CME INDIA Presentation by Admin.

CME INDIA Guidelines for effectively managing COVID-19 Vaccination. First Published – 29th April 2021. Last Updated – 19th February 2022. Updated PDF link available at the end.

Basic Framework By:

• Dr. Akash Singh, MD (Med) MSc (Diabetes) Consultant Physician and Diabetologist Spandan Multi Speciality Hospital, Vadodara.
• Dr. S. K. Gupta, MD (Med), FICP, CFM(France) Clinical Asst. Professor GS Medical College, CCSU, Uttar Pradesh India. Visiting Consultant, Max Super Specialty Hospital, New Delhi.
• Dr. Kiran Shah, Consultant Physician MBBS, MD, Spandan Multi Speciality Hospital Vadodara.

Edited By:

• Dr. N. K. Singh, MD, FICP, Diabetologist physician, Dhanbad, Editor – cmeindia.in.

Advisor and Reviewer:

• Dr. Awadhesh Kumar Singh, Consultant Endocrinologist, G. D. Hospital & Diabetes Institute, Kolkata, West Bengal.

Invitee Reviewer:

• Dr. Banshi Saboo, National President, RSSDI, Ahmedabad.
• Dr. Mangesh Tiwaskar, Consultant Physician & Diabetologist, Mumbai, Hon. General Secretary, API.

Reviewer:

• Dr. R. Rajasekar, MD, FICP, FACP (USA), FRCP (Glasgow), FRCP (Ireland), Consultant Physician & Diabetologist Heart & Diabetes Therapy Centre, Kumbakonam, Tamil Nadu.
• Prof (Dr.) L. Sreenivasa Murthy, MD, FRCP(Edin.), FRCP(GLAS), FICP, FRSSDI, PDCR, Diabetes Care Specialist, Senior Physician, Clinical Trial Specialist, Lifecare hospital and Research Centre, Bangalore, Karnataka, India.
• Dr. Venket Molio, Visiting faculty at Grace Cardiac, Victor Apollo Borkar and Trimurti hospital, Goa – Part of Covid Expert Committee – Govt. of Goa Task force.
• Dr. Sajith Kumar R., Prof & Chief, Infectious Diseases, Govt Medical College Hospital, Kottayam, Kerala.

Inputs:

• Dr. Sanjeev, Hematologist, Asso. Prof SGPGI, Lucknow.
• Dr. Arvind Gupta, MD, FRCP (Glasgow), FRCP (Edin.), FICP, FACE, Senior Consultant and Head, Department of Diabetes, Obesity and Metabolic Disorders, Rajasthan Hospital, Opposite, Jaipuria Govt Hospital, Jaipur.
• Dr. Swati Srivastava, Professor of Medicine, SMS Medical College, Jaipur.
• Dr. Sanjeev Phatak, Sr. Diabetologist, Ahmedabad.
• Dr. Urman Dhruv, Sr. Physician and Director, Department of Internal Medicine and Diabetes at HCG Hospitals, Ahmedabad.
• Dr. Anand Malani, MD, Sr Physician, Sangil, Maharashtra.
• Dr. Noni G Singha, MD, FICP, Consultant Physician, Dibrugarh, Assam.
• Dr. Padmanava Shenoy, DM, Rheumatology, Chochin.

Special Thanks To:

• Dr. B. B Rewari, MD, FRCP, Former Asso. Prof. of Medicine, Dr. RML Hospital, New Delhi. Scientist HIV/AIDS/STI/Hepatitis at WHO SEARO.
• Dr. Anil Motta, Delhi, Consultant Internist, Max Hospital, Delhi.
• Dr. Rajeev Jayadevan, MD, DNB, MRCP, ABIM (Med) ABIM (Gastro), NY. Vice Chairman, Kerala state IMA Research Cell. Member, National IMA Task Force on Corona Epidemic, Cochin.
• Dr. K Jagadeesan, Chief Medical Officer, MoHFW, Govt. of India, Chennai.
• Dr. Hemshankar Sharma, Asso. Prof of Medicine, Nodal Officer-COVID, JLNMCH-Bhagalpur.
• Dr. Keyur Acharya, MD (Med), MRCP (UK), IDCCM, EDIC, Intensivist, Bath, UK.
• Dr Rajiv Kovil, M.B.B.S (Bom), D. Diabetology (Bom), Consultant Diabetologist, Mumbai.
• Dr. Vaibhav Agnihotri, (DCH, DNB (Pediatrics), Fellowship Neonatology (IAP), PGPN, Boston, PCBD USA), Jaipur.
• Dr. Richa Agnihotri, MBBS, DGO, DNB (Obs & Gynae), FGES (lap surgeon), Jaipur.

Design and Content Management:

• Mr. Rishav Manaswi, Founder (Dynamic Cognition), MBA (France), 📧 cmeindia.in@gmail.com.

Disclaimer

The first guideline from CME INDIA – COVID-19 Management Protocol became an instant hit with medical practitioners. It amassed over 500,000 views and downloads in a matter of 2 weeks. With increasing demand for guidelines related to COVID-19 vaccination, CME INDIA is pleased to present its COVID-19 Vaccination Protocol 2022. This guideline has been compiled with inputs from numerous medical experts and the available literature. Please be aware that inputs and literature can change from time to time. The readers are hereby advised to follow their own discretion. With the feedback that we get from the readers and other medical experts this document will be updated accordingly.

Document Flow

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1.  Highlights

Mass immunization with vaccine is the only solution to prevent COVID-19 pandemic, worldwide. Therefore any ounce of hesitancy towards vaccination is not at all desirable. This guideline provides insight into the COVID-19 Vaccination Program in India and worldwide. This guideline provides information on the main COVID-19 vaccines available in India along with their indications, contraindications, side effects, complication, and use in special populations, etc. Brief information about other vaccines is also included. It also provides clarification and factual information on various circulating myths about the COVID-19 vaccines. A brief outlook on the vaccine failures and research and development of various future vaccines is also included. 

2.   Introduction

• India launched one of the world’s largest COVID-19 vaccination drives on Saturday, January 16, 2021. It is aimed at stemming the wide spread of infections across a nation of more than 1.3 billion population.
• In response to the pandemic, the vaccine development and approval process has been fast-tracked.
• The two main Covid-19 vaccines approved in India initially for emergency use are – Covishield (developed jointly by Oxford university and AstraZeneca pharmaceutical and manufactured in India by the Pune-based Serum Institute) and Covaxin (developed and manufactured by the Bharat Biotech). A third coronavirus vaccine Russia’s Sputnik V received approval in the middle of 2021 amid COVID-19 second wave.
• Numerous challenges prevented a smooth roll-out of the vaccination drive.
• Vaccine hesitancy was one big issue. The main reasons for this hesitation could be attributed to lack of supporting scientific data in public domain, misinformation about side effects, fast-track approvals and widespread reports of death in sick and elderly population. In spite of all the steps taken by the government to spread awareness about the COVID-19 vaccine among the public, a lot of misinformation was being spread. This led to unnecessary panic. But with public education and media support, Vaccine hesitancy has been largely won over in India.
• India has administered well over 1 billion doses so far and is on track to wining the war against Covid-19.
• This document aims to provide authentic and verified information to the general public and healthcare workers.

3. World Covid-19 vaccine overview

The worldwide endeavor to create a safe and effective COVID-19 vaccine is bearing fruit. More than 30 vaccines now have been authorized around the globe; many more remain in development.

Approved Vaccines Worldwide – Summary of WHO approved vaccines worldwide

Most COVID-19 vaccine development activity is in North America followed by China.

4. Indian landscape of Covid-19 vaccine(1,2)

• High-level coordination at the national, state, and district levels is essential for effective cooperation and collaboration among the key departments involved in administering COVID-19 vaccines.
• Therefore, the COVID-19 vaccine was introduced once all training was completed in the district/block/planning unit.
• COVID-19 vaccine was initially offered to healthcare workers, frontline workers and population above 60 years of age, population above 45 to 59 years of age with associated special comorbidities, and then to people above 45 years of age based on the evolving pandemic situation, and finally to the remaining population based on the disease epidemiology and vaccine availability. Recently, children below 18 years have been added to the list.
• The COVID-19 Vaccine Intelligence Network (Co-WIN) system, a digitalized platform is being used to effectively roll out and scale up the mechanism for Covid Vaccine Distribution System. It will also be used to track the enlisted beneficiaries for vaccination and COVID-19 vaccines on a real-time basis. At the vaccination site, only pre-registered beneficiaries were vaccinated per the prioritization initially, and there was no provision for on-the-spot registrations. After a month, spot registrations were allowed.
• Vaccinator Officer–Doctors (MBBS/BDS), staff nurse, pharmacist, auxiliary nurse midwife (ANM), lady health visitor (LHV); anyone authorized to administer an injection may be considered as a potential vaccinator.
• India has announced to launch of phase 4 vaccination drive from January 03, 2022. The key aspects of this phase are:
  • Everyone above the age of 15 years is eligible to get vaccinated.
  • State governments can open up vaccination to any category of people above the age of 15 years.
  • Vaccine manufacturers can release up to 50% of their supply to State Governments.
  • Vaccine manufacturers can sell the vaccine in the open market at a pre-declared price.
  • The state government can procure additional vaccine doses directly from the manufacturers.
• The initial two main Covid-19 vaccines approved in India for emergency use are – COVISHIELD manufactured by the Pune-based Serum Institute, and COVAXIN developed and manufactured by Hyderabad based Bharat Biotech. Both Covishield and Covaxin have been exported – some in the form of “gifts,” others in line with commercial agreements signed between the vaccine makers and the recipient nations, and the rest under the Covax scheme, which is led by the World Health Organization (WHO) and hopes to deliver more than two billion doses to people in 190 countries in less than a year.
• The Union Ministry of Health released guidelines for Covid-19 Booster dose and vaccination in children 15-18 years in January 2022. Covid vaccination of children in the age group of 15-18 years started from 3rd January 2022. For such beneficiaries, vaccination option would be Covaxin only. The precaution dose was started from 10th January 2022 for HCW, FLW and people aged 60 years and above with comorbidities who have received two doses of Covid vaccine.

5. Basics of main Covid-19 vaccines currently available in India(3,4,5,6)

Covaxin^®

• India’s Indigenous COVID-19 Vaccine developed by the Bharat biotech in collaboration with the Indian Council of Medical Research (ICMR) – National Institute of Virology (NIV). The Central Licensing Authority has granted permission for the sale or distribution of Covaxin® for restricted use in emergency situation in public interest in population above 12 years of age.
• The indigenous, inactivated vaccine is developed and manufactured in Bharat Biotech’s BSL-3 (Bio-Safety Level 3) high containment facility.
• The vaccine is developed using Whole-Virion Inactivated Vero Cell derived platform technology. Inactivated vaccines do not replicate and are therefore unlikely to revert and cause pathological effects. They contain dead virus, incapable of infecting people but still able to instruct the immune system to mount a defensive reaction against an infection.
• Unlike other inactivated vaccine developed for COVID-19 such as Sinovac and Sinopharm, covaxin^® contains an added immune-potentiators called Toll-like receptor (TLR) 7/8 agonist (which is an imidazoquinolinone derivatives) in order to increase T-helper-1 (Th-1) response to boost, cell-mediated immunogenicity.  These changes have been primarily designed to increase the cell-mediated immunity which is classically lacking in inactivated vaccines and was not seen with Sinovac and Sinopharm vaccine. Moreover, a vaccine adjuvant called Algel-IMDG (Imidazoquinoline molecule chemisorbed on alum [Algel]) has been added to traffic vaccine antigen directly to the draining lymph nodes without diffusing into the systemic circulation in order to minimize the vaccine related local or systemic side effects.
• It is a 2-dose vaccination regimen given 28 days apart. It is a vaccine with no sub-zero storage, no reconstitution requirement, and ready to use liquid presentation in multi-dose vials and stable at 2-8^oC.
• Covaxin^® contains 6µg of whole-virion inactivated SARS- CoV-2 antigen (Strain: NIV-2020-770), and the other inactive ingredients such as aluminum hydroxide gel (250 µg), TLR 7/8 agonist (imidazoquinolinone) 15 µg, 2-phenoxyethanol 2.5 mg, and phosphate buffer saline up to 0.5 ml.
• Covaxin^® demonstrated strong immunogenicity and protective efficacy in several preclinical animal challenge studies conducted in hamsters & non-human primates and clinical trials in humans.
• Global Acceptance of covaxin^® – Bharat biotech has been approached by several countries across the world for the procurement of covaxin^®. Clinical trials in other countries to commence soon. Supplies from government to government in the following countries to take place: Mongolia, Myanmar, Sri Lanka, Philippines, Bahrain, Oman, Maldives and Mauritius.
• Effective against multiple variants of SARS-CoV-2 – As per the Indian Council of Medical Research-National Institute of Virology (ICMR-NIV) recent announcement, covaxin^® is known to work against multiple variants of SARS-CoV-2.
• Covaxin Study Group published phase 3 data (Peer Reviewed) This study showed the clinical efficacy of BBV152 against symptomatic COVID-19 disease.
• In this randomised, placebo-controlled, phase 3 trial, 24 419 adult participants with no serological evidence of previous exposure to SARS-CoV-2 received two doses of BBV152 vaccine or placebo, 4 weeks apart. Efficacy against any severity of COVID-19 with onset 14 days after the second vaccination was 77·8% (95% CI 65·2–86·4), and efficacy against severe COVID-19 was 93·4% (57·1–99·8). Efficacy against asymptomatic COVID-19 was 63·6% (29·0–82·4). The preliminary analysis found an efficacy of 65·2% (95% CI 33·1–83·0) against the delta variant. Safety monitoring and reactogenicity assessments of BBV152 did not raise concerns about the vaccine. (55)

