 Hello everyone, good evening, good morning. I'm Sarisha Yadlapalli and I welcome you all to another episode of USP COVID Connect. Through this series, we have been speaking to various leaders and experts in the pharmaceutical and healthcare sector. We gather fresh insights on the challenges as well as potential solutions and best practices with respect to COVID-19. Today, we are very happy to welcome back Dr. Dagindip Khan, professor and head of Welcome Trust Research Laboratory at CMC Velour. Dr. Khan has spoken to our audience in an earlier episode of USP COVID Connect. We also welcome Dr. Geeta Prasadani, director of Public Health and Family Welfare Government of Andhra Pradesh. Dr. Khan, with decades of experience in vaccines, is known for her interdisciplinary research, studying the transmission, development and prevention of enteric infections in children in India. To develop practical approaches to support public health, Dr. Khan has also built various national rotavirus and typhoid surveillance networks. She's established laboratories to support clinical trials and conducted phase one to three clinical trials of vaccines, a comprehensive approach that has supported two WHO-qualified vaccines made by two Indian companies. She's seeking to build stronger human immunology research in India. Based at CMC Velour, she has established strong training programs for students and young faculty in clinical transitional medicine, aiming to build a cadre of clinical researchers studying relevant problems in India. Welcome, Dr. Khan. Our next speaker, Dr. Geeta Prasadani is the current director of Public Health and Family Welfare, the Government of Andhra Pradesh. She's also a gynecologist and obstetrician. She has 38 years of experience in the Public Health Department. Before becoming director, she was the state-level nodal officer for maternal and child health, communicable and non-communicable diseases, and integrated disease surveillance program. She's managed various public health emergencies in the state, swine flu, dengue, lead poisoning, and currently the COVID-19 pandemic. Recently, under her guidance, the state has completed 13.9 lakh vaccinations on a single day, the highest in the country. Her rich experience in implementing programs for communicable diseases, vaccinations, establishing IDSP labs, and coordinating with stakeholders like CDC, WHO, and extensive experience in engaging frontline public health workforce is most relevant for today's topic. Welcome, Dr. Geeta. So without further delay, I'll get to the first question for today's discussion. So India has seen several hugely successful immunization programs in his planned strategy to carry out these programs at the national level. I want our audience to hear from both of you today on the collective experience we have from running these programs. So maybe we could start with Dr. Geeta. So at the administration level, Dr. Geeta, could you share what are the typical challenges of a universal immunization program in terms of infrastructure or logistics or capability building? If you could elaborate on the typical challenges, that would be great. Sure. You're welcome. And the main challenges in the universal immunization program, in the beginning of this universal immunization, we used to have the challenges at the time of infrastructure regarding the establishing the cold chain points, and then the logistics and the way we have to get the vaccine, and all these things, we started this UAP program. But in our state of Andhra Pradesh, now we didn't have any of these problems. Now we are having sufficient cold chain points for even at the every BHC where we are rendering the services for the 30,000 to 50,000 population. And then the even at the sub-center level also where we have a stable in this cold chain points for the storage in Andhra. And the logistic point of ULO, we used to have the very good system of the storage from the state level to regional level, from the regional level to we are having the DVC, that is district vaccination centers. From there, we used to have the affluent seas and again to the CCPs. So regarding that, one more challenge is now and then everybody knows after the inception of the universal immunization program at 1985, we used to got so many new vaccines in the middle, so up to this time. At the time, capacity building, that is who are the workers, vaccinators who are on the continuous training of them. That is also one of the hurdles what we faced at the time. But any vaccine is when we are introducing into the public domain, then we have to give the capacity building of the all the frontline workers, we are going to have the vaccination. But in this COVID era, now we are able to do this sort of training, keeping in view of the COVID. We are now also, we are arranged all these trainings for our vaccinators by virtual trainings. We are now been able not able to take up the physical trainings, but we are able to do the virtual training before the vaccine. These are the some of the things for any universal program what you are doing. These are the main challenges. But we have in our state, we didn't have the resources everything is adequate. For that reason, only we have doing this COVID-19 vaccination in the same phase like that, without having any much difficulties. So from an infrastructure standpoint and logistic standpoint, a lot has been eased in the usual immunization. Okay, great. Thank you. Dr. Khan, from a policy standpoint, what are the typical challenges for a