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In January 2021, India embarked on one of the world’s largest vaccination drives ever in an attempt to control COVID-19 in the country. After nine months, 29 percent of the national population is partially vaccinated, and only 15 percent is fully vaccinated.

Vaccinating the entire Indian population within a short time period is not feasible due to supply or resource capacity constraints and the sheer size of the population. So policy makers have had to decide on who to vaccinate first (e.g. elderly, clinically vulnerable, schoolchildren or the working population), where vaccination campaigns may be most impactful (e.g. urban areas with high transmission intensity or rural areas with greater number of susceptible) and how quickly a population can be fully vaccinated (i.e. rate of vaccination). They also must decide whether to deploy innovative strategies to maximise scarce vaccines to reduce COVID-19 deaths, such as using seroprevalence data to inform vaccine prioritisation or stretching vaccine doses.

Cost-effectiveness evidence can help answer some of these questions by helping policymakers understand how best to allocate resources to ensure that available vaccines provide the best value for money.

Today, the Center for Global Development, in collaboration with Indian School of Business and Imperial College London, presents novel results at the Indian Public Health Association Conference on the cost-effectiveness of seroprevalence informed vaccination strategies for COVID-19 prevention and control in the state of Punjab, India.

We project the health and economic impact of prioritising vaccine roll out dependent upon known seroprevalence in urban or rural areas after the first wave (31 percent and 21 percent respectively), in order to reduce the magnitude of a future second wave. We considered three potential scenarios to vaccinate 75 percent of the state’s population: (1) prioritising rural areas first (where seroprevalence is low); (2) prioritising urban areas first (where seroprevalence is high but so is the intensity of transmission); or (3) prioritising both rural and urban areas simultaneously (see full methodology in the Appendix here). Here, we share three insights from our study.

1. Regardless of the vaccination strategy, COVID-19 vaccination is not just good value for money, but could potentially provide savings for the government

Initiating a COVID-19 campaign to vaccinate 75 percent of the Punjab population 60 days prior to the second wave starting, would have averted over 10 percent of COVID-19 cases and over 14 percent of COVID-19 deaths, regardless of the vaccination strategy that followed (rural fist, urban first, or in parallel). This effort would have cost between USD $12.5 and $12.9 million but would have averted between $25.2 and $27.3 million in hospitalisation costs. In other words, allocating vaccines regardless of the rural-urban relative seroprevalence across all differing vaccination strategies could have saved money in Punjab. These results are of major importance considering Punjab has only double vaccinated 14.78 percent of its population and, nationally, India has only double vaccinated 15 percent of its population until now.

2. Time is of the essence - vaccinating as early and rapidly as possible before a second wave would have averted over 20 percent of new cases, and saved money

If vaccination in Punjab had started 90 days prior to the start of the second wave, 21-24 percent of cases and 24-28 percent of deaths due to COVID-19 could have been averted across all 3 seroprevalence informed vaccination strategies. The magnitude of costs saved through averted hospitalisations would have also increased to $53.9 - $58.8 million across all three strategies. In short, an additional month between the initiation of vaccination and of the second wave could have doubled the potential health impact and could have more than doubled the potential costs saved through averted hospitalisations.

During the second wave in Punjab and across the whole of India, vaccine timing was constrained by supply. Current national vaccination rates—7.4 million doses administered daily—are now encouraging but remain below the set governmental target of 10 million doses a day to fully vaccinate all eligible adults by the end of 2021. National and state level policy makers must now aim and prioritise for vaccine coverage to be completed as rapidly as possible, in advance of any future wave in India to further ensure cost-savings and incur maximal public health benefits.

3. When vaccine supply is high, governments need to identify potential bottlenecks and deploy innovative solutions to increase resource capacity

India took the logical decision to implement any COVID-19 vaccination campaign through its routine immunisation network. It further stated that routine immunisation campaigns would continue in conjunction with COVID-19 vaccination. This automatically leads to the idea that there is a potential ceiling on how many resources can be devoted to distributing and administering COVID-19 vaccines.

We estimated that on average across the state of Punjab, current utilisation for existing routine immunisation activities account for 40 percent of walk-in coolers, 75 percent of large ice lined refrigerators (at the district vaccine store), 4 percent of rural and 16 percent of urban ice lined refrigerators (at the cold chain points), 68 percent of rural and 53 percent of urban vaccinators alongside 31 percent of transport. Hence, our results suggest that on average human resources (i.e. vaccinators) across the state and ice lined refrigerators in district vaccine stores are constrained, with only 25 percent of additional space left for COVID-19 vaccines to be stored in large ice lined refrigerators, and 32 percent and 47 percent additional capacity left for vaccinators to conduct COVID-19 vaccination.

Our model shows that, when vaccine supply was the limiting factor, mobilising resources (such as vaccinators) had minimal impact on the health and economic impact of any seroprevalence informed vaccination strategies. However, the government of India has now stated that it is confident it will have enough supply to fully vaccinate nearly all adults across the nation by December 2021. Increased vaccine supply is likely to lead to operational challenges such as potential bottlenecks (e.g. cold chain, transport, human resource) in the supply chain network. 

To avoid this, state level planners should take stock of their existing vaccine supply chain resources, identify which may be constrained if the supply of vaccines is to exceed the existing capacity of the supply chain and then deploy innovative solutions such as well-regulated public-private partnerships for more efficient and earlier vaccine roll out. For example, such a partnership may involve using resources such as ice lined refrigerators or vaccinators from the private sector to help rapidly scale up a vaccination programme in advance of any future wave.

Conclusion

Globally, all nations are trying to identify novel methods of allocating a scarce vaccine supply.  These methods can include vaccine stretching and dose sparing, targeting high or low transmission areas, and targeting specific populations. We provide evidence that COVID-19 vaccination, regardless of relative seroprevalence in rural and urban areas, will not only save lives and be good value for money, but can additionally provide cost savings in the state of Punjab. India must now ensure that vaccine supply is increased immediately, and that all states have sufficient resource capacity to rapidly scale up COVID-19 vaccination to save lives and save money.

Want to find out more?

To find out more information about our analysis, methods, and results, we’ll be hosting a free and open access webinar with global health stakeholders on Friday 5th November 2021 at 2pm (BST). Here, we hope to present in-depth results and discuss ideas on how supply chain, epidemiological and health economic evidence from modelling can be used to inform COVID-19 vaccine distribution and allocation.

Ahead of and during the event, please share your reactions and questions in the comments section below, on Twitter @CGDev #CGDtalks, or via email at cgdevents@cgdev.org. We look forward to your thoughts and to continuing the important conversation.

We will also be publishing all methods and results in peer reviewed scientific literature which will be announced to the public in due course.

You can access the Methodological & Detailed Results Appendix here. As with any modelling study, all results should be viewed considering the assumptions made and caution is therefore advised in interpreting our results so as to avoid generalisations not supported by the data. Hence, all findings are likely to depend on specific scenarios of relative urban vs rural seroprevalence.

Acknowledgements

We acknowledge Sarang Deo, Sripad Devalkar and Abhishek Reddy for their expertise and work on the supply chain modelling, Sandip Mandal for his work in epidemiological modelling and Francis Ruiz, Abha Mehndiratta and Prashant Yadav for their contribution to this study.

Disclaimer

CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.