Covishield^TM

• Covishield^TM Vaccine is produced by Serum Institute of India Pvt. Ltd. (SIIPL) and is approved for restricted use in emergency situation vaccine that may prevent COVID-19 disease in individuals 18 years of age and older.
• One dose (0.5 ml) contains ChAdOx1 nCoV- 19 Corona Virus Vaccine (Recombinant) 5 × 10¹⁰ viral particles (vp) which is a recombinant, replication-deficient chimpanzee adenovirus vector encoding the SARS-CoV-2 Spike (S) glycoprotein. It is produced in genetically modified human embryonic kidney (HEK) 293 cells. This product contains genetically modified organisms (GMOs). The other ingredients include L-Histidine, L-Histidine hydrochloride monohydrate, Magnesium chloride hexahydrate, Polysorbate 80, Ethanol, Sucrose, Sodium chloride, Disodium edetate dihydrate (EDTA), Water for injection.
• Covishield^TM is supplied as colorless to slightly brown, clear to slightly opaque and particle free ready for use solution for injection in rubber-stoppered multi-dose vial and single dose vial in below listed presentations:
  • 1 dose – 0.5 ml per vial
  • 2 dose – 1.0 ml per vial
  • 5 dose – 2.5 ml per vial
  • 10 dose – 5.0 ml per vial
  • 20 dose – 10 ml per vial

• The Covishield vaccination course consists of two separate doses of 0.5 ml each.
• Dose Schedule:
  1. As of now, based on the recommendations by the National Expert Group on Vaccine Administration for COVID-19 (NEGVAC), the schedule of the Covishield vaccine under the National COVID-19 Vaccination Strategy is to administer the 2nd dose at 12-16 weeks interval (i.e. after 84 days), after administration of the first dose.
  2. For people going abroad, second dose will be issued after 28 days, they have to produce documentary evidence like passport, visa and letter from the company or college.
• The Covishield^TM vaccination course consists of two separate doses of 0.5 ml each. The second dose should be administered between 4 to 6 weeks after the first dose. However, there is data available for administration of the second dose up to 12 weeks after the first dose from the overseas studies. So govt of India now revised its schedule and now it recommends duration should be between 6-12 weeks.
• Special precautions for storage Store in a refrigerator (+2ºC to +8ºC). Do not freeze. Protect from light.
• Once opened, multi-dose vials should be used as soon as practically possible and within 6 hours when kept between +2ºC and +25ºC. All opened multi-dose vials of Covishield^TM should be discarded at the end of immunization session or within six hours (4 hrs.) whichever comes first.
• Covishield is having 76% vaccine efficacy against symptomatic Covid 19 disease,100% efficacy against severe or critical disease and 85% efficacy against symptomatic Covid 19 in participants 65 years and above.
• Production by Serum Institute of India already ramped up to 65 million doses in June, 70 million in July and 100 million each in August and September.
• New Studies(49)
  • Oxford University new study has revealed that a long gap of 45 weeks or ten months between the first and second dose intervals invokes a better immune response.
  • The study highlights the gap of 44-45 weeks between the two doses increased the antibody counts by nearly four times compared to the current regimen of 8-12 weeks apart.
  • A third booster shot of Covishield was given six months after the second dose.
  • It demonstrated that the third shot nearly doubled the antibody levels on an average among 90 recipients.
  • The third dose was effective in neutralising the SARS-CoV-2 variants like the Alpha (B.1.1.7), Beta (B.1.351), and Delta (B.1.617.2).
  • It also boosts T-cell responses.

Sputnik V

• The Drug Controller General of India (DCGI) approved the vaccine under the emergency use authorisation process recently, citing promising outcomes from clinical trials performed in Russia and additional Phase III clinical trials conducted in India in collaboration with Dr Reddy’s Laboratories.
• The developers of Sputnik V, which has been granted approval for emergency use by India’s drug controller, have tied up with Indian pharmaceutical firms such as Dr Reddy’s Laboratories, Gland Pharma, Hetero Biopharma, Panacea Biotec, Stelis Biopharma and Virchow Biotech to manufacture more than 850 million doses a year.
• Gamaleya researchers developed a vaccine prototype using common cold viruses. Importantly, they chose to administer two distinct adenovirus vectors (rAd26 and rAd5) in a first and second dose, 21 days apart.
• The University of Oxford and AstraZeneca has initiated a trial in Russia to determine if combining doses of their vaccine with Sputnik V may result in additional benefit.
• The efficacy of Sputnik V against COVID-19 was reported as 91.6% and was validated by published internationally peer-reviewed data. Dr. Reddy’s had earlier said that Sputnik V meets the primary endpoint of safety in the phase-2 clinical trials in India.
• Russia’s Sputnik Light Covid-19 vaccine is a single shot version of Sputnik V.
• Phase I and II of the safety and immunogenicity study of Sputnik Light had demonstrated that it can elicit the development of antigen specific IgG antibodies in 96.9% of individuals on the 28th day after vaccination, and that elicits the development of virus neutralising antibodies in 91.67% of individuals on the 28th day after immunisation.
• Sputnik V will be the core vaccine while Sputnik Light will be cheaper and more affordable, and ensure that more people can be vaccinated quickly.
• Sputnik Light works well with all existing mutations of the Coronavirus. It includes all the mutations in its code. Sputnik Light can also be used as a booster shot for other vaccines and trials are currently underway with AstraZeneca.
• There are two forms of the Sputnik V vaccine – liquid, which would have to be stored at minus 18°C and lyophilized (freeze-dried), which can be stored at 2°C to 8°C.
• The lyophilized form was developed especially for the transportation of the vaccine to remote places.
• The vaccine is safe with mostly mild-to-moderate side effects.
• Doses – Sputnik V requires two full doses with a gap of 21 days. The Sputnik Light is given as single dose.
• Availability – Approved in India and is expected to be available from May onwards. Three (3) million dose to be supplied by Russia. 850 million doses will be produced in India.

Zydus DNA vaccine

• Fully indigenous. Made in India as well as Make in India by Indian company Zydus Cadilla.
• Named Zycov-D.
• Three doses Schedule at 0, 28 and 56 day (a two-dose schedule also being worked out).
• Can be stored at 2-8℃ for long term and 25 ℃ for the short term.
• Technology:
  • First DNA vaccine of World.
  • The vaccine codes for virus spike protein using plasmid-DNA. (The plasmid is a small DNA present in plasma of cell as opposed to nuclear chromosomal DNA. It is also commonly found in bacterial cells and has the ability to replicate independently).
  • Genetically engineered plasmid-DNA codes for spike protein which induce immune stimulation.
• Needle free administration – When administered with an ordinary hypodermic needle, DNA vaccines confer only weak immunity. So ZyCoV-D is administered through a needle free injection system (NFIS)- a jet of fluid is accelerated to the high speed providing significant penetrating power through a fine diameter nozzle placed against the skin.

• May become preferred vaccine for children.
• The jab is also being tested on children in the age group of 12-18 years. Soon this may be the vaccine for children and needle less administration might give it desired edge in children.
• Production:
  • Zydus claimed to produce over 240 million doses in a year i.e. 2 crore doses a month.
  • Zydus applied to the DCGI for EUA on 1st July 2021 to launch ZyCoV-D. It presented the interim results from Phase III clinical trials in over 28,000 volunteers which demonstrated adequate Safety and Efficacy data of the vaccine trial. Study was carried out in more than 50 clinical sites spread across the country and during the peak of second wave of COVID-19 reaffirming the vaccine’s efficacy against the new mutant strains especially the delta variant. The study also shows that ZyCoV-D is safe for children in the age group of 12 to 18 years. The Company plans to manufacture 10-12 crore doses annually post approval. ZyCov D was granted EUA on 20 Aug 2021.

Corbevax

• Corbevax is India’s first indigenously developed RBD (Receptor Binding Domain) protein subunit vaccine made by Hyderabad-based company biological-E limited.
• Other vaccines on Similar technology are Hepatitis B and Acellular pertussis. The vaccine should be administered intramuscularly in two doses of 0.5 ml each with intervals of 28 days (Day 0 and 28) and has to be stored between 2 degrees to 8 degrees Celsius.
• It is developed by Biological E. Limited in collaboration with Texas Children’s Hospital Centre for Vaccine Development (Texas Children’s CVD) and Baylor College of Medicine (Baylor) in Houston, Texas.
• In Corbevax protein antigen of SARS-CoV-2 Spike receptor binding domain (RBD) is, adsorbed to the adjuvant Alhydrogel (Alum), in combination with another approved adjuvant, CpG 1018 (from Dynavax’s). Downside of protein sub-units is that they contain only a part of the virus, they may miss certain characteristic signatures of the virus and body’s the immune system may fail to recognise them to induce adequate long-term immunity. This problem is overcome by using an adjuvant.
• Primarily Humoral immunity in form of Neutralizing Antibodies us generated by Protein Sub Unit Vaccines. Because another weakness of protein sub unit vaccine is that these vaccines don’t infect the cells (like inactivated, DNA or mRNA vaccines) and therefore don’t elicit the long-lasting immunity conferred by cells (or the T-cell response).
• Corbevax, the spike protein is grown typically in yeast cells (Pichia pastoris) whereas in Covovax, spike proteins are grown in moth cells. Covovax further uses a nanoparticle formula to make it resemble the structure of the coronavirus spike protein to stimulate the immune response.
• Corbevax has completed two Phase III clinical trials involving more than 3000 subjects between the ages of 18 and 80 at 33 study sites across India. The vaccine was found to be safe, well tolerated and immunogenic. In trials apart from Nab, CorbeVax vaccination also generated significant Th1 skewed cellular immune response. In the pivotal Phase III study Corbevax demonstrated superior immune response in comparison with Covishield vaccine when assessed for Neutralizing Antibody (nAb) Geometric Mean Titers (GMT) against the Ancestral-Wuhan strain and the globally dominant Delta variant. It’s effectiveness against original Wuhan Strain was >90%.
• CorbeVax nAb GMT against the Delta strain indicates vaccine effectiveness of >80 percent for the prevention of symptomatic infections.
• On 3 June 2021, India’s Ministry of Health and Family Welfare pre-ordered 300 million (30 Crore) doses of Corbevax. Biological E. Limited plans to complete production at a rate of 75 million (7.5 crore doses) of its COVID-19 vaccine Corbevax per month, anticipating over 100 million doses per month from February 2022 which will enable the company to deliver 300 Million doses as promised to the Centre. It is predicted to be among the most affordable vaccinations available in the country, as it is manufactured on a low-cost platform. The company has estimated the vaccine to be priced at ₹250 (around $3) per dose and may even be priced below ₹400 (around $5) for two doses in India.
• Booster Dose trials for Corbevax are in progress. Biological E has got the Drug Controller General of India’s nod to conduct trials of its vaccine Corbevax as booster shots on 29 Dec 21. This makes Biological E the second company after Bharat Biotech to conduct clinical trials for booster doses.
• India has already rolled out its plan to administer booster doses, which is being called ‘precaution dose’ in the country, from January 10. *Bharat Biotech’s Covaxin or SII Covishield are being administered as precaution doses to frontline workers and senior citizens.

