Does Bangladesh have the infrastructure to vaccinate 130ml people?

The resurgence of the COVID-19 pandemic in Bangladesh in April 2021, after the relatively quiet autumn and winter months, and despite the beginning of the vaccination campaign in January 2021, illustrates the grave error of thinking short-term when thinking about COVID-19. 

Infection numbers have gone down in recent weeks in Bangladesh but it would be folly to think that the country is out of the woods already. 

The one way out of the pandemic is vaccination and a successful vaccination campaign partially depends on a robust vaccine infrastructure and distribution network. 

After four months of the vaccination campaign, Bangladesh has administered a modest 9.5 million doses of COVID-19 vaccines against the overall target of administering nearly 265 million doses. 

The government is trying hard to procure enough vaccine supply but a successful vaccination campaign will largely depend on rapid scaling up of the vaccine infrastructure network. Vaccines are a biological product that requires maintenance of a predetermined temperature from the production to the last mile and any temperature mistake leads to its spoilage.

We at the BRAC University, partnering with the University of Birmingham, Heriot-Watt University, and BUET, under a UKRI/GCRF grant, is researching "Fast-track vaccine cold-chain assessment and design for mass-scale COVID-19 vaccination in Bangladesh", (VaCoBD). 

For this, we conducted a nationwide survey during January-February 2021 to shed some light on the state of preparedness of Bangladesh's vaccine infrastructure. 

Survey activities covered all eight Divisions of Bangladesh and were carried out at all the administrative levels in the country from divisional headquarters to the local community/village level by interviewing relevant officials and stakeholders.

At the divisional, district, and the Upazila level, officials of the Expanded Programme for Immunisation (EPI) were interviewed and the existing cold-chain equipment was surveyed. At the village level, open discussions were conducted with different communities to understand their experiences with and perceptions of the last-mile immunisation practices and other health services.

The survey identified several supplementary challenges in addition to the pre-existing challenges in vaccine cold-chain infrastructure. These include challenges in the distribution network, storage, transport, and human capital, all of which must be addressed for a successful fast-track mass vaccination campaign. We discuss here some preliminary findings on the current status and challenges concerning the vaccine infrastructure in the country gathered through our survey.

EPI under DGHS and Health Department is responsible for the national immunisation programme and maintenance of the vaccine cold-chain infrastructure of Bangladesh. The headquarters of EPI is the first node of Bangladesh's vaccine distribution network. 

Vaccines enter Bangladesh through the national airport and are stored at EPI HQ for up to 6 months from where they are sent to each district quarterly. From the district nodes, vaccines are sent to the city corporations and Upazila health complexes (UHC) monthly. EPI has divided Bangladesh into 108,000 sub-blocks and a vaccination session is organised by the UHCs in each of these sub-blocks in the Upazila once every month. These are the four nodes of Bangladesh's vaccine distribution network. 

Under this system, people do not have to travel very far to reach the nearest vaccination session, which is both time and cost-effective. The ability to remain 'safe' within one's community while getting vaccinated has proved to be very successful among the rural population.

However, the COVID-19 vaccination campaign is not using the whole vaccination network yet. So far vaccines are administered at the district centres and city corporation areas, large medical colleges, and the district hospitals. And outside these urban areas, vaccinations are primarily being administered from the UHCs. 

Discussions with rural communities during the survey revealed that it will be very difficult for the rural population to travel to UHC for vaccination and many of them would not seek out vaccination unless vaccination sites were brought closer to them. To encourage uptake, vaccination sites may need to be taken down to the union or ward levels.

Vaccine storage is another important challenge for Bangladesh historically. The total storing capacity at the EPI HQ is 173m3, which is not enough for the routine immunisation activities, let alone the additional load of a COVID-19 vaccination campaign. 

Similarly, 16% of districts in Bangladesh do not have adequate storing space for vaccines for routine immunisation. Constraints in storing capacities persist at the Upazila level as well. In addition, many of the deep-freezers in use are very old and are with numerous technical difficulties. 

To meet the target of administering about 265 million vaccine doses, Bangladesh needs to have a robust vaccine cold-chain infrastructure. PHOTO: REUTERS

In terms of monitoring, manual temperature checks of each piece of storing equipment are supposed to be performed at all nodes twice every day. A survey in the nodes revealed that this practice is maintained locally but not monitored centrally.

At a more general level, allocating storing equipment to the nodes is of little significance without also ensuring skilled mechanics are also available at each node. The current practice is to have only one dedicated cold-chain technician at each district and one cold-chain engineer nationally which seems insufficient.

The EPI staffing guideline indicates that there should be three employees at each district: one district EPI superintendent, one cold-chain technician, and one EPI district storekeeper. Upazila level officials include a medical technologist in charge of vaccination activities in the Upazila, health assistants, health inspectors, assistant health inspectors, and porters. 

However, many of these posts are vacant. Survey findings suggest that the percentage of vacancies in these posts are 12.5% for cold-chain technicians; 29.82% for health assistants; 48.28% for health inspectors; 28.40% for assistant health inspectors; and 2.63% for porters. DGHS's "real-time health information dashboard" gives similar numbers as well.

The transportation facilities are the weakest link in Bangladesh's vaccine cold-chain infrastructure. As per the survey findings, EPI has less than six trucks to deliver vaccines and logistics to the 64 Districts. This often proves insufficient, and during campaigns, EPI has to hire private trucks to send vaccines and logistics separately to the respective district. In addition, these trucks are non-specialised vehicles without any cooling facilities. Every unexpected stoppage or delay increases vaccine spoilage risk. 

Once the vaccines reach the health complexes, they are sent to the vaccination sites. Nearby vaccination sessions can be easily reached on foot or a bicycle. But reaching some vaccination sites may need the use of motorcycles, autorickshaws, vans, and even boats. A fixed amount is allocated to the health complexes to cover the cost of transporting the vaccines and logistics between nodes, regardless of the distances they have with the UHCs. 

Since the COVID-19 vaccination campaign is currently being administered from the health complexes, the vaccine transporting concern in the final node is not relevant yet. However, expansion of the campaign to the union or ward level will require a rethinking of the existing strategy.

Vaccine-waste disposal is another major challenge particularly in the context of environmental degradation. The current practice of vaccine-waste disposal is to bring all the vaccine wastes (syringes and needles, broken vials containing some left-over vaccines, packaging materials, PPE, etc.) back from the vaccination sites to the health complexes and burn them in pits dug in the ground on the health complex premises. 

Site visits at the health complexes found these pits to be mere feet away from the health complex. This is environmentally harmful and may also have debilitating health implications for the patients and staff of the health complexes and nearby residents, flora, and fauna. This issue will be exacerbated by the increased volume of COVID-19 vaccine wastes in the next few years.

Investing in developing a robust cold chain will not only help the country to control the pandemic within its borders but will continue to pay dividends for years to come. Despite the pressure that the government must be facing right now, strengthening the country's vaccine infrastructure, and finding solutions for the challenges, should be of urgent policy focus. 

Farzana Munshi is a Professor at the Department of Economics and Social Sciences (ESS), School of Humanities and Social Sciences (SHSS), BRAC University; and a Co-Investigator at VaCoBD.

Ahsan Senan is a Lecturer at the ESS, SHSS, BRAC University; and a Postdoctoral Research Associate at VaCoBD.

Disclaimer: The views and opinions expressed in this article are those of the authors and do not necessarily reflect the opinions and views of The Business Standard.