The TLDR: The Prime Minister kicked off a four-day Tika Utsav in the midst of looming shortages of vaccines—and a rising tsunami of new cases. Dear rock, meet hard place. But how did we get ourselves into this impossible situation?

Rock: ever-rising numbers

The present numbers: As of Sunday, we added 169,899 new cases, and 904 new deaths. Our reproductive number is more than 1.53—as in, every 10 persons will infect 15 others. That number is as high as 2 in states like Jharkhand, Uttar Pradesh and Bihar—all of which have poor healthcare resources.

The projected numbers: Epidemiological models out of the University of Michigan suggest that we could witness between 180,000-300,000 cases a day by May, and daily deaths will be between 1,500 and 2,200. The lower end of the estimate is already looking overly optimistic. 

Leading epidemiologist Dr. Giridhar Babu estimates that by May 1, the total number of cases will be 17 million—compared to 13.3 million right now. Of the four million cases we add, around two million may recover—leaving us with 2 million active cases as of May 1. And here’s the big problem:

“Even if we assume that 5–10% of the cases are severe, we need 15,000–30,000 critical care beds (with oxygen) by May 1, assuming the trajectory continues as it is now, resulting in 300,000 cases each day. This will severely strain the health system, especially in areas that do not have robust infrastructure and human resources.”

Left uncontained, the second wave is expected to be bigger than the first—and perhaps more deadly.

And yes, it’s a variant: Other than the government, all health experts agree that the only rational explanation is the rapid spread of one or more variants. And the only reason we can’t be sure is because only 1% of all samples have been processed for genomic sequencing. So we have no clue which ones are more infectious or are able to evade the immune system. And most importantly, this:

“The more the virus replicates, the higher are the chances of newer mutations and development of more variants of concern. And more variants will certainly emerge due to the ongoing high circulation.”

Point to note: The ‘double mutant’ variant found in 20% of Maharashtra cases (explained here) now has an official name: B.1.617. Scientists involved in its sequencing say, “This is a homegrown variant and widely exported internationally”—including California. It has not yet been officially classified as a ‘variant of concern’—unlike the UK, South Africa and Brazil variants. But an infectious diseases expert in California says:

“The mutations are either identical or eerily similar to mutations in variants that we already know about that have been scientifically proven to be more transmissible and/or evade vaccines. Hence many believe that this Indian variant will also have these superpowers.”

Hard place: rising vaccine shortages

The good news: India crossed a major milestone on Saturday, administering 100 million vaccinations. And we did it in just 85 days—faster than the United States (89) and China (103). 

But, but, but: The number of doses administered daily had dropped sharply from 450,000 on Monday to 290,000 on Saturday. In fact, the numbers have been dropping steadily each passing day.

What’s in stock: According to the Health ministry, there are 35 million either in the pipeline or in stock. This would be the equivalent of 10-13 days of supply for the entire nation—and therefore, the government insists there should be no talk of ‘shortage’. 

Where’s the shortage? Here are the states raising the alarm:

• Punjab, which has only five days of stock.
• Rajasthan, Odisha, Jharkhand and Andhra Pradesh says it will run out in two days. Odisha has already shuttered 700 vaccination centres.
• Delhi says it has a week’s supply, while Chhattisgarh may be out in three days.
• The worst-hit is Maharashtra where dozens of vaccination centres have shut down due to shortages. Only 33,551 people could be vaccinated in Mumbai on Friday—down from a daily average 53,000. And statewide numbers fell precipitously from 430,000 to 300,000.
• There are signs of shortages in Madhya Pradesh and Uttar Pradesh (especially Ghaziabad), but they have not complained as yet.

Point to note: Government officials say, “At present the stocks are limited and the supplies are rationalised as per requirement. There is, however, no shortage.”

How did we get here?

There is a ‘demand side’ and ‘supply side’ answer to that question.

Increasing demand: In the early days of the vaccination drive, the government was only inoculating frontline workers—which was then expanded to 60-plus citizens and everyone with underlying health conditions. But when the criteria was broadened to include anyone over the age of 45, the pool of eligible people expanded dramatically.

Adding to the demand: The second wave which has dispelled widespread complacency—and any personal hesitation about being vaccinated. As long as the numbers were shrinking, everyone just assumed that India had dodged the bullet, and doing nothing was a viable option. But now the threat of spiralling infections has sent people running to get vaccinated. Just see the data:

• Between April 1 and 10, Maharashtra administered 3.17 million doses—a staggering 96.39% increase over the previous nine days. 
• The nationwide increase for the same period: 89.48%.
• Five of the six districts with the highest caseload are in Maharashtra. And the increase in the number of vaccinations administered is mind-boggling. In Nagpur, it was 209% higher than before!