Covovax

• World Health Organization (WHO) granted emergency use approval to Serum Institute’s Covovax vaccine on 17 December 2021, making it the 9th COVID-19 vaccine to get WHO’s approval. On 28 December 2021, India approved the vaccine for emergency use. Serum Institute of India’s Covovax is a protein subunit of the vaccine developed under license from American biotechnology company Novavax, and the Coalition for Epidemic Preparedness Innovations (CEPI). The collaboration was made official in 2020, wherein Novavax had given the Pune-based company SII the license to manufacture and supply the vaccine to low-and-middle-income countries including India. Like other COVID-19 vaccines in India, it is a two-dose shot 3 weeks apart that requires 2 to 8 °C refrigerated temperatures for stability.
• Covovax is a recombinant protein vaccine that uses spike proteins to infect and train the immune system to fight off infections. The vaccine is made by creating an engineered baculovirus containing modified SARS-CoV-2 spike genes. Then the virus carrying the spike gene is used to infect the moth cells. The cells then create spike proteins associated with the novel coronavirus. The spike proteins are harvested and purified, following which a certain dosage of these spike proteins are used as the vaccine. The Spike proteins are adsorbed on the surface of lipid nano particles giving it shape of a virus. Given that these spike proteins contain no live components of the virus, they are said to be safe and do not lead to actual infections. However, these work towards triggering an immune response, which in turn produce antibodies. That said, vaccines are a mimicry of the virus, aimed to build a protective layer of antibodies against an actual virus.
• Vaccine is free from fetal cells lines unlike mRNA vaccines. So should be acceptable to even the Orthodox/catholic religious minds. The formulation includes a saponin-based adjuvant extracted from the Chilean soapbark tree (Quillaja saponaria) Matrix M used to enhance its immunogenicity. The downside of protein sub-units is that they contain only a part of the Virus; they may miss certain characteristic signatures of the Virus, and body’s the immune system may fail to recognize them to induce adequate long-term immunity. However, this problem is overcome by using an adjuvant. Protein Sub-unit Vaccines generate primarily Humoral immunity in the form of Neutralizing Antibodies because another weakness of protein subunit vaccines is that these vaccines don’t infect the cells (like inactivated, DNA, or mRNA vaccines) and therefore don’t elicit the long-lasting immunity conferred by cells (or the T-cell response).
• Clinical studies have shown an efficacy of 96.4% against mild to severe COVID-19 infection. Additionally, it also showed an efficacy of around 83.4% two weeks after the first dose. The vaccine has also proved efficacious against some of the new emerging variants. While it showed an efficacy of around 86.3% against UK’s Alpha variant of SARs-COV-2 virus, it only managed a 49% effectiveness against the Beta variant that was reported in South Africa. Serum Institute conducted a trial of its COVID-19 vaccine Covovax, in the 12-17 age group and has presented safety data for an initial 100 participants. Later kids 7 to 11 years were also enrolled in study in Sept/21 October. Data is still not in public domain.
• In terms of the Delta variant, Novovax, the US brand name for Covovax, said that a third booster dose of its vaccine administered six months after the two-dose regimen could provide 4.6-fold increase in the antibody count. It is yet to be seen whether Covovax vaccine will prove effective against the new variant, Omicron.
• When it comes to booster shots, it is believed that Covovax has greater efficacy than Covishield. Soon Serum Institute is about to launch Covovax jab for kids from age 3 years, in the next six months. Novavax on 23 December 21 said that receiving an additional booster dose of Novavax’s vaccine further increased people’s immune response to Omicron. The data was taken from Novavax’s ongoing studies of its vaccine’s effectiveness in adolescents and as a booster.
• Most common side effects with Covovax in the trials were usually mild or moderate and got better within a few days after vaccination. Side effects affecting >10% people include headache, nausea (feeling sick) or vomiting, muscle and joint pain, tenderness and pain at the injection site, tiredness and feeling unwell.
• Side effects affecting <1% people include redness and swelling at the injection site, fever, chills and pain in the limbs, enlarged lymph nodes, high blood pressure, rash, reddening of the skin, itching at the injection site and itchy rash.
• Centre had in November permitted the export of 2 crore doses of Covovax to Indonesia before the Indian emergency use authorisation. Indian government has permitted the export of 7 crore doses of COVID-19 vaccine ‘Covovax’ produced by Serum Institute of India here to Netherlands, Australia and New Zealand.

Interchangeability of vaccines

• Vaccines are not interchangeable. However, in exceptional situations, such as a contraindication to the second dose of mRNA vaccine, interchangeability may be allowed.
• Major UK trial looking at whether Covid vaccines can be mixed with different types of jabs used for first and second doses is being expanded.
• Combining vaccines might give broader, longer-lasting immunity against the virus and new variants of it, and offers more flexibility to vaccine rollout.
• Adults over 50 who have had a first dose of Pfizer or AstraZeneca can apply to take part in the Com-Cov study.
• Mix and match the vaccines(50)
  • A study led by Oxford University has explored the potential benefits of pairing doses from two different COVID-19 vaccines:
  • Pfizer and AstraZeneca. Researchers tested the efficacy of the mixed vaccine regimen among 850 volunteers aged 50 and above.
  • The results of this mix and match approach showed strong immunity after the individuals were given alternating shots of Pfizer-BioNTech and AstraZeneca vaccines.
  • The mix of vaccines induced high antibodies levels against the SARS-CoV2 when administered at the gap of four weeks. However, the immune responses differed with the order of immunization. The team noted better immune response when the prime shot was of Oxford-AstraZeneca, followed by a second dose of Pfizer-BioNTech vaccine, rather than vice versa. Moreover, both the approaches induced higher antibody levels than the existing practice of two doses of Covishield alone.
  • The team is planning to analyse further the data from the 12-week dose interval, which is likely to come out soon. The results could induce more flexibility to the roll-out strategy of vaccines based on their production and availability.
  • The study, referred to as the COVID-19 Heterologous Prime Boost study or ‘Com-Cov’, commenced in February 2021, and the results are yet to be published in a peer-reviewed journal. The study is available in the preprint server of The Lancet.
  • As per reports, countries like Spain and Germany have started offering second doses of the Pfizer or Moderna vaccines to young people after the first dose of the AstraZeneca vaccine.

Interval between Covid-19 and other (non-Covid-19) vaccines

• A time interval of 14 days should be maintained between COVID-19 vaccination and other (non-COVID-19) vaccines. However, COVID-19 and other vaccines may be administered in a shorter period in urgent situations such as a tetanus toxoid containing vaccine for after wound management, or to vaccinate residents of long-term care facilities to avoid delays to COVID-19 vaccination.

6. Booster Dose of Covid-19 vaccine (52, 53)

• The Union Ministry of Health has released guidelines on precaution dose and vaccination in the age group of 15-18 years in January 2022. It is important to note that the booster dose will not be a mix and match of the COVID-19 vaccines. This means individuals who received two doses of the Serum Institute’s Covishield will get the same vaccine this time, and those who got Bharat Biotech’s Covaxin will get a third jab of that vaccine.
• The prioritization and sequencing of this precaution dose for Health Care Workers (HCWs) & Front Line Workers (FLWs) would be based on the completion of 9 months i.e. 39 weeks from the date of administration of 2nd dose.
• The prioritization and sequencing of this precaution dose for all persons aged 60 years and above with comorbidities who have received two doses of COVID-19 vaccine on doctor’s advice would be based on the completion of 9 months i.e. 39 weeks from the date of administration of second dose.

Efficacy of Covaxin in Children:

• Studies showed superior antibodies formation in children when compared to adults.
• Study also demonstrated that vaccine responses were skewed towards a Th1 response with IgG1/IgG4 addressing concerns of Cell mediated Immunity or Th1-dominant response found preferable for Covid-19 vaccines.
• Additional advantage of Covaxin over Omicron – Further advantage of a whole-virion vaccine such as BBV152 is that vaccine contains multiple epitopes, as illustrated by the marked Antibody levels in trial against S-protein, RBD, and N-protein in the above study. It might give the vaccine an edge over Spike protein vaccines especially in view of changing strains like Omicron.

Factors favoring vaccination among Children:

• COVID-19 is generally asymptomatic or mild in children, but can be more severe in those with certain comorbidities.
• Two longer term consequences of SARS-CoV-2 infection might therefore be more of a concern in this age group. The first is ‘paediatric inflammatory multisystem syndrome-temporally associated with SARS-CoV-2 (PIMS-TS)’, also known as ‘multisystem inflammatory syndrome in children’, MIS-C an immune-mediated disease that occurs in a small proportion of children 2–6 weeks after being infected with SARS-CoV-2. The second is long COVID-19, the persistence of symptoms following SARS-CoV-2 infection, a heterogeneous group of conditions.
• Population-level factors, such as reducing community transmission.
• Avoidance of quarantine.
• School closures and other lockdown measures.
• The potential impact on routine immunisation programmes.
• Ending the Pandemic.

7. Covid-19 vaccine indications and contraindications

Indications

The currently available vaccines in India (Covaxin^® and Covishield™) have been approved for restricted use in emergency situations for active immunization to prevent COVID-19 in individuals of above 12 years (Covaxin) and 18 years (Covishield) of age and older.

Contraindications

Only absolute contraindication of Covid vaccine is known hypersensitivity to the components of the vaccine

• Administration of COVID-19 vaccine is contraindicated in people with the following conditions:
• Anaphylaxis or anaphylactic reactions to a previous dose of COVID-19
• Immediate or delayed onset anaphylaxis or allergic reaction to vaccine injections or other pharmaceutical products.
• Pregnancy and lactation – These appear to be relative precautionary contraindications:
  • Pregnancy and lactation are not a contraindication to vaccine receipt. However, caution should be exercised while administering the vaccination in this population and benefits should outweigh the risks.
  • None of these vaccines contain a virus that replicates; thus, they do not cause disease, but nonspecific side effects from activation of the immune system may occur. Based on how mRNA and viral vector vaccines work, experts believe they are unlikely to pose a risk for pregnant persons, the fetus, or breastfeeding newborns.
  • However, data gathered from the US regarding the use of mRNA Vaccines Pfizer-BioNTech and Moderna in pregnancy did not show any safety concerns. The recommendation for these vaccines is that pregnant women in high-risk groups, like health care workers if choosing to get vaccinated, may receive the vaccine. The decision has to be taken after discussing the benefits weighed against the risks. The timing of the vaccine can be any time during the pregnancy; however, some may choose to wait until after 12 weeks and prior to the last trimester.
  • On 25 June 2021, Union Health Ministry, Ministry of Health and Family Welfare (MoHFW), Government of India (GOI), has stated “Pregnant Women Can and Should get Vaccinated” against COVID-19.
  • On 19th May 2021, Centre had approved Vaccination for Mothers Breasting their Babies.
  • Before Vaccination, Pregnant Women and Lactating Women should be fully Informed that the “Long Term Adverse Reaction & Safety on Fetus & Child are Not yet established.”
• In certain cases, like the ones listed below, it is recommended to delay administration of the COVID-19 vaccine dose by 30-90 days:
  • Individuals with confirmed COVID-19 infection or suspected to have COVID-19 infection.
  • COVID-19 patients who were given convalescent plasma or anti-SARS CoV2 antibodies
  • Acutely ill patients who have been hospitalized (not necessarily in intensive care)
  • Individuals who have taken another vaccine within the previous 14 days or who intend to take a dose of another vaccine in the next four weeks after the planned vaccine dose.

Special Caution

• The vaccine should be administered with special caution in the following patients:
  • Patients who have a history of or are currently having any bleeding disorder.
  • Individuals having a history of being SARS-CoV2 positive.
    • Currently, there are no data on the safety and efficacy of COVID-19 vaccines in people who have received monoclonal antibodies or convalescent plasma as a part of COVID-19 treatment. Studies indicate that reinfection is uncommon in the first 90 days after the COVID-19 infection hence vaccination should be delayed for at least 90 days. This precaution is being taken to avoid any potential interference of the antibody therapy with vaccine-induced immune responses. This recommendation applies to people who receive passive antibody therapy before receiving any vaccine dose and to those who receive passive antibody therapy after the first dose of this vaccine but before the second dose, in which case the second dose should be deferred for at least 90 days following receipt of the antibody therapy. Receipt of passive antibody therapy in the past 90 days is not a contraindication to receipt of the COVID-19 vaccine.
• With history of chronic diseases and comorbidities including cardiac, neurological, pulmonary, metabolic, renal, or malignancies should be assessed on case basis. These groups are usually eligible vaccination.
• Autoimmune conditions/ Immunocompromised individuals: Patients who have a history of immunodeficiency or are immunocompromised as in the case of HIV patients, can still be administered the vaccine. Since the immune system is already compromised, their response to the vaccine could be lesser than healthy individuals.  Data for responses in immuno-compromised individuals are currently insufficient to conclude the safety of this vaccine in these populations. However, if they are planning to get themselves vaccinated, then the vaccination should be completed at least two weeks before the initiation of immunosuppressive therapies. 

Precautions

According to recent reports, in some cases, a combination of thrombosis and thrombocytopenia, in some cases accompanied by bleeding, has been observed very rarely following vaccination with AstraZeneca COVID-19 Vaccine (COVISHIELD™). The majority of these cases occurred within the first 14 days following vaccination. Some cases had a fatal outcome. Regulators and healthcare professionals are monitoring the safety of this vaccine on a continuous basis. As a precautionary measure, healthcare professionals should be alert to the signs and symptoms of thromboembolism and thrombocytopenia, as well as other coagulopathies in patients receiving this vaccine.

8. Covid-19 vaccination common side effects(7,8.9,10)

Before a vaccine is approved or administered to the public at large, it is tested for efficacy and safety. Despite the benefits that a vaccine provides, there are some risks associated with the use of these vaccines as well. If an individual experiences side effects after getting vaccinated, then it is an indication that the vaccine is doing its work and your immune system is responding to the vaccine well. Immune response or side effects of a vaccine can be different in different individuals based on the medical history of the individual, any underlying illnesses, the current level of immunity, and also the type of vaccine administered.

Mild-to-moderate side-effects are normal in individuals who have received the vaccine. In fact, they are signs that the body’s immune system is responding to the vaccine well. These side effects usually go away on their own after a few days.

