There are several challenges to the massive and rapid mobilization of vaccines in Bangladesh
On November 9, 2020, Pfizer and BioNTech announced that their Covid-19 vaccine was found to be more than 90% effective from a Phase 3 study (later upgraded to 95%). A week later, on November 16, Moderna announced that their own Covid-19 vaccine had been 94.5% effective in clinical trials. Both these vaccines are set to be commercially available soon.
While these announcements are causes for optimism, for many governments, difficult challenges remain to overcome before the pandemic is successfully brought under control. The primary challenge to implementing a successful immunization campaign for Covid-19 is in undertaking the necessary scaling-up of existing vaccine infrastructure.
Today’s routine immunization programs typically target selected groups within a population, whereas Covid-19 vaccination will need to cover a substantial portion of a country’s population at rapid speed to enable effective herd immunity.
For example, while over the entire last 10-years, around 1 billion children have been vaccinated, the Covid-19 vaccine needs in Bangladesh alone could be around 250 million doses (assuming that the vaccine requires 2 doses and around 70% of the population needs to be vaccinated for herd immunity) in a six-month period. (Globally, the need may be well in excess of 10 billion doses.)
This illustrates the need for a very rapid expansion and redesign of the existing vaccine delivery mechanism and logistics chain in Bangladesh. This scaling-up extends to vaccine storage and transportation, availability of appropriate cold-chain equipment, technical capacity to maintain and repair cold-chain equipment, availability of skilled workers to administer the vaccines, outreach and campaign to inform and instruct the entire population to seek vaccination, and safe disposal of waste material, among others.
While the issues of inter-country transportation of vaccines, financing, and other geo-political issues are important considerations, the rest of this article will only focus on in-country vaccine-infrastructure challenges that all countries, including Bangladesh, will have to overcome.
Storage capacity and cold-chain equipment
Vaccines need to be stored within a strictly defined temperature-range by its manufacturer, deviations from which leads to a loss of potency of the vaccine. The Pfizer vaccine will need to be stored at temperatures between -70°C and -20°C. The capacity of Bangladesh, and most other countries, to safely store (and transport within its borders) a large amount of vaccines within this temperature range is low.
As a result, it is likely that the Pfizer vaccine will mostly be used in special circumstances and in developed countries. The Moderna vaccine can be stored in temperatures between 2°C and 8°C for up to 30-days (-20°C for shipping and long-term storage; and at room-temperature for up to 12-hours), which makes it a much more appropriate vaccine for mass immunization campaigns.
Vaccines are transferred through various nodes of the vaccine-infrastructure process that takes them to every corner of the country. Once the vaccines are delivered to Bangladesh from the manufacturer, they are stored in the national storage depot, located in Dhaka.
From Dhaka, they are transferred to districts every three months; to upazilas every month; and then to various vaccination-points on the day of vaccination. In each of these nodes, the vaccines need to be stored properly. Without proper storage facilities, the vaccines will quickly lose their potency, rendering the vaccination process a failure.
According to GAVI, the current capacity of the central cold room is 173m3, which is inadequate for the current program, let alone the added needs of Covid vaccination. The construction of a new warehouse at the central level, in addition to 8 walk-in-coolers and 2 walk-in-freezers (total new capacity of 40m3) are under progress.
It is difficult to state whether this planned expansion will be sufficient for Covid-19 vaccines since we do not yet know the volume of each dose of a Covid-19 vaccine. If the available capacity proves insufficient, the amount of each delivery of vaccine will have to be reduced, meaning delays until herd immunity can be achieved.
Improved district-level cold and dry store capacity through construction and renovation of medical stores in 29 districts and walk-in coolers in 51 districts is being undertaken. However, the same concerns persist. It is not known whether this expansion will be sufficient, and whether construction will end on time.
Vaccines are also stored in upazilas on their way to vaccination-points. It is imperative that each of these nodes are equipped with the appropriate cold-equipment to ensure proper vaccine storage and efficacy. Malfunctioning equipment used in the cold-chain can significantly affect the performance and efficiency of immunization efforts. The world wastes vaccines worth almost $35 billion every year due to exposure to temperatures outside of their recommended range.
This calls for a very rapid expansion of the vaccine storage capacity at all the nodes (central, district, upazila). In addition, such an expansion must not be based on technologies that are environmentally harmful, and be equipped with a power generator to ensure vaccines are not stored outside the recommended temperature range. Facilities with unreliable energy supplies will need diesel generators for back-up power, which are polluting.
