How do you vaccinate the world’s second largest country?

Earlier this month, Mehmooda Jabeen followed an anxious-looking middle-aged man through snow-covered apple orchards in South Kashmir’s Kulgam district. The man was reluctant to get vaccinated against COVID-19.

“I sat him down and offered him a glass of water. Talking to him made him comfortable, and soon his fears were assuaged. He was convinced that getting vaccinated was the best thing to do,” says Jabeen, a health care worker in the country’s northern-most region.

“We are doing door-to-door drives to convince hesitant individuals, going into fields and orchards during the busy harvest and sowing seasons, visiting workplaces to vaccinate those who can’t afford to leave their work.”

India started the world’s largest vaccination drive in January 2021. A year on, the country recently crossed the milestone of administering two doses of COVID-19 vaccine to 75% of its adult population.

When India opened the vaccination drive for all people aged 18 and above on 1 May last year, its huge population, operational logistics, and vaccine hesitancy were the biggest challenges, particularly in rural areas.

“First, India does not have a standing adult vaccination programme. To convince 75% of adults to get vaccinated was quite an achievement,” epidemiologist Ramanan Laxminarayan notes.

“Second, the system for tracking vaccinations – CoWIN – appears to have delivered the goods despite some initial problems. Third, the commitment of the health care workforce to deliver on the vaccine promise is truly laudable,” says Laxminarayan, director of the Centre for Disease Dynamics, Economics and Policy in Washington.

Laxminarayan believes India’s achievement is something that will stand out when the story of COVID-19 is told.

As of 6 February, India had administered more than 1.69 billion total doses of the vaccine, which includes over 950 million total first doses and 720 million second doses. More than 46 million total first doses have been administered to beneficiaries aged between 15 and 18 years, while 14 million booster doses have been administered so far.

It has not been an easy task. Community engagement, dispelling myths, suspicions and reaching far-off rural areas has helped the country achieve the feat.

Huge credit goes to healthcare workers like Jabeen, known as ‘COVID warriors’, who have been at the forefront of India’s fight against the pandemic.

India had set an initial target of fully vaccinating its entire adult population by the end of 2021. However, during the peak of a devastating second wave in spring, the country experienced vaccine shortages as new COVID-19 cases at one point crossed 300,000 per day.

New Delhi-based immunologist Vineeta Bal notes that it was an ambitious aim.

“India is a big country and reaching all its corners is not easy,” says Bal from Pune’s Indian Institute of Science Education and Research.

Laxminarayn agrees that the initial target was ambitious but, he says, reaching 75% in January this year is no less of an accomplishment.

“There will invariably be people who are missed, either because they lack the internet access to register, are not close to vaccination session sites, or are outside the reach of the public health system. And of course, some would prefer not to get vaccinated,” he adds.

Overcoming the challenges of short supply, India is ramping up the drive to vaccinate those left behind.

“We are doing door-to-door drives to convince hesitant individuals, going into fields and orchards during the busy harvest and sowing seasons, visiting workplaces to vaccinate those who can’t afford to leave their work,” Jabeen says.

“Over 90% percent coverage is possible in the next few months if that is made the focus,” Laxminarayan adds.

India is also employing technology in the form of drones to deliver COVID-19 vaccines to difficult-to-access areas to ensure everyone gets access.

The country has given emergency authorisation to eight vaccines, but so far Covishield, manufactured by the Pune-based Serum Institute of India, accounts for nearly 90% of doses administered while the indigenously-made Covaxin accounts for the rest.

Authorities are also planning to roll out vaccines to children over 12 soon.

Supply lines of vaccines also seem to have vastly improved in the past few months. In early March 2021, there were an estimated 3,000 vaccination sites in India. There are now more than 43,000 across the country, according to CoWin portal.