The COVID-19 pandemic has caused significant morbidity and mortality globally, across multiple waves. The recent situation in India has been grim. Evidence suggests that the spread of the virus can be mitigated through physical distancing, non-pharmaceutical interventions like use of face masks / shields and maintaining hand hygiene, and in advanced cases of morbidity, therapeutics.

The risk of outbreaks and disruption to societal and economic activity likely remains until effective vaccines are administered to prevent hospitalisation and limit infection. Emerging evidence also suggests that even a single dose of some COVID vaccines reduces infection rates across population groups. Therefore, it is essential to ensure equitable access to vaccines within and across all nations.

Several novel vaccines were developed in rapid response to the urgent need for a long-term solution to curb the spread of COVID 19 infection. Some COVID-19 vaccines have now been authorised or approved for human use, with some in the late stages of clinical development. The speedy rollout of vaccines is essential for complete economic reopening and recovery across the country.  The Government of India’s CoWIN portal reported in the last week of April that 150 million doses of vaccine have been administered with 25 million individuals having received both the doses.

Vaccine hesitancy has been reported anecdotally, although the prevalence of this phenomenon remains to be rigorously studied in India, particularly as the second wave mounts. India is phasing this summer into opening vaccines to all adult populations of age group 18 years and above, and vaccine acceptance will be critical. 

The Rapid Evidence Synthesis team at the George Institute for Global Health and the Knowledge Management Division (KMD) of the National Health Systems Resource Centre (NHSRC) have collaborated to identify evidence on the determinants of vaccine acceptance and hesitancy, interventions that can promote vaccine acceptance, and also review relevant literature that contextualises this evidence in light of the ongoing pandemic crisis in India. 

Based on discussions and a scoping brief, this rapid evidence synthesis (RES) addresses the following objectives: 

• What are the determinants of COVID-19 vaccine acceptance and hesitancy?
• What interventions have been shown to improve COVID-19 vaccine acceptance and reduce hesitancy?
• What contextual considerations related to the aforementioned are relevant for India’s COVID scenario?

Policy Implications

• This RES lays out evidence from LMICs, including India, in relation to a (WHO) framework to understand COVID vaccine acceptance and hesitancy. 
• It contextualises evidence – including from pre-prints- to make recommendations (see below).
• It expands the scope of response to vaccine acceptance and hesitancy beyond vaccine communication strategies, which, as evidence suggests, are necessary, but not sufficient. 

Policy Recommendations

Policy makers at national and subnational levels may consider the following key determinants of vaccine acceptance – which likely shape strategies 

• Risk perception and severity of illness
• Gender, occupation, education, income, place of residence, certain occupations and religious beliefs – these tend to be associated with population sub-groups neglected by the health system 
• Vaccine effectiveness, side effects, perceptions of safety (including exposure risks while getting vaccinated), misinformation and affordability 
• Endorsement from health provider and employers 
• Communication and public engagement 
• Most centrally, trust in government and pharmaceutical companies

No evidence was found assessing strategies or interventions. Multipronged strategies were recommended, and include

• At the overall systems level
  • Addressing historic issues and sensitivities, particularly in pockets where vaccine acceptance may be heterogenous
  • Minimisation of vaccine associated costs borne by the public
  • Measures to ensure infection control and reduce infection spread o Increase in availability of human resources and vaccine delivery capacity, including innovations to improve pre-registration access
• Engagement directly with communities by mobilisers and frontline workers, as well as providers sharing knowledge and encouraging vaccination in their personal networks – in the Indian context, this should include support for vaccine registration especially for those with access constraints.
• Clear, consistent and transparent communication regarding service availability, risks, and benefits through general as well as intensive campaigns with
  • Engagement of community leaders, celebrities, as well as health and scientific experts to build awareness, and
  • Tailoring messaging according to health, scientific and general literacy of sub-populations using traditional and social media, as appropriate.

