August 13, 2021

Vaccine Uptake, Equity and Implications



The COVID-19 vaccination drive in India started on 16 Jan 2021 in a phased manner with healthcare workers and frontline workers. The vaccination policy has evolved since then, from regulating the number of doses available to private hospitals and prioritising different age groups, to increasing the time interval between doses. These shifts have affected vaccine supply and increased the time it takes to get fully vaccinated. Understanding their impact is critical for making the necessary course corrections to ensure coverage of all vulnerable groups.



We analyse the progress of vaccination achieved so far, the policy decisions accompanying the vaccination drive and related trends like coverage among different demographic groups, the load on health infrastructure and severity of the disease. 



Vaccine Uptake and Equity 


As of 19 July 2021, approximately 6.2 million doses have been administered in Mumbai. The highest number of doses have been administered for the age group 18-44 years and the monthly doses administered have increased 9x from June to July. From 1 June 2021, there was a policy shift from vaccines being provided by private players to the Centre providing them for this age group. This may have translated to the increase in dose administered.


However, the overall share of fully vaccinated people is the highest for age groups above 60 years; around 44% are partially vaccinated and 46% are fully vaccinated.  52% of citizens in the 45-59 cohort have been partially vaccinated and only 1% of the 18-44 cohort is fully vaccinated, with 31% partially vaccinated. The gap between partially and fully vaccinated individuals may be due to the increase in the time interval between the two doses of Covishield. 


In the initial months of the vaccination drive, the bottleneck was limited supply of doses. In June 2021, there was a policy shift and the vaccine uptake steadily  improved but the issues of digital divide, vaccine accessibility and hesitancy still remained. First, the system of booking appointments online requires people to have access to the internet and accurate information about registration, availability, etc. This limits the number of people who can get vaccinated easily. Second, vaccine accessibility has been a challenge due to supply constraints, lower number of offline registrations, inconvenient vaccination timings for professionals and daily wage workers, and vaccine centers distributed unequally across urban and slum communities in Mumbai. Lastly, according to a study conducted by a coalition of NGOs in urban slum communities in Mumbai, approximately 45% of the respondents were either not willing to or were unsure of getting the vaccine. The fear of side effects, misconceptions such as the COVID-19 vaccine altering DNA, the disease being an urban phenomenon and insufficient information have decreased vaccine confidence. 


The gender gap in vaccine uptake is also increasing in Mumbai. In April, 46% of the administered doses were for women and 54% for men. By 19 Jul, 2021, the ratios had shifted to 44% and 55% respectively.  The gender gap between men and women who have received at least one dose has increased from 8% to 11% in Mumbai as on 19 July 2021. In India, 47% of the doses were administered for women and 53% for men as on 20 July 2021. Hence, the gender gap is more prominent in Mumbai compared to the country’s average.The gender gap at the city and national levels does  not take into account the gender imbalance. A few reasons, apart from the skewed sex ratio (Mumbai City sex ratio is 832 females per 1000 males), for the gender gap could be the inability to access technology to register for the vaccines, inadequate information, not being able to go to the vaccine centres alone, needing permission from other family members to take the vaccine and myths about menstruation and infertility.


Implications of the vaccination drive 


One of the crucial effects of vaccination has been reducing  severe COVID-19, resulting in fewer Intensive Care Unit (ICU) admissions and lower case fatality rate (CFR)  in countries where a significant proportion of the population has been vaccinated. In light of this, we analyse how the ICU bed occupancy rate and CFR have varied as vaccination efforts have intensified in Mumbai.


ICU Bed Occupancy Rate 

The ICU occupancy rate started falling from 2 May, 2021 after a sustained period of high occupancy from 9 April, 2021 to 1 May, 2021. We must also examine other causal factors here. 


First, an increase in ICU bed capacity could have pulled down the ICU occupancy rate. However, we observed that the ICU bed capacity was not increased but rather reduced, with a lag of about five days, in response to the occupancy rate. Thus, change in ICU bed capacity has not been the driving force behind the falling ICU occupancy rate. 


Second, a decline in the total active cases could have also led to a decline in the ICU occupancy rate. The total active cases from 11 April, 2021 to 3 July, 2021, have indeed been on a downward course, and thus may have driven the decline of  Mumbai’s ICU occupancy rate.


