Health workers take blood samples to check for Covid-19 antibodies in New Delhi on September 27, 2021.

India has administered more than 1 billion Covid-19 vaccine doses, a remarkable feat just months after a second wave of infection killed thousands of people across the country.
But as India celebrated passing the milestone on Thursday, some experts warned the pandemic threat was not over -- in a nation of 1.3 billion, millions of people are yet to receive any dose at all.
So far, India has fully vaccinated just 30% of its adult population and given one dose to 74%, according to India's Ministry of Health on October 16. Those statistics don't include children under 18 who make up 41% of India's population and aren't yet eligible for the jab.


But even as India races to fully vaccinate its adult population, the country is opening up and exporting millions of vaccine doses. On Friday, the first foreign tourists arrived in the country after an almost 18-month pause, and within the country millions are traveling to celebrate various festivals, with movement expected to increase in November during Diwali, the Hindu festival of lights."
Experts fear that interstate travel and the possibility of new variants could lead to a third surge in infection -- leaving unvaccinated people and children most at risk.
"It's difficult to predict because the global experience shows that things could turn sour at any point of time," said Dr. Anant Bhan, a global health and policy expert from the central Indian city of Bhopal. "But the trend in India right now is very encouraging. The number of vaccines administered is high and there is no upswing in cases."
Up to 8 million doses are being administered on a typical day, but the Indian Medical Association is calling for the government to cease exports until more people are vaccinated at home.

Commuters wait for local trains during peak hours at Chhatrapati Shivaji Maharaj Terminus in Mumbai on September 30, 2021.

Second Covid wave beat vaccines
India has had two waves of Covid-19 -- one last year before vaccines were available, and the second that began only weeks into the country's ambitious inoculation program earlier this year.
The first doses started rolling out in January to vulnerable citizens and frontline workers, part of a priority group of 300 million people -- almost as many people as the entire US population.
At the same time, millions of doses of Covishield -- the AstraZeneca vaccine produced in India -- were being exported to other countries and the global vaccine-sharing platform COVAX.
Prime Minister Narendra Modi claimed India was saving "entire humanity" from tragedy. But at home, the world's largest vaccine program was struggling.
"We absolutely faced hiccups in the beginning," Dr. J. A. Jayalal, president of the Indian Medical Association told CNN. "We weren't able to meet our huge demand, and there was a lot of hesitancy, especially among our rural population."

Vaccination rates were still very low as the second Covid wave built in early March, and by the end of the month, the government had stopped vaccine exports to prioritize Indians.
The surge in Covid cases brought panic and despair as millions tried to navigate the country's collapsing health care system. Some desperately posted for help on social media, hopeful to secure a hospital bed or medical oxygen.
In April -- weeks before cases peaked at more than 400,000 a day -- vaccine supplies dried up, with at least five out of India's 29 states reporting severe shortages.
Several districts in the western state of Maharashtra had to temporarily suspend vaccination drives, including more than 70 centers in financial capital Mumbai, according to the state's health minister, Rajesh Tope.
The government faced widespread criticism for its handling of the crisis. For many, Modi underplayed the severity of the pandemic. Authorities belatedly ramped up the vaccination program, and in August more vaccination centers were opened and education campaigns rolled out in rural areas.

Photos: India's Covid-19 crisis
A young man receives a Covid-19 vaccine in Guwahati, India, on Saturday, May 8.

On September 17, Modi's birthday, India set a single-day vaccination record by administering more than 25 million shots. That week, the country crossed a major milestone by delivering at least one dose to more than 60% of its eligible adult population.

But like many countries, India's vaccination rates aren't evenly spread. In rural areas, more than 64% of people have received at least one dose of a vaccine. In urban India, where people live in more crowded cities and towns, the figure is close to 35%, according to data from the Ministry of Health.

India's challenge is to improve rates across the country -- and most importantly, to vaccinate its children.

Children next in line

Since the pandemic began, fewer than 1% of India's Covid-19 deaths were of children under 15, according to the country's Health Ministry. But several states are taking extra precautions and preparing for a worst-case scenario should a third wave hit.

