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Why Covid-19 booster dose uptake is so dismal across India

Experts complain that people aren’t taking their third Covid-19 vaccination shot—but do not seem to have examined how hard it is to get the booster

People queue for covid-19 testing in Beijing on 13 July 2022.
People queue for covid-19 testing in Beijing on 13 July 2022. (AFP)

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The government has finally responded to the increasing number of Covid-19 cases in India by announcing free boosters for the 18-59 age group, too, from July 15 – albeit for a limited period of 75 days. Last week it had reduced the duration between the second and the “precautionary” third doses from nine to six months. If only these logical decisions had been made earlier.

Periodic laments from government ministers and officials, public health experts and doctors about the slow uptake of booster doses of Covid-19 vaccines in India have been appearing in the media ever since “precautionary shots” were made available, at least theoretically, to people in the 18-59 age group from April 2022. 

Statistics have been regularly rolled out: “Only 5-7% took booster dose in 18-60-year group,” stated the headline of a recent report in The New Indian Express quoting N.K. Arora, head of the Covid-19 Working Group of the National Technical Advisory Group on Immunisation (NTAGI). According to him, even among those above 60 years, booster dose coverage is only around 40-45 per cent, which is considered very low.

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According to the CoWIN dashboard, only 4.91 crore precautionary doses have been administered so far, in contrast to over 101 crore first doses and 92 crore second doses (as of 11 July 2022).  It is not clear whether or not any of the frequently quoted decision-makers, policy advisors and experts have attempted to find out why the booster dose uptake has been so dismal across the country.

The experiences of at least two low-income individuals in Bengaluru who attempted to get booster shots after they were technically made available to the younger age group suggest that the authorities need to look beyond (questionable) data to examine the realities on the ground that could help explain people’s assumed lack of enthusiasm for boosters.

The first individual is a driver in his mid-50s with serious co-morbidities, which made him eligible for the first and second doses soon after vaccination was opened up for senior citizens in India in March 2021. His second dose was administered in the last week of April 2021. When precautionary doses were made available from January 2022 onwards to those in the 60+ age group who had completed nine months from the second dose, younger persons with co-morbidities were not eligible even though their vulnerability obviously remained the same. By the time the government announced boosters for the 18-59 age group it was nearly 12 months since he had taken his second dose.

To make matters worse, his CoWIN account had evidently been hacked and he is now labelled “unvaccinated” on the app – despite the fact that he has printouts of vaccination certificates from the same app/account, attesting that he was fully vaccinated as of April 2021. There seemed to be no way to get the technical error corrected despite repeated appeals to local health authorities. Considering his high susceptibility to infection, he was left with no choice but to get a first shot as his third shot at a private clinic. Thus, he has had his booster dose but it is not officially certified or documented as one.

The second individual is a cook in her late 40s. She and her husband (who has co-morbidities) were first vaccinated in April 2021. By May, when they should have received their second shots, the gap between jabs had been extended to 12 weeks. As a result, they were able to get their follow-up shots only in the first week of July 2021.

By April 2022 they had completed the mandatory nine months to become eligible for precautionary shots. However, even in May they were, inexplicably, told by a public hospital to come back after completing 12 months. A few days ago, a full year after their second jabs, they returned with their previous vaccination certificates and were given appointments for their booster doses. On the scheduled day tokens were handed over and they were asked to wait. However, when their turn finally came around, they were told that, since they were below 60, they could not be given booster doses in a public facility. They were advised to get them in a private vaccination centre. Why did the staff of the government-run hospital not convey this to them two months earlier, when they had first sought precautionary shots? Most low-income workers would have lost at least a day’s wages in this process.

Vaccine hesitancy is clearly not the only reason for the low prevalence of coverage, especially of boosters. ... How is the average citizen supposed to keep track of all the twists and turns in policies and prices?

The private hospital option is not so simple either. First of all, the number of private vaccination centres has vastly reduced since 2021. Once the vaccine shortage crisis ended in the second half of last year and free vaccination became readily available in public hospitals, as well as in camps run by municipal authorities, politicians and others, few people chose to go to private clinics where they would have had to pay between Rs. 700 and Rs. 1200 or more per shot.

In the early days of the vaccination roll-out last year, the government supplied vaccines to the private sector and all they were allowed to charge was a relatively affordable service fee. However, thanks to the mix-and-match policy announced in the summer of 2021, private hospitals had to buy vaccines directly from manufacturers at the prices they quoted (Rs. 600-780 for Covishield, Rs. 1200 for Covaxin). In April 2022 this misguided policy was revised, manufacturers reduced prices to Rs. 225 and private clinics could collect only an extra Rs. 150 as service charge. How is the average citizen supposed to keep track of all these twists and turns in policies and prices?

Secondly, there is understandable anxiety about the expiration dates of vaccines. It was clear by January 2022 that the accumulated, unused vaccine stocks held by private hospitals were due to expire by March 2022. However, there was little clarity on what was to be done about this dire situation. The private sector was understandably unwilling to invest more funds to acquire new stocks without any assurance of uptake. With what confidence can even individuals able and willing to pay for a precautionary shot go to a private facility for vaccination under these confusing circumstances?

According to recent news reports, “hundreds of millions of Covid vaccines” are likely to expire by September 2022. Some experts suggest that this is probably what led to the recent policy decision to reduce the required gap between the second and precautionary doses to six months (the norm in most countries all along). It could well be the reason for the sudden decision to provide free boosters to all adults as well.

Vaccine hesitancy is clearly not the only reason for the low prevalence of coverage, especially of boosters. Of course, recent reports suggesting that the new, leading Omicron sub-variants are “immune evasive” and that even those who have already been infected or “boostered” are susceptible to infection may be demotivating. At the same time, available evidence that previous infection and/or vaccination generally result in milder infection and less likelihood of hospitalisation, let alone death, can be motivating. Growing evidence of the “long Covid” phenomenon – long-lasting, often serious, after-effects of infection – can also tilt the balance in favour of protection. Yet clear, consistent, persuasive public messaging about the advisability of vaccination is sadly missing.

The ongoing 'Har Ghar Dastak 2.0’ campaign, meant to accelerate the pace and coverage of vaccination in the country through June-July 2022, is unlikely to improve the situation unless the many questions and doubts ordinary people have, and the various problems those who want to get a booster dose face on the ground, are addressed and resolved.

Ammu Joseph is an independent journalist and author based in Bengaluru.

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