VACCINE ACCESS INITIATIVE (VAI): EXPANDING VACCINE ACCESS TO COMBAT LAST MILE DELIVERY CHALLENGES

                                                   – AN INITIATIVE BY LIVER FOUNDATION, WEST BENGAL AND COVID CARE NETWORK, WEST BENGAL

PROBLEM STATEMENT

Despite the emergence of variants and the uncertainties around the prevention of infection transmission, vaccination has emerged as a key intervention in preventing severe novel coronavirus disease (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)1. Since early January 2021, two vaccines have been approved for emergency use by the Indian drug regulator, Central Drugs Standard Control Organization (CDSCO), headed by the Drugs Controller General of India (DCGI) – the Oxford AstraZeneca vaccine, manufactured in India as Covishield™, and Bharat Biotech’s Covaxin™, an indigenous product developed in collaboration with the Indian Council of Medical Research (ICMR)2. Subsequently, Sputnik V™, the vaccine produced jointly by Dr. Reddy’s Laboratory and Sputnik LLC, was also accorded emergency use for deployment in India. Despite the rapid scale up of the vaccine program, and a stage-wise priority for roll out of vaccination, a combination of factors has hampered the universal access to COVID-19 vaccines, especially in highly vulnerable groups, residing in areas with lower service outreach.

Evidence from high-income countries, with a high proportion of elderly respondents, has shown that there are multiple age-related determinants which hamper vaccine acceptance3. A global survey of vaccine acceptance revealed that elderly people recognized the potential risk that COVID-19 posed to them, and were more open to the idea of accepting an appropriate COVID-19 vaccine4. However, it is well established that despite higher desire to receive vaccinations, elderly populations generally have lower access to vaccination programs and have lower vaccination coverage rates5. This is especially true for people living alone, or having physical or mental disabilities, or other comorbidities6. In addition, evidence from both high and middle-income countries have shown that the digital divide has hamstrung elderly individuals from accessing vaccine products effectively7–9. This gulf is likely to be wider in India, especially in rural India, where the mandate of using COWIN app-based approach might discourage a segment of the society from accessing vaccination programs readily10.

Further, evidence indicates that vaccination programs, which are not sensitive to the plights of elderly individuals, can often exclude them from actual vaccination, despite a policy recognition that the elderly need to be prioritized11. These issues were further complicated by the vaccine hesitancy during the early stages of vaccine roll out, especially in the rural areas, where the elderly have continued to experience multiple barriers to vaccine access. Going forward, as the government mandates include younger people within the eligibility criteria, COVID-19 vaccine access will become harder for elderly groups.

In addition to the issue of elderly and differently abled whom LFWB  target as the initial group , other potential groups that have social vulnerability , exclusion and marginalization ( Hawkers, street vendors , unorganized sector workers )  as well as physically located in areas that are relatively difficult to access / relatively less addressed by health systems (Sundarban area ) will be in LFWB focus , as vaccination evolves.   

The Government of India  program for vaccination , as of now , is aimed at reaching out to every citizen of the country above 18 years after 20th June with a space for private sector vaccine distribution at a price that is capped . Within this framework of vaccination, the states have their liberty of deciding on delivery group priorities.   

Given these issues, we anticipate that despite increased risk of suffering from severe disease and death from COVID-19, unless systematic steps are taken to address vaccine access issues affecting elderly people residing in underserved areas, the vaccine coverage gap in this age group will continue to widen. In this proposal, we outline an innovative Vaccine Access Initiative (VAI), which will accelerate and expand vaccine coverage, targeting elderly individuals, utilizing a community-driven, bottom-up approach.

PROGRAM CONCEPT AND OBJECTIVE

The VAI program proposes to bring vaccination services to the doorsteps of elderly individuals who are indigent or have other disabilities barring them from accessing vaccination services through the usual mechanisms. Given that the barriers hampering elderly individuals from accessing vaccination programs in the West Bengal setting are well-understood, we propose creating a program that leverages the strengths of a community-based approach, and breaks down these barriers. We propose creating mobile units which would serve as “Vaccine Voyagers” and provide vaccination services to elderly individuals at their doorstep. The program will be deployed through a VAI team, comprising of VAI coordinators (c-VAI) and VAI vaccinators (v-VAI), along with other support members, such as drivers and local volunteers.

The main objective of the first phase of the VAI program, as outlined in this proposal, is to pilot test the mechanism of “near to home vaccination efforts” in order to provide COVID-19 vaccine coverage to individuals aged over 70 years of age, and residing in underserved areas of specific districts. We also envision delivering at least 30,000 doses of vaccines during the  SCALED UP PHASE  of this proposal( Ten districts , selected based on NGO linkages and resource constraints ), after an initial pilot in three districts ( Darjeeling, Purba Bardhaman and Paschim Bardhaman)   . In case the pilot test is successful, we propose scaling up the program to a wider geographic ambit, covering a larger age group of elderly and vulnerable individuals who have been deprived of access to COVID-19 vaccines through the conventional mechanisms.

