The problems with one-shot Covishield

NDTV quoted unnamed sources in the Indian government saying it will be conducting a study to assess the feasibility of deploying the Covishield vaccine in a single-dose regimen instead of continuing the extant double-dose regimen.

At any other time, such a statement may have been sufficient to believe the government would organise and conduct a well-designed trial, publicise the findings and revise policy (or not) to stay in line with the findings, informed by socio-economic considerations. But the last 15 months have thrown up enough incidents of public-health malpractice on the state’s part to make such hope outright stupid. I’m fairly certain, especially if the vaccine shortage persists and the outbreaks on an upward trajectory in some parts of the country at the moment aren’t tamped down quickly, that the government is going to conduct a trial, not publish its methods and findings and push through a policy to deploy Covishield as a single-dose shot.

Of course I would be happy to be proven wrong – but in the event that I’m not, I’m already filled with a mix of sadness and fury. The government seems set on finding new ways to play with our lives.

News that the government is going to conduct a feasibility study broke to the accompaniment of a suggestion, by NDTV’s same unnamed sources, that Covishield was originally intended as a single-dose vaccine and that it was later found to be better as a two-dose vaccine. This is ridiculous to begin with, considering Covishield’s phase 3 trials around the world, conducted by AstraZeneca and the University of Oxford, tested the two-dose regimen.

But it is rendered more ridiculous because Public Health England (PHE) reported just a week ago that two doses of Covishield are necessary for a recipient to be sufficiently protected against infections by the B.1.617.2 variant. The PHE study found that one dose of Covishield had an efficacy of 33% against symptomatic COVID-19 caused by the variant, increasing to 60% after both doses. Has the Indian government forgotten that B.1.617.2 is becoming the more common variant circulating in the country? Or is laundering the national party’s image more important than the safety of hundreds of millions? (The latter is entirely plausible: in the last seven years, the country has seldom been larger than the supreme leader’s ego.)

The PHE study isn’t without its shortcomings – but I’d be more inclined to pay attention to them at this moment if:

  1. I didn’t have to contend with the non-trivial possibility that the Indian government will bury, obfuscate and/or twist the data arising from its assessment, and therefore we (the public) need to bank on whatever else is available;
  2. I didn’t have to contend with the fact that data from Covaxin’s phase 3 trial (which apparently went past its final interim-analysis endpoint in April) and Covishield’s bridging trial (which IIRC concluded on March 24) are still missing from the public domain;
  3. If we could access large-scale effectiveness data of the two vaccines (the National Institute of Epidemiology, Chennai, is set to begin collecting such data this week); and
  4. If there was any other reliable data at the moment about the two vaccines vis-à-vis the different variants circulating in India.

There is another problem. If Covishield is administered as a single-dose vaccine, its efficacy against symptomatic COVID-19 caused by B.1.617.2 viral particles is 33% – which is below the WHO’s recommended efficacy threshold of 50% for these vaccines. If the Indian government formalises the ‘Covishield will be one dose’ policy and if the B.1.617.2 variant continues its conquest, will the vaccine, as it is used in India, lose its place on the WHO’s vaccine list? And what of the consequences that will follow, including other countries becoming reluctant to admit Indians who received one dose of Covishield and one dose of the BJP’s way of doing things?

I would be wary, too. The longer the particles of the novel coronavirus are able to circulate within a population, the more opportunities they will have to mutate, and the more mutations they will accumulate. So any population that allows the virus to persist for longer automatically increases the chance of engendering potentially deadlier variants within its borders. One-dose Covishield plus B.1.617.2, and other variants, will set just such a stage – compounded by the fact that Serum Institute, which makes Covishield, has a much larger production capacity than Bharat Biotech, the maker of Covaxin.

(The PHE study also found that Covishield and the Pfizer-BioNTech vaccine had an efficacy of “around 50%” against symptomatic COVID-19 caused by an infection of the B.1.1.7 variant.)

In fact, the government could have made more sense today by saying it would prioritise the delivery of the first dose to as many people as possible before helping people get the second one. This way the policy would be in line with the most recent scientific findings, be synonymous with a single-dose campaign and keep the door open to vaccinating people with both doses in a longer span of time (instead of closing that door entirely), while admitting that the vaccine shortage is real and crippling – something most of us know anyway. But no; Vishwaguru first.

A meeting with the PSA’s office

The Office of the Principal Scientific Adviser (PSA) organised a meeting with science communicators from around India on January 27, in New Delhi. Some of my notes from the meeting are displayed below, published with three caveats.

