Glitches in CoWIN also responsible for low COVID-19 vaccine uptake

Clubbing the problems with CoWIN into one phrase — vaccine hesitancy — is a convenient way to abdicate responsibility and deflect the blame for low uptake on the community. Despite the dry run across the country, CoWIN platform is still a work in progress with improvements and upgrades being made each day based on the needs of different areas and States.

There has been a low turnout of healthcare workers at over 3,000 COVID-19 vaccination sites across the country even a week after the massive exercise began on January 16. If vaccine hesitancy, especially in the initial days, may be the reason for the low turnout, the glitches in the CoWIN platform too contributed to that.

On January 16, the first day of COVID-19 vaccination in the country, at about only 1.91 lakh health-care workers taking the jab, only about two-third of the eligible people were vaccinated. January 17, a Sunday, saw very small numbers — 17,072 beneficiaries vaccinated in six States. Since January 18, the numbers per day have been slowly but steadily increasing — from 1.48 lakh on January 18 to 2.28 lakh on January 22. At the end of one week, 1.27 million were vaccinated, with the number crossing the one million mark on January 22 morning.

Ramp up the pace of vaccination 

With the majority of States vaccinating only on four days a week, with the most populous State Uttar Pradesh vaccinating on just two days, the pace of vaccination has to be ramped up, says Dr Rijo John, Health Economist and Consultant. “If only about two lakh people are vaccinated in a day, we’re looking at eight years to vaccinate even 20% of Indians with two doses,” says Dr. John.

“To vaccinate the original target of 300 million people with two doses each by end-August, about four million doses need to be administered per day for four days a week,” says Dr. John.

Vaccine hesitancy Vs glitches in CoWIN 

The major reason for low uptake has been vaccine hesitancy arising from short timelines for vaccine development and clinical trials, questions about Indian regulator’s approval process, data of the trials not being made public, and approval to Covaxin even in the absence of efficacy data. But the glitches in the CoWIN platform and the way it was programmed to assign people for vaccination may have also contributed much to the problem.

“I am not sure if vaccine hesitancy is a real big problem in India as it is projected to be. We are known for vaccinating millions of children and adolescents, a sensitive age group, yet there are no major vaccine hesitancy issues,” says epidemiologist Dr. Giridhara Babu of Public Health Foundation of India, Bengaluru. He had led the team of World Health Organisation’s polio eradication efforts as Karnataka’s senior medical officer and is a member of the Karnataka COVID-19 Technical Advisory Committee.

“I am hesitant in clubbing the problems with CoWIN into one phrase — ‘vaccine hesitancy’. This is a convenient term for those who have abdicated their responsibility and want to deflect the blame for low uptake on the community,” says Dr. Babu.

CoWIN is still a work in progress 

Discussing about the CoWIN platform, Dr. Babu says: “My own stand is that any technological tool should complement but not replace human interface or ignore India’s strength in vaccination programmes. The human interface is needed for improving confidence. Microplanning is a strength of the supplementary immunisation programmes.”

CoWIN platform, developed quickly, is a work in progress with improvements and upgrades being made each day based on the needs of different areas and States, he says. And connectivity issues too are affecting the platform. While the improvisation of the platform theoretically allows beneficiary registration, session microplanning, real-time reporting of vaccination and issuance of vaccination certificates, the real challenge arises in allocation of eligible people to a specific site on a particular day. “Allocation to a session site based on one’s institution of work or pin code is a complex process. This is probably the first time any country is deploying such software for vaccination campaigns of this scale,” says Dr. Babu. Incidentally, sending out SMS messages and issuing certificates soon after vaccination have been a challenge.

The CoWIN was supposed to have alerted people of the time and date of vaccination and also get a digital certificate following vaccination, which has not happened.

When people assigned to a vaccine site on a given day do not turn up, the platform was originally not designed to alert and invite others assigned on other days to receive the vaccine. “People are manually reaching out to others. The health ministry has now made it possible to add available people to an ongoing session and vaccinate them provided they are registered previously,” explains Dr. Babu.

Incomplete dataset and self-registration

But the bigger problem is that the registration of health-care workers on CoWIN is incomplete. “Many people practicing alternative medicine are not registered on CoWIN. And such people do not know how to register themselves for vaccination,” informs Dr. Babu. “Imagine the problem when we reach the stage of vaccinating of people with comorbidities, where data of such people is very sketchy.”

The platform now allows registration on the spot, which permits States to accommodate walk-ins. However, this message has not been widely communicated. “Many health-care workers are simply not aware that they can walk-in and register on the spot,” he says. The below tweet from the Health Ministry does not talk of walk-ins and on the spot registration.

Why uptake is more in Karnataka, Andhra Pradesh

Despite very less vaccine hesitancy generally seen in Tamil Nadu, the number of jabs at the end of one week stands at just about 48,000. At 1.82 lakh vaccinations as on January 22, Karnataka has the most number in the country, followed by Andhra Pradesh (1.27 lakh) and Odisha (1.21 lakh). Kerala has just recorded about 47,000 jabs even though the daily fresh cases reported are still high.

Explaining the reason for the higher uptake seen in these two States, Dr. Babu says: “In Andhra Pradesh and Karnataka, the administrators are continuously following up field templates and doing more sessions a day. Additional manpower has been deployed at the State and districts only for this. And district and State control rooms have been set up and co-ordinated each day at all levels.”

Heeding to demands from States such as Karnataka, the CoWIN software has been enhanced by creating more session sites, more sessions per site and change in site locations. “It now allows up to seven sessions per site. But running it in offline mode to vaccinate people and using the CoWIN platform to update the vaccine stock and list of beneficiaries whenever feasible can help in reaching more people in a short time,” says Dr. Babu. 

Take a leaf out of UIP implementation 

Despite not relying on an IT solution, India’s universal immunisation programme immunises millions of children each year. In January 2020, India achieved a record 90% coverage of all vaccines to be given in infancy. Are there measures that the COVID-19 vaccination programme can adopt from the UIP to improve coverage? “The Universal immunisation programme (UIP) and supplementary immunisation programmes (SIAs) (Pulse Polio or MR campaigns) have adapted polio micro plans,” says Dr. Babu. “These are prepared using the bottom-up approach from sub-centre to the primary health centre (PHC) to the district. The physical micro plan is prepared well in advance every year, updated, and implemented weekly.”

He then adds: “All planning in CoWIN is centralised at the district level. Instead, an approach similar to UIP can be adopted for the COVID-19 vaccination. Many of the States have physical copies ready at the PHC level and referring to them even now. The UIP approach needs to be refined to target adults across all age groups.”

Apparently, the UIP approach can be applied everywhere — urban as well as rural areas. “Rural areas have reasonable manpower. In urban areas, we need volunteers. This is how the supplementary immunisation programmes — Pulse Polio and MR campaigns — are implemented in India,” he adds.

Published in The Hindu on January 23, 2021