A million-dose success for Nepal: insights from Nepal's national vaccine deployment plan against COVID-19.

Introduction

Globally, more than 60 vaccine candidates against COVID-19 infection are under clinical research and development, but only 8 of them have been authorized for emergency use at country level., The UK became the first country in the world to approve the emergency use of COVID-19 vaccine (Pfizer-BioNTech vaccine, 3 December 2020) and to administer it to the public (8 December 2020). Oxford-AstraZeneca vaccine got approval from the UK regulators on 30 December 2020. While political leaders in high-income countries are debating harshly and working rather messily to secure the maximum vaccine doses for their own population, global vaccine diplomats and social scientists are deeply concerned about the possibility of unfair distribution of effective doses, hindering fair and equitable access to all countries., There is a risk of high-income countries easily securing their future supplies of vaccine, leaving the rest of the world in a looming uncertainty.

As of 8 February 2021, more than 80 countries have rolled out the vaccination programme nationally. However, its successful and equitable implementation requires a co-ordinated and sustained allocation of monetary, logistic and technical resources from resource-rich to resource-poor countries. Local demand and need of vaccine, indicated by country priorities and local epidemiology of COVID-19 infection, are also important for an effective vaccination. At population level, flow of correct information about immunization centres and vaccine being used, including risk communication, adequate public engagement and strong governance, are essential to gain vaccine confidence, trust and acceptance.

The Government of Nepal (GoN) rolled out COVID-19 vaccination in all seven provinces from 27 January 2021, a little over a year after the detection of first case (https://www.who.int/nepal). Nepal’s launching event was digitally inaugurated by the prime minister in all provinces at once. This article highlights seven insights that the world can take from a lower-middle-income country’s relatively quick vaccination deployment.

Amendment of health regulations opened door for new vaccine registration

On 20 December 2020, the GoN amended the Drugs Act 2035 though an ordinance, allowing the registration of new drugs and vaccines at the Department of Drug Administration (DDA) for emergency use. Such registration would open door for manufacturers to import new products even if these were not in the WHO list. On 13 January 2021, DDA called global vaccine manufacturers and their authorized dealers to submit applications for the listing and registration of their products. Accordingly, the Serum Institute of India, which manufactured Covishield vaccine (originally developed by Oxford-AstraZeneca team), filed the application. On 15 January, DDA registered the Covishield vaccine, allowing its import from India. The same day, the vaccine got approved for the emergency use in Nepal.

Vaccine choice was guided by science and evidence

Covishield vaccine was approved based on its efficacy (62% with the first dose and 90% with the second dose) and suitability for cold chain requirements, i.e. storage, transportation and handling at 2–8°C, unlike other vaccines which need −70°C (Pfizer-BioNTech) or − 20°C temperature (Moderna) for storage. Other reasons for choosing India-made vaccine could be: similar climatic conditions between two countries and generalizability of clinical trial findings in light of comparable socio-demographic features, epidemiological profile and spatiotemporal patterns of disease occurrence. Moreover, India’s capacity of mass production would ensure availability of future doses to Nepal.

Strong political will and vaccine diplomacy was observed in the region

A high-level political delegation of Nepal led by the Minister for Foreign Affairs visited India on 14 January 2021 to participate in the Nepal–India Joint Commission that held discussions on bilateral trade, energy, border disputes and COVID-19 assistance. The minister had assured that COVID-19 vaccine procurement was one of the priority meeting agenda. On 21 January, the Government of India, in co-ordination with the Embassy of India in Kathmandu, approved aid of 1 million doses of Covishield vaccine to Nepal. The Indian government also extended similar support to Bhutan, Maldives, Bangladesh, Myanmar, Mauritius and Seychelles. Moreover, during a recent telephonic conversation between Nepal’s Minister for Foreign Affairs and his Chinese counterpart, China confirmed a grant assistance of half a million doses of its locally manufactured COVID-19 vaccine (Sinopharm or Sinovac) to Nepal (https://mofa.gov.np/press-release-on-telephone-conversation-between-the-foreign-ministers-of-nepal-and-china/). The use of vaccine as a diplomacy tool by neighbouring countries would also help Nepal resume its tourism and trade much earlier than anticipated.

