This January, soon after the central government began its Covid-19 vaccination programme, a 37-year-old anganwadi worker in Andhra Pradesh received her first shot of a two-dose vaccine. A few days later, she developed a skin allergy and bleeding in her gums, and her platelet count dropped, according to her cousin Ankaiah Pallala.

“We have been trying to get authorities to investigate properly whether her health issues after the vaccination have anything to do with the Covid-19 vaccine, but no one is being responsive, nor sending us any reports, or telling us if there is an ongoing investigation into the case,” Pallala told IndiaSpend on the phone speaking from Bengaluru this month.

Pallala’s cousin is still in hospital receiving treatment for the low platelet count. Doctors have told Pallala that they can administer another course of treatment, but her pending bills have to be cleared. Pallala is also facing difficulty in obtaining her health insurance claims for these bills.

Until March 1, Covid-19 vaccinations were only open to healthcare and other frontline workers, like the anganwadi worker. On that date, the government expanded the eligibility for receiving a Covid-19 vaccine to persons aged over 60 years and persons between 45 years to 59 years who have specified comorbidities.

The government also brought private hospitals, which are empanelled under various central and state government health schemes, into the vaccination programme. Those eligible would pay up to Rs 250 per dose to get vaccinated at these private hospitals or get vaccinated at a government facility free of charge.

Until March 1, Covid-19 vaccinations were only open to healthcare and other frontline workers. Photo credit: Amit Dave/ Reuters

Along with this scaling up of Covid-19 vaccination infrastructure come concerns about how well adverse events following immunisation are being tracked, reported, recorded and investigated by the government, experts told IndiaSpend. The Ministry of Health and Family Welfare’s daily updates on the vaccination effort, however, have provided no information on adverse events following immunisations since February 26.

Even before that, what little information was provided was incomplete. Where numbers of cases of adverse events following immunisations were mentioned, there was no detail or description of the adverse events. In one case, the cause of death was written intracranial bleeding. In other instances, the updates only said that post-mortem details were awaited or that the post mortem was not done.

The government’s target is to give 500 million Covid-19 vaccine shots to 250 million people by July. India is looking to vaccinate “one-sixth of humanity”, said RS Sharma, CEO of India’s National Health Authority, on March 2. This makes India’s vaccination programme the “world’s largest”.

With a mass-immunisation programme operating at this scale, experts say that a robust surveillance system is necessary to detect and treat adverse events.

Discrepancies in data

India has administered 1.77 crore shots (either first or second dose) of one of two Covid-19 vaccines, by March 4. This is 3.5% of its target of 500 million shots by July 2021.

Among countries, India has administered the fourth-highest number of vaccines so far, after the United States (8.05 crore), China (5.25 crore) and the United Kingdom (2.1 crore). Of these, how many adverse events have people faced, how many have been recorded, and how many investigated?

As of now, the data on this are hard to find because the health ministry has reported adverse events intermittently, and without much detail, in its daily press releases on India’s Covid-19 vaccination effort, according to an IndiaSpend analysis of these releases since January 16, when vaccinations began. IndiaSpend has sent queries to the health ministry on March 4, asking how it is recording adverse events cases and conducting investigations, and will update this article when they reply.

On February 26, the government said 46 people had died and 51 had been hospitalised following Covid-19 vaccinations. These were healthcare and other frontline workers. Thereafter, the government has not reported serious adverse events (involving deaths or hospitalisations) of people after Covid-19 vaccinations.

Even for some cases of deaths reported in February, information on the stage of investigation into the cause of death is uneven and scant. Post mortem had been done in some cases but not in others. These and other press releases say that the government was still waiting for the investigation reports.

In fact, in none of the 46 cases of deaths or 51 hospitalisations so far, has the government publicly announced the conclusions from any investigations. On the other hand, the daily updates repeatedly said “No case of serious/severe adverse events/death is attributable to vaccination, till date” till February 26. After that date, even this limited adverse events update has stopped.

“India needs solid monitoring of safety data given the scale of vaccinations coming up, and especially as people already with comorbidities and the elderly are being vaccinated first,” Swapneil Parikh, internal medicine specialist and co-author of The Coronavirus: What you Need to Know about the Global Pandemic, told IndiaSpend. “Whether or not safety issues are linked to the vaccine, data should be collected well and analysed.”

A total of 8,483 adverse events had been recorded in India’s vaccination programme as of February 4, the health ministry informed parliament. On February 5, however, the ministry reported 7,580adverse events following immunisations to parliament. There is no explanation for the discrepancy, or a break-up of what kind of adverse events people experienced, or categorisation by the level of health risk, or status of investigations.

On February 13, the government also said that 11% of the healthcare and other frontline workers vaccinated reported that they had not been informed about adverse events and that state and Union Territory governments should improve efforts to provide this information.

“Currently, we are observing gaps in how serious adverse events are being investigated at the district level. In many instances, local authorities have been quick to make public statements that there is no link to the vaccine, even before investigations and post-mortem have taken place.

In some cases there is a post mortem, in some cases, there is not. It is important that investigations at the district level are robust and the quality of evidence is sufficient because higher-level adverse events committees at the State and national level depend on this evidence for making causality assessments,” said Malini Aisola, a public health activist based in New Delhi.

Aisola has been in touch with families of those who have had adverse events following Covid-19 vaccinations and is documenting how many of them are trying to get these adverse events investigated and get medical treatment.