The most commonly reported side effects of COVID-19 vaccines have been mild to moderate and short-lasting. They include:

• Some adverse reactions in post-authorization experience have been reported following administration of the Pfizer-BioNTech/Moderna/Janssen COVID-19 vaccine-like severe allergic reactions, including anaphylaxis and other hypersensitivity reactions e.g., rash, pruritus, urticaria, angioedema, diarrhea, vomiting.
• In rare cases, some of the individuals after taking the COVID-19 vaccine reported having a severe allergic reaction like anaphylaxis, breathing difficulty, swelling of face, throat, and low blood pressure. However, these are very rare and the COVID-19 vaccines administered in the Indian population have shown a very good safety profile. 
• There is a possibility that some individuals may experience serious and unexpected side effects other than those listed above. If the person experiences any of the listed side effect(s) or any other severe reactions in the body, please advise the person to contact/visit his/her healthcare provider or medical staff supervising the vaccination.
• Reports from multiple vaccine studies indicate that many people do not experience any side effects with the first dose of the vaccine but may experience side effects with the second dose of the vaccine. Vaccines are proven to be safe and getting vaccinated may give you the required protection from a COVID-19 infection in the future. It is important to remember that mild or moderate side effects of the vaccine should not be a reason for avoiding vaccinations. We should get vaccinations as per the schedule and continue our practices of wearing a mask in public places, maintaining adequate social distancing, avoiding crowds, and washing hands often.

9. Covid-19 vaccination use in special situations

It is always recommended to schedule an immunization program for those aged 15 years or older only after considering certain special situations such as age, existing medical conditions, and other indications. The same thumb rule applies to COVID-19 vaccination as well. The table below summarizes some special situations and COVID-19 vaccination recommendations in such situations.

10. Covid-19 vaccination complications(26,27,28,29)

Emerging variants of the SARS-CoV-2 virus pose a serious global clinical concern. Despite adequate evidence of vaccine efficacy is available, there are reports of individuals experiencing complications related to COVID-19 vaccination. These observations indicate a potential risk of illness after successful vaccination and subsequent risk of infection with the variant virus, and they provide support for continued efforts to prevent and diagnose infection and to characterize variants in vaccinated persons.

1. Delayed local injection-site reactions to vaccine may occur, though they are uncommon (T-cell mediated reactions).

2. Other reactions observed include aphthous ulcers, petechial rash, ear eczema, painful lymphadenitis (axillary), episcleritis, recurrent urticaria, seizures, neurological pain, tremors, spinal pain, transient blurring of vision.

3. In susceptible high-risk (pro-inflammatory and/or pro-coagulative) individuals, reactogenic vaccines can trigger transient thrombo-inflammation lasting the first few (up to four) days. This was first reported in Norway in mid-January and 33 deaths occurred in a short time after the COVID-19 vaccine (Pfizer-BioNTech mRNA vaccine) were reported as well. All of them were elderly (≥75 years) and frail individuals. UK’s Medicines and Healthcare Products Regulatory Agency reported 227 deaths shortly after the Pfizer vaccine and 275 deaths after the AstraZeneca vaccine, through February 28. The Paul Ehrlich Institute in Germany reported the deaths of 7 elderly people shortly after receiving the Pfizer vaccine. The US, which has three vaccines (Pfizer + Moderna + J&J), reported 1637 deaths till March 8. All deaths were in comorbid patients, either evident or silent.

4. Austria was the first country to report coagulation disorders (venous thromboembolism).

• Thirty-nine deaths out of 71 deaths reported in India (till 13th March) were related to cardiovascular disease. Three patterns have been observed: Venous thrombosis presenting as pulmonary embolism, arterial thrombosis presenting as sudden cardiac event and frail people, who died suddenly after the vaccine.

• The COVID-19 vaccine is an acute thrombo inflammatory non-replicative non-contagious viral protein. Like the natural infection, vaccines too may cause inflammation, thrombosis, and immune reactions. However, unlike the vaccine, the natural viral protein will not cause allergy (anaphylaxis). The vaccine will cause allergic reactions.

• The AstraZeneca vaccine is showing more reactogenicity than other vaccines as double reactions are occurring in the body.

5. Local injection site BCG-like reactions (type 4 reaction) may occur between the 2nd and 4th day, which usually fade after the 6th Such reactions may occur even remotely. No scar develops.

6. Non-Ig-E mediated (complement-mediated) reactions may occur after 6 hours: angioneurotic edema, rash, urticaria; not fatal and can be prevented by montelukast + levocetirizine.

7. The adenovirus also provokes the immune system by switching off the cell’s alarm response. Anaphylaxis occurs with 15-30 minutes of the vaccine. Allergy is caused by a protein (PEG or polysorbate 80). Serious allergic reactions occur one in a million. Their incidence is very low in India.

8. A case of death due to rupture of abdominal aortic aneurysm 10 days after receiving a COVID-19 vaccine has been reported in Thailand.

9. Post vaccine loss of smell and taste in a person who developed loss of smell and taste post-COVID-19 also.

10. Sympathetic overactivity can manifest as accelerated hypertension and transient atrial fibrillation.

11. Transient hyperglycemia after the vaccine has been reported.

12. Post-vaccine systemic inflammation with normal pulmonary function (no pneumonia on HRCT chest) may occur manifesting as rising CRP and high fever. Inflammation can be prevented: Prevent Th17 response by preloading with vitamin D; if routine inflammation with raised CRP, preload with colchicine; if very high LDL, preload with a statin; if cardiac manifestations, preload with doxycycline; in high-risk patients, preload with aspirin.

13. Antibody-dependent enhancement post-vaccination (ADE)

• It occurs when the antibodies generated during an immune response recognize and bind to a pathogen, but they are unable to prevent infection. Instead, these antibodies act as a “Trojan horse,” allowing the pathogen to get into cells and exacerbate the immune response.

• The risk of exacerbating COVID-19 severity via ADE is a potential hurdle for antibody-based vaccines and therapeutics.

• ADE can increase the severity of multiple viral infections.

• ADE in respiratory infections is included in a broader category named enhanced respiratory disease (ERD). It also includes non-antibody-based mechanisms such as cytokine cascades and cell-mediated immunopathology.

• Neither COVID-19 disease nor the new COVID-19 vaccines have shown evidence of causing ADE. People infected with SARS-CoV-2, the virus that causes COVID-19, have not been likely to develop ADE upon repeat exposure. This is true of other coronaviruses as well. Likewise, studies of vaccines in the laboratory with animals or the clinical trials in people have not found evidence of ADE.

14. Vaccine induced ITP

• IVIG is drug of choice. Should be given earliest to nullify vaccine antibody binding to platelet.

• For milder cases without bleeding symptoms, it should be treated like acute ITP i.e., Steroids (prednisolone or Dexamethasone).

• Relapse or refractory case will require TPO mimetics (Elthrombopag/ Romiplostim) or other 2^nd line drugs like Azathioprine/ Dapsone/ MMF

• Rituximab is another option for release or refractory cases.

15. Vaccine induced Immune thrombotic thrombocytopenia (VIIT)(30,31)

• A rare syndrome of thrombosis, often cerebral venous sinus thrombosis, and thrombocytopenia is being noted and is highlighted as affecting patients of all ages and both genders; at present, there is no clear signal of what the risk factors are.

• For patients presenting with acute thrombosis or new onset thrombocytopenia within 28 days of receiving COVID 19 vaccination, VIITP may be the reason. The cases are unusual because despite thrombocytopenia, there is progressive thrombosis, primarily venous, with a high preponderance of cerebral venous sinus thrombosis. Arterial events have also been noted.

• Typical laboratory features include a platelet count less than 150 x 10⁹/L, very raised D Dimer levels above the level expected for VTE and inappropriately low fibrinogen. Antibodies to platelet factor 4 (PF4) have been identified and so this has similarities to heparin-induced thrombocytopenia (HIT), but in the absence of patient exposure to heparin treatment. These antibodies are detected by ELISA HIT assay.

Possible case

Any patient presenting with acute thrombosis or new onset thrombocytopenia within 28 days of receiving COVID 19 vaccination.

Investigations

1. Check a CBC-specifically to confirm thrombocytopenia <150 x 109/L
2. Coagulation screen, including Clauss fibrinogen and D Dimers
3. Blood film to confirm true thrombocytopenia and identify alternative causes
   • Unlikely case:
     • Reduced platelet count without thrombosis with D dimer at or near normal and normal fibrinogen.
     • Thrombosis with normal platelet count and D dimer <4000 and normal fibrinogen
   • Probable case:
     • If D Dimers >4000.
4. Serum sample for PF4 antibody assay (HIT assay).

Management of a suspected case – treat first while awaiting confirmatory diagnosis.

1. AVOID platelet transfusions. Discuss any required interventions.
2. AVOID all forms of heparin including heparin-based flushes. (It is unknown whether heparin exacerbates the condition but until further data is clear, this is best avoided).
3. GIVE intravenous immunoglobulin 1g/kg (divided into two days if needed) and review clinical course. Further IVIG may be required balancing bleeding and thrombotic risk.
4. ANTICOAGULATE with non-heparin-based therapies such as DOACs, argatroban, fondaparinux or danaparoid depending on the clinical picture.
5. Steroids and/or plasma exchange may also be considered.
6. Avoid thrombopoietin receptor agonists.
7. Antiplatelet agents are not recommended based on current experience.
8. If no overt thrombosis, but thrombocytopenia with raised D Dimer, thromboprophylaxis with non-heparin-based anticoagulants should be considered – balancing bleeding and thrombotic risk. DOAC, fondaparinux or danaparoid can be used.
9. Until further structures are in place, advice on management should be sought from the Expert Haematologist.

Confirmed case

If PF4 antibodies positive by ELISA

1. Continue ongoing treatment as above.
2. Serum sample for Covid antibody testing and storage.
3. EDTA sample – to be stored locally until location of central lab is confirmed If negative, please discuss before changing treatment.

16. Herpes zoster following the COVID‐19 vaccine(33)

It is reported in large numbers since the start of Corona Vaccination. Almost 1 out of 3 people will develop shingles in their lifetime. It is not surprising that shingles cases are appearing since many of the millions of people across the world who have gotten their COVID-19 vaccine are older and the risk of getting shingles increases with age. Almost certainly, those who got shingles did not have themselves Shingrix vaccinated. In fact, the vaccine has been out of supply for quite some time. Also, in general, the CDC advises that no other vaccines be given within 14 days of getting the COVID-19 vaccine. The review of the literature doesn’t point to a constant pattern in the appearance of Zoster and COVID-19 Vaccination. Herpes zoster caused by reactivation of VZV may occur spontaneously or be triggered by trauma, stress, fever, or immunosuppression. It is well known that fever, stress are common side effects of current COVID-19 vaccines.

17. Central venous sinus thrombosis

It is reported with Astra Zeneca COVID-19 vaccine in Europe Some patients developed cases of Central Venous Sinus Thrombosis (CVST), Pulmonary embolism, Splanchnic Vein thrombosis, DVT, etc. following Astra Zeneca vaccine AZD1222. Most of the patients were women under age 55, and the fatality rate among those who develop clots is as high as 40%. Central Venous Sinus Thrombosis typically happens between four and 20 days after getting the Astra Zeneca vaccine and the symptoms mimic a stroke or a heart attack. The mechanism is probably AZD1222 vaccine-induced prothrombotic state caused by the development of platelet-activating antibodies directed against platelet factor 4 (PF4). This prothrombotic disorder clinically resembles heparin-induced thrombocytopenia but showing a different serological profile. Though instances of such thrombosis are rare but grave nature of complication makes it a matter of concern.

18. COVID-19 Vaccination and Neuropathy especially Guillain Barre Syndrome (GBS)

Concerns about the risk of GBS in response to vaccines date back to 1976 when CDC has noted: “there was a small increased risk of GBS after swine flu vaccination.” Later It was found that the risk of GBS was no more than 1 additional case per one lakh doses of vaccine.  Hence the CDC later corrected itself stating “Studies suggested that it is more likely that a person will get GBS after getting the flu than after vaccination.” With billions of the world’s populations having been immunized one would have got thousands and thousands of cases of GBS associated with the vaccine if both had any correlation.  However, not more than one case of post-vaccination GBS has been reported to CDC to date. CDC is of the view that no instances of GBS were seen during clinical trials of the vaccines, that no published studies suggest any cause for concern, and that neither the CDC nor FDA recommends against the vaccine due to GBS. Concerns that COVID-19 vaccination might cause GBS in any significant numbers are therefore almost certainly unfounded. Scientists are studying the risk to benefit ratio of the vaccine in someone who previously developed Guillain Barre Syndrome after vaccination.

19. Vaccine induced enlarged heart symptom

US warns Pfizer, Moderna vax recipients to watch for enlarged heart symptom. The US government continues to recommend coronavirus vaccinations for everyone 12 years of age and older, albeit with a new warning to watch for symptoms of an enlarged heart reported by a fraction of people receiving the Pfizer or Moderna inoculation, the Centers for Disease Control and Prevention said. The known and potential benefits of COVID-19 vaccination outweigh the known and potential risks, including the possible risk of myocarditis or pericarditis [enlarged heart]. Also, most patients with myocarditis and pericarditis who received care responded well to treatment and rest and quickly felt better as reported by CDC in a press conference. The release, however, urged vaccine recipients to “be on the lookout for any of the following symptoms: chest pain; shortness of breath; feelings of having a fast-beating, fluttering, or pounding heart” and to seek medical care if any of the symptoms occur following the first or second jab. The US Food and Drug Administration is expected to add similar warnings accompanying both vaccines, according to media reports. The CDC release was issued following a day in which the agency’s Advisory Committee on Immunization Practices (ACIP) began reviewing reports of myocarditis connected with the two vaccines – the most detailed data coming from the Israeli Health Ministry, according to one presentation.