First, my notes are not to be treated as the minutes of the meeting; I only jotted down what I personally found interesting. Some 75% of the words in there are part of suggestions and recommendations advanced by different people; the remainder are, broadly, observations. They appear in no discernible order not because I jumbled them up but because participants offered both kinds of statements throughout. The meeting itself lasted for seven or so hours (including breaks for lunch and tea), so every single statement was also accompanied by extensive discussion. Finally, I have temporarily withheld some portions because I plan to discuss them in additional blog posts.

Second, the meeting followed the Chatham House Rules, which means I am not at liberty to attribute statements uttered during the course of the meeting to their human originators. I have also not identified my own words where possible not because I want to hide but because, by virtue of these ideas appearing on my blog, I take full responsibility (but not authorship) for their publicisation.

Third, though the meeting was organised by the Office of the PSA, its members were not the only ones of the government present at the meeting. Representatives of some other government-affiliated bodies were also in attendance. So statements obviously uttered by a government official – if any do come across that way – are not necessarily attributable to members of the Office of the PSA.

“We invest a lot in science, we don’t use it imaginatively enough.”

Three major science related issues:

  1. Climate change
  2. Dramatic consequences of our growth on biodiversity
  3. B/c of these two, how one issues addresses sustainable development
  • Different roles for journalists within and without the government
  • Meeting is about what each one of us can do — but what is that?
  • Each one of us can say “I could do better if only you could better empathise with what I do”
  • Need for skill-sharing events for science journalists/communicators
  • CSIR’s National Institute of Science Communication and Information Resources has a centre for science and media relations, and a national science library
  • Indian Council of Medical Research has a science communication policy but all press releases need to be okayed by health minister!
  • Knowledge making is wrapped up in identity
  • Regional language communicators don’t have access to press releases, etc. in regional languages, nor access to translators
  • Department of Science and Technology and IIT Kanpur working on machine-translations of scientific content of Wikipedia
  • Netherlands Science Foundation published a book compiling public responses to question ‘what do you think of science?’
  • In the process of teaching kids science, you can also get them to perform science and use the data (e.g. mapping nematode density in soil using Foldscope)
  • Slack group for science communicators, channels divided by topic
  • Leaders of scientific bodies need to be trained on how to deal with journalists, how to respond in interviews, etc.
  • Indian Space Research Organisation, Defence R&D Organisation and Department of Atomic Energy need to not be so shut off! What are they hiding? If nothing to hide, why aren’t they reachable?
  • Need structural reforms for institutional research outreach — can’t bank on skills, initiative of individual science communicators at institutes to ensure effective outreach
  • Need to decentralise PR efforts at institutions
  • People trained in science communication need to find jobs/employment
  • Pieces shortlisted for AWSAR award could be put on a CC BY-ND license so news publications can republish them en masse without edits
  • Please hold meetings like this at periodic intervals, let this not be a one-time thing
  • Issues with covering science: Lack of investment, few people covering science, not enough training opportunities, not enough science communication research in India
  • Need local meet-ups between journalists and scientists to get to know each other, facilitated by the government
  • Outreachers needn’t have to be highly regarded scientists, even grad students can give talks — and kids will come to listen
  • Twitter is an elite platform — science communicators that need to stay in touch need to do more; most science communicators don’t know each other!
  • Can we host one edition of the World Conference of Science Journalists in India?
  • What happened to the Indian Science Writers’ Association?
  • Today the mind is not without fear! The political climate is dire, people can’t freely speak their minds without fear of reprisal — only obvious that this should affect science journalism also
  • ISRO is a darling of the media, the government and the masses but has shit outreach! Rs 10,000 crore being spent on Gaganyaan but the amount of info on it in the public domain is poop.
  • CSIR’s Institute of Genomics and Integrative Biology is very open and accessible, director needs to be kept in the loop about some press interaction but that’s it; perhaps the same template can be recreated in other institutes?
  • Outreach at scientific institutions is a matter of trust: if director doesn’t trust scientists to speak up without permission, and if PR people don’t respond to emails or phone calls, impression is that there is no trust within the institute as well as that the institute would like journalists to not be curious
  • People trained in science communication (informally also) need a place to practice their newfound skills.
  • Private sector industry is in the blindspot of journalists
  • People can more easily relate to lived experiences; aesthetically pleasing (beautiful-looking) stories are important
  • Most people have not had access to the tools of science, we need to build more affordable and accessible tools
  • Don’t attribute to malfeasance what can be attributed to not paying attention, incompetence, etc.
  • Journalistic deep-dives are good but lack of resources to undertake, not many publications do it either, except maybe The Wire and Caravan; can science communicators and the government set up a longform mag together?
  • Create a national mentorship network where contact details of ‘mentors’ are shared and mentees enrolled in the programme can ask them questions, seek guidance, etc.
  • Consider setting up a ‘science media centre’ — but can existing and functional models in Australia and the UK be ported to India without facing any issues?
  • Entities like IndiaBioscience could handle biology research outreach for scientific institutes in, say, the South India region or Bangalore region with some support from the government. That would be better than an SMC-from-scratch.
  • Consider including science communication in government’s new draft Scientific Social Responsibility policy and other S&T innovation policies
  • Allocate a fixed portion of funding for research for public outreach and communication (such as 2%)
  • Need more formal recognition for science communication researchers within scientific institutions; members currently stuck in a limbo between outreach office and scientists, makes it difficult to acquire funds for work
  • Support individual citizen science initiatives
  • Need better distinction between outreach groups and press offices — we don’t have a good press office anywhere in the country! Press officers encourage journalistic activity, don’t just promote institute’s virtues but look out for the institute as situated in the country’s overall science and society landscape
  • Any plans to undertake similar deliberations on philosophy of science (including culture of research, ethics and moral responsibilities)?
  • Scientific institutions could consider hosting journalists for one day a month to get to know each other
  • What’s in it for the scientist to speak to a journalist about their work? Need stronger incentives — journalists can provide some of that by establishing trust with the scientist, but can journalists alone provide incentives? Is it even their responsibility?
  • Consider conducting a ‘scientific temper survey’ to understand science literacy as well as people’s perceptions of science — could help government formulate better policies, and communicators and journalists to better understand what exactly their challenges are
  • Need to formulate specific guidelines for science communication units at scientific research institutions as well as for funding agencies
  • Set up fellowships and grants for science communicators, but the government needs to think about attaching as few strings as possible to such assistance
  • Need for more government support for regional and local newspapers vis-à-vis covering science, especially local science
  • Need to use multimedia – especially short videos, podcasts illustrations and other aids – to communicate science instead of sticking to writing; visuals in particular could help surmount language barrier right away

