Kameshswar Prasad, a 60-year-old farmer from Gaya cycled several kilometers to deliver vaccines for pregnant women, newborn babies and young children in far-flung villages of Bihar during the Covid-19 lockdown. Thirty seven-year-old Alim Halder, a resident of Sonarpur, an auto-rickshaw driver by profession, faced many challenges when he tried to transport vaccines to remote areas of West Bengal until the government included immunization under essential services. However, Halder did not stop delivering vaccines. Sakarsingh Damor, a 40-year-old farmer from Jhabua, Madhya Pradesh delivered over 5- 6 vaccine carriers across villages on his bike, despite locals cowering to COVID-19 fears in the early days of lockdown.

These three men, along with more than a lakh other individuals across India, are part of the Alternate Vaccine Delivery (AVD) System of India. Farmers, camel riders, boatmen, auto-rickshaw drivers, rickshaw pullers, village community members, volunteers, self-help group members, etc, comprise this network which ensures that vaccines reach remote areas of the country which are not easily accessible. This is to guarantee that during the time of a natural calamity, or emergencies like the COVID-19 pandemic, the crucial process of immunization doesn’t come to a screeching halt. Employed mostly by their respective state governments, the AVD persons are often individuals from the marginalized section of the society who are given an alternate employment opportunity to deliver vaccines and earn money on the side. However, their services are crucial as they help the section of the population with little or no access to the formal healthcare system to avail the critical process of immunization.

Reaching the Last Mile

According to UNICEF, the AVD system is a very well established system in our country. The states have different vaccine delivery mechanisms depending on the state’s topography ranging from motorcycle/bikes, cycle, boats, and by foot. During and after the lockdown, when the regular road transport mechanism was affected, the AVD system was instrumental in supporting vaccine delivery and resumption of Routine Immunization services.

Dr Rajesh Khanna, Deputy Director, health and Nutrition, Save The Children told News18, “During floods or any other emergencies, the AVD system has played a significant role in making vaccines available in the past as well. The most famous example of this is the boat clinics in Assam, which provide immunization and other medical services to millions.”

According to a report in The Wire, almost three million inhabitants of 2,500 saporis (sand islands) access immunization (as well as most of their other medical needs) through these boat clinics, as any formal medical facility is impossible to build on the sand islands, which are prone to re-occurring floods. Apart from the boat clinics, even air force helicopters provide vaccine delivery support to unreachable areas.

“These initiatives are innovative, not only in terms of the model they use, but also because they utilize those individuals who are already present on the ground to make this system work. They help us reach the last mile in terms of immunization. With Covid-19, the disruptions have been quite significant. Though we do not have any specific figures from India, the WHO says that 70 percent of all outreach programmes have been impacted. Under such conditions, it helps that we already have a mechanism in place with the AVD system. From the supply side, at least we are making sure that we have the vaccines in place.” he said.

However, Dr. Khanna added that while this push provided by AVD personnel ensured that vaccines are available even in remote areas during the pandemic, that did not automatically ensure immunization.

“The challenge so far has been to motive people to come in for immunization because there is an obvious fear of COVID-19. The supplies are there, but many healthcare workers have also been re-deployed for COVID-19 related work. Apart from ANM (Auxiliary nurse midwife), who mainly worked on immunization since the pandemic happened, healthcare workers focusing on immunization have been rather limited,” said Khanna.

How Important is it to Catch Up on Vaccination?

“Vaccination is one of the most effective and cost-effective ways to protect children’s lives and futures and for building healthier and safer communities. It is vital to ensure that immunization services continue to be available to every child and that communities, families, and caregivers of children are continually aware of the importance of full immunization,” said Luigi d’Aquino, Chief of Health, UNICEF India.

In fact, India runs the largest immunization programme in the world under Mission Indradhanush, which aims to provide immunization to nearly 27 million newborns, annually. Apart from newborns, babies are immunized when they are 6-week-old, 10-week-old, 14-week-old, and somewhere between 9-12 months old. Toddlers between the age of 16-24 months old also receive vaccines. 5-6-year- olds, 10-year-olds, and 16-year-olds, and women during their pregnancy also take vaccines under routine immunization.

However, immunization was on the decline, particularly in the initial months of lockdown (March to May 2020) due to COVID-19 fears and lack of public transportation. Several private practitioners also corroborated that they experienced a sharp decline in immunization during the lockdown.

“Babies born around January were due for vaccination in March, which is when the lockdown happened. Therefore, many skipped their doses. Although vaccination was later announced as an essential service, it was difficult for many parents to access transportation and get their babies immunized. The overpowering fear of COVID-19, which is life-threatening, also deterred many from stepping out for immunization, although they had private transportation. As a result, currently, there are many babies without immunization which is a major cause of concern,” said Dr J.S Bhasin, Director and head of Department of Centre For Child Health, BLK Hospital, New Delhi.

The problem is that immunization is something that doesn’t give you dividends immediately. So, you realize the importance of immunization only when you have really experienced the disease or seen someone suffering from it. Therefore many may not be very proactive in catching up with the immunization process after the lapse, but that would be a grave mistake, not just for them but for the community, and the country points out the doctor.

“We give early vaccination in our country so that the infection doesn’t spread, because the vaccines are given for several communicable diseases which are transmitted from person to person, or in densely populated areas or unhygienic places. Fortunately, due to lockdown, people’s movements were restricted, and they were more conscious of hygiene. So, even though the children were at the risk of the communicable diseases spreading due to lack of immunization, since everyone’s mobility was restricted, we didn’t see a spurt in the cases. However, now that the restrictions are being relaxed, we will have a huge number of babies who are not vaccinated. Imagine the likelihood of the spurt of these diseases if immediate immunization is not done.” said Bhasin.

Dr Rohan Sequeira, Consultant General Medicine, Jaslok Hospital and Research Centre, Mumbai, said, ” If a person missed a vaccine dose due to covid-19 they should take it at the earliest opportunity they get. A late vaccine is better than no vaccine.”

“An interesting thing about vaccines is that they sometimes show cross-immunity, which help you fight another disease for which it wasn’t even given. For instance, a study has already found that persons who have taken DTP vaccination have better immunity against COVID-19,” said Sequeira.

How Immunization changed after COVID-19

The immunization system is gradually recovering, and an improvement in the immunization coverage is being seen post the lockdown. ” In my case, I have also seen elderlies coming in for vaccination, which they did not generally take before, like the pneumonia vaccine, or flu spots. In the last few months, I have received several requests from patients who wanted the flu shot, even though it is something that is generally given at the onset of the rainy season, that is May or June,” said Sequeira.

The logistics and infrastructure of giving immunization have also changed drastically during COVID-19 times, and have been tailored to cater to the challenging health crisis that is looming large. According to UNICEF, some of the efforts to give a jump-start to routine immunization that the government has undertaken are: Catch up vaccine rounds for missed sessions especially for migrant families, to avoid overcrowding of immunization centres staggering the sessions, finding alternate immunization session sites where social distancing norms can be followed, and development of IEC material for awareness generation and mobilization of beneficiaries during COVID-19 and to maintain the confidence of the community in the immunization program.