Once Nepal gets vaccines, they need to be fairly distributed
Global inequities in the distribution of the Covid-19 vaccine have revealed themselves during the past six months. Based on the most up-to-date data today, more than half of the population in Bahrain, the United States and the United Kingdom have been fully vaccinated.
In Nepal, this number is 2.6%. During times of public health crises, a convergence of social and economic inequalities sharpen disparities in access to health, food, and financial security. Moreover, in countries like Nepal with a pronounced urban-rural and regional divide in infrastructure, education, and health access, these divisions intersect with wealth and social inequities during a pandemic creating tremendous stress on an already tenuous local health system.
This results in worse health outcomes for underserved populations. With low vaccine coverage against the Covid-19 virus in Nepal, and the slow trickle of vaccines into the country it is imperative to question how vaccines will equitably be distributed across the country.
Biological risk factors like age tend to be used to assess risk of infection of any virus. But what about social disadvantage or inequities? Can such identification of population strata that have a high risk for transmissions will help inform the formation of the next tier?
Typically, when planning for vaccine rollout, the most common approach is identifying risk factors that are highly correlated with the virus and, thus, most vulnerable to infection risk. With Covid-19, risk factors that have informed prioritisation of target groups have been those highly correlated with mortality (age) and those that can aid in preventing mortality (healthcare workers).
Thus, age and being a health worker have almost universally informed Tier 1 (or first recipients) of the vaccine. But what about the next Tier? From an epidemiological perspective, vaccination efforts aim to reach the highest or tipping point of coverage that allows some level of herd immunity or reduction of transmission.
So, an obvious question is who is most at risk of transmitting the virus, and when positive for the virus, what non-biological factors put groups at a higher risk of having the worse health outcomes?
Historical learnings from Nepal have taught us systemic inequities persist along the lines of wealth, region, and caste to ensure and protect access to adequate and quality health care. There have been impressive gains in public health in recent decades: maternal mortality has dropped 73% since 1990, young child mortality has decreased from 47 to 30 deaths per 1,000 live births since 2010 and routine childhood immunisation coverage has increased 21% since 2001.
But inequities persist in health and nutrition outcomes. For example, households with lower wealth, no maternal education, and residence in Province 2 have significantly lower immunisation rates amongst infants.
Further, Dalit and Tarai caste groups (including Muslims) have a lower likelihood to have their children fully immunised compared to Brahmins and Chhetris. Similarly, socioeconomic disparities have been noted in stunting reduction, with the poorest experiencing a lower rate of decline than those who were wealthier.
Taken together during this unprecedented time of a global pandemic, the question is why is it essential to achieve equitable distribution of the vaccines prioritising not just medically vulnerable, but also historically socially excluded groups? Which are these groups? And how do we address the issue?
As of 6 July 6 nearly 1,500 people were testing positive daily for Covid-19 and a total of 9,261 deaths have occurred since May 2020. These numbers are most likely grossly underestimated, given a lack of mass testing. Only 11% of the population have been tested to-date and with 85% of the population residing in rural areas, access to testing centers can be challenging.
In a country with a dominant youth population - nearly 41% is between the age of 16-40 years of age, having age alone decide vaccine prioritisation tiers seems ill-informed. Further, reports of differential age cut-offs between Kathmandu, and those residing outside the capital municipality could well be short-sighted and discriminatory.
Another issue in pandemic management has been a lack of widespread contact tracing to identify transmission patterns. While recognising significant efforts underway by the Ministry of Health and Population to implement community contact tracing and border health checkpoints, this challenge remains non-trivial given the sizeable proportion of in-migration of migrant workers since March 2020 who are returning to inconsistent testing and quarantine protocols.
This inflow of workers means further potential economic slowdowns, given that 25% of Nepal's GDP is reliant on remittances. But here, let us start with the why. Why should the focus of the vaccination campaign rollout for Tier 2 focus on underserved populations?
The WHO states there are three C's that inform higher transmissibility of Covid-19: Crowded places, Close-contact settings, Confined and enclosed spaces. In many areas across Nepal, as with many countries worldwide, economically constrained households and their residents tend to locate in densely clustered areas where conditions are ripe for the spread of the virus.
These tight dwelling quarters in Nepal are even more pronounced among slum dwellers. Social isolation is but a privilege enjoyed by those of higher socioeconomic status. Close living spaces mean higher transmission rates among these communities.
In Spain, the US, and elsewhere, there have been stark disparities in the impacts of Covid-19 related deaths, cases, and hospitalisations among low-income groups compared to the general population.
As mentioned, the intersection of social exclusion has fueled health disparities in Nepal despite successes. Ultimately, there are health, social and economic consequences at stake if we fail to take an equitable approach to vaccine allocation. Socially excluded and underserved minority groups include Dalits, Muslims, Tamangs, and Tharus.
As with economic inequities, we see evidence globally with Covid-19 hitting hardest ethnic and racial minorities. Lower socio-economic groups are typically employed in jobs that make up the backbone of the country's economy, providing essential services such as growing and selling food, waste management, and public transportation.
If we do not prioritise these communities, we will not only have no chance of controlling the pandemic but also no chance of allowing our economy to survive.
Who do we need to prioritise beyond those age 65 and above, and healthcare professionals? The groups most vulnerable include frontline workers: food production and food service workers drivers, custodial staff, security personnel, transportation workers, caretakers of people who are immunocompromised residing at home, adults living in a shared living facility such as prisons, nursing homes, or close-quarter communities such as the sukumbasi communities.