11. Vaccine failure(35)

• To understand Vaccine failure, we should first understand vaccine efficacy. Vaccine efficacy/effectiveness (VE) is measured by calculating the risk of disease among vaccinated and unvaccinated individuals and determining the percentage reduction in risk of disease among vaccinated individuals relative to unvaccinated individuals. The greater the percentage reduction of illness in the vaccinated group, the greater the vaccine efficacy/effectiveness.
• The VEs of COVISHIELD™ and COVAXIN^® are 54.9-82.4% and 81% depending upon the interval between two doses, respectively which means that though being vaccinated, the individual is still susceptible to infection. In other words, the vaccine had failed to give 100% protection. Even asymptomatic infection will be considered as vaccine failure.

No vaccine can be or is 100% effective.  Any effectivity above 60% is considered good enough. And if any vaccine is protecting > 90% from getting a serious disease and > 99% from death, it has to be called a highly effective one!!

• The failure rate of COVID-19 vaccines, even though ranges from 19-45%, it is claimed to be more than 90% effective in preventing serious disease and 99-100% effective in preventing deaths according to anecdotal unconfirmed reports about death in fully vaccinated people.
• Paradoxically the failure of COVID-19 vaccines against asymptomatic infection is high enough. In fact, it only means that this population would have progressed to symptomatic or more severe disease otherwise.
• There are two types of vaccine failures – Primary and Secondary.
• Primary vaccine failure means non-development of immune response in the subject to whom it is administered for various reasons. The reasons may be extrinsic or intrinsic.
  • Extrinsic reasons like -non-maintenance of cold chain during transport and storage, Improper handling during vaccination, Improper technique of administration, Improper dosing or dosing errors, Improper scheduling, and many others. These are and should be preventable at least to a certain extent by appropriate training on all relevant fronts.
  • Intrinsic reasons are subject related – An immunocompromised state, On steroids or immunosuppressants, Cross reactivities, etc.  Some of these may be modifiable to some extent.
• Secondary vaccine failure means the development of infection despite an immune response or a Breakthrough Infection. The reasons can be the development of very low antibodies and antibodies waning over time, and a very low cell-mediated response as well. Mutant strains can be immune evasive and cause infection despite being armed with antibodies. This is to be considered a very important cause of vaccine failure in the present scenario.
• It may be extremely difficult to assess the reason for vaccine failure and will involve many technicalities and investigations pertaining right from manufacturing- storage-transportation, to measuring humoral and cell-mediated immune responses in the failed subjects.

What to infer?

• The failure rates of existing covid-19 vaccines in preventing death and serious disease are very low. Because fully vaccinated people usually have some immunity against the disease, breakthrough cases usually have either no symptoms or mild symptoms.  A breakthrough case occurs when an individual has had a lower immune response from the vaccine. No vaccine is 100 percent effective.
• Vaccine failures should be thoroughly studied.
• A person not developing a good immune response as judged by measuring antibodies may be still protected by virtue of cell mediated immunity.
• A person developing sky high antibodies may be still vulnerable if attacked by immune evading mutant strain.
• COVID-19 Breakthrough Case Investigations and Reporting – Vaccine breakthrough case definition (CDC):
  • A person who has SARS-CoV-2 RNA or antigen detected on a respiratory specimen collected ≥14 days after completing the primary series of a U.S. Food and Drug Administration (FDA)-authorized COVID-19 vaccine.
  • As FDA-authorized COVID-19 vaccines are administered more broadly, it will be important to monitor breakthrough cases to identify unexpected trends or clustering in the patients (i.e., demographics, geography, underlying medical conditions, time since vaccine receipt, and clinical severity), the administered vaccine (i.e., type, dosing, lot, storage, and handling), or infecting virus (i.e., variant strains and mutations).
  • The Centers for Disease Control (CDC) is currently investigating all reports of COVID-19 breakthrough cases. Breakthrough cases are studied as part of the CDC’s ongoing research to assess how COVID-19 vaccines work in real-world conditions COVID-19 vaccine breakthrough case investigation form pdf icon[2 pages]

12. Future vaccines(36,37)

Several vaccine candidates are in different stages of trials in India to test safety and efficacy. One of them is:

• A nasal vaccine by Bharat BioTech. The intranasal vaccine is different from the intramuscular vaccine Covaxin (BBV157) currently approved in India and abroad. The product on trial is BBV154, a novel adenovirus vectored, intranasal vaccine using Replication defective Chimpanzee Adeno Virus. One drop of vaccine in each of the nostrils is sufficient,” Single-Dose Vaccine. Bharat Biotech’s BBV154 is the first publicized attempt at getting an intranasal vaccine against coronavirus. Pre-clinical trials in Hamster mice have shown successful response. The company had tied up with the Washington University School of Medicine in St Louis to develop an intranasal vaccine for COVID-19. Bharat Biotech had also been working with the Univ. of Wisconsin in developing another Nasal vaccine FluGen. Current trials are with the University of Washington. An intranasal vaccine stimulates a broad immune response – neutralizing IgG, mucosal IgA, and T cell responses. Immune responses at the site of infection (in the nasal mucosa) – essential for blocking both infection and transmission of COVID-19. The nasal route has excellent potential for vaccination due to the organized immune systems of the nasal mucosa.

Benefits of Intra Nasal Vaccines:

• An intranasal vaccine stimulates a broad immune response – neutralizing IgG, mucosal IgA, and T cell responses.
• Immune responses at the site of infection (in the nasal mucosa) – essential for blocking both infection and transmission of COVID-19.
• The nasal route has excellent potential for vaccination due to the organized immune systems of the nasal mucosa.

13. Fifty Frequently asked questions(40)

(MoH-Ministry of health, India, Updated 25th March 21)

1. How will I know that I am eligible for vaccination?

• India makes COVID-19 VACCINE Available to All above 15 yrs of age.

2. Is it mandatory to get vaccinated? Any option to choose among vaccines in India?

• Vaccination for COVID-19 is entirely voluntary. Kindly make an informed decision with the information that is provided to you. Vaccination can protect against development of severe disease and attenuate development of symptomatic infections.
• The vaccine will be supplied to various parts of India as per availability and distribution plan, beneficiaries load and so at present the option of choice of vaccine is not available.

3. With Emergency Use Authorisation (EUA)/accelerated approval, will the vaccine be safe for users?

• Yes.

4. What is benefit of taking COVID-19 vaccine?

• COVID-19 vaccine will protect against severe disease and development of a symptomatic infection. It does not protect against transmission of disease and hence we request that people who are vaccinated, strictly comply with infection control precautions at all times i.e., universal masking and social distancing even after administration of the vaccine.

5. What is the route of the vaccine? How many doses of vaccine to be taken? What is time interval?

• The route of all available vaccines is intramuscular. Two doses of vaccine are required for development of a robust immune response.
• The time interval between two doses of the Covishield vaccine has been extended from four-six weeks to 12 to 16 weeks. The second dose of Covaxin can be taken four to six weeks after the first. (MoH) in special cases.

6. Is the vaccine necessary for a COVID recovered person?

• Yes, the duration of immunity acquired after a natural infection to SARS- CoV2 is believed to be 3-6 months only based on the presence of neutralizing antibodies. Vaccine may be taken 1-3 months after recovery.

7. Can a person with recent/current COVID-19 infection be vaccinated?

• I received the First Dose of the Vaccine and then tested COVID-19 Positive in between the two doses? Can I take the second dose? Answer: You can receive the second dose three months after testing positive. (MoH)
• In case of individuals having lab test proven SARS-2 COVID-19 illness, all Covid vaccination including Precaution dose to be deferred by 3 months after recovery (MoH, (DO No.l 94040712020/lmm), dated I 9th May, 202I updated on D.O No. T-213966812021 – Immunization Dated: 2lst January, 2022.

8. As per MoH, India – Is it necessary for a COVID-19 recovered person to take the vaccine? And if I had COVID-19 infection and was treated, why should I receive the vaccine?

• Yes, it is advisable to receive complete schedule of COVID-19 vaccine irrespective of past history of infection with COVID-19. This will help in developing a strong immune response against the disease. Development of immunity or duration of protection after COVID-19 exposure is not established therefore it is recommended to receive vaccine even after COVID-19 infection. Wait for 4-8 weeks after recovery from COVID symptoms before getting the vaccine.

9. Are there any side effects of this vaccine? (MoH)

• Covishield®: Some mild symptoms may occur like injection site tenderness, injection site pain, headache, fatigue, myalgia, malaise, pyrexia, chills and arthralgia, nausea. Very rare events of demyelinating disorders have been reported following vaccination with this vaccine but without the causal relationship establishment.
• Covaxin®: Some mild symptoms AEFIs may occur like injection site pain, headache, fatigue, fever, body ache, abdominal pain, nausea and vomiting, dizziness-giddiness, tremor, sweating, cold, cough and injection site swelling. No other vaccine-related serious adverse effects have been reported.

10. Can persons with allergic reactions/history of anaphylaxis safely be vaccinated?

• If history of anaphylaxis/allergic reactions to a component of the vaccine is known, then vaccine is contraindicated. Any person with history of allergic reactions and anaphylaxis to a previous vaccine is required to report the same before the administration of vaccine.
• All staff receiving the vaccine will be observed for a period of 30 minutes after administration of vaccine. A history of allergies to food, pet, insect, oral medications or environmental agents are not considered as contraindication/does not need additional precautions.

11. Out of the multiple vaccines available, how is one or more vaccine chosen for administration?

• The safety and efficacy data from clinical trials of vaccine candidates are examined by Drug Regulator of our country before granting the license for the same. Hence, all the COVID-19 vaccines that receive license will have comparable safety and efficacy. However, it must be ensured that the entire schedule of vaccination is completed by only one type of vaccine as different COVID-19 vaccines are not interchangeable. (MoH)

12. How will I know about efficacy and safety of the vaccine administered?

• The two vaccines being administered by the government are AstraZeneca- SII Covishield or Bharat Biotech Covaxin. The safety and efficacy are now visible by experience of mass vaccination and by post vaccination Covid cases are mild in nature at large.

13. Can I get COVID-19 because of vaccination?

• No, all COVID 19 vaccines either use inactivated virus, or parts/gene of the virus. Hence infection will not occur due to vaccination.

14. How long will the vaccine protect from an infection?

• The data on duration of protection is not yet available. It is expected to protect for at least 6 months or possibly even longer. However, ongoing trials may provide efficacy data in 1-2 years.

15. Is it mandatory to follow the safety precautions (masking, hand hygiene, physical distancing) after receiving COVID19 vaccine?

• Even after vaccination, all standard precautions and transmission-based precautions i.e., appropriate usage of masks/respirators, hand hygiene; physical distancing should be STRICTLY followed.

16. The Health Ministry has advised caution in vaccinating persons with a history of bleeding or coagulation disorder. How does a person know if he/she has a coagulation disorder? What tests can be conducted?

• There are a few bleeding disorders like ‘haemophilia’. These persons should take the vaccine under the supervision of their treating physician. Patients who are admitted in hospital or ICU and have bleeding problems should delay the vaccination till they are discharged. However, several people with heart and brain disorders are on blood thinners like aspirin and antiplatelet drugs. They can continue with their medicines and have the vaccines. For them, vaccines are absolutely safe. (MoH)

17. If I refuse the vaccine now, will I be able to take it later?

• At the moment vaccine rollout is only through government sources. As and when the vaccines become available in the private market there may be an opportunity to avail these vaccines then.

18. Will the vaccine work against the newly identified UK strain known as 20B/501Y.V1, VOC 202012/01 or as B.1.1.7 and South African strain 20C/501Y.V2 or B.1.351 lineage?

• It is believed that there are escape mutants in the South African strain which may reduce the vaccine efficacy; however, the expert recommendation is to go ahead with vaccination.
• Even though the new UK variant has mutations to the spike protein that is targeted by the vaccines, available vaccine produces antibodies against many regions in the spike protein. At present preliminary communication indicates that this vaccine will provide protection.
• Covaxin: “Twelve isolates of VUI lineage B.1.617 were propagated in VeroCCL81 cells and characterized. Convalescent sera of the COVID-19 cases and recipients of BBV152 (Covaxin) were able to neutralize VUI B.1.617.” (bioRxiv preprint doi: https://doi.org/10.1101/2021.04.23.441101; this version posted April 23, 2021.)
• Covishield: Covishield protects against B1617 variant as per a very preliminary study. Early results using in vitro neutralization assay show that both convalescent (prior infection) sera and Covishield vaccinated sera offer protection.

19. Can other vaccines (Eg: Influenza or Pneumococcal) be given along with COVID vaccine?

• Inactivated or sub unit vaccines can be safely administered simultaneously or can be given after 2 weeks. If a live vaccine is required, it may be given simultaneously or 4 weeks after administration of this vaccine.

20. The health advisory also states that those with immunity issues should be cautious about taking the vaccine. What are the markers of ‘Immunity issues’?

