World's largest vaccination drive in India: Challenges and recommendations

GMERS Medical College, Gandhinagar, Gujarat, India Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa School of Health and Related Research, University of Sheffield, Sheffield, UK Bhaskar Medical College, Hyderabad, India Medical Research Center, Kateb University, Kabul, Afghanistan Global Health Focus Asia, Kabul, Afghanistan Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK Faculty of Management and Development Studies, University of the Philippines (Open University), Los Baños, Philippines

Workers (FLWs), followed by citizens more than 45 years of age and eventually citizens more than 18 years of age. 2 This requires registration on a digital platform called COVID-19 Vaccine Intelligence Network (Co-WIN), after which information of the vaccination site to visit and time will be shared with the beneficiary. The number of individuals who receive vaccine doses is tracked on this system. 2

| GAPS AND CHALLENGES IN INDIA'S COVID-19 VACCINE DRIVE
Globally, India has the potential to produce 60% of the vaccine stock. 3 While the Government plans to inoculate around 300 million individuals of the priority group in the initial phase, 2 the problems rarely revolve around production; instead, they center on equitable distribution. According to the World Bank, India's rural population of 895 million accounts for 65.5% of the total population. 4 The ultimate goal should be to ensure that this vaccination drive is accessible to these rural populations, many of whom reside in remote villages and are often neglected. While COVID-19 does not discriminate, society does.

| Logistical and administrative requirements
India has instituted extensive Universal Immunization Programs (UIPs), notably in the field of polio. 2 Yet, the lack of sufficient distribution of cold chains across different states of India poses the most significant challenge. Out of India's 29 000 cold chain points, 52% are concentrated in just six states, accounting for a third of the population: Maharashtra, Karnataka, Tamil Nadu, Rajasthan, Gujarat, and Andhra Pradesh. 5

| Vaccine hesitancy, misinformation & distrust
The spread of misinformation, particularly in India, is one of the biggest challenges for the COVID-19 vaccination drive after cold storage and other logistic concerns. Globally, the rise in the misinformation during the COVID-19 pandemic is evident, prompting WHO to convene the first infodemiology conference. 11 The COVID-19 pandemic has shown widespread misinformation than any other pandemic or epidemic in the past, especially with the rise in the content available on multimedia platforms. 12,13 After India's first reported case in January, major communication channels flooded with an infodemic of fake news regarding every facet of the pandemic, from its origin to its cure. In an analysis by Boom, a fact-checking organization, out of 178 fact-checks, 35% of them were fake videos and 29% of misleading images, exposing doctored information on a range of issues such as fake diagnosis and cure, falsified quotes by famous personalities, tailored guidelines, and promising home remedies among other. 14 Misleading information specific to a particular religion is also rampant in India, where majority of the population practices Hinduism (more than 80% of the total population), followed by Islam (more than 13% of the total population). 15 Members of Hindu community encountered fake news claiming meat of cow used for vaccine production.
Likewise, members of the Muslim community encountered fake news claiming traces of pork in the vaccine. 16 Fake communal rumors falsely alleging Muslims for spreading COVID-19 virus were reported, following a mass gathering in Delhi in March 2020. 14 Sensational stories by few journalists further aggravate this condition. 14 Media in India, are often known to sensationalize stories. 17 All these events promote fear within the community, intensifying the existing obstacles.
Due to the rapid development of COVID-19 vaccines, hesitancy and distrust regarding safety and efficacy thrive. It is especially true for India's local vaccine, Covaxin, due to its emergency approval despite insufficient efficacy data. 18 On January 3, 2021, India's top drug regulating body, the Central Drugs and Standards Committee (CDSCO), granted emergency approval for Covaxin 19 even though phase III clinical trials were still ongoing and phase II studies were yet unpublished, then.
It was later on published in The Lancet on March 3, 2021. The study stated that the results reported during the phase 2 study did not permit efficacy assessments and concluded that evaluating safety outcomes requires extensive phase 3 clinical trials. 20,21 This resulted in initial incidents of skepticism among HCWs, with less than 30% of New Delhi's HCWs across six government hospitals accepting vaccinations. 22 In addition to this, since the onset of the pandemic, HCWs in India, especially doctors, have been the victims of abuse and violence. [23][24][25] Loss of the beloved fosters a sense of dissatisfaction amongst family members and friends of patients resulting in anger and abuse on doctors.

| Strengthening healthcare personnel infrastructure
Even if the challenges mentioned above are overcome, the vaccination drive is incomplete without qualified healthcare personnel. India has 2.9 million registered nursing personnel, translating to a ratio of However, the lack of internet access in rural areas coupled with digital illiteracy could be a potent barrier to conducting online training.
Therefore, state governments are directed to complete face-to-face training in situations where virtual training is not possible while also ensuring that the staff strictly adheres to COVID-19 appropriate behavior for on-ground training. 9

| POLICY RECOMMENDATIONS
The pandemic needs the support and coordinated efforts of both the public and the private sectors. While the Government pulls in the private sector in manufacturing vaccines, 2 it should also effectively devise logistical needs and ensure continued transportation of vaccines with equitable distribution at its core.
At present, there are more than 30 000 Primary Healthcare Centers (PHCs) in India. 7 Upgrading these centers with the required facility for vaccination can be beneficial to aid in the COVID-19 vaccination process. As COVID-19 strains our health system, PHCs can play a key role in preparedness and efficient vaccination service in rural areas. In Bhutan, within 2 weeks after launching its vaccination program, the authorities vaccinated 93% of adults. 30,31 Strong PHC networks across the country and partnerships with local government officials to reach citizens in even the most remote parts of the country aided this remarkable speed. Bhutan's Ministry of Health (MoH) used data from local governments and village leaders to determine the number of vaccines to distribute to each area, making COVID-19 delivery easier. 30 Bhutan's small population size is a major advantage over many other countries, like India; yet their strategies and experiences are a lesson for the world. The Government can utilize social media as a powerful tool to curb the infodemic. This approach has been adopted in Finland, where health authorities collaborate with a network of social media influencers to help spread factual data about COVID-19. Moreover, Finland claims to be the only country globally to have defined social media as "critical operators" during crisis-along with doctors, bus drivers, and other essential workers. 35 The influencers' quick mobilization was possible because they have been part of Finland's emergency contingency plans for nearly 2 years. Social media influencers were added to the pool of essential actors a year and a half ago, after the media section of the national emergency supply organization realized traditional media would not be enough to reach the whole nation in a crisis. 36 Embracing this mindset is critical, especially in this modern technological era. The Indian Government has incorporated celebrities and religious/faith-based leaders in India's COVID-19 Communication Strategies, including local folk songs, story-telling, drama, and dance as the modes of community media. If successfully delivered, these will prove to be a critical move to get the right message in the community, especially in remote areas. 37  To enhance our knowledge and understanding and instill public trust and confidence, post-marketing surveillance of the efficacy and safety of COVID-19 vaccination is critical and requires long-term monitoring. 40 With the discovery of the delta variant in India, 41 it is vital to enhance our understanding for better usage of the available interventions for treating COVID-19. Owing to the ever-changing scenario and advancement in the ongoing research, a robust data management infrastructure and knowledge sharing are vital across the nations. In addition, Governments worldwide need to harbor a sense of solidarity for equitable distribution of vaccines because no one is safe until everyone is safe.

CONFLICT OF INTEREST
The authors have completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author) and declare no conflicts of interest.

FUNDING
No funding from any institution or department.

TRANSPARENCY STATEMENT
Gladson Vaghela affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
Data sharing does not apply to this article as no new data were created or analyzed in this study.