COVID VACCINATION IN SLUM POPULATIONS IN MUMBAI: AN

IMPLEMENTATION RESEARCH PROJECT

Implementation Problem:

Since two years, the COVID-19 pandemic has raged worldwide. An airborne disease,
COVID-19 has caused more than 600 million infections and 6 million deaths, a figure that
places it close to World War I in terms of mortality [1].

Disease burden: The easy transmissibility of the disease means that populations living in
congested slum areas in confined settings are at a terrible risk of infection leading to high
disease burden [2]. Dharavi in Mumbai is one such ticking bomb. It is among the, if not ‘the
largest slum’ in the world. Close to 1 million people stay within an area of 535 acres [3].

Background: This high population density of close to 500,000 people per square kilometre
proved to be a logistical nightmare for healthcare epidemiologists even while doing contact
tracing of COVID-19 patients during the initial phases of the lockdown with every person
having numerous secondary and tertiary contacts due to shared bathrooms, living spaces and
common water sources. However, the city responded effectively to this challenge with public
health specialists coming up with the much famed ‘Dharavi’ model that effectively ensured
that disease spread was not only restricted but effectively mitigated with Dharavi being
among the earliest hotspots in the city to eventually record very few cases [4,5].

The Problem: While the rapid development of COVID vaccination (an effective promising
intervention) was a victory for the healthcare community worldwide, rolling out this
efficacious prophylactic measure on-ground in areas like Dharavi came with its own set of
roadblocks. Chiefly, the problem can be broken down into three key challenges:
In a lower middle-income country like India, possible reasons for failure include:
a. access to the cold chain facilities were not feasible in areas like Dharavi [6],
b. the literacy rates are yet to reach encouraging levels [7] and
c. high vaccine hesitancy [8] was commonplace.
Research on vaccination reports that double jab protects recipients against contracting severe
illness as well as reduces the risk of hospitalization and mortality. [9]
 Implementation Approach/Research Proposal:

Strategy: Administering vaccines locally at specially designed community vaccination

centres (the answer to ‘how to?’) to the population of Dharavi after targeted awareness drives
that included vaccine ambassadors, indirect incentivisation and motivational messaging
would improve vaccine coverage (as per PICO Framework)

Objectives: (Primarily influence)

- To develop a strategy to boost vaccine uptake and distribution in slums like Dharavi in an
effective manner, thereby developing a protocol for effective future vaccine rollouts and
scaling.
- To assess operational feasibility of providing COVID vaccination to Dharavi and assessing
community attitudes towards the same.

Pre-conditioning Phase:
Needs assessment:
- Effective delivery technique that would avoid vaccine wastage and shortage
- Is it possible to use local community centres in addition to hospitals to increase vaccine
rollout and uptake by enhanced patient convenience?
Barriers include the possible reasons of failure that have been previously discussed.
Facilitators include training the high local youth population

Pre-implementation Phase:
- Involving local community stakeholders including popular celebrities, social workers and
influencers is among the primary tasks that improves confidence and assures that the local
people develop good rapport with the project.
- Identifying implementation context settings:
Outer setting:
Dharavi serves as a diverse hub of different cultures that represent the cultural potpourri that
is India. Clashes are frequent and this is taken advantage of by vested interests. Managing
community emotions and ensuring unity for a greater cause is a primary necessity.
Inner setting:
Migrant labourers form a large segment of the population. They are extremely dependent on
their daily livelihoods to eke out a very hand-to-mouth meagre existence. The COVID-19
 pandemic which deprived many of their jobs and led to immense starvation and other hurdles
of poverty means that a major chunk of this population is psychologically weary and thus,
eager to take the necessary steps to bring an end to the pandemic. This is an interesting facet
that can be tapped into.

Implementation Phase:
Multi-faceted
- Situation Stakeholder analysis:
o Community training programs were held and local youth were onboarded to aid in the
massive process of registering and identifying all who had been vaccinated
o Government: A centralized app (Arogya Setu) had already been launched for contact tracing
in view of COVID. CoWIN was an additional platform that was eventually launched to assist
in maintaining a database of national vaccination. It served as a transparent booking system
where e-certificates could be easily generated within minutes after the jab as a proof of
vaccination. To avoid vaccine shortages, international deals with neighbouring countries for
vaccine imports and exports as part of ‘friendship pacts’.
o Individuals: Awareness drives targeting doctors at hospitals to motivate the community.
When those who had been vaccinated posted online social media posts of photos captured at
‘I am vaccinated’ booths in these centres, snowballing effect increased vaccine scale.
o Multiple actors: Powerful high-impact high-interest stakeholders targeted to carry out
campaigns via text, mobile calls and advertisements to mitigate vaccine hesitancy and
alleviate population concerns.