• Immune issues are of two types: one, immunosuppression due to any disease such as AIDS, and people on immunosuppressant drugs such as anti-cancer drugs, steroids, etc. Second, immunodeficiency in people who suffers from some defect in the body’s protective system such as congenital immunodeficiency.
• Currently, available COVID-19 vaccines do not have any live virus and therefore individuals with immune issues can have the vaccine safely. But the vaccine may not be as effective in them. One should inform the vaccinator about the medicines they consume and if they are suffering from any known immune issues. The vaccinator should have a record of one’s medical condition. (MoH)

21. Can persons who have undergone convalescent plasma or monoclonal antibodies treatment for COVID19 infection take vaccination?

• Persons previously treated for COVID-19 infection with monoclonal antibodies or convalescent plasma should have vaccination deferred for 90 days (from the date of treatment) to avoid potential interference with vaccine induced immune responses.

22. How safe are mRNA vaccines?

• mRNA vaccines do not have a risk of modifying the vaccine recipient’s genetic makeup, which could theoretically happen with a DNA vaccine. After injection, mRNA vaccines penetrate and introduce an mRNA sequence into host (the vaccine) immune cell cytoplasm that instructs the cell to synthesize a target protein (not a whole virus) for the immune system to react to.
• For COVID-19 vaccines, the spike protein is then excreted locally from the cell or presented directly on the cell surface to other mobile immune cells to stimulate a SARS-CoV-2 specific immune response. The cells penetrated by the vaccine mRNA serve as passive protein factories. The mRNA produces protein and then degrades after a few days (maximum) because RNA is very unstable. No effect on host DNA is possible because DNA is located in the nucleus and is protected.

23. Will I need third Booster Dose?

• Pfizer and Moderna recently announced that people who have received both doses of the Pfizer-BioNTech or Moderna coronavirus vaccines will probably need a booster shot this year and might need an annual shot thereafter.
• An expert panel of the Drugs Controller General of India (DCGI) had permitted Bharat Biotech to give a third dose of its COVID-19 vaccine Covaxin to a few volunteers in its clinical trials.
• Currently, people eligible for inoculation in the country are being administered Serum Institute of India’s Covishield and Covaxin. Both vaccines are being given in two doses in a gap of up to eight weeks.
• Bharat Biotech has proposed a booster dose after six months of the second dose.
• Regarding applicability and effectiveness of a third dose, especially in view of the raging second COVID-19 wave, experts opine that third booster dose needs more studies to determine if it will help in fighting infections more effectively.

24. If one is taking medicines for illnesses like Cancer, Diabetes, Hypertension etc, can s/he take the COVID-19 vaccine and/or If I suffer from HTN/DM/CKD/heart disease/lipid disorders etc., can I safely take this vaccine?

• Yes, persons with one or more of these comorbid conditions are considered among the high-risk category. They need to get COVID-19 vaccination. Overall, the vaccine is safe and efficacious in adults with comorbidity. The maximum benefit of getting the COVID-19 vaccine is for those who have such co-morbidities.

25. Why vaccination is not provided to children who are usual target?

• COVID-19 affects all age groups; however, morbidity & mortality is several times higher in adults particularly in those above the age of 50 years. Children have either asymptomatic or mild infection. The general practice is to first evaluate any new vaccine in older population and then age reduction is done to assess the safety and effectiveness in paediatric population. The currently available vaccines have not been evaluated in children so far. There are some clinical trials now underway to test the effectiveness and safety of the COVID 19 vaccines in children. (ICMR).

26. Is Covishield® same as the vaccine been given in UK by Astra Zeneca?

• Yes, Covishield® vaccine, manufactured by the Serum Institute of India, is based on the same patent technology as the Astra Zeneca vaccine.

27. Developing a vaccine takes years. But this time our scientists have developed a vaccine against the novel corona virus in such a short time. How was this possible?

• Developing a vaccine generally involves years of research. First, we need a vaccine candidate that is evaluated in animals for its safety and efficacy. After a vaccine candidate passes a preclinical trial, it enters the clinical trial phase. While scientists have worked around the clock in the laboratory, even regulatory approvals which used to take several months have been fast tracked. It helped eliminate all the time lapses between the pre-clinical and clinical trial stages. Earlier, the vaccine development involved a series of steps, but in the case of the coronavirus vaccine, the scientists and regulators worked in tandem, accelerating the whole process without compromises on any protocols and any step. (ICMR)

28. Does vaccination protect me against newer strains / mutated virus of SARS-CoV2?

• The body responds to vaccination by making more than one type of antibodies to virus parts including spike protein. Therefore, all vaccines are expected to provide reasonable amount of protection against the mutated virus also. Based on the available data the mutations as reported are unlikely to make the vaccine ineffective.

29. Which vaccine is better between Covisheild and Covaxin

• There is no head-to-head comparison done between the two vaccines being used in India so one cannot choose one over the another. Both would work fine in preventing the infection as well as prevent a person from going into severe state of the disease. As a long-term effect, it would be preventing death for elderly people or those who have co-morbidities. Both have been shown in preliminary studies to be effective against mutant strains.

30. In how many days will the vaccination create an adequate immune response and protection?

• Adequate immune response takes 2-3 weeks after completion of entire vaccination schedule i.e., after the second dose of Covishield® and Covaxin®.

31. Does this vaccine provide herd immunity?

• When an increasing number of people get vaccinated in the community, indirect protection through herd immunity develops. The percentage of people who need to be immune in order to achieve herd immunity varies with each disease. For example, its 95% for measles, however the proportion of the population that must be vaccinated against COVID-19 to begin inducing herd immunity is not known.

32. Which drug should be taken to minimize the adverse effects of this vaccine?

• In case of minor adverse effects such as injection site pain, tenderness, malaise, pyrexia, etc., paracetamol may be used to alleviate the symptoms.

33. Should you avoid alcohol after receiving the COVID19 Vaccine?

• As per experts, there is no evidence of alcohol impairing the effectiveness of the vaccine. Moderate to heavy alcohol intake suppresses immunity, so it is suggested to avoid heavy intake.

34. Claims on social media suggested that covid19 vaccine could affect female fertility. Is it true?

• Rumours or social media posts suggesting that COVID-19 vaccines could cause infertility are not true and totally baseless. None of the available vaccines affects fertility. Vaccines are authorized for use only after their safety and efficacy is assured.

35. What is the efficacy of a COVID-19 vaccine if I only receive one dose of a two-dose series?(41)

• There is very limited data on the efficacy of Pfizer’s and Moderna’s COVID-19 vaccines when only one dose is given. Pfizer has indicated that the efficacy of their COVID-19 vaccine after one dose is at least Updated 4/22/2021 52%. Moderna has noted 80.2% efficacy after one dose.
• Covaxin and Covishield have been found to provide reasonable protective effect even after first dose.
• For best protection, it is recommended that individuals receive two doses.

36. The administration of the Johnson & Johnson COVID-19 vaccine was paused in the United States. What does this mean?(41)

• On April 13,2021, the FDA and CDC recommended a pause in the administration of the Johnson & Johnson COVID-19 vaccine. As of April 13th, there were over 6.8 million doses of the Johnson & Johnson (J&J) vaccine administered and reported in the U.S. The CDC and FDA had received six reports of a rare and severe type of blood clot in individuals who had received the vaccine. (Breakdown: that means the blood clot is extremely rare and currently estimated to occur at a rate of 1 event per 1.13 million doses administered.) The type of blood clot is called a cerebral venous sinus thrombosis (CVST), and it was seen in combination with low levels of blood platelets (thrombocytopenia). All six cases occurred in women between the ages of 18 and 48, and symptoms occurred 6-13 days after vaccination. Of these cases, one has died.

37. Is it true that people in the COVID-19 vaccine clinical trials died?(41)

• According to data released by COVID-19 vaccine manufacturers, clinical trial participants did pass away during the safety monitoring period following vaccination. Deaths occurred in participants in the vaccinated and the unvaccinated groups. However, it is important to note that the deaths that occurred in the vaccinated group were not caused by the vaccination.

38. Do COVID-19 vaccines cause people to faint?(41)

• Fainting, also called syncope, is a common event surrounding vaccination. It is not caused by a vaccination itself; fainting is thought to be caused by the vaccination process (ex. anxiety associated with vaccination).
• Fainting is usually not serious and has no long-lasting effects. Because fainting is a common occurrence for vaccinated individuals, we expect to hear reports of individuals who faint when they receive their COVID-19 vaccine.
• Fainting is not a sign of a vaccine reaction. To help minimize the risks associated with fainting, everyone who receives a COVID-19 vaccine is recommended to be monitored for 15 minutes following vaccination.

39. Will getting the COVID-19 vaccine affect a woman’s menstrual cycle?(41)

• There have been anecdotal reports of menstruation changes following COVID-19 vaccination, but there is currently no scientific evidence to say the vaccine itself causes a change in menstruation patterns. Changes in menstruation following vaccination could be linked to the body’s stress response to the immunization or the pandemic; the changes could also be a coincidence. Researchers are currently exploring this question in further detail. It is also not possible for the vaccination of one woman to affect the menstrual cycle of another woman. Additionally, the menstrual cycle of one woman cannot affect the menstrual cycle of another.

40. Can I take pain medicine (e.g. paracetamol or a non-steroidal anti-inflammatory) to manage the side effects of COVID-19 vaccination?(41)

• The CDC has stated that patients can take pain medication (e.g. non-steroidal anti-inflammatory or acetaminophen) after their vaccination if they feel side effects (e.g. pain, headache, or fever that cannot be tolerated). There has been debate on whether or not taking pain medication prior to vaccination may dampen an individual’s immune response to the vaccine. Until we know more, it is not recommended for individuals to take pain medication in anticipation of potential side effects prior to their vaccine. If you have to take pain medication to alleviate side effects, it is advised for you to take it after you have been vaccinated.

41. Should people who are currently in quarantine present for vaccination?

• No. People who are quarantined because of exposure to COVID-19 should wait to be vaccinated until their quarantine period has ended. This is to prevent spread to COVID-19 vaccinators. Your local public health authorities make the final decisions about how long quarantine should last based on local conditions and needs. Follow the recommendations of your local public health department if you need to quarantine. Options they will consider if you remain symptom free include stopping quarantine after: ● Day 10 without testing ● Day 7 after receiving a negative test result (test must occur on day 5 or later)

42. Should I get a COVID-19 vaccine even if I have had a positive antibody test?

• Yes. Due to the severe health risks associated with COVID-19 and the fact that reinfection with COVID19 is possible, you should be vaccinated regardless whether you have received a positive antibody test or not. It is not recommended to conduct serologic testing to assess for prior infection for the purpose of vaccine decision-making.

43. Can pregnant women receive COVID-19 vaccine?(41)

• Yes. Pregnant women may choose to be vaccinated and should discuss vaccination with their healthcare provider. They should weigh the risk of COVID-19 with the risks and benefits of vaccination; pregnant women are at an increased risk for severe COVID, resulting in ICU admission, mechanical ventilation, and death in pregnant woman than non pregnant.
• Risk is even higher in Pregnant women with coexisting illnesses such as diabetes, hypertension, and obesity.
• No pregnancy-related safety concerns have been detected via vaccine safety monitoring systems.
• Considerations for vaccination include: 1) level of COVID-19 community transmission, 2) her personal risk of contracting COVID-19, 3) the risks of COVID-19 to her and potential risks to the fetus, 4) the efficacy of the vaccine, 5) the known side effects of the vaccine, 6) the lack of data about the vaccine during pregnancy.
• In its latest statement, the Union Health Ministry said pregnant women “can and should” get the COVID vaccine.
• Pregnant women should be fully informed that “the long-term adverse reactions and the safety of the vaccine for foetus and child are not yet established.”
• They should follow the 30 minutes of in-hospital observation rule post-vaccination.
• COVID-19 vaccine can be provided any time during pregnancy.
• Higher risk of pregnancy complications — preterm birth, cesarean delivery, and preeclampsia — associated with Covid-19 during pregnancy.
• Even Indian study from ICMR showed that second wave of pandemic hit pregnant and postpartum women more severely compared to the first. *Case fatality rate (CFR) among pregnant women and postpartum women was 5.7% (22/387) during the second wave, in comparison to 0.7% in first wave*. Overall CFR~2%.
• Robust Safety *data of as high as 35,691 pregnant woman* of 16 to 54 years of age from USA. Of these ladies 86.5% had a known pregnancy at the time of vaccination, and 13.5% reported a positive pregnancy test after vaccination. 29% received vaccine in the Ist Tm, 43% in the second trimester, and 26% in the 3rd Tm*. Data pertains to mRNA Vaccines being used in USA. Delivery after vaccination: Among live-born infants, the incidences of preterm birth (9.4%), small size for gestational age (3.2%), and congenital anomalies (2.2%) were consistent with those expected on the basis of published literature in pre-pandemic period. There were no neonatal deaths.
• Antibody levels were measured in maternal blood as well as Fetal Cord Blood after vaccination in a prospective study of of 131 vaccine recipients (84 pregnant, 31 lactating, and 16 nonpregnant women). Vaccines generated robust humoral immunity in pregnant and lactating women, similar to nonpregnant women. Vaccine-induced immune responses were greater than seen after natural infection.  Immune transfer to neonates occurred via placenta and breast milk.
• Extrapolation of Pregnancy safety and efficacy data of mRNA vaccines to vaccines available in India – In such precedented situations like covid pandemic we need to rely upon science. Data from Other Vaccines in pregnancy so far, other non-live, inactivated vaccines and toxoids (recombinant or killed organism) tdap have not reported to cause adverse effects in pregnant woman. None of the clinical trials of the vaccine available so far (including Covishield and COVAXIN) have included pregnant and lactating women as study subjects for obvious risks and compensation issues. But now with thousands of doses of mRNA vaccines having been used in pregnancy and Covishield and Covaxin having been tried tested in Crores of people we can exercise in favour of these vaccines with possibility of little risk even in pregnant woman. None of the vaccines – Covishield and COVAXIN – that are being administered in India, are live-virus vaccines. Since there is no live Virus to cause any harm.
• Known side effects of currently available vaccines in India are fever, chills, and muscle aches, may occur in pregnant or lactating woman as much as non pregnant woman. Follow-up calls to their clinicians may be essential both for reassurance and to reduce the anxiety. Paracetamol is a safe and sufficiently effective drug to manage these side effects during pregnancy.
• Covaxin or Covishield or Sputnik V– which one is preferred in pregnant women: None of the vaccines (Covishield and COVAXIN) have included pregnant and lactating women in trials. Incidence of side effects is lesser with Covaxin than Covishield. One study (Covat study in India) reported better reactogenicity and higher antibody titers with Covishield in health care workers (non-pregnant). Covishield is far more easily available on more nearby centers than Covaxin. 28 days interval between two doses can tilt balance in favor of Covaxin during late pregnancy (because currently recommended 3-month interval between two doses of Covishield may lead to 2nd dose time limitations before delivery). However, government announcement makes no such preference between Covishield and Covaxin for pregnant women may be for logistic reasons. No report of Cortical Sinus thrombosis or other unusual thrombosis after Covishield during pregnancy but it will not be possible to deny the same for paucity of data. True picture will emerge only after mass vaccination (1in 1 lakh possibility of this Serious Side Effect in non-pregnant patients especially women less than 50 years of age). Altogether 35 countries offer Covishield to pregnant women, most of them with restrictions. Covishield – is WHO approved, and two countries Canada and Mexico ‘recommend’ it, while Austria, Iceland and Croatia ‘permit’ it in pregnancy. Pregnancy is known to increase the risk of blood clots, and so do ‘viral vector vaccines like Covishield. This is one of the reasons some countries avoid giving it to pregnant women. Sputnik V is a viral vector vaccine and is available to pregnant women in four countries, of which only Mexico recommends it. Argentina and Honduras allow it with conditions, and Pakistan’s position is not clear.

