28 March,2021 06:36 AM IST | Mumbai | Anju Maskeri
An elderly woman poses for a photograph at a kiosk after getting inoculated with the Covid-19 coronavirus vaccine in Mumbai. Pic/AFP
In January, when the Coronavirus inoculation programme rolled out for frontline workers, Dr Vivek Talaulikar, CEO - Global Hospital, realised that they will need to start using the vaccine vials judiciously. "We learnt on the very first day that opening too many vials at the same time could lead to wastage," he says. Each vial typically holds 10 vaccine shots or 0.5 ml each. And each vial must be utilised within four hours once opened.
Currently, this Parel-based hospital has three booths operational for vaccination. At 5 pm every evening, when the crowd begins thinning, they shut two booths and operate one. To utilise excess doses, messages are circulated among staff groups to put in a request if someone would like to get vaccinated. Workers have been instructed to give vaccines to people who have registered, but are on the waitlist to minimise the chances of vaccines being discarded. "The staff coordinates to understand how many more shots are remaining in existing open packs. A new pack is opened only if the footfalls increase by 10 during the last hour before closing the booth." Details of the recipients are tracked through the CoWin app to evaluate if they are due for the second dose. Every day, the hospitals and COVID-19 vaccination centres need to submit a report of the number of people who have been vaccinated to the Brihanmumbai Municipal Corporation (BMC).
Dr Talaulikar claims they haven't returned a single vial to the BMC, ensuring zero wastage.
But, this is not the case everywhere. Wastage of one of the most precious commodities the world over - the COVID-19 vaccine - has been a recent topic of discussion in the medical fraternity. The poor performance and wastage by some states in India was flagged off in a meeting between Prime Minister Narendra Modi and the chief ministers. The PM is believed to have asked the states to take the matter seriously. Every state must review the reason behind the waste and end of day monitoring should be a must, he stressed. Union health secretary Rajesh Bhushan shared details that showed that in certain states the vaccine wastage percentage had exceeded the national average of 6.5 per cent. Telangana is the worst performer at 17.6 per cent, followed by Andhra Pradesh at 11.6 per cent. Jammu and Kashmir (6.6 per cent), Karnataka (6.9 per cent) and Uttar Pradesh (9.4 per cent) have also fared poorly. Himachal Pradesh, at 1.4 per cent, on the other hand, is wasting the least vaccine doses. The permissible wastage in most vaccines administered under the Universal Immunisation Programme (UIP) is 10 per cent except in the case of BCG, Measles-Rubella (MR), and Japanese Encephalitis (JE) vaccines. The Centre has, in its vaccination guidelines issued to states, said that all opened vials should be used within four hours. Because the vials lack preservatives, leftover vaccine from different vials can't be pooled due to fear of cross-contamination. If not used, the opened vials should be discarded at the end of the session, the guidelines stated. The ministry, has arrived at a Wastage Multiplication Factor of 1.1 for COVID-19 vaccines. If 100 people have to be vaccinated, 111 doses are required as per this formula.
One reason for the wastage could be that the initial enthusiasm and excitement to get the jab is slowly waning, resulting in fewer footfalls. Given the sudden surge in infections in Mumbai, Global Hospital, which is currently providing only the Covishield vaccine, is contemplating extending the vaccine hours from 9 am to 9 pm. "We are doing our backend planning of allotting the required number of staff for this, and hopefully in the next 10 to 15 days, we will be open for longer hours," Dr Talaulikar says.
Incidentally, the situation at the state-run JJ Hospital at Byculla is quite the opposite. Dr Lalit Sankhe, nodal officer for the vaccination centre, says wastage was higher in the case of Covaxin as each vial of the Bharat Biotech vaccine had 20 doses, unlike Covishield where you can administer 10 doses per vial. "They [Covaxin] have now reduced it to 10 doses per vial, because 20 doses becomes too much if the turnout is not upto expectation." Dr Poornima Dhake, medical officer at Kalyan-Dombivli Municipal Corporation (KDMC), faced a similar situation in the initial days of the vaccination drive in her ward. "Barely seven to eight frontline workers would turn up, so wastage was bound to occur. We had to work hard to get people to sign up. But now, things are looking up. We have at least 200 people come in daily. We make a rough estimate of how many vials to use based on the previous day's turnout." To preempt cases of breakage or mishandling, only one vial is opened at a time. The current batch of vaccines that JJ has received will expire in July.