Monitoring and surveillance phase:

Positive feedback-enhancing loop:
- Effective messaging served as reminders for people to take the second and precautionary
doses.
- Incentivisation via ensuring that public transport, theatres and restaurants only accessible to
vaccinated people.
- Generation of on-ground reports and publication of vaccine milestones by giving wide
coverage in national and international media.
- Collecting data, analysis and making tweaks as per gaps found: Improved interest of local
youth, healthcare community as well as healthcare stakeholders worldwide to replicate the
success achieved
Conceptual Framework:

(P.S.: I do not have access to high-end software to develop images and videos :( hence, I
made use of traditional paper-and-pen method to develop this over a couple of days. Please
feel free to contact me in case any part of the handwriting is unclear)

Figure 1: Conceptual Framework of the Vaccine Rollout Process at Dharavi, Mumbai

(Implementation Research)
Implementation Research Outcomes: Assessment

Implementation Outcomes:
Outcome Levels of data Approach made use of
collection and
subsequent analysis

Acceptability Of the vaccine at Qualitative methods including interviews,

community and Surveys to identify causes and predictive factors
individual levels of vaccine hesitancy that can be then specifically
targeted

Adoption Individual, Observing trends of people’s behaviour, KAP

Community studies, Administrative data that will give insight
and Organization into vaccine administration statistics
Levels

Appropriateness Individual, Due to vaccine ambassadors and motivational

Community interviewing, people developed a positive
Organization Levels perception to the vaccine program. Identified by
on-ground studies and proven by program
reports.

Feasibility Individual, High quality effective service provided by a

Community trained team specializing in vaccine
and Organization administration facets and capable to address all
Levels concerns that may arise. Studied via
miscellaneous feedback collected about process.
Fidelity Individual, Low vaccine wastage was noted. Delivery as
Community intended to patients. Identified by checklists kept
and Organization by service-personnel and from self-reporting
Levels measures.

Implication Cost Individual and From administrative data. The vaccine was
Organization Levels provided for free at participating government
institutions with free subsidized rates collected
for private centres.

Penetration Individual, High coverage even at remote, inaccessible

Community locations via local community vaccine centres
and Organization and tie-ups. Transportation arranged to take
Levels people to vaccine centres when vaccine could
not be taken to locations convenient for them.
Sustainability Individual, Via central audits, the checklists in place ensure
Community that similar vaccination campaigns can be
and Organization effectively run as and when needed with
Levels adequate technological and on-ground support.
 Service Outcomes:
➢ Timeliness: Achieved within a short duration
➢ Patient satisfaction: Convenient process from registration to post-vaccine monitoring for side-
effect development
➢ Efficient: Non-redundant smooth process that ensured no overcrowding at vaccine centres
(reducing risk of vaccination becoming a potential super-spreader event) with online
documentation and seamless integration with national identification schemes (like Aadhar)

Patient Outcomes:
➢ Reduced disease burden: High vaccine coverage would effectibely break the community
transmission cycle and pave the way for the slow elimination of the pandemic.
➢ Improved patient outcomes: Less severe infections with more survival rates
➢ Return to normalcy: Would ensure that better hospital care is provided to patients with other
illnesses. ICU Beds available for Non-COVID emergencies. Patients having chronic illnesses
like cancer requiring long - term follow-up and care have had their care impacted the most
with diversion of healthcare resources and staff towards management of COVID ICUs.
 References:

1. Accessed from: WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-

19) Dashboard With Vaccination Data Last accessed on 03 September 2022

2. Rahn S, Gödel M, Köster G, Hofinger G. Modelling airborne transmission of SARS-CoV-2

at a local scale. PLoS One. 2022 Aug 30;17(8):e0273820. doi:

10.1371/journal.pone.0273820.

3. Accessed from: Shanty-towns emerge targets for development | Mint (livemint.com)

Last accessed on 03 September 2022

4. Khaparde S, Aroskar K, Taralekar R, Gomare M. Interventions to respond to COVID 19

pandemic in Mumbai and way forward. Indian J Tuberc. 2022 Apr;69(2):234-237.

5. Accessed from: Dharavi Coronavirus Once A COVID-19 Hotspot, Mumbai's Dharavi

Records 2 Cases Today (ndtv.com) Last accessed on 03 September 2022

6. Accessed from: Lack of Adequate Cold Chain Facilities Biggest Challenge in Covid-19

Vaccine Distribution: Report (news18.com) Last accessed on 03 September 2022

7. Accessed from: Literacy Rate in India 2022 | Kerala & Bihar Literacy Rate – The Global

Statistics – The Data Experts | Statistical Data Reports Last accessed on 03 September 2022

8. Bansal P, Raj A, Mani Shukla D, Sunder N. COVID-19 vaccine preferences in India.

Vaccine. 2022 Apr 1;40(15):2242-2246. doi: 10.1016/j.vaccine.2022.02.077.

9. Accessed from: COVID-19 vaccines continue to protect against hospitalization and death

among adults | CDC Online Newsroom | CDC Last accessed on 03 September 2022