UIP program at the scale that India usually does these programs? Well, I think the first policy talent is really around the decision to introduce a vaccine. And in order to do that, the elements that need to be considered is whether there is sufficient burden of disease to warrant introduction of a vaccine for the entire population or for a population of interest. Then you need to know that there are vaccines that work and the efficacy of that vaccine is sufficient for you to be reasonably confident that it will alleviate a significant proportion of the burden of disease. And the third component is that the vaccination program needs to be ready and able to deliver the vaccine. So all the challenges that Dr. Gita just spoke about in terms of infrastructure, in terms of human resources, all of those need to be prepared before a vaccine is introduced. So those are policy challenges with making the decision to introduce. And then you have to think about whether you want to introduce country-wide or you want to introduce in specific areas what your justification is for that. Currently, of course, for COVID-19, we have an additional challenge, which is the shortage of supply. So that results in the need to prioritize and make decisions about who needs to get vaccine first and why. So right now, the decision making everyone's aware of what the prioritization framework is. It's one that WHO has also aligned with and was actually the first group to develop. But now there are discussions about whether we should be changing policy because with this policy was designed for an old version of the virus. Now we've got a virus that is behaving differently. So should we be thinking about a different structure to our immunization? The challenges don't stop. That's very useful. So when you were very much part of the ROTA virus, as part of the getting into the immunization program. So from then to now in terms of being able to add something to a UIP program, is it similar or are the challenges different each time? So ROTA virus was the last vaccine that was introduced country-wide into the routine immunization program. And before the ROTA virus vaccine was introduced, there was an assessment of the cold chain. And some states had gaps that needed to be addressed. In addition to that, India was at that time building the electronic vaccine information network that has now morphed into the COVID-like structure. So a lot of things were changed for ROTA virus. And this year, we are going to be expanding pneumococcal vaccine by the end of the year to every state in this country. So then our children will be getting vaccines comparable to vaccines that are received by children in many developed parts of the world. So I think what we have done with the immunization program is built capacity for new vaccine introduction. And again, as Dr. Gepa said, the infrastructure is there, the people are there, the constant training to which she referred is an essential component of us being able to bring in new vaccines. So I think if I talk about what has changed, it's the level of preparedness. I think we've just become a much better program over the last five years. That is so reassuring together. That's fantastic. So that brings me to our next question. So given all of this preparation and you mentioned cold chains and there were gaps in some states and we filled those gaps, what is the situation with the COVID vaccination drive in the country today? And maybe we start with under probation, ask Dr. Gepa, where is the drive today and what are the lessons that we have learned from the universal immunization program that have been applied to the COVID vaccination drive? This is what a very important thing. What we learned from the UAP, the lessons, what you have learned and how best we can use those lessons to improve the COVID-19 vaccination. What are the lessons we have and the meticulous planning also? Whenever we are having the micro-planning of routine immunization, because the universal immunization, as everyone knows, it started long back. It is a systematic customized training and UAP program where we used to get all the vaccines at the time, in time, and we used to regularly vaccinate the people in specific schedules. In every state, we used to have one day is a fixed routine vaccination program in the UAP on every witness stage is at the site and every Saturday is outreach. That is the thing. That is the systematic planning and the micro-planning where we have to do, that always helps us in connecting now the COVID-19 vaccine. In the COVID-19 vaccine, the people are different. As everyone knows, when we started this program on January 16th for the implementation of COVID-19 vaccine, the beneficiaries are almost at the other end of the ages. They are all given 30. At the time, the Ministry of Health has taken addition to give the vaccination for the frontline workers. In comparison with the UAP, most of the vaccines are more dense for the pediatric age group up to 11, like that, 12, like that. Then COVID vaccination, when we started, is a large campaign, first time at the time. That is the lesson what we have learned day by day when we are doing the vaccination for the COVID, so many things, what the planning of this thing and micro-class planning, and then continuous administration and the capacity building of the A&Ms who are the vaccinators at the field level. All these things, the lessons what we have learned from UAP is very, very useful and in implementing the COVID vaccination in a