India’s second COVID-19 wave: vaccine shortages in the pharmacy of the world

by Francesca Gavins

On 25th April 2021, India reported 352,991 positive tests in a single day – the highest daily figure in the world, surpassing the biggest daily rise recorded in the United States (US) in January 2021. Its second wave has accelerated at a near vertical rate. Although, the reality of the infections and deaths may be far more prevalent than the numbers suggest. There are low testing rates outside the major cities and underreporting of deaths even in hospitals. In addition, the labs have a backlog of the gold-standard polymerase chain reaction tests. Christopher Murphy of the Institute of Health Metrics and Evaluation in Seattle reported on 23rd April that ‘there are more infections happening in India than what occurred globally two week ago’. In contrast to the first wave, which predominated in the Mumbai slums, the virus is spreading geographically into the poorer rural regions.

Crowded cities and overwhelmed health care systems, alarming images are shown in the media of funeral pyres burning and endless hospital queues due to severe shortages of oxygen and beds. India is being accused of under-preparing and under-investing in essential items. Other countries have sent aid with oxygen-generation plants from Germany, oxygen concentrators from the US, high-capacity oxygen tankers from Singapore and ventilators from the UK and Europe.

In contrast to many other countries, in February 2021 India had only one wave of COVID-19 and only 13,000 daily cases were recorded, manageable in a population of 1.4 billion. At the time, researchers proposed that a large proportion of the population may have reached herd immunity. Others suggested that as half of India’s population is under the age of 25, fewer people suffer from more severe symptoms of COVID-19. 

Fast forward to March and April, the un-masked mass gatherings for political rallies and religious holidays are partly being blamed for the second wave; farmers in Delhi, late night feasts for Ramadan by Muslims, new year for the Hindus and Sikhs and the ritual dip in the Ganges for Hindu festival of Kumb Mela. In addition, the more transmissible UK (B.1.1.7) and South African (B.1.351) variants have appeared in Asia, where past infections or vaccines may not provide immunity. India’s double mutant variant (B.1.617) could be one of several variants causing infections.

The dramatic second wave has consequences not only for India but also for the world. The Serum Institute of India is one of the world’s largest vaccine manufacturers of Covid vaccines. Here, Covishield is made, the Indian version of the Oxford/AstraZeneca vaccine. India’s government has rejected applications by Pfizer-BioNtech and others to licence local versions of their vaccine. Mr Modi’s government is set on national self-reliance or atmanirbharta. India and South Africa put forward a proposal for a temporary waiver of  patent rights for Covid-19 related medicinal products at the World Trade Organisation in 2020. It has been supported by over 60 countries, more than 100 members of US Congress and several former world leaders. Pharmaceutical companies have protested, stating that there could be a shortage of vaccine materials and many legal disputes if the proposal goes through.

There was a slow start to the Indian vaccination campaign and only 8.5% of the population have received at least one dose of the vaccine. Over 60s could be vaccinated by the end of May but it may take much longer for larger proportions of the population to be inoculated. Vaccines have been provided to Britain, the European Union and Covax, a global collaboration providing fair access to vaccines across the world. 

A total of 192 nations joined Covax with the promise that vaccines will be provided to inoculate 20% of its population. Africa, for example, is heavily reliant on receiving vaccines from the Covax programme. On the 24th March, Indian exports were halted, who planned to provide 86% of supplies for Covax. Before the ban, Covax had delivered 32 million doses to mostly low income countries. AstraZeneca is the vaccine of choice as Moderna and Pfizer are costly and hard to distribute as -80 °C storage was required. A number of countries have bypassed Covax, contacting the institute directly with Argentina, Brazil, Myanmar, Saudi Arabia and South Africa acquiring 12 million doses between them. 

Emmanuel Macron urged Europe and the US to send 5% of their vaccine supplies to developing countries. African nations were being charged double or triple the European rate for the AstraZeneca vaccine and being offered the Chinese or Russian vaccine where the efficacy against the new variants has not been determined. The US, however, rejected the proposal and sent money to Covax instead. Supplies of AstraZeneca vaccine sit in their boxes as they have not been approved in the USA yet. The vaccination strategy in higher income countries has changed. Due to the high efficacy of the vaccines, many countries have offered their vaccines to the general population as well as healthcare workers and the clinically vulnerable. As a result of the ‘me-first’ approach, the rich and vaccine-producing countries are powering ahead in their vaccination targets. 

Covax is still trying to reach its principle aim of supplying the first 3% of vaccines to every healthcare worker in the world. According to Oxfam, nine out of ten people in poor countries may miss out on the vaccine in 2021. Dr Tedros Adhanom Ghebreyesus, head of the World Health Organisation, warns the world is on the brink of a ‘catastrophic moral failure’.

The lack of vaccine manufacturers could be considered the ‘wake up call’ Africa needed. Africa imports 99% of vaccines it uses and 70% of pharmaceutical materials. In South Africa, Aspen Pharmaceuticals agreed to manufacture the Johnson & Johnson Covid-19 vaccine at its facility, where its first doses have been made. Senegal, Ghana, Tunisia, Nigeria, Rwanda and Kenya could be potential vaccine producers. When the pandemic is over, facilities could switch to making vaccines for Dengue, Yellow Fever, or Zika. This could be a promising step towards fair access to medicines.

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