India started this week by registering the lowest daily rise in coronavirus cases in seven months even as it finished administering the first dose of the Covid-19 vaccines to 4.5 lakh healthcare and frontline workers.

“The fall in the number of daily new cases is accompanied by a fast-rising number of people getting vaccinated against Covid-19 across all states and Union Territories,” the Centre announced in a jubilant press release. “The total number of people vaccinated is more than double the number of active cases.”

The number has since increased to 6,31,417 as of Tuesday evening.

But beyond these big-picture numbers, India’s Covid-19 immunisation drive has so far been bumpy, marred by vaccine hesitancy and technical glitches. As is expected in a country of its size, there is great disparity in coverage among India’s states.

Under-performers and overachievers

On Monday, for instance, Odisha not only achieved its target of vaccinating 31,902 people, it went beyond – vaccinating over 32,500 people. “We managed this because all the key opinion makers, influential doctors and social celebrities have over the last two months motivated people to take vaccines,” said Jayant Panda, a physician who is the technical adviser to the state government on Covid-19.

Punjab, on the other hand, struggled to vaccinate even 35% of the intended recipients the same day. The state’s performance was even poorer on the first day of vaccination: barely 20 % of the targetted beneficiaries turned up.

Tamil Nadu began on a lackadaisical note too. The southern state struggled to cover even 20% of the healthcare and frontline workers who had been enlisted on the first two days. But on the third day, it bounced back clocking a coverage rate of nearly 60%.

So what explains these low turnout numbers in several states?

A ground staff member walks past a container at the Indira Gandhi International Airport, New Delhi, December 22. Credit: Reuters/Anushree Fadnavis

‘Vaccine still under trial’

The director of health and family welfare in Punjab, Gurinder Bir Singh, said there is a “little bit of hesitancy among our health service providers”.

The first recipients under India’s Covid-19 vaccination program are healthcare and frontline workers. However, many of them have expressed concerns about how the vaccines were approved by India’s drug regulators.

Of the two vaccines at India’s disposal, one – the indigenously developed Covaxin by Bharat Biotech – has no large-scale efficacy and safety data. The other, Oxford-AstraZeneca’s Covishield vaccine manufactured by the Pune-based Serum Institute, has shown favourable results in large scale trials in Brazil and the United Kingdom, but data from Serum Institute’s India trials are yet to be fully examined.

While scientists and doctors have expressed more apprehensions about Covaxin, Punjab’s experiences seem to suggest vaccine hesitancy isn’t limited to the Bharat Biotech vaccine. The state, which has the lowest coverage rate so far, is currently only administering Covishield – and yet has found few takers for the vaccine.

Tamil Nadu’s health secretary J Radhakrishnan said there were several reasons for the state’s sluggish beginning. First, it was the timing – the rollout coincided with the state’s most important festival of Pongal.

Then, there was, Radhakrishnan pointed out, information on the social media and the news which seemed to dissuade people from taking the jab, particularly Covaxin. “There are all these headlines which said the vaccine is still under trial and should not be given, a learned person will read that,” he said. “And the fact that there is no choice if you go to a Covaxin centre.”

While doctors were largely willing to take the shot, other healthcare workers were not too enthusiastic initially, he said.

Things looking up?

Radhakrishnan, however, said things were now looking up with people turning up in large numbers. “We addressed the concerns. The nursing association took one day to decide…you have to allow that in a democracy. It is not about meeting short-term targets.”

Indeed, Tamil Nadu vaccinated more than 10,000 people on Monday compared to the just over 6,000 it did over two previous days combined. Yet, its coverage rate in Covaxin centres continues to languish at below 34%, perhaps indicating low level of trust in the vaccine.

Singh said in Punjab too, the initial hesitancy was waning and more people were turning up the vaccination centres. “It is increasing day by day,” he said. “On day 1, we could cover only 1,300 people, but the number increased to 2,000 on day 2.”

As in Tamil Nadu, Punjab’s paramedics who were initially reluctant were also “coming forward now”, Singh said.

Contradictory trends

But this steady growth in coverage is not quite of a pattern across the country. In fact, the opposite has happened in several states such as Delhi, Karnataka, and Andhra Pradesh.

In Karnataka particularly, daily coverage has sharply declined. While the state began with a 63% coverage, it reduced to 47% by the third day of vaccination.

Delhi has seen a decline of 9% and Andhra Pradesh of 14% over two days of vaccination, as of January 18.

A vaccination drive underway in the Andaman and Nicobar islands. Credit: PTI

Software troubles

Apart from vaccine hesitancy, technical glitches have also slowed down things, states say. “The major problem is not people refusing the vaccine, it is the software,” said Ajoy Chakraborty, West Bengal’s director of health services. “People are supposed to get an SMS intimating them of the time and place of the vaccine but many of them are not receiving it.”

The software Chakraborty is referring to is the Covid Vaccine Intelligence Network (Co-WIN) system that has been described as a “digitalised platform to track the enlisted beneficiaries for vaccination and COVID-19 vaccines on a real-time basis”.

Chakraborty said Bengal’s coverage declined from 76% on the day of the rollout to 58% the next day because of software troubles.

Bihar also claimed to have been pulled back by Co-WIN troubles. “The portal is not working properly,” said a heath official of the state. Over two days of vaccination, the state has managed to cover just over 50% of the intended beneficiaries.

Even Kerala complained of troubles with Co-WIN. In fact, the state could not update the list of its beneficiaries in the system on the first day, seemingly leading it to being reprimanded by the Centre for low coverage. According to reports, the state during a review meeting, was reprimanded by the Centre for its “poor coverage of less than 25 per cent”. But official data show that the state has a coverage rate of nearly 70%.

“There are too many issues because of the Co-WIN portal regarding beneficiary updation,” said Preetha P P, state’s additional director of health services. “We have already reported it to the Centre.”