doctor, there's been a lot of talk about whether we are prepared in terms of political logistics. How effective has the National Coalition management system and the Electronic Vaccine Intelligence Network, which track and manage vaccine stocks, then could they take on this additional burden of tracking the vaccine is?


The fact is that over the last decade or so, both these two systems have been refined a lot. The additional challenge is the space requirement, plus the temperature requirements, depending on which vaccine is going to be inducted into each area. But I repeat, there are enough that there is enough preparation on this. And I don't see this these aspects getting overwhelmed. Right.


Doctor, what could be the challenges that we might face and last mile delivery? We all know by now that the vaccine is probably going to be two doses. How effective is the follow up system? For instance, if we are immunizing an elderly person with abilities who has to come in on a particular day and get his immunization and then possibly come in a couple of weeks later for the second dose? How effective will be will we be in challenge in tackling that?


I agree. It's this last mile downstream issues that's really going to test the system, whether it's the public system or the private system or whatever form of collaboration is put in. It's both in terms of adverse events. It's also in terms of the efficacy, what proportion is going to be protected and for how long. What if there are additional charges of infections? These are these are as yet really unknown. But the bigger another big thing that governments, all governments, state governments and the central government will have to grapple with is competing demands from multiple vulnerabilities.


The fact is, as the covid pandemic has shown, that vulnerabilities are very complex in their nature, that each vulnerable group has a legitimate demand to the vaccine as as well as to treatments and rehabilitation of of various kinds. And therefore, at one level, one could perhaps foresee a political minefield of sorts, notwithstanding the fact that a whole lot of technical preparation is underway and some of those problems may prove to be less wicked than managing political demands and some very legitimate expectations.


Are there any lessons we can take from any of our other programs, for instance, in managing tuberculosis or in managing polio? Any lessons that we could draw in terms of following up with patients to track them and to see how well they're doing that we could possibly use in this program all these programs that you named with the National AIDS Control Program, the tuberculosis control program, polio and so on, have matured over time. The fact is that programs are built brick by brick.


And India has done that admirably. Well, for many of these, we are into TB elimination. We are into malaria elimination. We are in the business of elimination. But the key factor has been time. Let's not forget that all deadlines also all all milestones have got pushed by years, if not decades. And that's not to be taken negatively. But the fact that learning does take time, problems do built brick by brick. The challenge in this case is that no one is really prepared to wait, whether it's at the across the political spectrum or across the community spectrum.


Everyone simply wants to get back to life, just as you and I ought to do. And and that really is the challenge here, how fast we can learn things and how fast we are able to to to to modify ongoing things to the best of to the best that one can make of the evolving situation. And he gets DOCA that need to be addressed before the vaccination program is rolled out.


Any specific gaps in the big challenge, the big challenge, and that's that's been manifest with these words. Almost a year of the pandemic now is communication. There is communication experience. India has not been very encouraging. Unfortunately, there hasn't been emphasis. There hasn't been research inputs in. To prevent the behaviors that hasn't really been research and other kinds of inputs and innovations into communication strategies, that's where a lot needs to be done even as the pandemic will grow.


Just the availability of vaccines doesn't mean that the pandemic will be switched off overnight. So communication strategies particularly and we know this from earlier vaccine campaigns is extremely crucial. It will need refinement of a different degree now. It will need to be proactive and a lot of make or break situations. Right. On communication strategies. And that, I think, is something that that ought to get a lot more consideration than it's getting at present. Could lack of effective communication lead to vaccine hesitancy?


Vaccine hesitancy is an important issue all across the world, more so in a heterogeneous, multicultural country such as India. Even with the best of communication, there will be vaccine hesitancy. And here we are with a new vaccine. So it's going to be a very strange mix of vaccine optimism and vaccine skepticism. And already you can see glimpses of it in the media reports, even from very prominent personalities. You would have various political, religious and cultural positions on this.


And therefore, communication outreach really has to be absolutely decentralized. It will it will need a different kind of political and cultural imagination. And it should receive the same background preparatory work that has been there on vaccine logistics, that's been there on the laboratory aspects of it. I really don't see an effort of that scale in these elements and it could prove costly. Doctor, if people hesitate to take the vaccine, up until now, all of the immunization programs have been run on the basis of the fact that parents want their children to be vaccinated and come forward to get them vaccinate.


There is no legal compulsion to do so. Let's say with that change with this, I am not aware of any legal of the legal route. Now, the other side of the coin of a legal element is that it would really the government of the program should really be in a position to provide 100 percent coverage with this. Let's also remember that the seasonal influenza vaccines or the experience with the seasonal influenza vaccines in some of the advanced economies, the fact is that it doesn't protect against all strains.


The fact is that the strains shift across the years. It protects for a certain number of months. It does come with some benefits. But here the popular expectation around vaccine is that the pandemic would probably disappear with a magical wand. But in this case, the vaccine, at least as it seems now, given the results now, is not going to be the only tool that is going to end the pandemic or that is going to get things back to normal as we expect.


It would be a significant tool. It would certainly be critical in providing protection to the most vulnerable, whether it's health workers, whether it's other frontline workers, those who have the maximum exposure and the privatization strategy, what to take and take that into account in a much more wider sense as as some countries, at least in the discussions are going through. But the vaccine is not going to be the only magic bullet. So we have to continue to make sure that we go with all the precautions that we already are following.


Absolutely. The vaccine is going to be another important tool in the whole spectrum of pandemic control activities, but it's not going to be the only one. And we don't even know the full extent of its efficacy and how soon we'll be able to cover what proportion of the population. A lot of it is still at the drawing board stage, but there is always going to be that difference between the map and the territory.


That's right. Doctor, before we sign off, if you going back to our previous podcast, when we discussed how the pandemic and controlling it could have impacted other routine health care issues, could you give me a quick glimpse about whether routine immunizations for children and pregnant women have been affected because of the lockdown to various parts of the country? There are two issues to two aspects to it. One, of course, routine immunization has been affected. And that's not the.


India, that is globally, so all in all regions, the WTO has taken stock with its member states, all countries also have put in corrective measures, including India. There is a catch up strategy and therefore this additional strain is going to be visible. Now, also, the only silver lining perhaps, is that a lot has been learned since routine immunization was equally affected by very frequent rounds of polio nearly 20 years back to the late 90s and the early 2000s.


And it's only after 2002 that when a whole lot of corrective measures were put in that you actually witness quite a dramatic rise in many states who were considered laggards at that time, actually making spectacular gains and correction in coverage. So that is both the risk as well as the evidence that the country has been able to handle that. And therefore, we can only expect that it would not now adversely impact to that extent. But yes, there is certainly going to be an additional demand and strain on the ongoing activities if it took some of the states some years to catch up.


Could that also mean that with this additional vaccine coming in, there could be a time lag of some years before full coverage was achieved? Even if even if adequate numbers are available, it would still require a number of months for full coverage? No, one second. This is not a situation where one dose or even to those schedules is going to accord lifelong immunity. So will it be just like influenza vaccines? Do you need to do it seasonal every year?


Those are some of the unknown elements we will see and we will learn as we go along. Thank you so much for speaking to me today.


Thank you for the invitation. InFocus will be back soon with analysis of the biggest news issues in the meantime, you can find our podcast on Spotify, Apple podcasts, Twitter and other platforms. Just Search for InFocus by The Hindu. We'll see you soon.