Today, India faces its greatest challenge in averting the second wave of the novel coronavirus pandemic that is raging through Europe and the Americas. But as India embarks on the world’s greatest vaccination drive, there is hope that we will stop the pandemic.
Unlike many European and Asian countries which are facing huge shortages of the Covid-19 vaccine, India’s Atma Nirbhar policy ensured that two of the vaccines approved by the regulator are being produced in India. The Serum Institute of India, which is the world’s largest producer of vaccines, has enhanced its capacity to produce 1 billion doses of the Covishield vaccine. This, coupled with Bharat Biotech’s vaccine production, would largely be able to meet the vaccination needs of priority groups amongst India’s huge population by the end of 2021.
Managing the programme
However, managing the logistics, cold chain, and training the required huge workforce to roll out such a vaccination programme is a gigantic task.
The Government of India has issued a comprehensive set of vaccination guidelines that target 300 million people, including health and frontline workers, and people above the age of 50. While countries like France and Germany are struggling to speed up their vaccination drives, Israel has succeeded in vaccinating more than 20 per cent of its population, or about 2 million people. India has already put in place two of the main factors responsible for Israel’s rapid progress: abundant access to vaccines, and a well formulated logistics and supply chain plan.
A major factor in Israel’s success was boosting the number of personnel available to administer the vaccine by mobilising staff from other sectors, and providing overtime benefits to health staff. Following the newly amended labour laws, India can create large-scale fixed term employment amongst educated rural young people with basic digital training to undertake the registration and vaccination drive. Large numbers of nursing students, auxiliary nursing midwife trainees, and retired Army and defence services personnel in every village can also be mobilised for the vaccination drive.
Priority for the vulnerable
The guidelines also provide for the prioritisation of people with co-morbidities. Studies have shown that over 70% of mortalities from Covid-19 occur due to pre-existing non-communicable diseases such as diabetes, cardiovascular ailments, and cancers. Prioritising vaccinations for those with pre-existing non-communicable diseases will keep the Covid-19 case fatality rate as low as possible.
The relationship between a country’s non-communicable disease burden and Covid-19 case fatality is direct. Countries with very high underlying non-communicable disease mortality show high Covid-19 case fatalities, as a comparison across Singapore, India, and Indonesia shows. All this points to the urgency and importance of first vaccinating patients suffering from NCDs.
In this task of vaccinating all people with pre-existing non-communicable diseases, India faces a serious unknown quantity. Unlike many communicable diseases which manifest themselves early through perceptible symptoms like fever, pain or other indicators, many slow-onset non-communicable diseases such as diabetes, hypertension and cancers do not have any perceptible symptoms in early stages. Therefore, many people unknowingly live with diabetes, hypertension and cancer during the earliest stages of disease — the time when such diseases can be easily and cost-effectively cured.
Burden of NCDs
It is estimated that although India has 30 million diagnosed diabetes cases, the prevalence rate estimated by the National Diabetes and Diabetic Retinopathy Survey is 11.8% in the adult population. This comes to nearly 72 million. Similarly, studies show that undetected hypertension cases may be as high as 26% of the adult population. India has one of the lowest incidences of cancer per 100,000 population, but this is largely due to inadequate early screening and detection. An EY report found that while the cancer incidence rate in India was estimated to be at 94 cases per 100,000 people, the actual rate was somewhere between 150-200 cases due to deficiencies in data collection and screening.
As with most low- and middle-income countries, roughly 40%-50% of the non-communicable disease burden in India remains undiagnosed or undetected until the very late stages of the disease. This leads to high rates of mortality and high out-of-pocket expenses: NCDs are very costly to treat at the advanced stages, and India’s Multisectoral NCD Action Plan estimates that 47% of all out-of-pocket health expenditure is due to NCDs.
Therefore, the strategy for Covid-19 vaccination can be dovetailed into a comprehensive screening programme for people aged 50 and over for major NCDs like diabetes, cardiovascular disease (CVD) and even common cancers. This will reveal the undetected cases of hypertension and diabetes. The current operational guidelines for Covid-19 vaccination aim to mobilise all the district collectors, rural frontline health staff from primary health centres and urban civil and sub district hospitals. The vaccination centres have been very meticulously planned to deliver the vaccination efficiently. This is a great opportunity to equip all the frontline vaccination staff, including vaccination officers, with glucometers and blood pressure measurement instruments to screen people for potential co-morbidities such as diabetes and hypertension.
An opportunity to integrate
As the entire Covid-19 vaccination drive in India will be recorded on the digital CoWin platform, a little bit of tweaking will enable CoWin to be integrated with the government’s Health Management Information System (HMIS) databases, where all the details of newly detected NCDs can be recorded. The National NCD Action Plan already aims to promote continued surveillance and screening surveys to detect undiagnosed NCD cases. The Covid-19 vaccination drive offers a nationwide opportunity to screen and update the national database of NCD patients, and an updated database which captures a larger number of patients at the early stages of NCDs will help in demedicalising the care of NCD.
Through advocacy and through the newly created health and wellness centres, all registered NCD patients can be provided with advice for self-care, reduction of aggravating risk factors like sugary and salty foods, taking more exercise and reducing harmful alcohol and tobacco use. The continuity of self-care by patients can be monitored on various mobile based applications like the Digital Life care solution developed by Dell with the Ministry of Health, which has been adopted by over 40,000 frontline health care professionals. This can easily be integrated with the CoWin platform to capture the newly detected NCD patients.
The Defeat Non-Communicable Disease Partnership anchored in the United Nations Institute of Training and Research, Geneva, has espoused a similar win-win approach in Rwanda and Myanmar, its two programme countries. A nationwide Covid-19 vaccination drive is the ideal entry point for enrolling all the co-morbid patients below the poverty line in Ayushman Bharat so that their future out of pocket expenses are minimised. A win-win for eliminating Covid-19 and reducing NCD mortalities by one-third in line with Sustainable Development Goal 3.4!
Praveen Pardeshi is Global Programme Coordinator, Defeat Non Communicable Disease Partnership, UN Institute for Training and Research, Geneva. He was formerly the Commissioner of Brihanmumbai Municipal Corporation, serving in that post during the early months of the pandemic in Mumbai until May 2020