successful way. But now in Andhra Pradesh, COVID-19 vaccine already we have covered more than 1 crore people, 1 crore, 17 lakhs people, as on today. By then, that means one-fifth of our population is already covered. And I think in India also, it is 33 crores, 50 lakhs was covered in India whole. The AAP is having, this is as per the guidelines, the first when the vaccination has started in a phase-wise manner. In the beginning, we have covered the frontline for HLHCW, the healthcare workers. Then we shifted to frontline workers. Then again, we have gone to the 60 plus. After that, we have taken into the phase four, is the 45 plus with comorbids and without comorbids also. Now the government of India open up the vaccination for the 18 to 44 age group. In that also, keeping in view of the availability of the vaccine, now as in the Andhra Pradesh government, now we are focusing for the mothers who are having less than five children, less than five years children. Keeping on, someone as everybody knows, everybody is telling the third wave may, that may come and it affects mostly the children. For that sake, as in 18 to 44 age group also, now we are focusing for the mothers who are having less than five years children. Like that in state of Andhra Pradesh, the wax COVID-19 vaccination is going in a smooth way. Thank you, Dr. Vita. That was a lot of good information. So in summary, all of the planning preparation that was very systematic because of how we did the UIP programs basically helped in the COVID drive, the vaccination drive. Now there were issues related to availability, there are issues related to the rollout itself and maybe even some vaccine hesitancy that you may have come across. So amongst these three, vaccine availability, hesitancy and rollout, where were the challenges in the last three months maybe or last four or five months versus right now? So what are the challenges that were there last three, four months and today what do you face as a change? In the beginning what you are telling the first one is the vaccine availability is there, but at the time we have faced the vaccine hesitancy because it's a new vaccine and the people, the beneficiaries are not able to come what we have for the expectations. So immediately after the new vaccine has come and everybody's thought of it is in trials, something like that. The hesitancy has got a first thing and then vaccination was started in the month of January. After that what we have noticed, the lesson what we learned and everyone when we started to getting the frontline workers, all the emergent doctors and the professors who are working in the medical colleges and the people working in the medicine medical field, they have taken first and they become the role model and they have proved that nothing will happen if you take the vaccine also. Like that with a lot of IEC campaign and the behemoth campaign and not only that creating awareness in the people that is the what are the benefits if you take the vaccine. Like that. The IEC has come down so many beneficiaries coming forward now to have it vaccination on their own. Without we are having the mobilization also they are coming on their own to have vaccination. That is the number one. Number two is the vaccine availability. It should be continuous vaccine supply should be there. In the beginning we used to get so much a very minimum vaccine and then beneficiaries also now we want to have that is the vaccine availability. Continuous supply of vaccine availability should be there to cope up. Now and now we are able to cross that also. Recently what our state is receiving and once in a week or twice in a week now we are getting the both co-vaccine and co-wishing and one more thing when the beginning everybody wants to have co-vaccine only for the reasons. But after that because of our creating awareness that both are same and the duration and the efficacy what are the things what then the people are coming now for the both vaccines. Now the acceptability of both co-vaccine and co-wishing is also there in our state. So vaccine hesitancy that you've seen in the first few months has been overcome to a great extent you feel and the supply issue is also easing and you're able to get more supply. So those are all wonderful news to hear. I'm sure that's reassuring to a lot of our audience as well. My last question on this roll out is Dr. Dita the scale at which India does immunization programs is probably much larger than any place else even for our regular vaccine immunization programs. But with COVID-19 the scale at which India has to achieve vaccination to 70% is huge. So what specific issues do you see because of the scale of operations? There is no nothing much what I have seen that is the roll out is also becoming easy also because of our meticulous planning and the inter-departmental coordination and the micro planning also. Great thank you. Dr. Kang switching to policy level for a similar question this coming to COVID-19 vaccination drive. What is the situation today at a policy level? What do you think are challenges and what can be improved? Right now at the policy level in India we have multiple groups that are engaged in developing the policy and then overseeing it. So what has been in existence for a really long time is the National Technical Advisory Group on Immunizations and it's important to emphasize that the NTAGI which is a body that requires to exist in every country they call the NITAG elsewhere for National Immunization Technical Advisory