The supply side problem: According to some calculations, the daily production capacity of the manufacturers of the only two available vaccines—Covishield and Covaxin—is roughly 24 lakh vaccines a day. The current daily demand: 37 lakh vaccines. That’s a huge gap, and it will grow along with the shortages unless we ramp up production. 

The big shortfall: Back in January, Serum Institute—which makes Covishield—said it would be able to supply 100 million doses to India per month. But so far it has only managed 65-70 million. One reason: A big fire at its facilities in January which affected its production capacity—even though CEO Adar Poonawalla flatly denied it would have any effect "due to multiple production buildings that I had kept in reserve to deal with such contingencies." 

Why this matters: In comparison to Serum, Bharat Biotech is a minor player, supplying only 6 million doses per month. So anything that affects Serum has a disproportionate impact on our vaccine supply. 

Also this: Serum has also taken orders from countries around the world—and has exported 30 million doses to Covax, a global vaccine alliance to help inoculate poorer countries. Experts say that vaccine makers "oversold" their ability to churn out doses both in India and overseas—creating “a mismatch” between their targets and actual vaccines supplied.

Point to note: There’s now a lot of grumbling about 64.5 million doses exported as part of our vaccine diplomacy initiative called Vaccine Maitri—including 10.5 million given as a grant, 35.7 million which were sold, and 18.2 million doses through the Covax alliance. But all such exports have been halted as of now. 

Of course, now these poorer countries—which are as much in need—are facing dire shortages of their own. And our neighbours—who have commercial contracts with us—are growing increasingly anxious, despite New Delhi’s assurances.

What’s the solution?

The solutions to the rise of cases are fairly straightforward: frequent genomic sequencing to identify and isolate variants; strict enforcement of social distancing; accelerated vaccinations; and better data transparency (and honesty). 

As for ramping up vaccine capacity, the experience of the UK and Israel suggests we have to vaccinate at least 25% of our population to stem the second wave—which is around 350 million. That gives us a target of around 5 million a day. So how do we get there?

One: Give lots of money to Serum which says it needs bridge funds to ramp up production— Rs 30 billion in government assistance or bank financing. The reason: It isn’t making enough of a profit on its sale price to the Indian government (which is Rs 210 per dose). Also this: "This [revenue shortfall] was not budgeted or planned initially because we were supposed to export [more] and get the funding from exporting countries.” In any case, Serum plans to meet its original target of 100 million doses per month in May, while Bharat Biotech will up its capacity to 15 million.

Two: Put more eggs in other baskets: 

“[A]ccelerate approval of some of the vaccines in use in other countries, including those from Pfizer Inc., Moderna Inc. and especially the logistically easier, single-shot Johnson & Johnson vaccine. If those companies can’t expand production quickly enough, the government should pursue licensing agreements to make their vaccines in India.”

Point to note: Johnson & Johnson is still waiting to get the nod for bridge trials—limited human trials to prove safety and efficacy in India. The Russian Sputnik V may get the nod for emergency use. Serum expects to roll out Covovax—which is the Indian version of the US vaccine Novovax—in September. Pfizer withdrew its application after facing numerous demands from the vaccine approval authorities last December. Moderna has no plans to enter the Indian market as of now. 

Three: Allow direct import and sales to the individual consumer of a wide range of vaccines at a higher price—especially since foreign vaccines are too expensive for the government to purchase and distribute (for free or otherwise). Allowing companies to profit helps them make the money they need to expand production.

Four: Leverage the buying power of private individuals and companies:

“Millions of Indians can afford to pay for faster access to vaccines, maybe hundreds of millions since private companies are keen to vaccinate their employees and charitable institutions have pledged large amounts to support the effort.”

Five: Since there are limited supplies in the short term, we can focus on where there is the greatest need: “Make everyone above 18 eligible for vaccination in states experiencing the surge, while staying with the 45 plus eligibility in states not experiencing the surge.”

The bottomline: The vaccination campaign is structured around giving the government total control over who is vaccinated, where they are vaccinated, and when they are vaccinated. This may have worked if the government had planned carefully for each contingency at each stage of the rollout. It has not. 

Reading list

BBC News has the best reporting on the shortfalls on the production side. Mint has an excellent piece on how to fast-track our vaccination drive. Also in Mint: What went wrong with phase 1 and 2 of the vaccination campaign. The Telegraph looks at how many vaccinations will turn the tide. Dr. Giridhar Babu co-wrote this News18 piece on how to battle the second wave, and did this informative interview with The Hindu. A good watch: Dr. Brahmar Mukherjee speaks to Karan Thapar on the trajectory of the second wave.