Covid-19 vaccination unspoken challenges and potential solutions

The world is optimistically waiting for the crisis caused by the unprecedented Covid-19 pandemic to be rolled back. Three vaccines have received emergency approval at unexpected speed for which scientists must get the credit. Some other vaccine candidates are also in the process of getting approval within months to come. Now, mass vaccination with a coverage of 7.5 billion people on earth within a short time-frame is a real logistic and management challenge ever faced by human civilization.

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

An unhealthy race to secure vaccines: Due to limited capacity and uncertainty of effective candidate vaccines, many developed countries already have pre-orders, 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, COVAX, a global taskforce established for equitable vaccine distribution around the globe led by 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 Oxford-AstraZeneca vaccine from 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 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-AstraZenecca vaccine. Among the mRNA vaccine, 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 of CureVac with a 2-8°C storage temperature which is also affordable can be considered. The protein subunit vaccine of Novavax could also be considered for pre-orders. However, similar to the 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 services 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 the 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 equitable access to vaccines, Bangladesh should start lobbying with WHO, COVAX, GAVI and CEPI, which may help in securing early access to vaccines.

Challenges for countrywide fast-track mass vaccination

Because of lack of a 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 Bangladeshis live in remote areas and therefore it is expected the authorities will face numerous challenges in reaching out to the community. 

Is the existing EPI program effective for Covid-19 mass vaccination?  EPI targets vaccination among children and Bangladesh is reputed in the world for successful EPI coverage. It took a huge amount of effort and time over the years by 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 the developed countries where the healthcare system is highly developed.

Challenge in making a vaccine priority list: Covid-19 disproportionately kills 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. Because of corruption and a culture of a fostering of political influence a climate of mistrust and promoting misinformation may be created.  

The good thing is that the young age 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 --- a real challenge: 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 within a few months of the pandemic; many people make fun of coronavirus. Against such a backdrop, it could be difficult to make people understand the importance of vaccination, particularly elderly target groups in the community.  Further complications might occur due to national ID card based online registration. Many people in remote areas may not be interested due to the hassle 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 not generally up to the mark yet in the country. 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 at the national, regional and community level is expected to be a gigantic task due to a 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. Lack of proper registration could be associated with risks of giving first dose from one company and second dose from another company. Thus, a proper registration system is a must. Additionally, due to 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 the developed countries (for example, in influenza vaccination), Bangladesh lacks experience in adult vaccinations. The acceptance rate of adult vaccines is not known. In case a significant number of people are not interested in taking vaccines against the coronavirus, there should be steps taken to motivate those people and inform them 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 to overcome challenges ahead

Given its limitation of resources, Bangladesh should plan smartly by capitalizing on 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 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 in engaging the whole community in 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 Affairs of Georgetown University highlighted the importance of engaging community-level faith-leaders in the developmental sector of Bangladesh. 
3. Mobilizing the military as part of disaster management efforts: Bangladesh has a long history of successful military engagement in disaster response. Our armed forces are also reputed for international peace-keeping and disaster management. Field level distribution, management and coordination skills of armed forces personnel supported by the government could be a game changer for successful mass vaccination in resource-poor countries like Bangladesh. Developed countries, such as the US and member-states of the EU have mobilized the military for distribution and logistics management at 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, 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: The mainstream media can play an important role to debunk the 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 publicised.
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. Imparting training to this manpower is a must for effective coordination at field level.  

Dr Mohammad Sorowar Hossain, 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; Scientist, Biomedical Research Foundation, Bangladesh.