At the start of 2021, India launched the world’s largest vaccination drive against covid-19 across 3006 vaccination sites in the country. During the initial phase, the plan was to vaccinate 300 million people across cities and rural areas.  Of the 267 covid-19 vaccine candidates at different stages of development (83 in clinical development and 184 in preclinical development) and tested at breakneck speed, eight are scheduled to be manufactured in India alone.  Two of these are developed solely in India. With the approval from the Drugs Controller General of India under an emergency authorisation, two coronavirus vaccines—the Oxford/Astra-Zeneca vaccine (Covishield, the Indian version of the AZD1222 vaccine), and the Covaxin, BBV152, developed by a domestic manufacturer Bharat Biotech—are currently been used under an emergency authorization. 
However, the greatest challenge at the moment lies in the logistics of dispensing the vaccine to the vast population, a task that is extraordinarily difficult to accomplish. With just about 30,000 cold storage facilities scattered across the country, the numbers don’t add up.  Anticipating these challenges, the Indian administration launched the Electronic Vaccine Intelligence Network, a digital platform to manage its entire vaccine stock, logistics, and cold chain tracking of all the country’s vaccine storage levels.  The National Cold Chain and Vaccine Management Resource Centre has been set up to monitor the process. Placed under the National Institute of Health and Family Welfare, this government agency provides technical support for the immunisation supply chain. Managing vaccine stocks at thousands of local inventories and health centres is enormously challenging. In a country that is often plagued by power cuts and transmission faults, the stakes are higher than ever. The government of India and state owned public sector organisations are partnering with private companies to cover all eventualities. Customised refrigerators are being manufactured to meet the demand for covid-19 vaccine storage locally. These fridges can hold temperatures at 2-8°C for several days in the event of a power outage.
India’s immunisation scheme covers childhood vaccinations and has a reputation for running one of the world’s most successful vaccination programmes, catering to the needs of more than 26 million newborns and 29 million pregnant women.  However, an adult vaccination drive of this magnitude is an altogether new experience. Accomplishing this mission entails enormous challenges, specifically in reaching out to populations in remote areas. The task force assigned to the vaccine distribution network has to vaccinate nearly 1.4 billion people spread out over cities, districts, and villages. Administering an average of 3.4 million vaccine doses per day across a country comprising 28 states and eight union territories presents new challenges. During the initial phase, the National Expert Group on Vaccine Administration for covid-19 prioritised healthcare and frontline workers; in the second phase, this has been expanded to include people older than 60 years and those aged between 45-59 years who have comorbidities.  With the government’s launch of the covid-19 vaccine self-registration portal, participation has increased. Since March 2021, the government has also allowed the private sector to join in its vaccination drive to speed up this process. However, complete vaccination (both doses) has so far been achieved in only 3.1% of the total population. 
Although both of the vaccines currently used in India have been approved, an adverse event following immunisation task force was set up to deal with any post-vaccine complications. Despite this initiative, vaccine hesitancy is still hampering full participation. According to the World Health Organization, the three key reasons for vaccine hesitancy are a lack of confidence (in the vaccine itself or in the healthcare system), complacency, and difficulties in obtaining the vaccine (logistics).  Some of these concerns are understandable, given the fact that both the covid-19 vaccines were approved under an emergency authorisation without completing the full phase 3 trial. For a socially, linguistically, religiously, and culturally diverse country such as India, the reasons for vaccine hesitancy do not always lie in health concerns, but are deep-rooted in the cultural fabric of its citizen’s lives. Allegations about animal products, like gelatin, in the vaccines may affect compliance because they may clash with the beliefs of some communities.  India’s biggest challenge is to mobilise the population to attend the inoculation sites.
As for now, it seems that the challenges with the “known knowns” (covid cases, hospitalisation, and effective management) are being dealt with, and India is transitioning through the “known unknowns” (managing vaccine logistics and unforeseen complications). The real test will lie in dealing with the “unknown unknowns” (short-term and long-term vaccine efficacy, capacity to control the pandemic, and boosting the economy and healthcare).
For India, unprecedented challenges of this nature are nothing new. With the emergence of new SARS-CoV-2 variants, India is experiencing a second covid wave. This makes it imperative to vaccinate its citizens faster to prevent further disaster. India is currently managing the challenges of rising covid-19 cases, and a high number of hospitalisations as well as managing vaccine logistics. A further test will lie in dealing with short-term and long-term vaccine efficacy, long term capacity to control the pandemic, and restarting the economy and healthcare. Although uncertainties remain in how to deal with new viral variants, giving hope to the population is as essential as injecting the vaccine itself.
Ruby Dhar, Scientist, All India Institute of Medical Sciences, New Delhi, India
Babban Jee, Scientist, Department of Health Research, Ministry of Health and Family Welfare, Government of India, New Delhi, India
Subhradip Karmakar, Associate Professor and Team Leader, All India Institute of Medical Sciences, New Delhi, India
Conflict of interest: None
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