Bangladesh’s vaccination transparency challenge

Bangladesh has a good infrastructure for vaccinating children. Due to a robust network of trained personnel, adequate cold chain support, an effective motivation and information campaign, and a long history of aggressive policy implementation by well-trained professionals, vaccination coverage is  95% according to a Unicef report. These rates are comparable to the highest national coverage rates in the world. The current vision for Covid-19 vaccination for the general population is to utilise this tried and tested infrastructure to eventually deliver vaccine to the eligible population to achieve the 70-75% coverage required to achieve herd immunity. 

This is largely theoretical, however.

The number of vaccines procured for distribution by public and private channels remains a mere fraction of the total number of vaccines required. The Covid-19 vaccine may however pose a different kind of challenge due to the nature of the two groups that should be prioritised for the vaccination — the elderly and “essential” frontline workers.

The elderly, as opposed to children, are not accustomed to vaccination, many never having received vaccination of any form. Vaccination of this older population may therefore present unforeseen challenges. While in the past there has been no real attempt at mass vaccinations involving this group, the low coverage rates for pneumococcal and influenza vaccines for this age group may portend some resistance to the Covid-19 vaccine as well.

The priority ranking of essential workers poses the opposite kind of challenge — as different occupational groups compete to be part of this category. Private sector vendors already appear to have become embroiled in a protracted discussion on what constitutes an “essential worker”. The definition of frontline workers who are both exposed and likely carriers of the virus, often asymptomatic carriers, makes this population, and the communication challenge much more difficult.

The World Health Organization (WHO) recommends that priority should be given to the most vulnerable groups, health workers and essential workers. In Bangladesh it is important that the first batch of vaccinations are well distributed and well accepted. It stands to reason that those involved in providing frontline healthcare, who are at particularly high risk because of their higher and prolonged exposure to the virus, should be prioritised before other groups of essential workers. In addition to being exposed to disease health workers are also conduits of spread. Immunising health workers thus has the added benefit of reducing the chance of spread and thus the risk to others who are exposed to them.

Bangladesh, like most fast growing developing countries, has a young age structure. Due to Bangladesh’s age structure only 2.1% of the total population is in the 75+ age group. That is much lower than in most of Europe where the proportion needing to be vaccinated is high. Similarly, only 5.2% are 65+. These proportions are three times greater in North America and four times greater in Europe.

It is conceivable that using existing immunisation campaign personnel and infrastructure would allow the health system to vaccinate at a rapid pace using protocols such as designated days for designated areas. Within this structure, areas with high prevalence in and around the large metropolitan areas could be prioritised to limit the potential spread of the virus.

Similarly, as has been shown in most countries that have already rolled out the vaccine, health workers are also relatively easy to vaccinate given their proximity to and familiarity with health service provision.

Relative to the elderly and to health workers, arriving at a protocol for defining, prioritising and delivering vaccines to other essential workers will be more challenging. This is the category that has dominated conversation in the media.

It is fortunate that the Bangladesh government made an extensive investment in community clinics — the country has over 15,000 clinics in rural settings. Each clinic attempts to reach a population of 25,000 . Urban coverage is likely to be more of a problem. Health service access and utilisation is more difficult in urban areas. Unfortunately, according to IEDCR maps and other spatial analysis Covid-19 is concentrated in and around the two major metropolitan areas in the country — Dhaka and Chittagong. While the veracity of this mapping is unclear this is the best data we have. In general, urban health for the poorest most marginal groups is inadequate and they rely much more extensively on private clinics that can be plagued with problems of unequal access and price excesses.

An important aspect of any successful immunisation campaign is the extent to which it can understand and address how information and misinformation spreads. Surveys conducted in five rural districts of Bangladesh during the current pandemic by the Population Council showed that while levels of knowledge and information are high, compliance with recommendations regarding mobility restrictions are not commensurate.  Repeated surveys conducted at bi-monthly intervals show that over time the influence of and trust in instant messages and texting has increased. However, interpersonal messaging remains dominant. It is less clear what the trusted sources of messaging are in Bangladesh but it is likely that any national approach will have to think strategically about influencers at the community level given the combination of their role as providers as well as their social influence.

It is unlikely that Bangladesh will have more general anti-vaxxer response in the way that has been experienced in the US and parts of Europe where misinformation about vaccines is significant. In the US in particular anti-vaccine sentiments is an important concern that has been further politicised by movements such as QAnon. While Bangladesh has been fortunate that vaccine resistance does not appear to be politicised, there are other reasons for concern.

A more intractable problem may be that the threat of Covid-19 is no longer being taken seriously in Bangladesh anymore despite ranking fifth highest-at-risk countries in Asia as well as its inclusion in the highest risk tier for international travel. A quick scan of headlines since the advent of mild temperatures during the winter, a season for melas and outdoor activities, shows that the local media has all but stopped covering news of the virus. People have resumed their essential and non-essential activities. There is no authoritative effort at limiting public gatherings or restricting movement and travel. The only exception is schools that have remained virtual, and virtually ineffective, for the duration of the pandemic. By all accounts, there are no evident efforts at implementing social distancing and other compliance measures such as wearing masks, limiting large gatherings and reducing mobility.

There is a pervasive notion of Bangladeshi exceptionalism that is invoked to argue greater immunity to the disease, despite the absolute absence of any evidence to corroborate these assertions. To the extent there is any evidence of differential genetic vulnerability it is to the contrary — that the Neanderthal gene that is much more common among Bangladeshis, has been strongly associated with greater morbidity and mortality and is attributed to the higher mortality among people of Bangladeshi and Indian origin in the UK.

Universal and free access to vaccines is essential. Transparency in distribution and selection criteria is essential to promote trust and ensure compliance.●

Sajeda Amin, a senior sociologist and demographer, leads the Population Council’s work on livelihoods for adolescent girls.