Group has been in existence in India for about 20 years and it was reshaped in the early 2010s and has functioned to review and make decisions on the introductions of new vaccines. In other countries the programs also and how programs are implemented decisions are made around that. In India the NTAGI has been largely limited to just making decisions on introduction of new vaccines. So when COVID-19 came around a working group was established for COVID-19 specifically. The group is shared by Dr. Narendra Aroda who is I think President of In-Clent which is the International Clinical Epidemiology Network. He used to be a pediatric professor at INS. He's been very involved with many vaccine things. He chairs the meeting and he's also a member of another committee. It's called NEGVAC. This national expert group for I think for vaccine administration and that is shared by Dr. Vinod Khol who is the member health NETI IU. So NEGVAC is supposed to make the decisions about the actual vaccine administration whereas the role of NTAGI has been around things like the dose interval between vaccines and whether or not a vaccine should be introduced and also on what the priority groups should be. So sometimes NTAGI can recommend but NEGVAC does not necessarily need to accept that recommendation. NTAGI it's very important to emphasize is an advisory body and has no executive function whereas NEGVAC consists mostly of government officials and they are the ones who make the decisions about how implementation and administration will take place. So different aspects of policy looked after different. Thank you Dr. Khan. So that is probably a detail that a lot of our audience is not very aware of. So we're not aware of the structures of how these decisions get made. So it appears that it's a little complex the way they are structured in India because there is not a single body or a committee in charge of everything and there are multiple advisory bodies or multiple committees where these decisions are being made and there's been so much discussion on whether it's the interval between the two doses of COVID shield or whether it is just various aspects of how eligibility is being decided on who's eligible for vaccine when and the second wave has really exaggerated the kind of conversations we've been having in the country. So it's useful to know where these could be improved and what can be improved at a policy level so that the vaccination drive is faster and more successful in India. Oh absolutely. So I think in other countries where you have had where you have expert advisory groups who actually don't need the multiple additional structures that have been created. So for example, if the Joint Committee on Vaccinations and Immunizations in the UK makes a recommendation it's taken for granted that the recommendations will be accepted by the UK government because the UK government established this body. Similarly for the American Committee on Immunization Practices which is housed at the Centers for Disease Control and Prevention when the ACIP makes a recommendation and again its members are made up while the Secretariat is in a government organization, the CDC, the members of ACIP are actually independent and they vote to make recommendations and it's dependent on their votes that recommendations are made but once they are made by ACIP they are binding including to the point of insurance facilities needing to HMOs needing to provide the vaccines, insurance coming under the National Vaccine Injury Prevention Act to make sure that compensation is paid. So in most countries it is this advisory group that gives advice on policy after appropriate review and it's accepted by government and I'm also chair of the Immunization Technical Advisory Group for Southeast Asia for WHO. So I get to see the all 11 countries of CF operating and there are other countries also where the advisory group is not independent, is not the single group, Sri Lanka for example, their committee is entirely made up of government officials but they get informed by scientists. So I think there is a variation in how different countries operate and I guess the Ministry of Health and Family welfare must think that this approach is the best approach for India but it can be a little difficult sometimes when the science points in one direction and the policy goes in another direction. So I'll ask the same question I asked Dr. Geeta so from a policy standpoint between vaccine availability, rollout and hesitancy, why do you think more of the challenges are that need to be addressed at a policy level? I think the current challenge is supply and policy is not going to be able to ramp up supply in the short term. What needed to be done in terms of investing in companies or meeting purchase agreements should have been done a while ago. Now some investments have been made and we hope that supplies will improve in the latter half of this year. It's already evident that supplies are improving. We were able to give over about a hundred and fifty million doses of vaccines in June which is the best we've done so far. The fact that last Monday we were able to deliver eight and a half million doses of vaccine shows that the capacity to deliver vaccines exists. If there was enough supply we could ramp up but you know changing policy today will ramp up supply next year. Hesitancy I think is a problem tomorrow because right now from what Dr. Geeta said there was an initial reluctance because people were worried about vaccine safety where