First in line for vaccine should be those over 65, not frontline workers

The govt must retain, in this last lap, a focus on evidence-based policy making, rather than attempting to appease special interest constituencies of one sort or another

It might appear that the worst of the pandemic is over as far as India is concerned. The number of recorded cases in the country crossed 10 million in the past few days, but the growth rate in cases has never returned to the high that it reached in September. In spite of another peak in November, following the festive season, the broad trend for new infections has been downwards.

Meanwhile, by all accounts, we are at most a few weeks out from the Indian regulators permitting emergency use of one or more vaccines. The early front-runner is, of course, the Oxford University/AstraZeneca vaccine, which is licensed in India to the Pune-based Serum Institute of India. But there are others that might also get approval in the next few weeks, including the Pfizer/BioNTech vaccine, which is already in rapid deployment across the United Kingdom and United States, and perhaps the Russian Sputnik-V vaccine, more than 300,000 shots of which have already been delivered in its home country. These decisions will be based, of course, on the Phase-III trial data for each.

While the government has expressed outward confidence that India is prepared for the vaccine roll-out, the fact remains that many questions remain to be answered, and some hard trade-offs lie ahead.

For one, the cost of the vaccine, and how its burden will be shared between Union and states, is likely to prove contentious. The Opposition Congress party has already highlighted the campaign promise of the ruling BJP to roll out universal free vaccinations in the state of Bihar. Other states will likely complain if those run by the BJP get a better deal in terms of sharing the cost burden.

Then there is the question of the vaccine infrastructure. The Union Ministry of Health and Family Welfare, in a FAQ that it recently posted on its website, has declared that storage and transportation will not be a problem as “India runs one of the largest immunisation programme[s] in the world, catering to the vaccination needs of more than 26 million newborns and 29 million pregnant women”. This is, of course, correct. But this particular vaccination programme carries with it specific and more stringent needs. The government needs to be clearer about the mechanism of the rollout, so that the necessary infrastructure can start being put in place well in advance.

Then there is the question of prioritisation. This has already become controversial in the US, which has a federal structure similar to that of India. The federal medical authorities at the Centre for Disease Control in the US are currently determining their recommendations for who will receive the shots first and in what order. Then individual states will apply that guideline as they see fit.

In India, the government has broadly signalled its willingness to follow World Health Organization suggestions on priorities. But the Union health ministry’s FAQ has been relatively disappointing in terms of explaining what India-specific tweaks will be made. The ministry says, “The first group includes healthcare and frontline workers. The second group to receive [the] COVID 19 vaccine will be persons over 50 years of age and persons under 50 years with comorbid[ities].”

This, unfortunately, elides over the real questions that will need to be asked, and are already being asked in the US.

For one, who counts as a health worker? This needs a clear definition. In the US, those working in hospitals are receiving priority, but the general practitioners who are often the first to diagnose Covid-19 are not. In India, even more questions will be asked, given the complexity that our labour laws make of employment contracts. Presumably full-time employees in public sector hospitals will naturally be in the first wave. But what of those in private sector hospitals, clinics or nursing homes? What of those who are on contract to public sector hospitals, but not full-time employees? Will only those in direct contact with Covid-19 patients receive the early dose? Or will that extend to all those required to turn hospitals into a genuinely secure zone?

Beyond the question of health care workers, things get genuinely controversial. For example, who are “frontline workers”. Initial releases from the government suggested these include soldiers and policemen, among others. No logic has been provided for this prioritisation. In the US, the plan to prioritise some “essential workers” — including, perhaps, delivery workers and bank cashiers — has created controversy.

Illustration: Ajay Mohanty

The same questions apply in India as well. The fact is that the data on Covid-19-related morbidity shows that age is by far the greatest factor in developing a severe case of the disease. The hazard ratio for age cohorts above 60 years is an order of magnitude higher than for other factors, including occupation or being immunodeficient. From the point of view of reducing the death toll — which should surely be the primary purpose of the early vaccinations — there is no alternative to prioritising first those above 80 years, then those above 70 years, and so on.

This becomes even more urgent a question when the amount of vaccines on hand are considered. Depending on when the approval is received and for what vaccine, there may be only a few dozen million immediately available. If those are spent on health care workers and “frontline” government employees, it is an unavoidable consequence that older people will not begin to receive the vaccine in numbers for months yet, and as so the death toll will be higher by many thousands.

Some might argue that the need is first to break the chain of infection, which is why frontline workers should be provided immunity. This reasoning is faulty, given that it is based on incomplete data. We know that the vaccines prevent most severe cases of the disease. But we absolutely do not know yet if they also have a “sterilising” effect — in other words, if they prevent infections. Constructing strategies around herd immunity or using the vaccine to manage outbreaks or control transmission is therefore extremely premature. It is a basic policy to tailor interventions to what is known about effect. And in this case, the known effect — preventing disease in the elderly — means that the intervention must be targeted towards those further up the age distribution.

In the UK, considerable work was done in advance to examine morbidities across the population, and subsequently advisors to the National Health Service prepared a detailed assessment of how the vaccine should be rolled out, that is uniform across the country. Given this fact-based approach, the UK has, alongside health workers, prioritised those above 65 years; only after all those are vaccinated will those with co-morbidities receive the vaccine, followed by those above 50 years. Only after that do other essential workers get a look in.

The Indian government has not done badly so far in preserving life during the pandemic. It must retain, in this last lap, a focus on evidence-based policy making, rather than attempting to appease special interest constituencies of one sort or another. There is no alternative to a nationwide focus on vaccinating the elderly.