OP-ED: Only greater challenges ahead

Unknown challenges of fast-tract vaccination against Covid-19 are waiting down the road with great optimism. Different countries have different sets of challenges and, therefore, no universal vaccination strategy would be effective globally. The strategy should be based upon resources available in a country.

Categorically, there are two major challenges that would be confronted by most resource-limited developing countries: 1) Securing enough doses of safe and effective vaccines for the population, and 2) Mass vaccination at community level.

Challenges of ensuring enough vaccine doses

Due to limited capacity and the uncertainty of effective candidate vaccines, many developed countries already have pre-ordered more than they require. The potential production capacity of 10 frontline vaccine candidates is around 10 billion doses by 2021. As a consequence, billions of people in 92 low-middle and low-income countries could be deprived of the Covid-19 vaccines due to unequal competition.

Notably, the COVAX -- a global taskforce established for equitable vaccine distribution around the globe led by the CEPI, GAVI, and WHO -- is struggling to secure money and vaccine doses required to vaccinate 20% of the population in each country (high-risk groups). Importantly, research conducted by the Duke Global Health Innovation Center has shown that many low-middle and low-income countries may have to wait until 2023-2024 for vaccines. 

Bangladesh has pre-ordered 3 crore doses of the Oxford-AstraZeneca vaccine from the Serum Institute of India, but it will cover only 8.8% (15 million, 2 doses per person) of the population. Therefore, Bangladesh must act immediately to secure the Covid-19 vaccine doses required to vaccinate its population.

How to ensure the required amount of doses of vaccines

Pre-orders without a delay: To secure enough vaccine doses, the Bangladesh government must start pre-ordering frontline vaccine candidates without any delay. In choosing the scientifically sound vaccine candidates, Bangladesh should also follow those vaccines pre-ordered by the developed countries that meet high quality and good safety and efficacy profiles.

Moreover, vaccine storage temperature and the cost of vaccination per person should be taken into account. Among the adenoviral vector vaccines, Bangladesh should pre-order vaccines of Janssen Pharmaceutica (Johnson and Johnson), Sputnik V, and more doses of the  Oxford-AstraZeneca vaccine. Among the mRNA vaccines, Bangladesh may consider the vaccines of BioNTech-Pfizer and Moderna-NIH. However, the (ultra-) low storage temperature and high cost should be taken into consideration.

Additionally, another mRNA vaccine -- CureVac, with the 2-8°C storage temperature, which is also affordable -- can be considered. The protein sub-unit vaccine of Novavax could also be considered for pre-order.

However, similar to EU countries and countries like the US, the UK, Australia, and Japan, Bangladesh should stay away from the inactivated vaccines of Bharat Biotech, Sinovac, Sinopharm, Institute of Medical Biology of Chinese Academy of Medical Sciences, Research Institute for Biological Safety Problems of the Republic of Kazakhstan, and Shenzhen Kangtai Biological Products Co Ltd, among others. 

Promote private initiatives to secure more vaccines: A significant proportion of the population can afford vaccination from private initiatives since around 70% of patients seek healthcare service in private hospitals/clinics in Bangladesh.

Therefore, the government should promote reputed pharmaceutical companies to make deals with vaccine companies to ensure that Bangladesh gets priority access to other suitable vaccines in addition to securing more doses of Oxford-AstraZeneca vaccine. In this way, the pressure on the government could be reduced significantly. 

Acquiring bulk lots of vaccines for fill-finish in Bangladesh: To secure enough vaccine doses within a short-time, Bangladesh could also ask Russia and other vaccine-developing companies to utilize the internationally recognized, high quality vaccine fill-finish platform available in pharmaceutical company(ies) in Bangladesh.

Play an active role in the equitable access of vaccines: For the equitable access of vaccines, Bangladesh should start lobbying with the WHO, COVAX, GAVI, and CEPI, which may help in securing early access of vaccines. 

Challenges for countrywide fast-track mass vaccination

Because of the lack of comprehensive healthcare infrastructure and information system, it is a mammoth task for a country like Bangladesh with a population of nearly 170 million. Around 70% of Bangladesh live in remote areas and therefore it is expected to face numerous challenges to reach out to the community. 

Existing EPI program effectiveness for Covid-19 mass vaccination: EPI targets vaccination among children, and Bangladesh is reputed in the world for successful EPI coverage. Over the years, it took a huge amount of effort and time from the government and NGOs to make this EPI successful.

In contrast, Covid-19 mass vaccination is largely targeted to adults and has to be implemented within a short time to achieve targeted herd immunity in the population. This is a new management challenge in the world even for developed countries where the healthcare system is highly developed.

Challenge for making a vaccine priority list: Covid-19 disproportionately kills old aged people and/or people with pre-existing medical conditions (esp. chronic diseases). The identification of vulnerable target populations is also a big challenge for Bangladesh since the chronic disease profile is unknown due to non-existence of population-based or national disease registries.

While making a priority list, transparency is critical to ensure that access is equitable, and that citizens must understand who will receive vaccines, and who won’t. Corruption and a culture of fostering political influence may create mistrust and promote misinformation. 

The good thing is that the young population structure of Bangladesh could be a blessing for prioritizing the target groups phase by phase . Around 90 million people are under 30 years of age, while 28 million people are 50+ years of age and only 13 million people are above 65 years of age.