these vaccines tested adequately and now people are more eager to get the vaccines but the supply has been sufficient. But I think once you've finished about 60-70% of the population we are going to come up against hesitancy again because there are people who have been given a lot of misinformation, disinformation on WhatsApp, on all kinds of discussions and different forms of social media. There is information being circulated that actually sounds very plausible, sounds very scientific but it isn't and to counter that is very challenging because you need to be able to tailor your conversations to the community that you're dealing with, the group within that community that you're dealing with. You have to understand what their concerns are, you have to listen to them and you have to be able to convey information but not push them to make a decision. Like for example one thing that happens in our tribal areas quite frequently is that people are told if you're coming to the ration shop you're not going to get a TDS supply unless you've been vaccinated. Go bring your Aadhaar card get the vaccine then we'll give you your rice and sugar. That works for some people but doesn't work for the bulk of people. So I think the messaging, the communication is something we need to start paying attention to because with this vaccine remember this is adult vaccination. With childhood vaccination we managed to get to 90% coverage after 30 years of building the program. Now we want 85% coverage to be able to teach herd immunity but 85% coverage of the whole population means that every adult needs to be vaccinated because right now we don't have vaccine for under 18. So how are you going to distribute Aadhaar? That is going to be very very difficult. Excellent so supply continues to be the bigger issue at the moment and given that supply is the bigger constraint at the moment it brings me to the next question of vaccine wastage. So we really cannot, usually itself you know we should look at how to minimize wastage but in a supply constraint environment globally on vaccines and certainly in India we have to do everything in our power to reduce the wastage of vaccines. So I wanted to understand from both of you and maybe Dr. Geeta first how is wastage the concept handled during universal immunization program even before we talk about COVID vaccines. How is this concept thought about what are the trends about vaccine wastage? How are they handled and minimized during the immunization programs in general Dr. Geeta? Yeah what you are asking for the wastage of vaccine regarding in the universal immunization program also what I told in the beginning also this is only the micro planning and the supply of the vaccine in time at the UIP we never across the across the problem of the difference of the vaccination always the vaccine is in it is sufficient to vaccinate all the people there is no vaccines not available at any time and not only that we are having a fixed schedule on the days where we have done and we also know that who are the people what they are going to when they are going to get the vaccine in advance and we intimate them also even in the UIP also the children when we are having we are having a system of ASEAN A&M they know the who is the waiting list who are the due list for this week where we have to do the vaccination for the children like that we used to inform them in advance to get them vaccinated like that also we have taken the care of not to have the wastage much and one more thing what we observed from the this thing in the universal immunization program we used to have the open by the policy that is the vaccine when he is open it can be used for some other time like that also we used to minimize the vaccine compared with the covid vaccine when we are having the we didn't have that the vaccine is the WHO guidelines are like that when we open the while we have to discard after four hours after the vaccine while it's open in the covid vaccine also what we have done in the state of Andhra Pradesh is a meticulous planning and like that we have when what we observed in the beginning is the you observe you have noticed the wastage is more in our state of Andhra Pradesh but after lessons what you learn from the beginning and now what we are adapting is the quite different one now we have given the instruction for the vaccinators we have to open a while when it was the people are in fisheries are more than eight to nine people like that we have done and one more thing the state of Andhra Pradesh is where we are having a village level and what secretariat system is there where we are having one ANM is with us in the village secretariat and what secretary one volunteer is also like that so in advance whenever we are planning for any campaign organization regarding the covid we used to intimate the beneficiaries one day in advance by giving them time time slots because of covid we don't want to have the much congregation of the people and the waiting time is also to be minimized even when the summer is peak also then we have developed this all these things so we beneficiaries advance by giving their token system and timing just we want to give them sleep at this time on the token then you have to come and get vaccinated like that we have taken the so much of precautions Asha and ANM is also trained in such a way they used to they know their persons in name by name also they know them so who are eligible for that slot we used to call them at that time and then we have opened