Vaccine scribble

Immunisation has been in use for centuries in what is now Bangladesh, even before Edward Jenner invented the first vaccine for smallpox. Historians have discovered that variolation or inoculation, the earlier form of vaccination, used to be carried out by a group of professional inoculators, locally called tikadars, who by experience learned how to do it. The tikadars, who charged a fee for their services, were active since the middle of the eighteenth century. Smallpox was the disease for which the tika was most popular. As the disease used to strike in the months between February and April, the tikadars returned just a few weeks beforehand and did their work – much like a campaign. The word 'tika' means vaccination but also pock scar. It is said that it came from the word ''gutika' which means small bead. Incidentally, smallpox in Bangla is called 'guti-basanta'. 

The Jenner vaccine, introduced in England in 1798, found its way to Bengal in 1802. Between 1802 and 1865, both immunisation systems, variolation and immunisation, ran side by side. During the later 19th century, the colonial state gradually imposed vaccination on an entire society, repressing the other system, which was characterized by confrontation and resistance.

The partition of Bengal in 1947 led to immense dislocation in health services due to the migration of many healthcare workers to West Bengal. Of the nine municipalities that became part of former East Pakistan, only four initiated immunisation in schools with cholera and later on BCG for tuberculosis. After independence in 1971, in line with the Alma Ata Declaration on primary health care (PHC), the Bangladesh government launched the Expanded Programme on Immunisation in 1979. But it was not until the mid-1980s that the EPI was up and running. Today EPI is one of the success stories for Bangladesh. With government leadership and assistance from stakeholders, including NGOs, the broader civil society, private sector, media and development partners, immunisation coverage in Bangladesh rose from 2% in 1986 to about 70% in 1989, just short of the magic number for universal coverage of 80%. This prompted some of the development experts to call it a 'Near Miracle'. Few other countries had the distinction of attaining such a feat in such a short period of time. 

The high coverage of EPI vaccines and its sustenance over time has attracted global attention. Covid-19 disrupted the EPI operations for the initial couple of months but is now on the verge of recovery. Like most other countries, the advent of new vaccine regimes for Covid-19 is a test for Bangladesh's healthcare systems. In many ways, the Covid-19 vaccine is a challenge. Unlike EPI vaccines, which are mostly for children, the Covid-19 vaccines are all but for children (at least for the foreseeable future). This may mean an entirely different ballgame. The logistical challenge could be daunting as some of the vaccines may have to be kept in a temperature that is much lower than the capacity of existing EPI cold chains. The supply system for EPI (from manufacturers to distributors to national warehouses to local destinations and villages) is already developed, but the Covid-19 vaccines may have to skip some of the steps in order to meet emergency lifesaving priorities. When and how much of the required vaccines will be available depends not only on our capacity to procure but much beyond – such as dealing with 'vaccine nationalism'. During the 2009 influenza A(H1N1) pandemic, for example, high income countries bought up virtually all vaccine supplies, leaving little or none for the low and middle-income countries. Vaccine hesitancy and acceptance, particularly for a new vaccine that is designed to reach adults, remain an issue to identify and manage. 

Vaccines save millions of lives every year. Indeed, one of the reasons for our ability to reduce child and infant deaths in Bangladesh is the successful implementation of EPI. Vaccines develop or induce immune systems within the body by creating antibodies to fight any invading pathogen, such as the coronavirus. A new vaccine goes through a rigorous process of safety and efficacy testing before being allowed for public use. The process usually takes five to ten years, but scientists have done wonders this time by discovering Covid-19 vaccines in just ten months – thanks to the advancement of science and the political commitment to do it. Governments, multilateral organisations and private foundations have invested billions and billions of dollars in making this happen. There are over 50 vaccine candidates being tested globally and at least half a dozen of them have already been licensed for public use. Most of these vaccines require two doses to be given, except for the one by Johnson & Johnson which requires a single dose. 

In recent times there has been a rich discourse in the country on the imminent arrival and rollout of the vaccine. There are a few issues regarding the vaccine itself, procurement, distribution, delivery, acceptance and monitoring of the vaccines. In the following these are summarised:

The vaccines: As mentioned above, a number of vaccines have been licensed by the appropriate authorities in the USA and Europe for public use. However, there are a number of unknowns and concerns. These include the length of time for which the vaccine would remain potent and effective, their effectiveness for all ages, gender and races, and for newer strains of the virus. The price of the vaccines is another factor (could skyrocket due to intellectual property rights) which has prompted some Nobel Laureates and top scientists led by Professor Muhammad Yunus to demand that this be treated as a 'global common good'.

Procurement and rollout: The government has decided to import the Oxford-AstroZeneca vaccine, produced by Serum Institute of India (SII). This is being facilitated through a deal struck between Beximco, a Bangladeshi business conglomerate, and SII. According to this, Bangladesh is expected to receive the first batch of the vaccine during the last week of January. Once it arrives, these will be kept in Beximco warehouses and then shipped to the Upazilas for the last-mile delivery to the target individuals. The government has chalked out an elaborate National Deployment and Vaccination Plan (NDVP) on how to rollout the vaccines. A determinant for the success of such a plan is uninterrupted supply from India. India alone produces about 60% of the global vaccines but it has its own huge population to look after and the commitment it has struck with many other countries and agencies for export. Bangladesh would do well by diversifying its sources, from depending on the sole source, SII, and expensive and logistically unwieldy Pfizer vaccines. Some of our neighbours, such as Nepal and Indonesia, are procuring vaccines from Russia and China; and Bangladesh should consider such options. These latter vaccines are thought to be much less expensive.

