Two months ago, India crossed the landmark figure of 100 crore administered vaccines—for the first and second dose combined. By December, 10, ~81 crore of its adult population received its first dose, with ~51 crore also having received a second dose so as to be admitted in the once elusive, fully vaccinated against COVID-19 club. While the figure is laudable for a developing country, it's important to continue examining our progress, especially as this impressive feat is occurring along with a dramatic decline in disease incidence since the peak of the second wave and a looming possible third wave driven by the new Omicron variant.

Today, it is crucial to understand that our present situation holds the potential for people to develop ‘vaccine complacency’—an attitude to delay getting inoculated. Vaccination trends from CoWin data indicated strong evidence of vaccine complacency in India between mid-September- end of October — a dramatic decline in daily dosage at a time when supply was no longer a problem. The sticky month-long trend resulted in the Centre asking the States to urge its first dose beneficiaries to get fully vaccinated, over a review of the COVID-19 vaccination drive (19th Oct 2021). Clearly, many people reportedly missed, and continue to miss their second dose — so just how far behind are we? And is it a pan-India problem?

Public Data

The nature of the CoWin dashboard makes it difficult to make one-to-one inferences about the quantum of people missing their second dose. Data is available on total first and second dose as well as total administered doses of Covaxin and Covishield, but since the recommended gap between the two doses of the two vaccines is different and has moved over time, one has to estimate the lags in second dose uptake.

To estimate these lags, we used the outer recommended limits of getting vaccinated, i.e., 16 weeks for Covishield and 6 weeks for Covaxin through data accessed on 10th December. The long outer gap between the two doses for Covishield (90% of all doses administered nationally) implies that people due for their second dose in December only got their first dose in August/September. It is important to recognise that our estimate on missed second doses will potentially be an underestimate as it does not capture the developing vaccine complacency – at worst hesitancy – for ~35 crore people who got their first jab between September and December.

On the surface, the aggregated national picture shows that ~51 crore people have received the second dose, against a minimum estimate of ~47 crore eligible people. However, this aggregated picture does not show the real quantum of the problem, which relates to developmental inequities and sits at the state and district levels. The heat map below shows that 43 districts in India have a ‘large gap’ in second dose coverage i.e., >20% lower number of second doses administered compared to estimated target number; and 119 districts show a ‘medium gap’ of 10-20% between administered second doses and estimated target. Encouragingly, the number of larger gap districts have about halved between October and December reducing from 98 to 43 districts, while the ones in the medium gap have only slightly reduced from 144 districts to 119. (Heat map above)

It is clear from the heat map that lack of second dose uptake is concentrated in specific States like Punjab, Haryana, Jharkhand, Chhattisgarh, Uttar Pradesh, Rajasthan, Kerala and the Northeastern States. A simple classification of districts in these States throws some noteworthy insights (Table 1):

Over 70% of districts in Punjab and 60% in Jharkhand are estimated to have >10% of first dosers missing the second dose

Big states like Uttar Pradesh, Rajasthan, Chhattisgarh, and Jharkhand throw up troubling statistics with a large share of districts indicating over 10-20% or/ or >20% of the first dose beneficiaries missing their second dose.

The 7 Northeastern states of India are falling significantly behind in coverage of second doses, with 64 of the 112 districts (~58%) in the region estimated to have >10% of first dosers missing the second dose.

If we go a layer deeper and look at some of the most problematic districts with over 20% of beneficiaries missing there second dose, we find that 23 of the 43 worst performing districts are in 4 states — 7 are in Arunachal Pradesh, 6 in Manipur, and 5 each in Jharkhand and Punjab (Table 2).

One potential caveat in this conversation is of the role of domestic migration—can migration alone explain the near absent national but alarming district-level second dose gap? With our assumptions and keeping in mind the demographic makeup of districts that show up, this is unlikely. Another point worth noting is that vaccine complacency itself is dynamic and responds to proactive public health messaging and general disease severity — a lot of districts have improved their performance between October – December while others have worsened.

Primary Data

Primary data from the urban slums of Bengaluru (1590 responses, conducted over 26th August- 4th September) indicates at least 10% of those who were partially vaccinated reported they were unwilling to take the second dose, another 11% were unsure.

32% of such respondents reported that taking one dose is enough to provide adequate protection.

29% reported that people are contracting COVID-19 even post-vaccination and hence were not confident that the second dose offered any immunity.

Crucially, 34% reported they were unsure of any specific reason informing their decision to not take the second dose.

Overall, 61% reported lack of convenience in getting jabbed — many were hesitant to go for the second dose due to the potential adverse occupational effects (48%), associated wage loss (27%) and time taken to get to the vaccine camp and back (30%).

Moreover, this sample indicated a significant impact of culture and community leaders on vaccination. While many people responded neutrally to the importance of religious beliefs in the decision to get inoculated, about 20% reported that there were religious and community leaders who did not encourage vaccination.

Way Forward

To guard against the risk of emerging COVID-19 variants, India must continually push out second doses, but also start to systematically focus on the uptake of potential booster doses to ensure that the effort and investment has a strong public health pay-off. The first step towards this would be to provide more usable, publicly trackable data, tailored towards the second dose gap.

Second, concerted efforts must be put into closely working with vulnerable communities, particularly tribal communities as highlighted in our analysis, that are more susceptible to mistrust in public health systems. An earlier sample from 25 aspirational districts across 7 states (863 responses, conducted over 8th-14th June) indicated that the mistrust in institutions among those who were uneducated/ below the poverty line caused general hesitancy to get jabbed.

Third, we must enable access to second doses, and potential booster doses, by revisiting strategies that worked for the first dose— organising village-level vaccine camps, ferrying people to and from vaccination centers and effectively leveraging the influence of local community leaders. As acknowledged by State Government representatives in the review meeting, the current approach of reminding people about their second doses through SMS is not working, especially since multiple people can be registered on one mobile number. They emphasised that people may simply be forgetting about the second dose given the long gap between jabs.

Today, for effective protection against COVID-19, India needs to inoculate ~10 crore of its eligible adult population (18+ years), while also closely monitor ~35 crore people who are not eligible for the second dose yet, in addition to strategising the approach to vaccinating ~40 crore children and adolescents.

It is clear that complacency can be addressed effectively with proactive data tracking and public health interventions. To effectively meet the challenge of jabbing all eligible adults at the earliest, and subsequently children and adolescents, it's important to understand both—the localised factors leading to complacency/ hesitancy as well as the archetypes of the population most vulnerable to being left behind, and leverage trusted local public health representatives such as ASHA workers to ensure vaccine adoption for all.

Geetika Dang and Sansiddha Pani are senior research consultants at Sattva.