The long road to a vaccine, and its mass administration

As the world craves for a vaccine, we can discern the desperate scramble among the world’s scientists to develop a wonder drug against coronavirus. Vaccination has always been perceived as affording both individual and community protection. But even if the scientific community comes up with a vaccine, massive public health efforts are often required to control infectious diseases in the most effective manner.

It is a truth universally acknowledged that vaccines are the most cost-efficient measures in medicine, should they work. But the history of mass immunisation does remind us that one size does not always fit all. What governs its need depends upon susceptibility and area(s) of moderate or high endemicity. Cholera, for instance, due to the classical biotype of V. cholerae, was endemic in the Ganges delta of West Bengal and Bangladesh during the last two centuries and caused epidemics and global pandemics. The first cholera pandemic 1816-1826, which began in Bengal, spread across India by 1820, killed some 10,000 British troops and millions of Indians. The trigger was insanitary conditions, lack of personal, food and water hygiene.

That prompted the British government to take drastic public health measures. It took tough measures by the end of the 19th century to control, besides cholera, a scourge as deadly as the plague. Those measures included quarantining, isolation camps, travel restrictions and the exclusion of India's traditional medical practices. Overarching powers were vested with Special Plague Committees to impose restrictions on the populations of the coastal cities and enforced by the British military. These were resented by a majority of Indians who considered the measures to be “culturally intrusive and generally repressive.”

The Russian bacteriologist Waldemar Mordecai Haffkine, then based in India and who was later appointed Director of the Plague Laboratory (now called Haffkine Institute) in Bombay -- where he tested vaccines against cholera and plague -- was pressed to develop a plague vaccine. He had to work with limited resources, but on January 10, 1897, Haffkine tested it on himself, to be followed by a control test on volunteers at the Byculla jail. By the turn of the century, the number of those inoculated in India alone reached four million. By 1898-99, government strategies of plague control changed tack in view of strong opposition to plague regulations as the plague had spread to rural areas and thus imposed logistical challenges. British health officials began to press for widespread community vaccination using Haffkine’s plague vaccine.

Perhaps the colonial administration thought it was required to wage a battle first against its microbial enemies, if it were to administer a place as rich as India. It might explain why several vaccine institutes were established in late Victorian India, well before many European countries, in response to plague, cholera and other diseases. More than half a dozen Indian vaccine institutes conducted research and also produced vaccines and sera against cholera and plague but also against rabies, tetanus, diphtheria, smallpox, typhoid and snakebites. Why, India’s long record of institutional research notwithstanding, colonial research policies failed to lay the foundation for a sustainable path for vaccine development and production in independent India, however, remains open to further analysis.

In post-independence India, the BCG campaign against tuberculosis developed into the largest immunisation campaign the world had seen, and the goal was to reach all Indians below the age of 25 (then estimated at 170 million people) by the end of the second five-year plan period in 1961. Facing stiff logistical challenges and powerful opposition, BCG was incorporated into the general immunisation programme in 1978.

Community participation, therefore, is another pre-condition of any programme of mass immunisation to be successful. The DOTS strategy (directly observed treatment, short course), promoted worldwide by the World Health Organisation (WHO), is highly efficacious only where fully implemented, but in the event of non-compliance it gives rise to multi-drug-resistant (MDR) strains, the instances of which are rising in several countries, including India. An estimate puts MDR cases at over 10% of all tuberculosis cases and more than 50 million people to be infected with MDR M. tuberculosis strains globally. If administration is not enforced by health workers on a day-to-day basis, such a programme is bound to fail, much in the same way the advice to remain quarantined at home to people with travel histories from countries afflicted with COVID-19 is flouted with a mix of disdain and impunity.

It is a matter of speculation when all this would come to pass. But the future is uncertain. Even though the eradication of smallpox by vaccination was envisaged by Edward Jenner as early as 1802, it was not until the WHO launched a determined global vaccination programme in 1966 that success was finally achieved. Beginning from the inception of the intensified Smallpox Eradication Programme (SEP) in 1967 in India, home to some 30–40% of all the smallpox cases in the world, the final stage (1973–75) of the South Asia SEP that closed the ledger convinced the world of the need for globally coordinated action for eradicating a number of other diseases and prompted the launch of the WHO’s worldwide Expanded Programme of Immunisation (EPI) in 1974, cited, in turn, to launch the global polio eradication programme in 1988.

Until we find a vaccine against the novel coronavirus, should India move to the higher stages of community transmission, we have to either scout for cover (which we actually cannot) or brave the virus because lockdowns, in the long run, are unsustainable. But the road to a vaccine might be long and tortuous and we must learn to brace for it.