that while and we have as netted as per the schedule that means the 10 doses are like that so like that also would have minimized the vaccination and then in the uiP also that is the only meticulous and the inter-departmental coordination in state of Andhra Pradesh we have taken the other departments who are working with us that is especially the woman and child department the municipal administration and the administration and the district level where we are having the joint collective we are looking after the health policy all health also like that with their guidance and our this thing also we planned in such a way there is a maximum coverage minimum wastage that is our ultimate this thing we focused in such a way we want to cover as maximum as the people with minimum wastage now our wastage the AP state wastage has come down very much less than 2% or something like that except the steps taken by the state of Andhra Pradesh so it was quite concerning when we saw over 4 million dose wastage across the country by April's time frame especially because the supplies were not robust yet so it's really good to know Dr. Gita that there were analysis and understanding of what led to that sort of very high wastage in the initial parts of the vaccination program COVID vaccination drive and that they're being addressed at at the field level through all of these different tactics right so it would be great to see that number come down as you're saying thank you so much the Dr. Khan's reaching to policy level discussion on wastage what do you think generally for UIP the trend is on expectation on wastage ideas to minimize wastage and how does it relate to the COVID vaccination drive COVID policy COVID vaccination policy in India I think Dr. Gita has already highlighted what's done in the UIP in terms of having an open viral policy and the approaches that they have taken to make sure that every viral is fully utilized now if you wanted to have absolutely no wastage at all or minimal wastage the best way to do it is not to have multi-dose vials just have a single dose vial for everything that the problem with single dose vials is that it greatly increases the cost of your vaccine and it increases the amount of cool chain space that is required for the storage of the vaccine so you have to always balance how many doses you can get into a vial which drives down costs versus the question of wastage so in the UIP usually 10 wastage is considered okay you begin to worry if the program or parts of the program have a wastage of higher than 10 percent so by that account SARS-CoV-2 vaccination is doing really really well because we've managed to push down wastage even managed to extract extra doses out of multi-dose vials so I think we are doing a reasonable job with wastage but it's something that you need to keep your eye on and for the policy level ensuring that there is a tracking of and looking at best practice across is always helpful so Kerala was the first state that gave more vaccinations than the number of doses seed so that is something that I think other states could look at emulating and would certainly also drag down their wastage rates but it's also important to remember that not every state has the kind of dense population that Kerala had so there being able to gather enough people for an immunization session is here than let's say in a remote part of Andhra Pradesh. Thank you Dr. Kang we've seen some very heartwarming videos on social media with Asha workers carrying the waxing boxes and crossing rivers and little lakes and trying to get to very very remote parts so kudos to all the frontline workers and Asha workers and the program administrators for trying to do this and I would assume that in a place like that if you're trying to get every dose out of the vial you may not be able to have enough people to give it to so that makes sense so now continuing on the topic of vaccine wastage we wanted to bring up the concept of the open vial and Dr. Geeta was referring to it earlier on the number of hours the vial is considered viable so each time the government introduces a new vaccine there is a guidance on vaccine administration and how to handle the open vials which is essentially reuse of partially used multi-dose vials of applicable vaccines within a recommended timeline so this we understand is specific and differs for each vaccine based on the manufacturing and stability data available for that vaccine so whether it is for the immunization program or for covid this is how we understand the decisions are based but for covid we know that the manufacturing data submitted has actually supported six hours however the decision for covid vaccine has been made to four hours so we were wondering the possibility of extending time of the open vial from four to six hours based on manufacturing and stability data is that possible what are the challenges advantages or risks involved Dr. Kang. So I think with the stability data the door on extending how long a particular vial can be used has not been closed yet but what you really want is to be absolutely sure that under every condition not just the conditions that the company has used for stability data but in real world use what is the potency of the vaccines after being open for a period longer than you have had specified in the open vial now those are studies that need to be conducted and need to be conducted in real life I am not aware that this has been done as yet but certainly before we do an extension that's what