Reaching out to the community: Health awareness among the general population is poor and people at the community level are either uninformed or misinformed. As a consequence, panic broke out nationwide during the early phase of the pandemic. Stigmatization and fear of death were widespread.

Strangely, the situation has reversed just after a few months of the pandemic; many people make fun of coronavirus. With such a backdrop, it could be difficult to make people understand the importance of vaccination, particularly the elderly target groups in the community. Further complication might occur due to national ID card-based online registration. Many people in remote areas may not be interested due to the hassle of coming to urban areas for online registration.

Inexperience with handling large databases for tracking: Even though Bangladesh is gradually improving, the record-keeping system is generally not up to the mark yet in Bangladesh. Keeping track of who got vaccinated, which vaccine they got -- both doses need to come from the same company -- and when people are due for a second dose would be another immense logistical challenge for a country like Bangladesh.

For inducing effective immunization, mostly two doses of vaccines are required for an individual; otherwise, it could be a waste of resources if the second dose is not ensured. Managing and coordinating such a volume of data on national, regional, and community levels is expected to be a gigantic task due to the lack of trained manpower. 

Besides digital infrastructure-related challenges, physical spaces will be needed to administer the vaccines and their multiple doses to millions of people as quickly and efficiently as possible without errors.

(Ultra) cold chain storage requirements: Pfizer and Moderna vaccines require (ultra) cold chain storage capacity. Such (ultra) cold-storage is expected to be a huge logistic challenge for the vaccination program of Bangladesh. Importantly, according to WHO estimates, over 50% of vaccines are wasted globally just because of not maintaining proper regular temperature (2-8°C); thus, proper planning and development of (ultra) cold storage, transport, and distribution facilities are mandatory. 

Challenges associated with 2-dose vaccine regimens: Other than the Janssen (Johnson and Johnson) vaccine, 10 frontline vaccines/candidates require two doses. The lack of proper registration could be associated with risks of giving the first dose from one company and the second dose from another company. Thus, a proper registration system is a must. Additionally, due to the common adverse effects (pain, swelling, chills, fever, fatigue, etc), people may not be interested in taking the second dose. Mass media and community leaders may play critical roles in motivating people to take the second dose.

Challenges associated with adult vaccinations: Unlike developed countries (for example influenza vaccination), Bangladesh lacks experience in adult vaccinations. The acceptance rate of adult vaccines is not known. In case a significant number of people would not be interested in taking vaccines against coronavirus, there should be steps taken to motivate those people to inform about the benefits of taking vaccines. 

Logistical challenges for consumables: Health co-workers giving vaccine shots need alcohol wipes, syringes, needles, masks and gloves, some of which could be in short supply in places. Managing all of those logistics is also critical, especially on the scale needed to vaccinate millions of people within a short span of time. 

Utilizing underutilized resources

Given the limitation of resources, Bangladesh should plan smartly by capitalizing the underutilized resources available in the country. . 

1. National advisory committee for Covid-19 vaccination: Formation of a national committee consisting of eminent and well-respected scientists, clinicians, public health experts, trustworthy public figures, and religious scholars is the key to establishing trust in the general population. Without developing public trust, it could be hard for the government to implement the vaccination program successfully. This national committee will formulate and discriminate public health messages to tackle misinformation and to convince the vulnerable target groups to take vaccines.

2. Engaging community leaders: Reaching out to the very fabrics of the society is critical to stop the pandemic through mass vaccination within a narrow window of time. In this perspective, religious leaders in the community could play a pivotal role to engage the whole community for delivering the public health message under the guidance of the national advisory committee. Recently, a study by the Berkeley Centre for Religion, Peace and World Affair of GeorgeTown university has highlighted the importance of engaging community-level faith-leaders in the developmental sector of Bangladesh. 

3. Mobilizing the military as a part of disaster management effort: Bangladesh has a long history of successful military engagement in disaster response. Our arm force is also reputed for international peace-keeping and disaster management. Field level distribution, management and coordination skills of arm force personnel supported by the Government could be a game changer for successful mass vaccination in resource-poor countries like Bangladesh. Developed countries including the USA, as well as the EU have mobilized the military for distribution and logistic management in field level.

4. Prioritizing target groups for vaccination: In Bangladesh, nearly 70% of Covid-19 deaths have been reported for people with 50+ years of age. Since it is not possible to acquire enough vaccines to cover the whole population at the same time, thus, vaccination has to be implemented phase by phase, targeting most vulnerable groups such as the 60+ age group, frontline health workers, journalists, and social workers. 

5. Mass media and responsible journalism: Mainstream media can play an important role in debunking myths and misinformation regarding vaccination and its possible side effects by providing trustworthy information. Moreover, the benefits of taking vaccines and the importance of taking the second vaccine dose should be well informed.  

6. Training of manpower: Mass vaccination will require a huge volume of manpower with diverse backgrounds including health workers, data collectors, data entry personnel, analysts, and community workers. Training of these manpower is a must for effective coordination at field level.

Dr Mohammad Sorowar Hossain is Public health researcher, Executive Director, Biomedical Research Foundation, Bangladesh; Associate Professor, Independent University, Bangladesh. Dr Rezaul Karim is an immunologist specialized in biologics drug and vaccine development and former project lead at WHO-Utrecht Centre of Excellence for Affordable Biotherapeutics, the Netherlands, and Scientist, Biomedical Research Foundation, Bangladesh.