Besides Covid-19 immunisation, the government runs the massive Universal Immunisation Programme for immunising children and mothers. Photo credit: Manjunath Kiran / AFP

Improving surveillance

While making decisions about vaccines, scientists, government regulators and people considering taking the vaccine, everywhere, look for the risk-to-benefit ratio: Do the benefits outweigh the risks? This means that there will be some risks, some adverse events, but that the benefits may outweigh these risks.

However, people also do not want to find themselves in medical trouble after taking the vaccine, uncertain about whether that trouble has stemmed from the vaccine and whether they can afford to then treat it. Such concerns about safety can lead to vaccine hesitancy. This is why surveillance for adverse events, thorough investigation and complete transparency is vital, say experts.

Currently, the CO-WIN app is open to administrators, not beneficiaries, and adverse events are to be reported on the app.

Shahid Jameel, virologist and director of the school of biosciences at Ashoka University, Haryana, as well as Parikh, both recommend that given the potential scale of Covid-19 vaccinations in India, the government should provide multiple ways to report adverse events, such as a dedicated call centre.

People should be able to call the centre to report adverse events, and the call centre itself should contact those who have been vaccinated and ask about any adverse events. The latter could be a more suitable solution for a developing country like India, where not everyone may have a smartphone or internet access, or even enough awareness to self-report adverse events.

“Having a phone number to call or receive calls from will set a person’s mind to rest about their adverse reactions,” Jameel told IndiaSpend. “This can build confidence in the system and the vaccines.”

Lessons from other countries

“Looking at how some other governments have been recording and analysing big volumes of adverse event data and publishing the findings, it is a big contrast with how the Indian government is reporting adverse events,” said Parikh, who has been vaccinated for Covid-19 in Mumbai. “While foreign governments are also saying the adverse events are not linked to the Covid-19 vaccine, this is after they have published their analysis. They have provided reasoning.”

In the US, where safety data have been collected by the Centers for Disease Control and Prevention from the start of the vaccination programme on December 14, 2020, the CDC has been publishing regular, large-scale analyses of adverse events following Covid-19 immunisation. “Safety monitoring for these vaccines has been the most intense and comprehensive in the US history,” said the Centers for Disease Control’s February report.

The deaths of 113 persons who received vaccine shots starting in December were studied for the February report. After analysing the death certificates, autopsy reports, medical records, clinical descriptions and background mortality (rate of death irrespective of the cause), the Centers for Disease Control concluded that there was no evidence to suggest a causal relationship between the deaths and the Covid-19 vaccines.

In the next study, published in March by the Centers for Disease Control’s Covid-19 vaccine safety committee, 966 deaths following vaccination were investigated. This report also concluded that the adverse events reported after 7.5 crore vaccinations were consistent with what was already observed in clinical trials for the vaccines, that more serious adverse events were rare, and that other safety monitoring, such as for pregnant women, would continue.

In the UK, the Medicines and Healthcare products Regulatory Agency has said it will follow a “transparent process” and will regularly publish an up-to-date summary of safety experiences and adverse events reports on the Covid-19 vaccines. The UK government also publishes a weekly report on Covid-19 adverse reactions.

The Medicines and Healthcare products Regulatory Agency’s February 2021 report says that 58,427 adverse events were reported between December 9, 2020, and February 14, 2021. Another 13,679 adverse events were reported before this period.

The regulator had also received 406 reports of deaths following vaccinations. After analysing 58,240 of these reports, it also concluded that the adverse events were not unusual in comparison to other types of vaccines, that the safety experience is consistent with the clinical trials, and there are no indications that the vaccine played a role in the deaths.

“To date, the Indian government has not reported the status of investigation in each serious adverse event and not even put out information of the final causality assessments of the few cases where this has been supposedly completed,” said Aisola. “But yet they have been saying there is no link to vaccination. The government should realise that there are merits to transparency in sharing adverse events and findings of relatedness to vaccination, especially since vaccination has been scaled up through the next phase.”

Representational image. Photo credit: Xavier Galiana/AFP

Non-Covid adverse events

Besides Covid-19 immunisation, the government runs the massive Universal Immunisation Programme for immunising children and mothers. Like the Covid-19 vaccination programmes, the immunisation programme is also massive in its reach and targets5.6 crore people with 39 crore vaccine shots annually.

The health ministry publishes consolidated reports on investigations into adverse events among children following routine immunisation. In the 19 adverse events reports published between 2012 and 2019, and among the 5,025 cases assessed, the government has found that none were related to a “quality defect in the manufacture of the vaccines used”. One undated report relating to 367 adverse events cases from 2012 to 2014 said that the adverse events are all “within expected rates – given scale of vaccination” but that the government still needs to improve “overall surveillance”.

The adverse events data published on the home ministry website also show a substantial lag. For instance, in November 2020, the home ministry published the results of investigations into adverse events from 2016 to 2019. In August 2019, it published adverse events data from 2014 to 2018. Data earlier than 2012 are not publicly available on the health ministry website.

Addressing adverse events following any and all vaccinations is important, experts say. “We focus a lot on mortality, but even less serious adverse events like fevers, if unaddressed, can cause fear in people’s minds,” said Parikh. “With thousands of people getting vaccinated now, their fears should be addressed so that they believe in the value of vaccines and carry on that behaviour with their families, getting their children and others vaccinated for other diseases too.”

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