Logistics: Bangladesh has a good warehousing system for storing the EPI vaccines. The government believes it will face no problem in storing the incoming vaccines if they arrive in batches as planned. An important question is whether this would be synchronized with SII's supply. The government is also reported to be considering importing the Pfizer-BioNTech vaccine. However, this requires ultra cold storage facilities which Bangladesh doesn't have at the moment. Having it could mean investment of huge scarce resources in infrastructure building.

Targeting: The NDVP plans to reach 80% of the population in four phases, through an elaborate system of priority. As in most other countries, frontline healthcare workers and those who come in direct contact with Covid patients have been prioritized over other groups. But it is not clear why 'other military and paramilitary defence forces' and 'elected people's representatives' have been put in this category. In a webinar organized by Bangladesh Health Watch, the participants felt the need to include in the top priority list individuals who come in direct contact with a large number of people on a daily basis in discharging their professional or business duties, such as sellers in wet markets (kanchabazar) and staff inside public transports (conductors). Such people are exceedingly vulnerable. The NDVP envisages bringing every district and upazila simultaneously under Covid-19 vaccination. However, this could be done in a phased manner too. The Covid map of Bangladesh shows that diseases or deaths from the disease are not equally spread. There are districts which have zero or near zero deaths and a few cases of the disease. On the other hand, some districts, particularly the city corporations of Dhaka and Chittagong and nearby areas, are hotspots for the disease. It would be advisable to concentrate initially in the hotspots and then move into other areas. Following the same argument, a recent Education Watch study recommended that the schools be reopened immediately in the non-hotspot areas, followed by those in the hotspot areas.

Vaccine hesitancy and acceptance: Due to its long traditions as mentioned at the outset, Bangladeshi society is largely vaccine friendly. The sustenance of EPI and its incorporation as part of the normal health system bear testimony to it. However, the EPI has certain unique features, different from Covid-19 vaccines. In EPI, all vaccines are for children, except for the TT. The Covid-19 vaccine, on the other hand, is for adults (at least for the foreseeable future). The decades-long campaign for EPI utilizing all conceivable stakeholders created the demand for children's vaccination. Adults have not received any vaccination (except the TT for women only) in living memory. In the absence of proper research, we do not yet know how the adults would react to calls for vaccination. The government has been promoting mask use since the advent of the Covid nearly a year ago. Unfortunately, the use of masks by the public is still a rare phenomenon. This is mainly because fears about the disease have declined and there is a lack of strong social mobilization efforts. If the former is true, there is serious doubt about how many people will turn up for vaccination when it is offered. Moreover, the NDVP envisages listing potential recipients by using a computer App which itself may be a barrier for some, particularly the elderly, the less educated, the poor, those living hand-to-mouth and in hard-to-reach areas. Reports are coming in from different countries such as the USA about presence of groups who are hesitant to accept the Covid vaccine. As reported in a recent article, some Pakistani politicians have been preaching that Covid-19 is a 'grand illusion and a conspiracy against Muslim countries'.  In Bangladeshi social media too, a section of mullahs has been spreading rumours against the vaccine, saying that this is made from pigs' blood.

In a study covering over five countries in three continents in the late-1990s, we investigated the social science perspectives of immunization programmes across cultures. People in these societies often accept vaccinations based on a perception of general benefits (to prevent future illness, to boost their general health, to mitigate the seriousness of future illnesses, or a combination of these) or a specific one (protection against a specific disease such as Covid). We also found that the perceptions of vaccinations are usually grounded in trust in the biomedical system, which may or may not coincide with trust in the health services or healthcare workers. More details on the findings from the Bangladesh part of these study is available here: AMR Chowdhury, KMA Aziz and A Bhuiya (1999). "The Near Miracle Revisited: Social Science Perspectives of Immunization Programme in Bangladesh", Amsterdam, The Netherlands, Het Spinhuis). 

The government from the beginning has been following a go-it-alone policy whereby people outside the public system were hardly involved in the Covid containment. Much has been written on the need to take a 'whole of the society approach' but to little effect. It will be expected that the government utilizes civil society and other groups working at the grassroots level to engage in social mobilization and demand creation. Nothing would be more powerful than to organize Covid committees with local opinion leaders in every village and mohalla for vaccination. 

Finally, there is a critical need for more data on the pandemic. Unfortunately, very little research has been done on issues related to the disease, its spread and containment measures. It will be a blunder if such a situation continues when the vaccine is rolled out. The implementation of the NDVP will need to be continuously monitored. Here, civil society groups should be more active so that credible independent information on the rollout is available for citizens.

The author is Convener of both Bangladesh Health Watch as well as Education Watch, the two civil society initiatives