Related People:

• Dr Devaki Nambiar, Program Head – Health Systems and Equity, The George Institute for Global Health
• Sandeep Moola, Research Fellow, The George Institute for Global Health
• Nachiket Gudi, Consultant, The George Institute for Global Health

India successfully averted any significant mortality and morbidity due to COVID-19 in 2020 through institution of several measures. India is now facing the second wave of COVID-19 which has overwhelmed the health system. State governments have revised strategies to deal with the pandemic surge but there is a need for crisis preparedness response on the second wave of COVID-19 in India. The National Health Systems Resource Centre (NHSRC) requested the George Institute for Global Heath for rapid evidence synthesis for the purpose. scanned key issues and developed an evidence informed policy brief which had the following objectives:

1. To understand the magnitude of the second wave of COVID-19 at a national and state level, together with resource requirements,
2. To synthesise evidence on interventions that can flatten the curve” of transmission and contain the spread of COVID-19 infection,
3. To identify strategies and synthesis evidence for rapidly scaling up health systems capacity during COVID-19 surges.

The policy brief is based on synthesis of six public health graded response frameworks, 115 research studies on several aspects, two reviews, and presents one inventory of resources. We also present estimates from one model to inform magnitude and temporality of the pandemic which can inform planning. All rapid evidence synthesis and policy brief development was carried out in 5 days.

Key policy considerations and recommendations are:

1. Estimates on the course of the pandemic as per the IHME model indicates that the second wave of COVID-19 will cause significant mortality and health system crunch in coming weeks to months with peak health systems burdening yet to be achieved in many states. There is an urgent need to rapidly act to prevent transmission and mount crisis response and state-wise estimates are provided. We however recommend using a multi-model approach, with the worst-case scenario being considered for planning and strategy development.  
2. There is an urgent need to “flatten the curve” of transmission and contain the spread of COVID-19 infection by:
   1. Adoption of a graded public health response for movement restriction and scaling it up guided by multi-indicator technical criteria. We recommend the use of Ontario COVID-19 response framework (with suitable state-level adaption, if necessary) which mounts five colour coded grades of responses, based on epidemiological, health system capacity and public systems capacity indicators. A state-level dashboard which captures indicators guiding the graded public health response might be developed to ensure better decision making and build citizen trust in restriction measures. Evidence on different types of restriction measures is presented and other graded public health response frameworks is also presented. 
   2. A multi-component community-based intervention to remove barriers to access and promote mask usage consisting of the following components needs to be invested on and scaled up across India:
      1. Engaging community-based organisations to ensure availability of free surgical masks (free door-to-door distribution of surgical mask would be appropriate strategy after surge is over),
      2. Offering information on mask usage and disposal with videos on tab, brochure in local languages and other community-based platforms,
      3. Endorsement and advocacy by local community leaders – healthcare, social, political and cultural,
      4. Periodic in-person monitoring of mask usage including providing reminders and distribution in public spaces,
      5. Development of protocols for disposal of masks in safe and environment friendly manner.
3. Ensuring health system preparedness for COVID-19 surge:
   1. Urgent investments to ensure scaling up of a crisis health system (for both COVID and non-COVID needs) is required. Evidence on several strategies (shelter hospital /alternate hospital sites; mobile field hospital, Biocontainment patient care units; recovery /rehabilitation units; deployment of hospital ships and planes; escalating ICU/HDU resources in ICU; community care facilities; hospital re-engineering; medical missions) used successfully in other countries for COVID-19 surge is presented. We recommend institution of all modalities, as relevant, considering the magnitude of crisis.
   2. Shortfalls in ventilator requirements, after purchase through routine supply chains and those received through aid, might be met by requesting support from organisations with capacity to manufacture open source ventilators. A resource on ranking of open source ventilator on several parameters is presented. Training for critical-care staff and accessories for ventilators including oxygen delivery need to be addressed.
   3. There is an urgent need to support people with COVID-19 who can undergo home care safely and scale up telemedicine provided by registered medical practitioners. Telemedicine facilities should be linked to transportation and hospital admission facilities such that severe patients can be optimally managed.
   4. The government needs to urgently develop and implement a fair, just and transparent triaging criterion for rationale allocation of beds, oxygen, and other critical care resources in consultation with bioethicists. Evidence on different triaging strategies is presented in the form of an inventory.  

