AZN AstraZeneca PLC

By Eric Bellman and Sumit Dayal for The Wall Street Journal 

India is simultaneously battling the world's fastest-growing surge of infections and carrying out one of the most logistically complex vaccination campaigns. New Delhi has set a target of vaccinating 300 million of its more than 1.3 billion people by the fall.

Some of those doses will be transported hundreds of miles -- by truck, plane, scooter, boat and even on foot -- before being injected into the arms of people living in small, remote villages. Along the way, each dose must be tracked and kept chilled. The enormous challenge has become all the more urgent as infections have skyrocketed in recent weeks. Here is the story of one dose's 1,500-mile journey.

PUNE, India -- A half-milliliter dose of a vaccine developed by AstraZeneca PLC and the University of Oxford began its life here in a 1,500-liter metal tank, along with millions of others in batch number 4120Z017, months before it was approved for use.

The tank -- one of the bioreactors used to grow the cells to make vaccines -- produces millions of doses at a time. Bioreactors are the workhorses of the Serum Institute of India, the world's largest vaccine maker. The Institute started making and stockpiling doses as soon as it got the formula and tiny seed vial of material used to grow the vaccine from AstraZeneca in May.

PUNE: Born in a Bioreactor

From the bioreactor, the dose on Nov. 11 was put in a 10-dose vial that was then sealed with a stopper and stacked with millions of others on the giant purple-and-white shelves of a warehouse kept at around 40 degrees Fahrenheit.

After weeks in storage, the dose would travel 1,500 arduous miles to a remote village in the country's northeast before being injected into the shoulder of a schoolteacher, some 120 days after its emergence from the bioreactor -- another small victory in one of the world's most ambitious and logistically challenging vaccination campaigns.

The campaign has gained urgency as the coronavirus has surged in India, with daily new cases surpassing 300,000 last week. India is now regularly delivering more than 3.5 million doses a day, second only to China.

The AstraZeneca vaccine wasn't approved for use in India until Jan. 2. The dose sat on the shelf for another week, until it was separated into an ice-pack-lined plastic-foam box containing about 1,000 vials and loaded onto an insulated truck.

From there it took a 30-minute drive to the Pune airport, one of millions of doses headed to different corners of the country. On the afternoon of Jan. 13, it was loaded into the cargo area of a regular passenger flight operated by India's largest airline, IndiGo, which has joined forces with the government to help deliver vaccines across the country. In Kolkata, it was transferred to another passenger flight operated by government airline Air India.

The dose was among the first deliveries in the country, leaving Pune days before India launched its nationwide vaccination program on Jan. 16. It stopped only briefly at Kolkata airport before moving on, but most of India's vaccines stop at regional distribution centers as part of the hub-and-spoke system it is using to reach across the country.

KOLKATA: Distribution Hub

The warehouse in the Central Family Welfare Stores in Kolkata, for example, which has been managing India's regular child vaccinations for years, takes care of Covid-19 vaccine deliveries for that state. On a recent Saturday, it was bustling as workers set up shipments across the state of West Bengal and tried to make way for the growing number of vaccines arriving every week.

India has given more than 130 million shots already and plans to vaccinate more than 300 million by fall. While in shots delivered it trails China and the U.S., India has set a higher target -- and in a country with a large percentage of people living near the poverty line and in rural areas.

"This is about reaching all of India. Nobody can be left behind," said Vivek Paul, one of the leaders of New Delhi's vaccination efforts. "We are looking at extinguishing the pandemic, not just controlling it."

After an overnight stay in Kolkata, the AstraZeneca dose was loaded onto another commercial flight for the 400-mile flight to one of India's remotest state capitals, Aizawl.

AIZAWL: Land of the Hill People

Aizawl is the capital of Mizoram ("land of the hill people," in the local language), a northeastern state wedged between Myanmar and Bangladesh. Over the centuries, its citizens have settled on the hills for protection. Now the winding ridges that make up the capital bristle with buildings like a little Hong Kong in the middle of a jungle. There is little level land anywhere -- even pigs are kept on hill-hugging bamboo platforms held up with stilts.

Of Mizoram's nearly 1.5 million people, many live in distant villages that are hard to reach. Trips between places less than 100 miles apart in a straight line can take 10 hours, often along narrow dirt roads that wind through the mountains. The state is rushing to provide shots before rainy season starts in June, making roads impassable.

"We have to finish as much as possible before the monsoon," said Eric Zomawai, the deputy director of the state's health department. "We get landslides and in spite of everything we have to manage."

The dose landed in Aizawl on Jan. 14 around noon. It was quickly packed into a smaller plastic-foam cooler with fresh ice packs and a credit-card-sized temperature monitor to ensure it stays between around 35 and 45 degrees for the next leg journey -- a long and winding eight-hour drive to the rural district headquarters of Lunglei.

There the dose had another long wait -- this time, for the distribution system to catch up with the supply. In the initial stages of the vaccination drive, there were technical glitches with the smartphone app-based system used to choose, notify and register people for vaccinations. Meanwhile, in parts of Mizoram and across India fewer people than expected were showing up for their shots.

NUNSURY: Shot in the Arm

After almost two months in a freezer used to store all sorts of vaccines, on March 11 dose it was packed into a small plastic-foam cooler equipped with a shoulder strap. A local health official slung it on her back, got on a scooter and drove it down to the Khawthlangtuipui River, which runs to the border between India and Bangladesh. She and four other health officials jumped in a long wooden boat to go downstream to the village of Nunsury.

Nunsury is little more than a riverside cluster of simple, single-story homes, some built of bricks, others of bamboo, most roofed with corrugated steel. Most citizens are fishermen or farmers. Around 10 of the oldest people in the village were the first to arrive at the makeshift vaccination center, set up in the village grade school. They all show their IDs and wait their turn.

Establishing age has been a big problem. Until May, the vaccine is being offered only to people at least 45 years old, but in the far corners of Mizoram, official birth certificates weren't given out until the 1980s, said Lalhnunmawii, a local medical officer who goes by one name.

"Some people here are illiterate, so their ages are just what they imagine," she said. "They don't know their exact ages."

The vaccine-distribution app that suffered glitches early in the campaign has a separate problem in this remote area: lack of connectivity. Health workers have to keep records on paper and transfer them when they are back in an area with a network. In some districts of Mizoram, cellular networks are so scarce that it is a full-time job for people to drive hours to a spot where they can update the database.

The vial containing the dose was pulled from the cooler and marked with the time and date: "9:20 11/3/21." Once opened, a vial has to be used within four hours.

Teacher Sulochana Chakma was among the first 10 people in line for shots. Before the injection, health workers told her that if she feels any side effects, she should notify a government hospital.

With false vaccine scare stories circulating around the country via WhatsApp messages, state officials have stressed the importance of not spreading rumors and fear. One small group in Mizoram was even claiming using the vaccine was un-Christian, a big problem in the Christian majority state.

After getting her shot in the arm, Ms. Chakma waited quietly for 30 minutes, sitting a safe distance from others on well-worn wooden benches built for small children.

She hadn't been notified to show up for her shot by text, as the government had originally planned. The system was scrapped after proving unreliable. Instead, older people were called by a loudspeaker atop a tower, which is usually used to notify villagers in an emergency.

"Yesterday they announced in the afternoon time, then again in the evening and then again in the morning," she said. "It's free and from the government, so we are happy to get it."

Photographs and video by Sumit Dayal for The Wall Street Journal, unless otherwise noted

Write to Eric Bellman at eric.bellman@wsj.com

(END) Dow Jones Newswires

April 25, 2021 05:44 ET (09:44 GMT)

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