India’s Covid-19 vaccination target of delivering up to 50 crore doses by July, which is largely piggy-backing on the country’s existing routine immunisation programme, may strain the system, public health professionals warn.

India’s Universal Immunisation Programme, which targets 5.6 crore people annually (2.67 crore infants and 2.9 crore mothers) with about 39 crore doses for 12 diseases, is one of the world’s largest. The country has also started the world’s largest Covid-19 immunisation programme this year. Both these programmes are being implemented in parallel, using much of the same human resources and physical infrastructure.

The country hopes to increase routine immunisation nationally to 90% under the Intensified Mission Indradhanush initiative, Minister of Health and Family Welfare Harsh Vardhan announced in February while launching Intensified Mission Indradhanush 3.0, the initiative’s third iteration to achieve the same target. India has been unsuccessful in reaching the target of 90% coverage for routine immunisations for the last four years.

Now that the country is additionally engaged in a massive Covid-19 vaccination programme, public health professionals tell IndiaSpend that both immunisation drives will be stressed and that the central government could consider making them work parallelly or with additional resources.

Large numbers of children, pregnant women and those involved in internal migration missed out on routine vaccinations in 2020. Photo credit: Noah Salem/AFP

India has three major health challenges this year: the very ambitious plan of Covid vaccination, the routine immunisation target, as well as ensuring that other public health issues (tuberculosis, nutrition, etc), do not suffer, said Swapneil Parikh, internal medicine specialist and author of The Coronavirus: What you Need to Know about the Global Pandemic.

“We may not be able to achieve scaled up Universal Immunisation Programme targets this year. But we should ensure we do not drop levels to less than previous years,” Parikh told IndiaSpend.

What data indicates

Increasing Universal Immunisation Programme coverage has been a slow, decades-long effort, as can be seen from data from five rounds of the National Family Health Survey for immunisation levels in every state and union territory. The first survey’s data were from 1992-’93 and the most recent data are from National Family Health Survey-5 in 2019-’20.

These data show that India’s national immunisation level (the percentage of children aged between 12 and 23 months who have received all basic vaccinations) has improved from 36% coverage in National Family Health Survey-1 (1992-’93) to 42% in National Family Health Survey-2 (1998-’99) to 43.5% in National Family Health Survey-3 (2005-’06) and 62% in National Family Health Survey-4 (2015-’16).

All-India coverage as per National Family Health Survey-5 has not been calculated and released thus far, but 17 of 22 states and Union Territories for which data were released saw over 70% vaccination rates.

For instance, National Family Health Survey-1 data from 1992-’93 showed that the lowest immunisation coverage in India was 3.8% in Nagaland. National Family Health Survey-2 (1998-’99) recorded the lowest immunisation coverage as 11% in the state of Bihar.

Data from the three subsequent surveys record the lowest rate of immunisation coverage again in Nagaland, with 21% coverage recorded in National Family Health Survey-3 (2005-’06), 36% in National Family Health Survey-4 (2015-’16) and 58% in National Family Health Survey-5 (2019-’20).

The latest data point to how India has consistently missed achieving the 90% Universal Immunisation Programme coverage target for which Prime Minister Narendra Modi launched a new programme – he announced the Intensified Mission Indradhanush in 2017 to bring up India’s level of immunisation to 90% by December 2018.

Since 1998-’99, only the Union Territory of Dadra and Nagar Haveli and Daman and Diu has managed to achieve 94.9% coverage – and that too just once – as recorded in National Family Health Survey-5 (2019-’20). No other state has achieved the 90% coverage target, as per data from the previous surveys.

“There are many existing reasons why routine immunisation has a hard time ramping up and why there is variation in the data,” said Yennapu Madhavi, senior principal scientist at the National Institute of Science Technology and Development Studies in New Delhi. “For example, sometimes people show up for the first and second shots but do not come for the remaining ones. Instead of spending a day getting a vaccination, mothers may choose to earn a wage.”

The two earlier Intensified Mission Indradhanush initiatives had hoped to cover short-falls in achieving 90% coverage targets for Universal Immunisation Programme. A central government roadmap to achieve 90% coverage said that insufficient demand from communities is one of the challenges in achieving immunisation targets.

One way to increase demand will be to address vaccine hesitancy and mitigate the fear of adverse events following vaccinations, according to the roadmap. Confidence-building communication will be key, and the government suggests using school children or religious leaders as ambassadors to talk widely about vaccination, ensuring that people get phone calls to remind them about vaccination as well as the provision of non-financial incentives to people.

The pandemic has added to these challenges. Large numbers of children, pregnant women and those involved in internal migration missed out on routine vaccinations in 2020, the government acknowledged in an official press statement.

With the third iteration of Intensified Mission Indradhanush now, the central government has again committed to increasing immunisation coverage to 90%. While the central government has not set a timeline for Intensified Mission Indradhanush 3.0, it hopes to focus efforts in vaccinating those who were left out during the Covid-19 internal migrations.

All this is being planned at the same time that India has embarked on its Covid-19 vaccination programme. As of March 2, India has administered 1.54 crore doses – either the first or the second – of the Covid-19 vaccine.

This is 3% of the target of 50 crore shots till July 2021. This implies that the remaining 97% of the doses must be administered rapidly in the next 20 weeks/five months.

To galvanise this, the government has permitted private hospitals to provide Covid-19 vaccination from March 1. “This might be able to reduce the burden on the public sector, which can then re-focus on routine immunisation,” said Srinath Reddy, president of the Public Health Foundation of India.

The problem for both the vaccination programmes is beyond the government’s ability to supply vaccines, pointed out Parikh. It is also a demand-side issue – existing reasons for low demand for routine immunisation, and the new problems of vaccine hesitancy with the Covid-19 vaccines – that will slow down both programmes, he said.

Routine immunisation delivery declined during the Covid-19 pandemic. Photo credit: Sajjad Hussain/ AFP

Resources diverted

Routine immunisation delivery declined during the Covid-19 pandemic, with 10 lakh fewer children receiving the Bacille Calmette-Guérin vaccine in April 2020 compared to January 2020, IndiaSpend had reported in August 2020.

Just like the Universal Immunisation Programme, the Covid-19 vaccination programme too is struggling to meet targets. A month into its launch, the programme was running too slow to meet its target of 50 crore vaccinations by July 2021, IndiaSpend had reported on February 16.

Sharing resources and infrastructure in this scenario could work to the detriment of both the programmes, IndiaSpend had reported in October, quoting public health experts. India’s Universal Immunisation Programme is already dealing with a birth cohort of 26 million children every year, and “it should not be stretched”, Gagandeep Kang, member of the World Health Organization’s working group on Covid-19 vaccines, had told IndiaSpend then.

Cold chain and vaccine logistics are critical to immunisation programmes. This infrastructure has not kept pace to meet the targets of both the vaccine programmes. Prior to Covid-19, the government had over 27,000 cold-chain points, which increased to 28,947 by December 2020 – an addition of just 1,947 to deliver nearly twice the number of vaccinations, from 39 crore (routine immunisation) shots to an additional 50 crore shots (Covid-19 immunisation).

All challenges considered, 2021 is an important year for India and the country will have to find a way to perform well on both immunisation targets. “Let us be mindful that Covid-19 is not the only health challenge we face here,” said Parikh. “The government will need to ensure that TB, malnutrition, diarrhoea, pneumonia and all other vaccinations are also attended to.”

This article first appeared on IndiaSpend, a data-driven and public-interest journalism non-profit.