Related people:

• Soumyadeep Bhaumik, Research Fellow, The George Institute for Global Health
• Deepti Beri, Research Officer, The George Institute for Global Health
• Jyoti Tyagi, Research Officer, The George Institute for Global Health
• Rupasvi Dhurjati, Research Assistant, The George Institute for Global Health
• Nachiket Gudi, Consultant, The George Institute for Global Health

Download full report (PDF 530 KB)

The Barisal Drowning Reduction Project – Bhasa is a multi-stakeholder approach to drowning reduction within a sub-region of Bangladesh.

It is estimated that 321,000 drowning deaths occur globally each year. That is a global drowning rate of one person every 80 seconds. More than 90% of drownings occur in low and middle income countries (LMICs). However, little is known about the impact of drowning on communities, both socially and economically. In this document, we report on the findings of a household population-based cross-sectional survey to understand the burden and context of fatal drowning in the Barishal division of Bangladesh. We investigated drowning cases by demographic characteristics and features of the drowning event. We also report on the qualitative findings, which helped us understand the context, beliefs and behaviour that influence water safety practices in the Barishal division.

Read the full project report (PDF 17 MB)

The burden of road traffic deaths is disproportionately high in low-and-middle-income countries (LMICs). In India, deaths due to road traffic injuries (RTIs) have increased by 58.7% between 1990 and 2017. In 2019, the Government of India amended the Motor Vehicles Act (MVA) on several counts including a hike in penalties and better enforcement measures to encourage safe road-user behaviour such as helmet and seatbelt use and deter drunk driving, over-speeding, and driving without license. However, several States are experiencing challenges in sound implementation of the act owing to the quantum in penalty hike.

Atal Bihari Vajpayee Institute of Good Governance and Policy Analysis (AIGGPA), Government of Madhya Pradesh requested the RES-TGI team for a rapid evidence synthesis to understand the evidence base behind the effectiveness of penalty measures in decreasing incidence and mortality due to RTIs. This would enable decision-makers in the State to better implement the MVA. The RES was conducted in 6 weeks to serve this purpose and the evidence-informed policy considerations were presented in a policy brief.

Key policy considerations:

1. There is no evidence from interventional studies on effect of financial penalties for violation of helmet and seatbelt laws in reducing road traffic injuries or deaths.
2. Fines in combination with license suspension, vehicle impoundment and demerit point system with or without jail sentences for excessive speeding violations may lead to statistically significant decrease in deaths due to RTI depending on context.
3. Financial penalties alone for drinking under influence of alcohol (DUI) violations does not lead to statistically significant decrease in road traffic fatalities and injuries.
4. Financial penalties in combination with jail sentences with or without license suspension
   for DUI violation leads to statistically significant decrease in road traffic crashes and injuries but in some studies, it was reported that the effect gradually wears over time. To sustain the effect, there is a need for sustained involvement of social groups or civil societies in advocacy and maintaining enforcement through local contextual reforms.
5. Mandatory fines with demerit points for DUI violations was shown to show a large and significant decrease, which was sustained over time in a study from Japan, but the law made both the bartender and the driver legally responsible. Institution of such laws may be considered.

Integration of different departments such as road transport, police, civil societies, judiciary, local bodies of the community groups and media are important in implementing and sustaining interventions.

Download policy brief (PDF 316 KB)

Download supplement document (PDF 452 KB)

The District Medical Officer (DMO), Malappuram, Kerala identified some undesirable and/or harmful postnatal care (PNC) practices being encouraged by post-natal care attendants supporting women for 40 days post-delivery. The DMO, with support from an action group of obstetricians in the district, intends to design and develop training modules to address the harmful practices, particularly in relation to nutrition and breastfeeding.

She requested our RES team to conduct a rapid review that could support her in this policy endeavour. The team together with the DMO concurred on summarising evidence on three relevant components:  recommendation from relevant guidelines on best practices for postnatal care, harmful postpartum beliefs and practices of mothers in India, and training of post-natal care attendants for post-natal care, nutrition and breastfeeding. This would provide the DMO with an evidence base to develop the training modules.

This policy brief provides a focussed summary of recommendations from guidelines on best practices related to Post-Natal Care (PNC) in Low- and Middle-Income Countries (LMICs) on improving nutrition and breastfeeding outcomes.

