Vaccines too little, too late for Nepal?

There is breaking news every other day: the United States donates 2 million Moderna shots to Bangladesh and Pakistan. Denmark announces 250,000 AstraZeneca doses to Bhutan. Japan pledges surplus AZ vaccines to Sri Lanka and the Pacific Islands.

Nepal is never in the news, even though 1.4 million people still wait for their second doses of Covishield AZ vaccines and another 20 million people need to be inoculated before a possible third wave this year. 

So far, Nepal has only been gifted or bought vaccines from India, China or the COVAX initiative. It has not even got 1 million vaccines from Serum Institute India that it paid for, and all other promises from western countries were never kept.  

Nepal’s vaccine diplomacy has failed miserably. And the only silver lining is that there are four million doses of the Chinese Sinopharm VeroCell starting next week to immediately inoculate its above 55 population.

Nepal is still recording an excess of 2,000 new cases a day and is seeing a slight daily increase following the relaxation in travel restrictions. Everyone, the public and the government, seem to have forgotten that the real peak during the first wave last year took place only after the lockdown was eased.

“The third wave is already on its way, our figures are going up and we must assume we will be hit by new variants,” says Buddha Basnyat, a physician at Patan Academy of Health Sciences (PAHS). “We must vaccinate as many people as quickly as possible, if not we will get more difficult variants that are potentially resistant to the vaccines.”

In other news, the Oxford Vaccine Group which developed the AstraZeneca (AZ) vaccine has found that administering two doses 44-45 weeks produced the highest antibody boost. This news, announced by Andrew Pollard, one of the developers of the AZ, is glad tidings for countries like Nepal where people above 65 are waiting for their second doses.

Pollard said antibody levels remained elevated for close to a year with a ten-month gap between AZ doses, as well as antibody levels twice that after the second dose among volunteers who were administered a third booster dose, pointing to a long-term, possibly life long immunity, also against variants.

“This is great news for the elderly, many of whom are panicking, unable to get their second dose in the recommended time frame. The additional time the study has afforded us shouldn’t lead to complacency in our effort to procure vaccines,” says Sher Bahadur Pun, an epidemiologist at Sukraraj Tropical and Infectious Disease Hospital.

Norway, Czech Republic and Denmark have unused AZ shots they want to donate to Nepal, but have been forced to go through COVAX, which is unlikely to deliver the doses before the end of 2021.

On 1 July, Denmark announced that it would donate 250,000 vaccines to Bhutan. However, it is understood that these grants still need to be facilitated by the EU. 

Also in the news this week is the result of a new modelling study published in the European Centre for Disease Prevention and Control’s medical journal Eurosurveillance that further strengthens the link between AZ vaccines and a rare blood clot.

The study models four months of a vaccine distribution strategy in France from May 2021 and concludes that using AZ on the entire adult population would avert 10 deaths from Covid among 18-39-year-olds. However, it would be associated with 21 deaths from blood clots in the same age group over the same time period. 

In other words, clot risk to younger people from the AZ vaccine is twice as high as Covid death risk. But public health experts in Nepal maintain that the benefit of mass vaccination still far outweighs the risk. 

“Similar studies in the context of the South Asian population are needed but as it is, transmission risk of Covid is much higher than the individual risk of blood clots here,” says epidemiologist Lhamo Yangchen Sherpa.

Buddha Basnyat of PAHS concurs: “The UK with over half of its population fully vaccinated is now being hit by the delta variant, although it has been largely spared from severity due to the mass inoculation. Nepal being mostly unvaccinated is unprotected both from transmission and severity. This should show us where our priority should lie.”

The European Centre for Disease Prevention and Control finding about clot risk therefore could indirectly be a blessing in disguise for countries like Nepal by further freeing up AZ stockpiles in Europe, as well as Korea and Japan.

Even so, blood clot risk has prompted leaders including Germany’s Angela Markel to opt for Moderna as a booster shot to her first dose of AZ jab.

Several EU nations including Germany have said mix-and-match doses are safe for Covid prevention, which according to new findings also point to a better immune response. This could also offer much-needed flexibility when vaccine supplies are uneven or limited.

“We need to introduce mixing and matching also in Nepal in the face of more virulent delta variants, particularly for the elderly who are at the higher risk of developing severity from an infection, instead of waiting endlessly for Covishield,” says Basnyat.

At a time when Nepal is yet to recover from a devastating second surge, only an equitable vaccination strategy will prevent an even more deadly third wave. But a mere 2.6% of Nepal’s population has been fully vaccinated, and less than 9% has received a single dose of either Covishield or VeroCell shots. 

And even the doses are unevenly distributed within the country. More than half the first dose of VeroCell was distributed in Bagmati province, according to the government’s own figures. Moreover, 97% of the booster jabs of VeroCell were used only in Bagmati Province. 

“We are seeing a similar kind of disparity in vaccination that we saw in testing, concentrated in urban centres and in particular Kathmandu,” notes epidemiologist Lhamo Yanghen Sherpa. “The excuse for using most of the doses in Kathmandu is that people elsewhere refused to inoculate. If that’s the case what is the government and others doing to dispel vaccine myths?” 

Virologist Sher Bahadur Pun says the government should immediately deploy its 60,000 or so female community volunteers and healthcare workers who have historically done such effective work in non-Covid childhood vaccination drives.

He adds, “They are spread across the country and are best placed to communicate the significance of vaccines and increase vaccination uptakes at  local levels.”