IMPLEMENTATION PLAN

The VAI program will be deployed through modular, vehicular units. Liver Foundation, West Bengal (LFWB) will be the nodal agency and it will organize peripheral implementation through coordination with NGO, CBO and other local organizations with whom LFWB HAS ESTABLISHED CONTACTS AND WORKING TOGETHER ON OTHER COVID PROGRAMS .    

The basic VAI team will comprise of 2 VAI coordinators (c-VAI), 2 VAI vaccinators (v- VAI) and transport crew comprising of a driver with a 4x4 wheel drive with option of air conditioning. C-VAI will be responsible for coordinating with the local partners and government stakeholders as well as data entry in the Co-WIN portal. v-VAIs in the unit will be authorized vaccinators, who will provide the vaccine (inject). The daily estimate is to provide 120 vaccine shots per day per VAI unit. The mobile VAI unit will be monitored and coordinated by a Central Coordinator (CC). The CC will also act as a liaison between VAI and district authorities.  Local members of CBOs will be engaged in outreach activities and local logistics.

In the proposed first phase, the VAI efforts will provide services to any individual aged above eighty years, or any elderly individual who is socially, economically or physically vulnerable or challenged or otherwise marginalized. This would include people living with physical and mental disabilities as well. Local microplans will be created with inputs from community based organizations (CBOs) with on the ground presence.

Every individual who received vaccination, will be observed for a period of at least 30 minutes after vaccination to observe for and manage any vaccine reactogenicity. All v-VAIs will be trained in the techniques of safe and aseptic vaccine delivery, and management of common post-vaccine local and systemic reactions. The vaccinees will also be counseled about the known and expected local and systemic reactogenicity issues, such as injection site pain, erythema, induration, fever, and myalgia. They will also be advised about the next steps they should take should such symptoms emerge based on the severity of symptoms.

The involvement of the local CBOs or other organizations, such as clubs or youth groups, will be leveraged to ensure that appropriate norms of physical distancing, masking, and hygiene, including crowd control, are conducted to ensure that the vaccination program is undertaken in keeping with all the rules and norms prescribed by the government agencies. All volunteers will be trained to provide these support services in a compassionate manner while dealing with the senior citizens and elderly individuals.

The program will be scaled up in a phase-wise manner. It would initially be deployed in the districts of Darjeeling, Siliguri, Purba Bardhhaman and Paschim Bardhhaman. The specific areas within each district, which would be served by this program would be identified in consultation with local health and general administration officials, in line with the directives issued in favor of the Liver Foundation West Bengal vide memo no. HFW-35099/108/2021/648(4), date June 9, 2021.

The requisite vaccine doses would be provided by the government through its existing stock. All necessary training of VAI staff required for deploying the vaccination efforts would be provided through the Dept of Health and Family Welfare, Govt of West Bengal. These commitments from the government ensures the sustainability and quality assurance of the proposed program. However, the current proposal seeks to raise funds to support the other aspects of deploying this program, such as staff, vehicles, consumables, and other local costs. The VAI staff and local coordinators required for the deployment of the initiative would be sourced by the implementing partners (Liver Foundation, COVID Care Network and local partners/clubs/CBOs). Consumables, vehicles, and other logistics, including costs related to local vaccine program deployment would be sourced through the implementing partners as well. The detailed funding requirement are outlined in the budget section below.

EXPECTED OUTCOMES

The VAI program is targeted to cover elderly individuals, especially those who are indigent, have physical or mental comorbidities which preclude them from participating in ongoing vaccination programs, or are socially, economically, or otherwise vulnerable and are unable to access COVID-19 vaccination programs with ease. The VAI program will help to bridge the gap and enable these excluded, but high-risk groups, to access vaccination services.

It is expected that we would be able to deliver 120 vaccine doses per mobile unit, per day. Considering an initial intense phase of activity of 30 days, with 10 mobile units in service( in different districts in scaled up phase) , we can provide a first dose coverage to 120*10*30 or 36,000 elderly individuals.

The proposed activities leverage government agencies and offices, NGOs and CBOs, and local volunteers, and brings together this tripartite collaboration, using community-driven, people-centric, and bottom-up principles of engagement, to deliver a life-saving intervention to the people that need it the most. While undertaking a formal impact evaluation of such a program might be difficult considering the current pandemic situation, the activities fall under a public health good and will contribute to prevention and control of the spread of COVID-19 thus helping to open up our societies and economies in a safe and responsible manner. If the initial experience of deploying the program in a limited scope is successful, we will, in a phase-wise manner, propose further scaling up of the efforts, especially to cover other age groups and a wider geographic scope.