A few key policy options:

Postnatal visits/contacts

• Healthy mothers and newborns should receive care in the facilities for at least 24 hours post-delivery, if delivered in a health facility.
• The first postnatal contact should be as soon as possible within 24 hours of birth, if birth is at home.

Breastfeeding

• Mothers should be encouraged to exclusively breastfeed for about the first six months of a baby's life, followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age.
• Breastfeeding should be continued for as long as mutually desired by mother
  and baby.

Nutrition

• Mothers should be advised to increase their intake of food and fluid, and to take foods rich in calories, proteins, iron, vitamins and other micro-nutrients.
• Iron and folic acid supplementation is recommended for at least three months
  post childbirth.

Family planning/Contraception and Immunisation

• Parents should be counselled on family planning, and the various contraceptive options available.
• Parents should be provided appropriate information on the benefits of immunisation.

Use of lay health workers in providing postnatal care

• Lay health workers should be used to promote exclusive breastfeeding, adequate nutrition and for providing iron and folate supplements during pregnancy.

Appropriate training should be provided to lay health workers and their trainers and supervisors on various key aspects of postnatal

The post-natal period is a critical phase in the lives of mothers and new-borns. Most maternal and infant deaths occur during this time. Yet, this is the most neglected period in the provision of quality care and maintenance of healthy practices. The District Medical Officer (DMO) in Malappuram, Kerala with support from an action group of obstetricians in the district, proposes to train Post-Natal Care (PNC) attendants. The DMO intends to design training modules, particularly in relation to post-natal nutrition and breastfeeding.

She requested our RES team to conduct a rapid review that could support her in this policy endeavour. The team together with the DMO concurred on summarising evidence on three relevant components:  recommendation from relevant guidelines on best practices for postnatal care, harmful postpartum beliefs and practices of mothers in India, and training of post-natal care attendants for post-natal care, nutrition and breastfeeding. This would provide the DMO with an evidence base to develop the training modules.

The team, with concurrence of the DMO, felt that evidence related to Traditional Birth Attendants (TBAs) may be relevant for their training, which was the focus of this rapid review.

Policy Options

Policy makers might consider engaging PNC attendants to improve post-natal care nutrition and breastfeeding even as direct evidence is lacking on their impact or training needs. Based on evidence from trained TBAs, training might be of 2-8 days in duration may be suitable, depending on domains being covered (No direct evidence was found related to maternal nutrition). Evidence suggests that training programs which focus on limited basic content accompanied by supportive supervision (by lady health workers or trained nurses or community midwives) and follow-up training may lead to better outcomes. An overall training plan should be developed which would include components related to “Training of the trainers”
and evaluation.

In different cultures and regions across India, specific traditional beliefs and practices are observed during the postpartum period to ensure recovery and avoid ill health of mothers in later years. However, some of these beliefs and practices may prove to be harmful and impact maternal and newborn health outcomes negatively.

The District Medical Officer (DMO), Malappuram, Kerala identified some undesirable and/or harmful postnatal care (PNC) practices being encouraged by post-natal care attendants supporting women for 40 days post-delivery. The DMO, with support from an action group of obstetricians in the district, intends to design and develop training modules to address the harmful practices, particularly in relation to nutrition and breastfeeding.

She requested our RES team to conduct a rapid review that could support her in this policy endeavour. The team together with the DMO concurred on summarising evidence on three relevant components:  recommendation from relevant guidelines on best practices for postnatal care, harmful postpartum beliefs and practices of mothers in India, and training of post-natal care attendants for post-natal care, nutrition and breastfeeding. This would provide the DMO with an evidence base to develop the training modules.

This rapid review identified and summarised some of the commonalities in harmful postpartum cultural practices across different regions and settings in India.

Policy options:

• Health education and promotion programmes should identify and discourage mothers and their family members from resorting to locally prevalent harmful postpartum practices.
• A checklist of healthy postpartum practices may be developed for postpartum mothers, their families and for newborn care.
• It is important that community level health workers such as the ANMs, Anganwadi, and ASHAs in rural India are supported to develop locally tailored behaviour change communication strategies related to postpartum care.