would be required now also thinking about open vial policies and what the challenges are and why you might want to restrict it to a shorter time period is because you will worry about two things one is the body of potency if potency declines and the person is not getting as much of the vaccine as they think they are getting it's not a full dose of the vaccine because there has been some degradation then the problem is you haven't immunized a person so that essentially becomes a wasted dose the other thing that you worry about is in an open vial policy is the issue of contamination whether you have inadvertently needed a safety concern the longer that a vial is open and open is a relative term right it's not like you're lifting the lid off and leaving the lid off right you are withdrawing from a stop off but nonetheless because you've been in and out several times you do worry about potential for contamination and you want to try and minimize that because contamination tends to be fungus of bacteria and bacteria and bacteria have a short generation time so the longer your vial is open the greater your chance of introducing a contaminant and having it. Thank you Dr. Ganga follow-up question on that to our knowledge Covid-free serum institute has done the studies and we believe it supports our open vial stability if they were to submit that data would that be network or n-taggy how does it work in terms of who makes the decisions or is it confusing so n-taggy definitely does not make the decisions on the duration of the open vial policy so as I mentioned n-taggy's focus has really been around the introduction of new vaccines and not so much about changing of protocol much of this is decided within the immunization program about possible or not occasionally the ministry of health and family welfare may constitute an additional committee to look at specific aspects of the immunization program so for example the rotavirus vaccine was being introduced deciding on which were going to be the first states to introduce was there was a separate committee that was established to make the decision on which would be the first four states and then which would be the next set of states and the next set of states so these are ad hoc committees that are constituted for specific decisions on which the ministry might want an opinion thank you so there is one other aspect we've come across that some countries use maybe to reduce wastage which we feel syringes we understand there's not a lot of studies to support this WHO has not recommended it but we see several countries are using prefront syringes as a way to minimize wastage as a way to speed up the vaccination program what are your thoughts on prefront it raises the cost of the immunization so the basically what you're doing is packaging single doses as prefront syringes and that makes it much more expensive to be able to deliver the vaccine because those have to be kept separately and also the design of a prefront syringe has to be such that until you have the needle on you're not going to use anything that is in the from an economic standpoint it may not be viable for a country where we have a very very large scale immunization to be done right now that we are using are quite expensive already they are among the most expensive vaccines that we've ever had none of our immunization vaccines with the exception of HPV have been this kind of price before but the cold space arrangement the storage is also a lot of space compared with the vials because our cold ccps and the cold change system where we have storage of the vaccine is also we have to see that one if you give that three-field syringes like this it occupies a lot of space also in that one more thing what madam is telling the different temperature that is also there that is in my opinion in the pre-field syringes will be very expensive not only that but the storage is also a problem so it's economic cost but also from a logistic standpoint you're saying it requires a lot more infrastructure than we are probably we have we can create so thank you for that so I will request the audience to submit questions I think we're coming up to the last 10 minutes so if you have any questions you can type in the chat box meanwhile I wanted to just summarize a few things that I thought were very interesting takeaways that overall for the India vaccination programs we have built capacity over the years with the universal immunization program we have actually addressed gaps that existed in some of the states for instance for cold chain capacities so from a capacity standpoint by the time covid came around it appears that India is well positioned to deliver on vaccines because of the capacities created over a long period of time however given that supply is an issue right now and it is easing but it is still an issue we haven't really hit any problems at scale with covid vaccination drive but when we do overcome the supply issue we think that vaccine hesitancy might come up again right now there's a demand supply gap but when we get to 50 60 percent of the population vaccinated we may again come up with the issue of hesitancy because we have seen significant misinformation floating on whatsapp through twitter in fact some popular people have also started to say some things about vaccination covid vaccines that are untrue and may be giving a lot of credibility though so they make people question the vaccines which is unfortunate so there needs to be a campaign to address the hesitancy even