Hospitals are stockpiling medical oxygen and some states -- including Maharashtra, Tamil Nadu and Karnataka -- are building Covid-19 treatment facilities, especially for children.

"We don't know how the virus will behave, but we cannot afford to be unprepared this time around," Suhas Prabhu, head of the Pediatric Task Force in the western state of Maharashtra, said, according to Reuters.

"No mother should have to run around looking for a hospital bed when her child is sick."

The first vaccine available for Indian children over 12 -- ZyCov-D, developed by Gujarat-based Cadila Healthcare Ltd -- was given Emergency Use Authorization (EUA) in August.

About 10 million doses of the vaccine would be available per month, India's Covid-19 Task Force Chief, V.K. Paul, told CNN affiliate CNN-News18 on Wednesday, adding the government had asked India's National Technical Advisory Group on Immunisation for guidance on how to allocate the shot.

"Our priority right now is to continue to explore options for children and adolescents for sure but our thrust is to cover the adult population for which there is no dearth of vaccines anymore," he said.

Another vaccine, India's homegrown Covaxin, developed by Bharat Biotech and the Indian Council of Medical Research, is expected to be given EUA for children age 2 to 18 soon.

However, the World Health Organization has not yet approved it for adults or children.

The US-developed Johnson & Johnson and Moderna vaccines are also expected to roll out in India this year, although the timeline is not known -- and neither have been approved for use on children in India.

Concern about exports

The delivery of 1 billion Covid vaccine doses is a milestone for India, but experts say it has to do much more to reach its target of inoculating its entire adult population by the end of the year.

Jayalal from the IMA says the country should be aiming to vaccinate at least 10 million people per day.

Then there is the issue of supplies. The IMA worries that by resuming vaccine exports, India could find itself in a similar position to last year -- when demand vastly outnumbered supply.

"Personally, we are not supporting exports," said Jayalal. "We are emphasizing that all our population should get the first dose at least before exports resume."

Some 1 million shots of Covaxin were shipped to Iran last week, the Indian embassy in Tehran confirmed on Twitter. Nepal, Bangladesh and Myanmar have also received India-made vaccines in October, according to Indian officials. Exports are expected to increase significantly in the next few months as domestic stocks build and most of India's population is inoculated with the first dose, officials said on October 14.

Dr. Bhan, the global health and policy expert, said while India plays an important role in the world's vaccine supply, a balance must be met.

"We should, of course, offer some of that supply to other countries, especially those where there has been a trickle of supply," he said. "We have ramped up production and local vaccine coverage is going up. But perhaps this is the time for us to enhance manufacturing in a way that supports local and export needs."

People queue for the Covishield vaccine in Siliguri, West Bengal, on October 1, 2021.

A spokesperson from Bharat Biotech, which manufactures Covaxin, said it is not facing any challenges in manufacturing the shot, and is working towards making 1 billion doses in India this year by expanding its production capacity across multiple facilities in the country.

SII, which manufactures Covishield, will produce 200 million doses in October, up from 160 million in September, according to the company, after it improved access to raw materials required to make the vaccines.

CNN reached out to the Ministry of Health but did not receive a response.

K. Srinath Reddy, president of the Public Health Foundation of India, said the country may not achieve full vaccination by the end of the year, but added authorities are "drawing comfort" from antibody surveys showing high positivity rates across the country, meaning there is some protection against the virus.

"This is being taken as an indicator of protective immunity acquired either during the Delta-driven second wave or through vaccination even from a single dose," he said.

Indian authorities will be hoping -- even without both doses -- that protective immunity offers Indians some safety as the long festival season gets underway.

The government hasn't announced a ban on religious gatherings and interstate movement, but it's urging the public to remain vigilant and avoid non-essential travel.

"We are starting to get back on our feet again, but we cannot afford to be complacent," said Jayalal, the IMA president.

"We are requesting the government not to allow mass gatherings. It's definitely a possibility that a third wave will come, and we need to be ready for it."