Vaccine transportation is currently one of the weakest links in Bangladesh’s cold-chain infrastructure. Since vaccines need to be maintained within a range of temperature, ideally, they are transported in specialized refrigerated vehicles.
However, in Bangladesh, the responsibility of transportation of vaccines from the central storage to districts rests with contracted vehicles. These hired vehicles are not specialized and vaccines have to be transported in cold boxes. From the districts, vaccines are transported to upazilas and then to vaccination-points by porters in cold-boxes.
Cold-boxes do not have any in-built cooling capacity but rather can preserve the cold temperature inside it for a period of time. Therefore, ice is used to keep the vaccines in a cold-box inside the recommended temperature. Both the use of commercially hired vehicles, in addition to the absence of temperature-monitoring/maintaining devices in the transportation process, are key vulnerabilities in the system.
Skilled workers and medical practitioners
Assuming that a vaccine dose can be administered in 5 minutes, and that there are 8-hour workdays and 22-workdays a month, a typical health-worker will be able to administer 2,112 doses per month in the best-case scenario.
If Bangladesh wants to achieve herd immunity in 6 months and vaccinate around 125 million people (assuming that the vaccine will require 2 doses), around 19,725 medical staff will be needed to work full-time, at full-capacity, without a break, for a six-month period. These are highly unrealistic assumptions.
Many people will have to be vaccinated at home, and so the 5 minutes per dose assumption is highly optimistic. There will be staff exhaustion and illness, personal days and leave, small breaks during every workday, etc. Factoring all these in, the calculated number - 19,725 - rapidly rises.
In addition, an insufficient supply of mechanics with the relevant skill set for cold-chain equipment installation and maintenance will result in broken cold-chains, leading to unnecessary energy use, vaccine degradation and waste, etc.
Disposal of waste material: Alongside vaccines, disposable syringes, personal protective equipment, and other vaccination supplies will demand more volume in transport and storage. Therefore, we will also need to consider the waste management and disposal/recycling. An absence of sustainable waste management practices in Covid-19 immunization programs may cause significant adverse effects on local ecology and wildlife, as well as impact human health.
Outreach campaign: An outreach campaign, on television and radio, to inform and instruct the people about why, where, when, and how to receive immunization will need to be undertaken. The timeline we will be working under can only be achieved if there is strong compliance from the people.
If a sufficiently large number of people need to be tracked down and immunized at home (Bangladesh does not have a very good record of vaccine-completion), it will become very difficult to meet the landmarks on time.
Community and social resistance: Resistance to vaccination is another concern that should be explored. Certain communities may be more resistant than others. Herd-immunity will need around 60-70% of people from each community to be immunized. If a sufficiently large number of people in a community is opposed to receiving vaccines, that may not be possible. In that case, will there be a case of compulsion or will vaccines be voluntary in all cases?
Adverse event following immunization (AEFI): The issue of compulsion also dovetails nicely into concerns surrounding AEFI events. Developing a sound and robust strategy to deal with AEFIs, including providing medical care for victims, handling the social fallout, etc is important.
Pfizer’s vaccine may become commercially available by the end of November. Moderna vaccine (and other vaccines in the late stages of development) may not be far behind. In contrast, we do not yet know when the expansions to the central cold storage will be completed, how much the expanded capacity will be, and whether that will be sufficient.
In terms of organizing an effective nationwide cold-chain, arranging for specialized cooling-vehicles, equipping each node along the chain with appropriate cold-equipment, and training medical and technical staff, a lot of progress still remains to be made in Bangladesh in a very short period of time.
The slow progress is worrisome for two particular reasons. First, Bangladesh is heading into the winter months when the virulence of the disease will magnify but the country will not be ready to receive large consignments of any vaccines until the end of the winter months.
And second, the COVAX-initiative under GAVI and WHO will provide vaccines to 20% of the population of every country in its program. Unless Bangladesh can demonstrate itself ready to effectively utilize the vaccines, GAVI will likely focus on better-prepared countries initially until their quotas are met.
Almost prepared is not good enough to tackle Covid-19. Immunizing 20% or 30% or 40% of the population will not lead to development of herd immunity in our communities and the entire endeavour might prove futile. Effective herd immunity needs 60-70% of the people to be immunized and to achieve that, a robust cold-chain needs to be put in place as soon as possible.
Farzana Munshi is a Professor of Economics from Brac University. Ahsan Senan is a Lecturer of Economics from Brac University.