44. What to do in Lactating Individuals?

• On 19th May 2021, Centre had approved Vaccination for Mothers Breasting their Babies. World Health Organization recommends that mothers continue to breastfeed after vaccination. CDC and the UK Joint Committee on Vaccination and Immunization stated that no safety concerns had been identified from studies*, so lactating mothers should get vaccinated.
• While lactating, individuals were not included in most clinical trials, COVID-19 vaccines should not be withheld from lactating individuals who otherwise meet criteria for vaccination. Theoretical concerns regarding the safety of vaccinating lactating individuals do not outweigh the potential benefits of receiving the vaccine. There is no need to avoid initiation or discontinue breastfeeding in patients who receive a COVID-19 vaccine. Breastfeeding is not a contraindication to vaccine receipt as well.

45. Can a COVID-19 vaccine cause you to test positive on COVID-19 viral tests?

• No. COVID-19 viral tests will not show a positive result after receipt of the COVID-19 vaccine.

46. Will getting the flu vaccine protect me against COVID-19?

• No. Influenza viruses and coronaviruses are different, so the flu vaccine does not protect against coronavirus. This fall and winter, both COVID-19 and influenza will be circulating at the same time. Both are respiratory illnesses and have similar symptoms. Influenza vaccination will be important to prevent illness this fall and the burden of influenza illness on health care providers. Additionally, influenza vaccine will prevent you from being sick and having to miss work or school. While it may seem like there is so much out of our control during this pandemic, getting vaccinated against influenza is within our control. This will protect not only those who receive flu vaccine, but also the community.

47. If Rabies vaccine is needed, should it be deferred?

• Rabies vaccine schedule must not be altered for any reason.

48.  Can Vaccine be administered on the day of menstrual period?

• There is no physiological, endocrine or immunological basis for such a consideration. Women should receive the vaccine on any day of the menstrual cycle, even during menstruation. Vaccine administration in the preconception period or for women undergoing fertility treatment including assisted reproduction Women should take the vaccine at any point of time before a pregnancy is confirmed as and when they have an opportunity to do so. There is no basis for deferring pregnancy or treatments for taking the vaccine. There is no evidence that vaccine administration affects fertility or miscarriage rates.

49. Can pregnant woman already infected with Covid in the past be vaccinated?

• A pregnant woman faces greater risks in pregnancy if she is infected with COVID-19 as compared to a pregnant woman who is not infected or a non-pregnant woman who is infected. Therefore, vaccination is advisable even if there has been a past infection. As for the general population, vaccination should be deferred for 12 weeks from the infection or 4 to 8 weeks from recovery.

50. Is Pregnancy testing needed before administering the vaccine?

• This is not necessary and creates a hurdle to vaccine acceptance. It is not recommended to test for pregnancy before vaccination. Vaccine administered inadvertently to a pregnant woman in early pregnancy. The vaccine does not have any known teratogenic effects as per available evidences. Women who are vaccinated in this manner should not be advised to terminate the pregnancy. They should be counseled that the risk of congenital anomalies does not rise above the baseline risk. However, at the present time, it would be prudent to defer vaccination in the first trimester as there is no substantial available data to establish absence of teratogenicity.

Fully Vaccinated but Fear of Infection by Newer Variant Lurks – Risk & Remedies

Vaccine manufacturers in World continue to use the original Virus/Spike Protein despite Newer Mutants taking center stage. However, few questions still continue to exist among people such as:

• Vaccines in India are produced using which Variant?
  • Covaxin (BBV152) is manufactured using the original ancestral variant G614 [virus strain (NIV-2020-770) containing the Asp614Gly mutation]. Virus was captured from a Covid patient to ensure that pathogenetic virus is used for manufacturing vaccine. It was further grown on Vero cell lines and chemically inactivated.
  • Covishield, the ChAdOx1 nCoV-19 vaccine (AZD1222) was developed at Oxford University and consists of a replication-deficient chimpanzee adenoviral vector ChAdOx1, containing the Gene for (early) spike protein, nCoV-19.

• What are major Variants of Concern in India till now?
  • Variant (The First lineage of Ancestral Wuhan Virus also called G614).
  • B1.1.7 or UK/Kent Variant* also Alpha variant.
  • B1.617.2 or Double mutation Variant or Delta variant
  • Few cases of other variants including Zeta P1 Brazil and few South African Variant called Beta were also reported recently.
  • In 2022: Delta or Delta derivatives (Few cases):
    • Omicron BA 1
    • Omicron BA 2 – Commonest

• What is the efficacy of Vaccines against Variants?
  • Covishield/Astra Zeneca has efficacy against ancestral strain. The efficacy of the vaccine is 76.0% at preventing symptomatic COVID-19 beginning at 22 days following the first dose and 81.3% after the second dose. Recent trial showed that, for symptomatic infection after 2nd dose, the vaccine is 66% effective against the Alpha variant (lineage B.1.1.7), and 60% against the Delta variant (lineage B.1.617.2). Two doses of AstraZeneca Vaccine 92% effective against hospitalization due to the Delta variant. 86% effectiveness against the Alpha variant (B.1.1.7) in reduction of hospitalizations and no deaths. Vaccine effectiveness after one dose against delta variant B.1.617.2 was found low for both Pfizer as well as Astra zeneca vaccines just ~ 33%.
  • Covaxin is effective against Delta variant as well as Beta Variant but 3-fold higher Neutralizing body levels are required to do so. The study from NIV Pune demonstrated a (3.0 and 2.7fold) reduction in neutralization titers with BBV152 vaccine against B.1.351 and B.1.617.2 respectively.

• Do vaccines produce these high much titres to fight the variants?
  • Yes, Vaccine gives people a huge amount of antibody, so even if there were 3 fold antibody requirement to neutralize the newer variants (than ancestral virus), one is still left with a bunch of antibodies that can bind and block the virus. Antibody titres have been shown to remain present up to six to 9 months. Once antibody titres wane off T cell mediated response take on.

• What are the further Implications of these findings?
  • Even a booster of the existing vaccines might be enough to handle variants by shooting up the levels of antibodies. A preprint study published recently found that people who recovered from Covid-19 and then received an mRNA vaccine had long-lasting and broad immunity against the coronavirus and its variants.

• Which vaccine is best at protecting against Variants?
  • As the major effect of vaccines are driven thru herd immunity the real-world efficacy is likely to be higher in countries with population having had higher vaccine coverage. So, one may not compare different vaccines being used in different populations at varying level of vaccination drive.

• How to drive maximum benefit from current vaccines against Variants?
  • Newer variants are more transmissible and hence require a higher percentage of people to be protected before their circulation tapers off. Delta is 50% faster than Alpha which is 40% more transmissible from original ancestor. Ramping up speed of Vaccination coverage remains the key to outpace the virus.

• Some questions remain unanswered.
  • Will people eventually need vaccine boosters?
  • Will vaccines need to be tweaked to better match the evolving virus?
  • How long does vaccine-generated protection last?
  • Will the waning process accelerate in the presence of certain variants?
  • If immunity starts to wane, will people still generally be protected from the worst outcomes, even if they’re more vulnerable to infection?
  • Could a souped-up version mix and match of existing vaccines be tried to ward of Variants?

• While those questions can’t be answered yet, work is in progress to prepare for the possibility of boosters. Vaccine makers are testing refined recipes of their shots.

• In conclusion, already vaccinated individual should not be concerned about being infected by present variants in short term. For Long term future variants- it may be difficult to predict But Mask and Covid Appropriate Behavior remain the key protection but difficult to implement for masses. Benefits of Vaccination are driven through Herd Immunity. Motivate others to get vaccinated. Dissuade AntiVaxers.

14. Supplementary information

Covat Study(38,39,54)

Original Indian Study (Peer reviewed – Published online on 5th February 2022)

What is this Study?

• The 6-month longitudinal study of humoral Ab kinetics following 2 doses of Covishield and Covaxin

What was done in the study?

• The first part (short-term) of this study has been published in Vaccine journal.
• Pan Indian researchers conducted a 6-month longitudinal study in vaccinated healthcare workers by serially measuring quantitative anti-spike antibody at 3-weeks, 3-months and 6- months after the completion of second dose.
• Geometric mean titre (GMT) and linear mixed models were used to assess the dynamics of antibody levels at 6 months.
• Authors now report the results from our 6-month longitudinal study that assessed the humoral antibody response after two doses of two vaccines administered in India.
• This cross-sectional Pan-India study has analysed humoral antibody dynamics in three groups of participants simultaneously which include:
• People who had past history of Covid-19 before the first dose of vaccine,
• People who developed breakthrough infection ≥2-weeks after the second dose and,
• People who remained infection naïve for entire 6-month after the completion of second dose.
• The study has also analysed the humoral response between Covishield and Covaxin over 6-month.
• The study was done on 481 health care workers.
• These HCWs showed a significant decrease in the anti-spike antibody at 6-months.
• Reduction in antibody was regardless of demographics, comorbidities and the vaccine type.
• T2DM cohorts had lowest seropositivity, while hypertensive had significant antibody decline at 6-month.

Quick Take-away

Myths and facts about covid-19 vaccine(34)

The several myths and facts about the COVID-19 vaccine are discussed below.

Myth: There is no need for me to wear a mask since I have been vaccinated.

Fact: The COVID-19 vaccine may provide some protection from catching the infection, but until more substantial data supporting the long-term safety and efficacy of this vaccine is available it is recommended to continue with the practices like wearing a mask, hand washing, and proper social distancing every time you step out of the house.

Myth: I do not need to take the vaccine as I already had COVID-19 in the recent past.

Fact: It is true that once infected, the body produces immunity against viruses, but we do not have enough evidence that this type of natural immunity would be long-lasting enough. There could still be high chances of catching the infection again as it takes some time for the body to produce an effective immune response against any potential coronavirus re-infection.

Myth: COVID 19 vaccines cause severe side effects.

Fact: There can be some short-term, mild or moderate vaccine reactions that resolve on their own and if needed, you may be advised to take some prescribed medication to manage them. These side effects can include pain at the injection site, headache, fatigue, chills, muscle pain, or fever which could last for a day or two. These side effects are indicators that your immune system is responding to the vaccine. You can always contact your physician or medical staff for guidance.

Myth: The COVID-19 vaccines were developed in a very short span of time to be safe.

Fact: It is a known fact that the development of vaccines takes years of research. The scientific community the world over was able to bring out the COVID-19 vaccines so quickly because of the following aspects.

Many years of research on the technology required to design flu-like vaccines. Fast track regulatory approvals based on scientific data presented by the drug manufacturers and researchers. Dedicated and continuous research and development activities to find faster ways to manufacture vaccines. Huge funding support helped in the conduction of multiple trials parallelly world over.