"To be honest, Maharashtra has fared well in terms of keeping vaccine wastage under control. Before the inoculation drive, we were given thorough training by the state and district level officials through Zoom sessions on handling vials and syringes, safe injection practices, what to do in case of AEFI (adverse effects following immunisation), waste disposal and cold chain maintenance; in fact, each person's responsibility was discussed at length," says Dr Dhake.
Pic/Pradeep Dhivar
According to experts, vaccine wastage could occur in unopened vials as well as opened vials. Reasons range from refrigeration (cold chain) lapses, followed by expiration to breakage and exposure to heat. The World Health Organisation estimates that more than 50 per cent of vaccines may be wasted globally every year because of temperature control and logistics and shipment-related issues. According to Dr Naveed Shah, Professor and Head, Chest Medicine, Government Medical College, Srinagar, the major reason for wastage in the state is the non availability of candidates. "Usually at high volume places, there is little wastage because the footfalls are good. I feel there's little scope for human error in this. The injection that we have to use has been specifically made for this. If we need to take 0.5 ml out of the vial, it will be logged at that amount. So, there's no chance of somebody pulling out more than the required quantity."
At the vaccination session site, the operation guidelines state that each vaccination session will be expected to cater to a maximum of 100 beneficiaries; however, in the case of sparsely populated areas, the state could organise sessions for a lower number of beneficiaries ensuring that there is no
vaccine wastage.
Dr Dhake says that they are mandated to provide daily data on the number of vials issued, used and returned to the health post. It's accountability that has ensured that dose information is systematically captured.
The number of vaccines issued to each centre depends on its size. Dr Satyendra Nath Mehra, Medical Director, Masina Hospital, Byculla, says the BMC had offered a maximum of 300 vials to them at one time and replenish it as needed. They make it a point that every time a vial or new batch is opened, the date and time is recorded and tallied at the end of the day. "Till date, that is, in the last 18 days, there have been five doses of wastage (half vial); two doses on the first day, two on the second and one on the third." If excess patients turn up, the doctors request them to come the next day and take them up for vaccination on priority. At Masina, all unused, open and empty vials are returned to the BMC.
Dr Jayaprakash Muliyil, Chairman of Scientific Advisory Commission and National Institute of Epidemiology, says a little spoilage is only natural during mass inoculation programmes. "In fact, wastage is anticipated during the manufacturing process itself. It is an issue with these multi-dose vaccines. Once pharmaceutical companies start manufacturing a vaccine, it's not expensive.
That said, of course wastage should be reduced and disclosed when it happens."
17.6 vs 1.4
Percentage of wastage in Telangana versus the best performing Himachal Pradesh
Masood Mallick is the Joint-Managing Director at Ramky Enviro Engineers Pvt Ltd that specialises in waste management. The firm is currently helping hospital administrators in 35,000 healthcare establishments across India to deal with the waste. "The COVID related waste, which includes vaccine syringes and vials, is bagged at the point of collection. There is a federal guideline on how to manage this. This is potentially infectious waste, and there is legislation in India on how to manage it because it is highly contagious. Our experts are ensuring that COVID-19 waste is packaged securely, tagged and carried in separate vehicles and incinerated at 1050 degrees Celsius as soon as the designated waste vehicle reaches the treatment facility." He says there is a chain of custody involved, which means once the batch is burnt, the chain of custody ends and the waste details are then sent to the Pollution Control Board. The quantity of COVID-19 waste is reported separately on an online portal that the government of India has created. "The purpose of doing this is to ensure that there is one federal database or only source of information that is officially mandated."
Deliveries of COVID-19 vaccines, produced by the Serum Institute of India (SII) to lower-income economies participating in the COVAX Facility (a global project to ensure equitable distribution of vaccines), have faced delays this month and could be delayed next month too. This is because India is battling a second wave and has ramped up its own vaccination drive. COVAX and the Government of India are in discussion to ensure some orders are completed in April.
Data in percentage as per Union Health Ministry
WORST PERFORMING STATES
Telangana 17.6
Andhra Pradesh 11.6
BETTER PERFORMING STATES
Maharashtra 5.2
Himachal Pradesh 1.4
INDIAN STANDARDS
Permissible limit 10
Survey Source: Ministry of Health and Family Welfare
