May 16, 2021

Vaccine Supplies: The Elusive Second Dose

Tejal Kanitkar

IN the months of May and June, India will need to administer at least 125 million doses of COVID-19 vaccines as second doses alone. The upper limit of manufacturing capacity in the country is about 75 million doses per month. By most accounts, the actual production is less than this. For the month of May, so far only 41 million doses—or a little more than half—have been procured, or are available for procurement. It is clear , therefore, that India faces a severe shortage of vaccines even to cover second doses, and this shortage is likely to continue for the next few months. If vaccine supplies are not augmented, many risk missing their second dose.

In the face of continuing supply shortages, the government must urgently review its vaccination strategy, and plan vaccine rollout carefully for the next few months. The government must also change its new vaccine policy which is likely to further exacerbate the current crisis by creating a highly iniquitous regime of vaccine access.

As of April 30, about 152 million vaccine doses had been administered in India. Of these, 18 per cent were second doses. This implies that of the doses to be administered from  May 1st onwards, at least about 125 million doses had to be reserved as second doses, to be administered in the months of May and June. This constitutes about 8-9 weeks over which everyone who received a first dose (before April 30th) but had not yet received a second dose, would be eligible for one. The guidelines of the ministry of health and family welfare state that there should be a 4-6 week gap between two doses of Bharat Biotech’s Covaxin, and a 4-8 week gap between two doses of Serum Institute of India’s Covishield.

If we contrast this with the stated manufacturing capacity of the two major vaccine suppliers, SII and BBIL, it becomes immediately apparent that just the second dose requirement will stretch the existing capacity to supply the vaccines. The government of India submitted an affidavit to the supreme court on May 9, in response to the court’s suo moto writ petition in the matter of “Distribution of Essential Supplies and Services During the Pandemic”. According to this affidavit, SII has the capacity to manufacture 65 million doses per month and BBIL a capacity of 10 million doses per month.

Of the total doses administered by  April 30, 91 per cent of Covishield and nine per cent were of Covaxin. Assuming that first doses are divided in the same ratio, about 113 million doses of Covishield and 12 million doses of Covaxin will be needed in the months of May and June – just as second booster doses. This implies that about 87 per cent of total SII capacity and 60 per cent of BBIL capacity has to be reserved for second doses alone.

This government affidavit also states that the central government had procured 21 million doses for the first fortnight of May, and another 20 million doses were available for procurement by state governments and private hospitals in this month through “other than the government of India channels”. The latter refers to the direct procurement allowed to the state governments and private hospitals under the GoI’s “liberalised vaccine strategy”.

This adds to only 41 million doses for the month of May. Subtracting 41 from the required 125 mil-lion, 84 million second doses, some of which will be needed in the month of May itself (perhaps in the second fortnight), and the remaining in June, are yet to be procured. There is a very high risk therefore, of many in the 45+ age cohort missing their second doses. If some of the 41 million doses go to the 18-44 age cohorts, which has been made eligible from May 1 onwards, the shortfall would be even higher!

The first doses across states must be distributed by criteria that the public health experts consider as important for distributing vaccines in an equitable and effective manner. However, the administration of the second dose is contingent on the first dose having been administered. Therefore, in subsequent phases of vaccination, when the requirement of second doses increases, the allocation must take this into account. However, the current allocation strategy of the government of India does not seem to have given any thought to this.

There is a variation in the number of doses of each vaccine type administered in states. For example, in most of the northeastern states and in union territories, no Covaxin doses have been administered. In Kerala and Rajasthan only about five per cent of the total doses administered have been of Covaxin. On the other hand, Covaxin doses constitute 30 per cent of the total doses administered in Delhi.

The data submitted by the government of India to the supreme court shows that while there is a shortfall in the availability of Covishield doses in all states, the allocation of Covaxin doses is higher than that required in some states, while others face a shortfall. For example, Karnataka needs about 7.8 lakh doses of Covaxin just as second doses in the months of May and June. The allocation for Karnataka (through GoI and what is available through non-GoI channels) is 5.7 lakh doses for the month of May indicating an additional requirement of two lakh more doses at least, just to provide the required boosters. On the other hand, Bihar requires about 3.2 lakh doses of Covaxin as booster doses in the months of May and June. However, its allocation for May alone is 6.6 lakh doses.

If the government’s strategy is to prioritise first doses, then it must devise a plan accordingly, in discussion with states, and communicate this to the public clearly. Experts must be consulted on questions of efficacy, the maximum possible gap between the two doses, and other relevant issues, with a view to developing a clear vaccination strategy. The current state of affairs indicates that the government is simply reacting to events as they unfold without any plan or direction. There are reports from many states, of citizens running from one vaccination centre to the next in search of the elusive second dose.   

The current “liberalised and accelerated vaccine strategy” of the central government has also been clarified further in the affidavit submitted to the supreme court. GoI has stated that the quota of vaccines to be procured directly from the manufacturers by the states and private hospitals will also be in proportion to the respective state’s population. The state governments will not be able to place orders exceeding this quota which will most likely be determined monthly, as vaccine supplies become available. Further, the GoI has also stated that 50 per cent of the non-GoI quota will be earmarked for private hospitals. The distribution between the central government, state government, and private hospitals/agencies will therefore be 50:25:25. This is in keeping with what the vaccine manufacturers wanted, as they get a higher price for supply to private hospitals. 

Along with all the other problems that India’s vaccination programme is currently plagued with – a severe supply constraint, unequal distribution across states, differential pricing – this 50:25:25 for-mula is likely to depress vaccination rates further and exacerbate the inequity in vaccine access across the country. Private hospitals that can procure vaccines are concentrated in the cities. Large sections of the rural population along with a significant section of the urban working-class will de-pend on state governments for vaccines. Due to the central government’s refusal to pay for universal free vaccination, many state governments have announced free vaccination programs. By restricting vaccine supplies to state governments, and treating private hospitals, which are likely to cater to fewer people, on par with state governments, the new vaccine policy of the government of India is also perpetuating a blatantly iniquitous regime of vaccine access. 

To sum up, the current vaccine supply is highly inadequate to even meet the requirement of second doses in the next two months. There is therefore an urgent need to review the vaccination strategy and put in place a coherent plan for the next few months in discussion with state governments, so that people do not miss their second doses or are not made to run from pillar to post in search of one. In addition, the Central Government must roll back its current policy, which is highly inequitable and unjust, and likely to further exacerbate the current crisis of vaccine supply.