SARS-CoV 2 is quite similar when compared to SARS-1, and hence the information from research conducted on SARS-1 and other similar flu viruses was a good base for the development of the SARS-CoV 2 vaccine. The entire scientific and healthcare community has worked tirelessly with the support of the governments to produce these COVID-19 vaccines in such a short time. We are yet to observe and understand the long-term effects of this vaccine, however, it has proven to improve the body’s ability to fight the infection caused by this virus.

Myth: One dose of the COVID-19 vaccine is enough to protect against a coronavirus infection.

Fact: When the first dose of vaccine is administered, it activates two important types of white blood cells. It helps in producing antibodies against this virus however, this immunity is short-lived.   The booster dose or second dose is a way of exposing the body to the antigens a second time which re-activates the immune system and provides a stronger immune response. When the same vaccine is introduced into the body again, the body produces antibodies from the B cell memory and gives a better immune response. Hence for having better immunity to fight the coronavirus infection, it is strongly recommended to take both doses of the vaccine as per the schedule given by the hospital/medical staff. 

Myth: COVID-19 vaccines are not effective against the new variants.

Fact: Advanced research on these vaccines is already going on and any changes in response to these vaccines are being monitored in detail by the healthcare providers. The virus tends to mutate quickly hence, like the vaccine for influenza or the common cold, the COVID-19 vaccine also could be modified after observing the development of variants annually. The vaccine can be adjusted to provide immunity against newer strains of the virus. However, while the vaccine is still available, it is in the best interest of each citizen to get vaccinated and be protected.

Myth: Indian vaccines are not as effective as their foreign counterparts

Fact: COVID-19 vaccine developed and marketed in India is as effective and safe as vaccines available in any other part of the world. The vaccine has been approved for use after a substantial amount of research on similar SARS-1 and other viruses pre-clinically as well as after conducting clinical trials on humans.

Myth: COVID-19 vaccine causes infertility, and one should not take it if one wants to conceive.

Fact: According to the National Institute of Immunology, Delhi these false claims were made by some studies based on studies conducted on anti-fertility vaccines. However, there is currently no reported evidence that COVID-19 vaccination causes any hindrance to conception or development of the placenta. Besides, there is no concrete evidence that infertility is a side effect of any vaccine, including COVID-19 vaccines. If you are trying to conceive now or want to conceive in the future, you may receive a COVID-19 vaccine if available to you after consulting your gynecologists. Research on the effects of taking a vaccine is a continuous process and researchers are gathering the data on the effects of COVID-19 vaccines on all populations including special populations. The long-term effects of this vaccine cannot be ascertained at this point of time.

Myth: Getting the COVID-19 vaccine gives you COVID-19.

Fact: According to the U.S. Center for Disease Control and Prevention, COVID 19 vaccine does not contain any live virus hence it cannot cause COVID 19 infection in a person. The body takes its own time to develop immunity even in people who have taken all doses of the vaccine. Hence it is still possible to catch the infection immediately after taking the vaccine. Wearing masks, maintaining social distancing, and sanitizing hands is the best precaution against getting infected.

Myth: The COVID-19 vaccine enters your cells and changes your DNA.

Fact: The COVID-19 vaccine is based on introducing mRNA into the body which gives the instructions to the body’s immune system to produce a certain kind of protein. These prompt the body to respond by producing specific kind of antibodies against the COVID-19 virus. DNA of a cell is in the nucleus of the cell and this part of the vaccine does not enter the nucleus of the cell. Hence it cannot affect the DNA of a person who is given the COVID-19 vaccine.

Myth: COVID-19 vaccine should not be taken by people suffering from HIV.

Fact: According to WHO, many of the trials conducted on the COVID-19 vaccine involved a small number of HIV patients. Although there is limited available data, scientific literature indicates that the current WHO-recommended COVID-19 vaccine is safe to be administered in patients suffering from HIV. The currently available vaccine does not contain any live virus hence there is no reported evidence that it can affect immune-compromised patients.

CDC summary document for interim clinical considerations

Indian vaccination completion certificate

Vaccine hesitancy table

Update on injection technique is an advisory

• If the tip of the needle doesn’t reach deep enough in the muscle or if it accidentally hits a small blood vessel, the vaccine can be directly injected into the bloodstream: an extremely rare possibility.
• This can happen when the skin is pinched up by an inadequately trained health worker. (IM injections are meant to be given without pinching up the skin so that the needle tip reaches the muscle).
• When skin is pinched up, the needle tip reaches only the subcutaneous tissue.
• When that happens, not only is the vaccine not absorbed properly because of the fatty layer, but rarely it can hit one of the blood vessels that travel through this layer (subcutaneous tissue is marked in yellow in my diagram; it is located between skin and muscle). This layer contains a network of blood vessels.
• One more problem is that people have stopped aspirating (pulling back the plunger of the syringe) to check if they hit a blood vessel while giving IM injections.
• These are recent “technique updates” it seems. I remember aspiration being standard practice before giving intramuscular injection during my training days.
• This means that in the rarest of the rare event of the needle tip entering a tiny blood vessel, the vaccine will directly enter the bloodstream and potentially cause an acute reaction. (This was originally proposed by Prof. Neils Høiby from Dept. of Microbiology, University of Copenhagen, Denmark).

*This advisory has been officially issued by SSI Staten’s Serum Institute of Denmark, for ALL COVID-19 VACCINES.

Vaccination below 18 years

The Federation of Obstetric & Gynecological Societies Of India Position Statement on Covid Vaccination

India’s National COVID-19 Program

Guidelines for COVID-19 vaccination of children between 15-18 years and precaution dose to HCWs, FLWs & 60+ population with comorbidities.

• Due to the recent global surge of COVID-19 cases and detection of Omicron variant which has been categorized as a Variant of Concern (VOC), scientific evidence, global practices and the inputs/suggestions of ‘COVID-19 Working Group of National Technical Advisory Group on Immunization (NTAGI)’ as well as of ‘Standing Technical Scientific Committee (STSC)’ of NTAGI it has now been decided to further refine the scientific prioritization & coverage of COVID-19 vaccination as follows:
  • COVID-19 Vaccination of children in the age-group of 15-18 years (from 3rd January 2022). For such beneficiaries, vaccination option would be “Covaxin” only.
  • As a matter of abundant precaution, for those Health Care Workers (HCWs) & Front-Line Workers (FLWs) who have received two doses, another dose of COVID-19 vaccine (from 10th January 2022). The prioritization and sequencing of this precaution dose would be based on the completion of 9 months i.e. 39 weeks from the date of administration of 2nd dose.
  • All persons aged 60 years and above with comorbidities who have received two doses of COVID-19 vaccine, being provided with a precaution dose from 10th January 2022. The prioritization and sequencing of this precaution dose would be based on the completion of 9 months i.e. 39 weeks from the date of administration of second dose.

Vaccine Passport

What is vaccine passport?

Vaccine passport is a documentary proof that the person vaccinated against Covid-19. Mostly it is a Digital document than in Paper format.

Which Nations have vaccine passport?

• In March 21, China rolled out its digital vaccine passport in form of a QR Code which could be accessed through an app to verify an individual’s vaccination status.
• In April Japan, In May UK announced, In June European Union too backed a ‘Digital Green Certificate’ to allow citizens travel across 27 member countries.
• India issuing a QR code based certificate to all Vaccinated Indians.

What all makes one eligible for EU Digital Green Certificate?

• Full vaccination using listed approved vaccines, OR
• A negative Covid-19 test result but would still need 10 days Quarantine OR
• Proof of recent recovery from Covid-19.

Why an issue with EU Green Pass?

• As none of the vaccines approved in India are included in EU Digital Green Pass.
• Meaning that all Indians would have restrictions in entry, or need quarantine after entry despite being vaccinated by highly effective vaccines Covishield, Covaxin, or Sputnik V
• Large number of Indians are expected to travel abroad with Covid-19 situation improving worldwide and universities and tourist places reopening.
• Surprisingly EU has included Vaxzevria which is absolutely the same vaccine as Covishield developed by same parent AstraZeneca but manufactured in Europe.

Currently 9 European countries have given recognition for Indian vaccines(covishield) namely Austria, Germany, Slovenia Greece Iceland Ireland Spain Estonia Switzerland.

Estonia is the only country approved both covariant and covishield!

How can one get Indian vaccine passport?

The government recently updated Aarogya Setu app making it possible for people to link their passport to their vaccination status.

Step-wise guide to get vaccine passport follow these steps:

• Vaccinated people can log in to http://cowin.gov.in
• Go to “Account Details” section and click on “Raise Issue.”
• Three options could be seen now. Choose “Add Passport Details” option. This will take you a different page, where one can select the name of the person whose passport details are to be updated in the app.
• Choose name of the concerned person from drop-down menu and fill up passport number accurately in the “Enter Beneficiary’s Passport Number” section.
• In step-5, you are required to tick the declaration box. Do cross-check and verify details before ticking the box and clicking on “Submit Request” tab.
• You will receive a message on the registered mobile number notifying that the status was updated successfully. In the final step, you need to go back to “Account Details” page and click on “Certificate” tab. Your vaccine passport is now available for download.
• All HCWs, FLWs and citizens aged 60 years or above with comorbidities will be able to access the vaccination for precaution dose through their existing Co-WIN account.
• Eligibility of such beneficiaries for the precaution dose will be based on the date of administration of 2nd dose as recorded in the Co-WIN system.
• Co-WIN system will send SMS to such beneficiaries for availing the precaution dose when the dose becomes due.
• Registration and appointment services can be accessed through both, the online and the onsite modes.
• The details of administration of the precaution dose will be suitably reflected in the vaccination certificates.
• All those aged 15 years or more will be able to register on Co-WIN. In other words, all those whose birth year is 2007 or before, shall be eligible.
• Beneficiaries can self-register, online through an existing account on Co-WIN or can also register by creating a new account through a unique mobile number, this facility is available for all eligible citizens presently.
• Such beneficiaries can also be registered onsite by the verifier/vaccinator in facilitated registration mode.
• Appointments can be booked online or onsite (walk-in).
• For such beneficiaries, option for vaccination would only be available for Covaxin as this is the only vaccine with EUL for the age-group 15-18.

What are other countries doing for vaccinating children?

USA – already started children vaccination programme. Children more than 5 years old can take Pfizer-BioNTech vaccine.

UK – All children aged more than 12 can get Vaccine. Booster for every one more than 18 years.

The European Union – rollout of Pfizer vaccine for 5 to 11 year olds began Dec. 13, one week earlier than planned.

Italy on Dec. 1 approved vaccinations for children aged 5-11, while France’s regulator backed this for high-risk children and those living with vulnerable people.

The Czech Republic has pre-ordered shots for 700,000 children aged 5-11 and Hungary started vaccinating 16- to 18-year-olds in mid-May.

Germany will likely offer jabs to children under 12 from early 2022, after approving shots for teenagers in August.

Estonia, Denmark, Greece, Ireland, Italy, Lithuania, Spain, Sweden and Finland are offering shots to children aged 12 and over. Nearly 63% of Dutch 12 to 17year olds are fully vaccinated according to government data as of Nov. 28.

Switzerland approved vaccinating 12- to 15-year-olds with Pfizer’s shot in June, and did the same for Moderna’s jab two months later.

Norway started offering one dose of Pfizer/BioNTech to children aged 12-15 in September.

Russia expects to make a new vaccine available for children aged 12-17 soon.

Middle East and Africa

Israel, Oman and Saudi Arabia have approved Pfizer’s shot for children as young as five, a shot Bahrain and the UAE have also approved for emergency use in the same age group.

Jordan, Morocco, Guinea, Namibia and South Africa are vaccinating children aged 12 and over.

Zimbabwe has made 14-year-olds eligible for COVID-19 shots.

Egypt said in early November it would begin vaccinating children aged 15-18 using Pfizer.

Asia-Pacific

China has approved two Sinopharm and one Sinovac vaccine for children as young as three years.

Hong Kong lowered the age limit for Sinovac’s vaccine to three in late November.

Singapore hopes to extend vaccines to children aged 5-11 from January and Japan by February.

Malaysia plans to buy Pfizer’s vaccine for this age group.

Indonesia authorized Sinovac’s jab for children over six.

South Korea, Australia and the Philippines are vaccinating children 12 and over, with Australia to inoculate younger children starting in January.

Vietnam began vaccinating teenagers aged 16 and 17, in late October.

Americas

Cuba, which is administering vaccines to children as young as two.

Venezuela is vaccinating children aged 2 to 11 with Cuba’s Soberana 2 vaccine sine as early as November 2021.

Argentina is vaccinating children as young as three with Sinopharm’s shot while Chile and El Salvador began vaccinating children aged 6-11 in Sept.

Costa Rica made COVID-19 vaccination mandatory for children from age five.

Canada authorized Pfizer’s shot for children aged five to 11 on Nov. 19, days after Mexico said it would start vaccinating 15-year-olds.

Brazil approved Pfizer’s shot for 12-year olds in June.

Columbia is offering Pfizer, AstraZenenca, Moderna, Sinopharm and J&J vaccines for those aged 12 and over, while neighbouring Ecuador is inoculating children as young as six with Sinovac’s shot.

15. References

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