Forced Consent and no Transparency Can Create a Backlash Against Vaccines
THE drug regulator's hurried emergency clearance to Bharat Bio-tech's Covaxin in a clinical trial mode has been followed by the government making it integral to its mass vaccination drive. It has bought 1.1 crore doses of Serum Institute-Oxford-AstraZeneca vaccine and another 55 lakh from Bharat Biotech. According to the government, neither states nor individuals will have a choice with regards to vaccines. Besides, those vaccinated with Covaxin, are being "asked" to sign a consent form that they have "voluntarily" agreed to participate in a Covaxin clinical trial.
There is a push back on the ground already. The numbers on the second day of the vaccine drive have dropped. Sections, such as the Resident Doctors Association in certain hospitals, have expressed their unhappiness over this mode of "voluntary" participation in a clinical trial. It has also added to vaccine anxiety and possible adverse effects from vaccines. Given the scale of a mass vaccination campaign, some adverse effects are to be expected. Some effects are normal in any vaccination, such as mild fever, inflammation at the site of the injection, etc., and some could simply be coincidences. From the 3.81 lakh health care workers who have been immunised (January 19: India Today), only 580 people have developed adverse event with only seven needing hospitalisation, and two have died. The post mortem results of one of the deaths show that he had pneumonia at the time of vaccination. According to vaccine guidelines, in his condition, he should not have been vaccinated at all.
Unfortunately, a high-decibel campaign for taking credit can result in overlooking basic safety norms required for mass vaccination. Again, we have a top-down messiah Modi type of government that led to the lockdown and untold miseries for the people without the benefit of containing the Covid-19 pandemic. This has been the problem with Modi government's top-down, a purely administrative model of handling every problem as if it is a law-and-order issue. Pandemic control is a public health issue and requires involving all tiers of governance – from the central to the state, and even the local governments. It also needs to treat the people whose health it is trying to protect, not as subjects to be bullied into submission but as partners in this vaccination drive.
Public health and immunologists had raised serious questions re-garding the Central Drugs Standard Control Organisation (CDSCO) emergency use clearance to the ICMR-NIV-Bharat Biotech's vaccine, along with Serum Institute-Oxford-AstraZeneca's vaccine. Their criticism is that the drug regulator, CDSCO, violated its own guidelines under pressure from the BJP government to clear a "nationalist" vaccine—Bharat Biotech's Covaxin—along with clearing Serum Institute-Oxford AstraZeneca's Covidshield. The fig leaf for this clearance was that its emergency use was to be in a "clinical trial mode". The drug regulator gave no details about clinical trial means, and no further guideline on the way it was to be implemented. Neither did its parent health ministry elaborate on how they proposed to carry out mass vaccination in a clinical trial mode.
The government officials including the health minister, Harsha Vardhan has now clarified that in their view both vaccines have "equal efficacy" and will be used interchangeably. How they have determined the efficacy of Covaxin without Phase 3 trial data is unfathomable. The government has also made clear that approxi-mately 3-3.5 crore frontline health workers and 27-30 crore citizens in a high-risk category (above 50 years or due to pre-existing health conditions) being vaccinated receiving the vaccine will be given no choice. Neither will the state governments. Take it or leave it, are the only two choices if this can be called a choice.
Serum Institute-Oxford-AstraZeneca has submitted Phase 1 and 2 trial data from India and Phase 3 trial data from other countries. Under current pandemic conditions, most country regulators have deemed this as sufficient for emergency use clearance. ICMR and National Institute of Virology, Pune had developed the basic inactivated virus for Covaxin, and given it to Bharat Biotech for further vaccine development. Bharat Biotech has conducted Phase 1 and 2 trials proving that it is safe and produces strong antibody reactions in the body. The Phase 3 trials are in an advanced stage and the preliminary efficacy data, the purpose of Phase 3 trials, are currently awaited.
Why did the drug regulator not wait the few extra weeks for the preliminary data of the Phase 3 trials to be available? Such hasty and shoddy steps damage the credibility of India's science institutions. It will sully its image already dented by cow-science, Vedic mathematics, plastic surgeries in and Indian flying chariots in ancient times, even further. Further, the anti-vaccination conspiracy theorists (anti-vaxxers), hitherto an exclusive preserve of the US, have now gained some followers in different parts of the world including India. Any attempt to force the people into taking a particular vaccine could result in increasing existing vaccine anxiety, harming the vaccination campaign in the same way that the forced sterilisation campaign did during the 1975 emergency.
What harm would have been there to wait the few weeks for Phase 3 data, especially as Indian figures for new Covid-19 cases are currently low? Secondly, clinical trials are conducted with volunteers. The current vaccination drive makes it mandatory for frontline health workers. Either take the vaccine we give you and sign the consent form as voluntarily participating in this clinical trial; or get no vaccine. This is not the informed consent that clinical trials call for, but coercing consent. Third, on what basis is the government spokespersons claiming equal efficacy for both vaccines? Phase 3 trials are primarily for finding out the efficacy of a vaccine, which Bharat Biotech is yet to submit.
Again, immunologists are not questioning that the vaccine in all likelihood will prove to have the desired efficacy—greater than 50 per cent— as set out by almost all regulators in the world. Bharat Biotech is also using an inactivated whole virus. This is one of the oldest vaccine technologies available and therefore very well-proven, unlike vaccine technologies such as the mRNA vaccines from Pfizer-BioNTech and Moderna. Covaxin is similar to Sinovac and Sinopharm vaccines that have been successfully tried and accepted by many regulators based on Phase 3 clinical trial data.
There have been attempts by western news agencies to muddy the waters regarding the Chinese and Russian vaccines. This is very much a part of vaccine nationalism of the news agencies including the desire to advance the case of their own pharma companies. Many regulators—regulators from Turkey, United Arab Emirates, Indonesia, Malayasia—based on trials in their countries and others have cleared the Chinese vaccines and started their mass vaccination drive.
There is confusion about what constitutes a good vaccine finding in terms of numbers. The key finding of the Sinovac and Sinopharm trials is that these vaccines see virtually no deaths and a drop in serious cases by a whopping 78 per cent. The 50.4 per cent that has been widely reported for the Sinovac vaccine is for one mild symptom and RT-PCRA confirmation of the infection. Each of the figures is important in their own right, but any vaccine that does not cuts down deaths almost 100 per cent and does not need us to see a doctor is welcome in pandemic times.
The hurried emergency use clearance with the only Phase 1 and 2 data for Covaxin, raises the question of why not similar clearance for other vaccines? According to WHO's landscape of Covid-19 vaccines, there are about 20 odd vaccines currently in Phase 3 trials, including Zydus Cadilla, another Indian company. The Russian Gamaleya vaccine has tied up with Dr Reddy's Lab and also has preliminary efficacy data from its Phase1 and 2 trials in India and Phase 3 trails from elsewhere. Are all of them to be cleared on the same basis? Or such clearance reserved only for our "indigenous" vaccine? Or is it to declare that we have scientific prowess equal to other countries like the US, Russia, China and the UK?
The government would do well to ponder on Sanjay Gandhi's sterilisation drive and damage it did to India's family planning programme. Before the 1975 emergency, the sterilisation rates of men and women were roughly equal. Today 93 per cent of sterilisation is of women and only seven per cent men. The shift away from men as a backlash of the forced sterilisation during emergency never got rebalanced. A forced vaccination campaign can do lasting damage to vaccines, the critical component of any public health policy.