The Indian medical devices industry stays foreign

India has a burgeoning medical tourism industry which, according to some estimates, is going to be worth Rs.9,500 crore in 2015 and Rs.54,000 crore in 2020. This industry evidently relies on medical imaging and diagnostics. According to an article published in 2013 by the Center for the Advanced Study of India at the University of Pennsylvania, over 75 per cent of India’s medical imaging equipment is imported, constituting a Rs.18,000-crore industry in 2011 and growing at a compounded rate of 16 per cent in 2010-2015.

There is an import duty on fully-finished devices averaging 10 per cent, which consumers pay. What is worse is that if device components are imported individually and assembled in India, there is an additional excise duty and VAT on the components, increasing the device cost. Therefore, taxation is not in favor of domestic production and against exports.

Another funny thing is that disposable medical equipment, which are technologically non-intensive, comprise less than 10% of our imports, i.e., we can locally produce the rest. Technology-intensive equipment make up around make up more than half of our imports, with the exception of X-ray imaging devices which comprise 25% of our exports. These are numbers from the Annual Survey of Industry, CMIE and the Department of Commerce (GoI).

The more some devices remain import-intensive, the more they could inflate healthcare costs in a country where only around 20% of it is publicly funded yet.

This seems a weird position to be in. On the one hand, we plan to expand our public healthcare system to more than 500 million people by 2020, and on the other, don’t reduce costs of the devices that will form the spine of this system. There was a situation in 2010, ahead of the presentation of the Union Budget, when the Department of Pharma sought a cut in the customs duty on some medical devices to facilitate imports while the Association of Indian Medical Device Industry sought a hike in the customs duty to promote domestic innovation.

Thanks to our population, per capita expenditure on medical technology is a frugal $2-2.5. This is an important figure because it highlights how lucrative the Indian market must seem like to giants like Siemens and GE. Further on the downside, urban centers are the primary consumers of high-quality, ‘high-technology’, high-price medical imaging/diagnostic equipment and implants. A July 2010 report from Deloitte explained this well:

One example to illustrate low penetration is sales of pacemakers. At 18,000 units per year, India’s pacemaker penetration is just 1% of western levels. According to Dinesh Puri, CEO, MediVed, India should be selling a million pacemakers a year, considering heart disease is a major killer in India.