As the third wave of the coronavirus gets underway in India, the prioritisation of vaccines has once again become a central topic. In response to the emerging threat, Prime Minister Narendra Modi on December 25 announced a new phase of the vaccination programme with shots for children and booster doses for priority groups. Following this, the Ministry of Health and Family Welfare issued guidelines on vaccination for those aged between 15-17 and for booster doses for health professionals, frontline workers and people aged above 60 or those with comorbidities.

While the decision to provide a booster dose to priority groups appears to be appropriate, the question of age prioritisation remains. There is overwhelming evidence of the increased risk of Covid-19 fatality associated with older age.

In West Bengal, people aged 60 and above accounted for 64% of all Covid-19 deaths. The case fatality rate was the highest (7.4%) among people aged 75 and above, followed by 3.4% for people aged 60-74, 1.2% for those between 46-59 years and just 0.1% for people aged 16-29.

Global data show the case fatality rate is 65 times higher for people aged 65-74 than for those in the 18-29 age group. For people aged 85 or more the rate is 370 times higher.

Because of these concerns, Dr Poonam Khetrapal Singh, regional director of the World Health Organisation’s South East Asia region, said: “The older population continues to be highly vulnerable in the ongoing pandemic. Protecting them against the deadly Covid-19 virus should be our priority. By vaccinating the elderly population as part of high-risk groups, countries can effectively reduce deaths and hospitalisation.”

Yet, as of January 1, nearly 18 million people aged 60 or more are yet to receive their first dose and 44 million are yet to get their second one, our calculations based on central government figures released on January 1 show. To date, 68.5% of those aged 60 or above have taken both doses of the vaccine. This is only marginally higher than the coverage for the entire adult population aged 18 and above at 64%. In other words, there is little evidence of age-prioritisation in practice, regardless of theoretical policy objectives.

There is a particular need to reach out to older people in those states and districts with low overall rates of vaccination. | Sujit Jaiswal /AFP

These national averages mask sub-national differences in vaccine coverage. The share of the fully-vaccinated population varies considerably across states, ranging from 29% in Jharkhand to 62% in Gujarat.

Aside from large inter-state disparities, vaccine coverage is also highly unequal across districts. India’s universally vaccinated districts, that is, districts where 100% of the adult population has received two vaccine doses, are Srinagar, Badgam, Poonch and Mahe. The least vaccinated districts are Kurung Kumey in Arunachal Pradesh, with about 9% coverage, and Kamjong and Kiphire in Manipur, both with 11% coverage.

As many as 33 districts in India have very low full vaccination coverage of 20% or less, while a fifth or 135 districts have achieved 30% or less. There are similar geographical disparities in the vaccine coverage of older people. In some states with high levels of an ageing population, such as Tamil Nadu, Uttar Pradesh, Punjab, Jharkhand, Bihar, West Bengal and Assam, the coverage of older people is well below the national average.

In Jharkhand, for instance, by January 2, only around 121 vaccine doses per 100 people aged 60 or more had been administered.

India’s vaccine policy must prioritise those at the highest risk of death or serious illness. These risks increase exponentially beyond the age 60. There is a particular need to reach out to older people in those states and districts with low overall rates of vaccination. Initiatives such as the Har Ghar Dastak campaigns have shown results and should be extended. Without a radical change of direction, India’s vaccination programme will deepen existing geographical health inequities and endanger the lives of millions of its older citizens.

Soumitra Ghosh is an associate professor at the School of Health Systems Studies, Tata Institute of Social Sciences.

Aravinda Guntupalli is a senior lecturer in global health at the Institute of Applied Health Sciences, University of Aberdeen.

Peter Lloyd-Sherlock is a professor of social policy and international development at the School of International Development, University of East Anglia.