Among these groups, targeting historically underserved minority groups such as differently-abled people, Dalits, Muslims, the sukumbasi, Madhesis, and rural dwellers would be crucial steps. Such prioritisation would help prevent further widespread health disparities and achieve broader population immunity once vaccines arrive in Nepal and immunisation efforts are scaled up.
We cannot overlook the intersectionality here: those who experience economic disadvantages, regional and social exclusion overlap in significant numbers. The time has come for public health targeting to be guided by something beyond health metrics, and carefully consider economic inequity and social disadvantage.
How can the health sector prioritise reducing health disparities, and promote equity? As a group of public health researchers and practitioners, we recommend for consideration the following strategies and responsive action:
#1 Utilise equity as a priority for vaccine distribution: After vaccination of those that belong to the Tier 1 group (the elderly, immunocompromised, and healthcare workers), prioritise equity for vaccine distribution should to those who comprise Tier 2 by identifying socially and economically underserved communities: Nepal is replete with available data, be it routine health information systems like the HMIS, the Nepal Demographic Health Surveys, the Survey of the Nepali People, Nepal Living Standards Surveys, and other databases.
These databases can be utilised to identify communities and geographical clusters of economically disadvantaged, and socially excluded, communities. Indices of economic and social disadvantage such as the Multidimensional Poverty Index (MPI) can be used to indicate regional targeting and directing of Covid-19 vaccines.
Additional professional groups that clearly need to be prioritised include teachers, transportation, and custodial staff. The ultimate goal will be not to sort individuals at the point of vaccination.
Instead, target groups that geographically cluster to get as close to herd immunity as is possible by targeting those among the most vulnerable in the 'herd' to economic and health disparities.
#2 Broaden and tailor behaviour change communication on Covid-19 vaccinations: Conduct clear and cohesive mass vaccination campaigns that include consistent messaging on the Covid-19 vaccines available and their efficacy and safety. With 139 mobile telephone subscriptions per 100 people, appointment management through text messages to avoid overcrowded lines should be considered.
Further, continue the mass communication push through trusted social media, local tv channels, and radio in languages beyond Nepali or English and include Maithili, Nepal Bhasa, Bhojpuri, Awadhi, Tharu, Tamang, and more. In addition, local religious and community leaders should be engaged to spread these messages among their communities.
#3 Facilitate equitable access to the vaccine: Leverage trusted members of prioritised communities such as community leaders, female community health volunteers, and others, our suggestion is to set up vaccination drives as close as possible to these communities to overcome barriers of physical access and to sensitise communities to the intervention.
There have been reports of employees being penalised or prevented from absenting themselves from work to get vaccinated in urban centers. Such barriers and penalties must be done away with, and no citizen should fear losing their jobs if they prioritise getting vaccinated. Similarly, those misusing power to strong-arm their way into vaccine access should be penalised.
Further, youth should be mindful of why their ranked order on the list of those prioritised and at this time are required to uphold, along with everyone else, a strong sense of public health duty and the common good.
#4 Build trust: While vaccine hesitancy was high during the first wave, this has shifted during this second wave. "Initially, the older people were afraid to get vaccinated and needed much encouragement. But now people are eagerly waiting for their turn to get the vaccine, according to Rekha Chaudhari, a Female Community Health Volunteer in Sarlahi District.
However, confidence in public institutions is not equal across the population. And, in some communities, trust is low given patterns of being politically, economically, and socially disenfranchised. Hence, it is vital to clearly communicate the importance and benefits of the Covid-19 vaccines and increase easy access to the vaccine for vaccine-hesitant and the most vulnerable groups.
Locating vaccine administration campaigns near trusted community spaces in the community, including tea shops, community centers, and places of worship, is a clear step to building trust.
#5 Leverage science: Data and its use cannot be underscored enough for evidence-based action against Covid-19. As noted above, the use of available population data and routine monitoring data is imperative to guide intervention.
Additionally, given the likelihood that a substantial proportion of the population will probably be administered a combination of vaccine (say Covishield AstraZeneca to begin with and Sinopharm VeroCell as a second dose) due to the staggered and varied release of vaccines to Nepal, there is the opportunity to plan and implement studies that examine the effects of such mixing of vaccines especially amongst high-risk groups on related health outcomes.
#6 Clear and justly enforced reopening guidelines: Clear and consistent messaging on the phased, cautious reopening of the country via multiple communication channels is essential. The government's implementation of a responsible phased reopening approach that balances economic slowdowns, people's livelihoods with health is imperative.
The importance of undertaking these steps with a strong sense of social justice must be emphasised: protecting vulnerable populations, addressing inequities between ethnic, social, and regional groups and those entrenched in unfair patterns of power and advantage.
Advancing equitable access to Covid-19 vaccines in Nepal, once adequate vaccine procurement occurs, is a clear opportunity for addressing existing health inequities in Nepal that have been further deepened by what indeed has been a global pandemic with a discriminating path.
Nepal-Johns Hopkins University COVID-19 Vaccine Advocacy Group is made up of:
Swetha Manohar, Johns Hopkins University (JHU)
Binita Adhikari, JHU and Health Foundation Nepal
Tsering Pema Lama, JHU
Bijay Acharya, America Nepal Medical Foundation, Massachusetts General Hospital and Harvard Medical School
Smriti Mathema, Department of Paediatrics, Kathmandu University, Nepal Paediatric Society
Angela KC, JHU, Acumen
Dinesh Neupane, JHU
Santosh Dhakal, JHU