Finally, the ICU occupancy rate began to fall in early May, when only about 15% of the population had received their first vaccine dose. Further, as of 19 July, 2021, 28% of the population is partially vaccinated, while a meagre 11% of the population is fully vaccinated. Immunisation coverage of 80-90% is required to see the benefits of herd immunity, and the current numbers are not significant enough to bring about a notable reduction in critical cases and ICU admissions.


Thus, it cannot be said that the upward trend in vaccines administered has been pivotal in bringing down the ICU occupancy rate. It is important to further ramp up vaccination efforts and address the concerns around vaccination hesitancy and lack of access.


Case Fatality Rate


The Case Fatality Rate (CFR) is the ratio of the number of deaths to the number of cases identified. The CFR  in Mumbai has seen a steady decrease since early last year, a trend seen in most countries around the world, and shows a significantly higher risk for older age groups (the groups in the graph are mapped to the age groups prioritised for vaccination.) Minor spikes were seen with routine reconciliation of data, but the downward trend has continued for all age groups. The decrease is more pronounced in the 40-60 and 60+ age groups. Multiple factors like effective treatment regimens and progress in vaccination may be responsible for the decrease in CFR.  


Policy and the way forward 


The initial phases of the vaccination drive prioritised sections of the population that are the most vulnerable to COVID-19 across age cohorts and have the highest risk of  exposure to the virus. States have also made specific exceptions for construction workers, election officials and journalists. As supply issues ease and systems are streamlined to ensure maximum capacity utilisation to administer vaccines,  the drive needs to further focus and prioritise certain sections of the population based on population density and geography. The allocation of vaccines at the ward level can be prioritised based on population density, slum population and mortality rate.  Vaccination of school teachers and staff can be prioritised to enable reopening of schools and colleges. In addition, monitoring and tracking is required as we vaccinate our population to understand its relation with parameters like CFR, ICU bed occupancy rate, severe COVID-19 cases, doses administered for various demographic groups, etc.


In addition, bridging the vaccine access gaps by having a mix of online and offline registrations, organising vaccination drives on suitable days in neighbourhoods will help boost uptake. 


Notes on data


The most widely used source of vaccination data for India is the CoWIN dashboard, which provides a variety of indicators including coverage by vaccine type, registrations and AEFI,  at the district level. The BMC dashboard has provided daily vaccination numbers for Mumbai from April 15, 2021. However, the data published by BMC does not match the data from CoWIN, possibly due to conflicting geographic definitions. Additionally, the data remained unchanged across consecutive days at the end of April, May and June, which could be indicative of no progress in vaccination or delays/issues with data updates. The vaccination categories used in the BMC data have also seen new additions (lactating mothers - 25 May 2021, International students - 6 Jun 2021, Physically Challenged Persons - 26 Jun 2021, Pregnant Women and Persons without ID covering prisoners, destitute persons and transgenders  on 20 July 2021) and modifications (International students category expanded to cover members of the Olympics contingent, healthcare and frontline worker categories are merged on 27 July 2020). Due to the dynamic changes in categories, data for the 18-44 age group is not  available in the report. These factors make a comprehensive analysis of the data much more difficult, and improved data quality (disaggregated, accurate, daily data) would go a long way in helping understand vaccine equity in urban India.


The BMC data covering administration and availability of vaccines is split into groups 18 to 44, 45 to 59 and 60+ years. This is different from BMC’s cases and deaths data which is available in 10 year increments ( from 0-10, 10 - 20, …, 90+). 


About the dataset 


The Brihanmumbai Municipal Corporation (BMC) started releasing a detailed daily PDF containing information on a variety of indicators such as mortality, containment zones, bed capacity, vaccinations, etc. from June 2020. Such data is extremely useful to formulate short-term policies and for assisting longer-term academic research. A long-standing issue with using the data, however, has been that the authorities replace the PDF each day with fresh information and remove the prior day's document. This practice has limited any kind of temporal analysis till now. 


At IDFC Institute, we have been able to gather all such PDFs from June 2020 until the present. We are in the process of converting all relevant indicators to a machine-readable output and will put them out as a public-facing database in due course. In the meantime, we will put out a brief analysis of them along with the related datasets.


In our previous posts, we discussed COVID-19 mortality data for Mumbai, COVID-19 testing datacontainment zones, spread across age and gender and bed capacities


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