though at the moment hesitancy is not an issue but India needs to start thinking about messaging and communication to overcome vaccine hesitancy for the last 30-40 percent of the population when supply eases up and regards to wastage we seem to be doing better than the usual universal immunization program where 10 percent is considered acceptable but with covid we had higher wastage in the first few months Dr. Dieter shared all the things that we're doing differently now to to improve on that which is fantastic I am looking at a few questions from the audience give me a second what if all the vaccines that are approved have the immunity for 8 to 12 months and if we are not covering 30 percent of our population by end of 2021 the entire population who got vaccinated will have to go for the next round much before the rest of the population who needs first dose of vaccination how is this going to be addressed considering current pace of vaccination and breaking upcoming covid waves can we consider this wastage maybe not about wastage but how do we address the immunity Dr. Khan so I think this refers to the fact that you may be wasting your entire vaccination drive if you can't cover enough of the population in time to induce protection before the next wave so I guess it's a fair way of defining wastage but I think where we are today on most scientific opinion is reaching to expecting longer than 8 to 10 months of protection it's possible that in some sub-populations the elderly the immunocompromised you may need to re-vaccinate earlier but in the bulk of the population I think that primary immunization series will protect us for a reasonable period of time so therefore even as the program is slower we will not be left unprotected when another wave comes we have questions Dr. Geeta how is each state managing such large-scale vaccine drive where almost 70 percent of the population has to be vaccinated with existing A&M Asha workers because we may not have been prepared for that level of scale Dr. Geeta because in the state of Andhra Pradesh we used to have there is no scarcity of the HR at all because we are having an ample of 42,575 Ashas and 18,000 people of A&Ms and there is a 13,000 of 30 A&Ms we are you are having a huge army of people where we used to use their services for that reason only we are able to cover most of the population. Got it and the next question for you Dr. Geeta with Aadhar being mandatory how is vaccine able to reach the underprivileged people like people on the street and those without Aadhar card? Yes that is the main challenge we have got it when we have started that one also but the people who are we didn't have the privilege of the Aadhar card that also we have taken and the government has taken a decision to show them not only the Aadhar card any evidence that is the other cards when they are having the ration card are like that also we used to take the help of that and we have vaccinated. Thank you the next question is with all the restrictions in travel physical training how are frontline workers adequately trained are they used to more face to face training and maybe Dr. Geeta mentioned you're adapting to virtual training yeah how have people really adapted to it are they able to understand and deliver what's required? For that reason whenever we are having a training classes and which are especially run by the virtual we used to conduct there's a pretest for their understanding level and after getting the training session also we used to take them off the post test also like that and not only that whatever the questions whatever the queries if there is we there are the people where we are having the coordination with the other people in the district we used to clear their doubts and practically we used to show them how to do it as a practically also if everybody should get vaccination that is the only one message to protect not only that even if they are vaccinated also we don't know how the when we are expecting we are also preparing to in a state of underposition every aspect of that when really somebody is telling that the possible third wave comes that how can we protect our people our children from that also. I think I echo doctor sentiments because I think that is the single most important thing that we should be doing now but as a society I think one of the things we have to think about is that we are global citizens and we have global responsibilities so once we have made significant progress on immunizing our own people given that we are one of the largest vaccine manufacturers in the world we should be sharing our vaccines with the world to make sure that everyone everywhere has the ability to be protected from SARS-CoV-2 this is our responsibility but it's in a way it's also a bit selfish because it's only by suppressing disease in other parts of the world that we ensure that new variants don't arise because variants will travel. That's an excellent note to end on Dr Khan in terms of we're not safe unless everyone is safe that which has been trying to stay this and we've seen a lot of countries are not yet sharing the vaccines but some countries have started to hopefully we we can get most global citizens vaccinated as soon as possible. Thank you so much for a wonderful helpful conversation with a lot of insights if we have more questions from the audience we're not able to answer today we'll try and share them offline. Thank you Dr Gita for taking the time and for being back with us on Covid Connect. Thank you so much.