Priorities were set to ensure health equity

The Ministry of Health and Population (MoHP) followed the principles of health equity and ethics by prioritizing frontline health and sanitation workers, ambulance drivers and hearse drivers (dead body handlers) in the first phase of vaccination. Although the government initially planned to vaccinate around 430 000 individuals in the first round alone (with equal number of individuals getting their second dose after 28 days), only 184 857 individuals received their first dose as of 6 February. With the available stock of vials, MoHP is now inoculating the remaining frontline health and care workers, security personnel, elderly people taking refuge at elderly shelters and inmates in the second round of vaccination drive. The MoHP has issued a public notice to vaccinate all health professionals registered with respective professional councils. Journalists, diplomats and government administrators are also in the priority list (https://www.aninews.in/news/world/asia/nepal-begins-second-phase-of-inoculations-with-indian-made-vaccine-against-covid-1920210209125924/).

Effective vaccine delivery system allowed equitable distribution of doses

National Immunization Programme is one of the most successful public health programmes in Nepal and it has been benefited by the newly instated federalism. According to the Annual Report 2018/2019, over two-thirds (68%) of under-5 children completed all childhood vaccinations, with high coverage rate of BCG (91%), diphtheria–pertussis–tetanus–hepatitis B–haemophilus influenza type b (DPT–HepB–Hib3) (90%), oral polio vaccine (OPV3) (87%), pneumococcal conjugate vaccine (PCV3) (81%) and measles-rubella (MR1) (84%) (http://dohs.gov.np/dohs-annual-report-fy-2076-77/). The latest COVID-19 vaccination programme also utilized the three-tier governance system for the delivery of vaccines even to the last mile. Co-ordinating with the provincial and local governments, MoHP deployed the vaccination programme through 60-plus hospitals across seven provinces and 201 vaccination centres in 77 districts, ensuring equitable distribution to the population. In the first phase, the number of vaccine recipients was 24 224 in Province 1; 25 637 in Province 2; 63 308 in Bagmati; 18 472 in Gandaki; 28 941 in Lumbini; 9420 in Karnali and 14 855 in Sudurpaschim. Both public and non-public sectors were equally benefitted by the vaccination drive. The vaccine delivery system may, however, suffer from a dearth of resources and inadequate preparedness while inoculating the general population in the following phases.

Phase-wise expansion of vaccine coverage has been planned

With the partial success of the first phase of the COVID-19 immunization programme, the government prepares to expand it to the ageing population (55 years and above) and chronic disease patients in the second phase. Similarly, the target group for the third phase would be the individuals between 40 and 55 years age, later expanding the coverage to remaining population in the fourth phase of vaccination. The government has announced a rather ambitious plan that it will provide full doses of vaccine free of cost to all eligible citizens by the end of April this year. However, it is unknown whether the current rate of vaccination (0.06 dose per 100 persons) would be sufficient to control the pandemic.

Sustainability of vaccination programme has been widely discussed

On top of the first 1 million doses, the government has planned to procure additional 4 million doses within a month. The country will require around 45 million doses to cover nearly three-fourths (72%, i.e. 21 million) of its total population, which excludes contraindicated groups—below 18 years age, pregnant or breast feeding mothers, expectant mothers, allergic and other high-risk individuals (https://www.who.int/nepal). This amount accounts for 10–15% of possible wastage. If Nepal receives 6 million vaccine doses through COVAX initiative co-led by Gavi, the Coalition for Epidemic Preparedness and Innovations (CEPI), and WHO, the need would drop down to 40 million doses. The GoN is expected to further ease the regulatory hurdles in order to import a variety of vaccines manufactured in different countries and purchase the needed doses through government-to-government procurement mechanisms. In the meantime, policymakers are also interested to know the people’s willingness to pay for vaccine, if in case, the government cannot fulfil its commitment to immunize all people free of cost.

Conclusions

Nepal’s vaccine diplomacy could be an example for many countries that have not started COVID-19 vaccination yet, especially the low- and middle-income countries (LMICs). Strong political will, adaptive changes in national policies and regulations, timely allocation of available resources, priority setting for equitable distribution of doses, multi-sectoral management approach and result-oriented collaboration with national and international stakeholders are key to successful vaccine deployment. The governments of LMICs need to act aggressively to vaccinate the majority of their populations ahead of consecutive waves, possibly due to more dreadful virus variants. Clear clinical and public health guidelines are also required to inform whether previously infected and recovered individuals should or should not take the vaccine. Moreover, nationwide studies are needed to gauge the level of public awareness and perception regarding the new vaccine to determine the factors associated with vaccine hesitancy, to report adverse events following immunization (AEFI) and to generate evidence on vaccine-induced immunity in the communities.

Funding

Authors did not receive any funding for writing this article.

Conflict of Interest: None declared.

Authors’ contributions

S.B. and J.D. conceptualized the article, did literature search and wrote the first draft. Both authors read and approved the final version of article.