Public Health

Waning Protection from Covid in the Wake of Low Takers for the Booster Dose

Till covid struck, a one -time vaccination or a pre-defined number of doses of vaccinations usually meant a full-stop to the disease. Covid has ensured that even vaccinations are not for ever and require citizens to resort to regular jabs to ensure immunity.

On June 11, 2022 there was a single-day rise of 8329 fresh COVID-19 cases was recorded in the country, pushing India’s infection tally to 4,32,13,435, while the count of active cases jumped to 40,370. The active covid cases showed an increase of 4103 cases in just one day. According to the MOHFW, the daily positivity rate on the same day was 2.41 per cent and the weekly positivity rate at 1.75 per cent. [1] At the time of publishing this article on 25th of June 2022, the daily positivity rate had gone up to 3.94 per cent and the weekly positivity rate to 2.90 per cent. [2] Vaccinations however continue to make progress with the MOHFW reporting that India’s cumulative vaccination coverage has crossed 196 crores as on 25th of June 2022.

These statistics of increasing covid cases worrying as they are, are also highly under-reported simply because of very low testing in laboratories. It is often difficult to distinguish between covid and the flu resulting in most people not bothering to test themselves. Those who do may just end up taking the home test, the results of which also they may not upload on the Cowin Site. Most people have taken it in their stride although many of them have reported that a bout of Covid has lingering common after-effects in the form of fatigue, cough, and pain in the limbs ranging from weeks to months. Some others have complained of far more serious after-effects and those are now being described as suffering from ‘long covid’

The surge of cases in India as also in other parts of the world is being identified as caused by the new Omicron sub variants BA.4 and BA.5 which spread faster than other circulating variants — mostly BA.2, which caused a surge in cases at the beginning of the year.  As per new research published in the New England Journal of Medicine, “The levels of neutralizing antibodies that a previous infection or vaccinations elicit are several times lower against the BA.4 and BA.5 subvariants compared with the original coronavirus.” [3] This suggests that these variants will allow them to escape pre-existing immunity from vaccination and infection. Further even if one was infected with Delta, that does not mean he or she is safe. Immunity whether by infection or vaccination wanes over time and needs to be bolstered. Therefore an overall vaccination number does not indicate whether the population is adequately covered or not.

Based on projections of population by Census 2011, there are an estimated 138 million people above 60 years of age, which means that there are still around 12.2 million people in the age cohort yet to receive a single shot. This means that there is sizeable elderly population which is yet to take their first dose.[4]

Further as reported on 10th of June 2022, 95.3 million people are yet to take their Second dose of the Vaccine. This includes 21 million in 12-18 years age group and 74.3 million adults. What is worrisome is that 78.1% of those who are eligible for a 3rd dose or better understood as booster dose or precautionary dose have failed to take it implying that the immunity coverage for a large section of population is waning. [5]

The government has recently arrived at an agreement with the two private producers of vaccine that is Bharat Biotech and Serum Institute of India to push down the vaccine price to only Rs 225 per dose. The government took on the responsibility of being the sole buyer of vaccines for empanelled hospitals which are affiliated to CGHS and PMJAY. In these hospitals it is supplying the same at a price of Rs 150 while these empanelled hospitals will be able to recover a maximum of Rs 250 per dose from the patient, leaving Rs 100 for them as a fee for storage, disposables, and manpower. For the private sector, the procurement price of the vaccine was a fixed Rs 225 but were allowed to charge a maximum of Rs 150 as service charge. Along with service taxation, a single dose at a private medical centre would cost you Rs 386-390. [6]

What it suggests is that the government would continue to provide free vaccinations at all its centres for the 1st and 2nd dose, there would be no free vaccination for the booster dose for adults in the age-group of 18-59 years. As per our knowledge, some states like Haryana and Delhi are providing free vaccination to all eligible population between the ages of 18-59 for the booster dose.  This practically means that for the most part, the private health sector has been handled the complete responsibility of henceforth protecting the country through administration of the booster doses.

Given the backdrop of a rising caseload and an increasing section of 80% population unprotected, would it lead to another public health nightmare. A further question that begs to be answered, is it the unwillingness of the private sector to work at considerably reduced margins or it simply a question of large-scale complacency that is responsible for the low uptake of booster doses.

Of the total vaccinations happening in all the states, except for Ladakh, there was hardly any state which had achieved a coverage of more than 4% for booster as a percentage of total vaccinations. This includes states of Delhi and Haryana which allow for free vaccinations at government establishments. This implies a strong element of complacency among the population. A conversation with a medical practitioner went like this, “People are just unconcerned and plain irresponsible.” There is also a certain section which feels that vaccinations have no role in protecting people against covid.  The low number of hospitalizations seemed to have lulled the public into a general complacency even for wearing of masks. Only those who must travel abroad or have some medical procedures to be taken are probably the ones who are more serious about it. At best, those who have some underlying serious medical issues or have a greater sense of self- preservation instinct seem more likely to take it. What people seem to miss out is that vaccinations while does not prevent people from contracting covid, definitely reduces the severity of it including preventing of hospitalizations. As a leading medical professional puts it, “I don’t think there should be any argument or debate on the efficacy of the vaccines. When it comes to the booster, everyone should take it.”[7]

As we look at the data, as coverage of the population increases, the daily vaccination slopes booster doses should have been a rising one instead of the tapering one that we see right now given that more people have become eligible for the booster dose. Taking an average of the last 30 days as on 11th of June 2022, the breakup for the vaccinations carried out was 16% for the 1st dose, 64% for the 2nd and only 20% for the precautionary/booster. Rudimentary check of the Cowin site for your district would show that only a handful of medical centres would be showing options for scheduling for booster doses. Within that also there would be very limited slots. This suggests that medical establishments within the district are simply not opting to schedule vaccinations and rely mostly on walk-in registrations for the same.  Some hospitals may also not be buying stock. One also needs at least 10 persons before a vial of vaccine is opened otherwise it leads to a loss. Obviously, wastage of even a single dose cannot be tolerated given that there is a dead loss of Rs 225 per dose. The service charge may not be enough to compensate for the loss due to wastage.

Whether it is complacency, or it is the lack of financial incentive for private healthcare institutions, the fact remains is that if we leave a high percentage of population unprotected, we may be inviting another deluge on our fragile health systems.  The government needs to step up messaging and encourage people to go in for vaccinations including for the booster dose. If demand picks up, then volumes will ensure that the private sector may do its bit in increasing coverage for vaccination. This is a delicate pricing game where you need at least that volume to cover the fixed costs plus some incentive. It is high time that the Government takes immediate stock of the situation and carry out a massive health communication campaign for vaccinations. It may also need to send in a delicately worded advisory to the private sector to up its game in vaccinating people.









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