The mission is clear, but highly ambitious: vaccinating 14 crore people – 80% of the population – in two years.
It is an unprecedented mission Bangladesh has been forced to embark on to tame the raging pandemic, save lives and livelihood as well as accelerate economic recovery.
As the crisis induced by Covid-19 is like no other crisis in the past, the country lacks experience, infrastructure and skilled manpower to accomplish the Herculean task.
The reality on the ground says there is no alternative but to complete the mission.
The Bangladesh government has done extensive homework and designed a masterplan to roll out the largest ever vaccination programme anytime in the New Year subject to availability of jabs.
The infrastructure that now exists is only fit for implementation of a routine vaccination.
In that routine immunisation programme, the masterplan says, there is no security concern for vaccination session or any campaign activities with routine vaccines. But for Covid vaccination, there will be a need for security at the storage locations, during transportation and during vaccination sessions.
The concerns speak about the work that needs to be done to ensure proper implementation of the vaccination programme in three phases from the capital to the villages – roughly 7 crore people in the first year.
Therefore, the to-do list is long.
Purchasing equipment and logistics for strengthening the cold chain as well as distribution network and recruiting and training 80,000 people such as vaccinators are among the major things that need to be done.
Ensuring safety of vaccines and waste management are some other daunting tasks.
A competent vaccine administration needs to be in place for successfully completing the Herculean task that will test the country's administrative efficiency.
The remarks made by Indian premier Narendra Modi on his country's Covid-19 preparation reflect the vastness of such a programme. He compared Covid vaccination with elections and disaster management involving administration at all levels.
Taking the challenge into cognisance, the Bangladesh government established planning and coordination committees at all levels to facilitate, coordinate and support the development of the Covid-19 vaccine deployment plan. It will also oversee the planning, implementation and monitoring of the deployment and introduction of Covid-19 vaccines in the country.
Money is a big factor, as usual. So far TK6,815 crore has been allocated for this. More funding is being explored.
Everything will start rolling out once the huge project gets approval in the government's highest policymaking body in January, says Helal Uddin, additional secretary to the health ministry.
Maintaining cold chain
Now, take the first shopping list for cold chain and distribution networks.
Of the country's 64 districts, 26 do not have the capacity to even handle the Oxford vaccine which has to be preserved at 2-8 degrees Celsius, according to an analysis of the masterplan.
Bangladesh is expected to get delivery of the first consignment of the Oxford vaccine by next month. The vaccine is expected to be approved for use in the UK in coming days. The vaccine is expected to be approved for use in the UK in coming days.
If the country wants to purchase the Moderna vaccine, which requires storage at minus 15 to 20 degrees Celsius, 56 districts will have to buy refrigerators to build the system afresh.
Meanwhile, Pfizer's vaccine requires ultra-low freezing temperature of minus 80 degrees Celsius.
According to an analysis of the masterplan, there is currently a shortfall of cold room space and free space in freezer rooms at the national level. As such, the crisis of cold storage will mount as vaccines start to come in.
Additional cold chain equipment would be required at district and upazila levels.
Ice-lined refrigerators/freezers, cold boxes, vaccine carriers, fridge tag-2s and freeze indicators among other equipment need to be purchased.
The additional storage requirements for Covid-19 vaccines can be met by renting cold rooms from other sources at the national level as implemented for the recent MR campaign, says the masterplan.
Safety boxes will be used to keep sharps (syringes) produced from the Covid-19 vaccination. Used vials will be counted before disposal.
The good thing is that the national EPI has a unique system to send regular vaccines from national to district and city corporation levels through refrigerated trucks and if required by cold boxes, states the masterplan.
From the district and city corporation levels they send it to upazila and zone/ward level by cold box where the vaccine is stored.
During the campaign activities, national EPI has to hire vehicles to distribute the vaccines and logistics.
Due to the huge volume, especially the AD syringes, they have to send the vaccine and logistics separately.
For loading and unloading they also need to hire help on a daily wage system.
"If there is a need to hire refrigerated trucks, Meghna Group of Companies or Pharma Solutions Bangladesh Limited can be contacted. They provide freezer trucks on a rental basis. The capacity is 200 and 400 cubic feet," says the document of the masterplan. TBS obtained a copy of it.
Regulatory preparedness for vaccination is another area that deserves careful attention.
Imported vaccines from assured source won't be tested
The import requirements will vary based on the origin of the vaccines and the purchase method.
The registration time is expected to take 2-3 days for vaccines purchased through the COVAX facility, 12-15 days for other imported vaccines and 12-15 days for locally produced vaccines, assuming the registration requirements have been met.
The health department will not perform testing on vaccines procured from assured sources, such as WHO-prequalified vaccines, vaccines listed as EUL or approved by stringent regulatory authorities.
In this case, review of the summary lot protocols will be conducted, and vaccine release will be expedited through the review of the minimum documents as advised by the World Health Organization.
In contrast, laboratory testing of the first three batches will be required for locally produced vaccines or vaccines imported from non-WHO prequalified sources.
Additional batches may be tested at the discretion of the Directorate General of Drug Administration for monitoring, pharmacovigilance and post-marketing surveillance.
High risk groups to get vaccine first
A risk management plan (RMP) should be in place to safeguard against any harm associated with the use of the products. In case of any harm occurring while using the products there should be a clear understanding between the COVAX facility, national authorities and the manufacturer(s) regarding liability and indemnity.
Everything needs to be done in a planned way.
A phased rollout of the Covid-19 vaccine(s) is anticipated, initially focussing on high-risk groups (including health workers directly involved in Covid-19 response, front line workers and immunocompromised patients, etc) and gradually extending to other groups like older adults, adults with comorbidities, education sector workers, and public transport workers.
The target population will be registered by different means such as by electronic voluntary registration using national identity card (NID) or Birth registration card or passport or by requesting different departments to provide lists of staff or by the first line health care providers.
Vaccine safety system to handle adverse effect
A vaccine safety system will be there to ensure quality and safety of immunisation and minimise the negative impact of the AEFI (Adverse Event Following Immunisation) on public health.
Health workers will detect and report all AEFIs and/or any other adverse events of special interests (AESI). They must report serious AEFIs (like death and hospitalisation) and investigate signals and unexplained causes after vaccination.
Like other vaccines, Covid-19 vaccines may produce adverse events ranging from mild side effects such as pain, swelling, itch, nausea and headache to rare/very rare or serious illness (i.e. anaphylaxis).
Where the vaccines are coming from
Bangladesh will need 28 crore doses for an 80% coverage, of which 6.8 crore doses are expected from COVAX and 3 crores from India's Serum Institute.
Though Bangladesh was in talks with Moderna, Pfizer as well as China and Russian manufacturers, it has finally opted for COVAX for reasonable pricing and its world class laboratory facilities.
"While taking supplies from different manufacturers, COVAX will get those tested in its own laboratories. If we get supplies from COVAX, we will not need further tests," said M Helal Uddin, additional secretary to the Health Services Division of the health ministry, explaining why the global collaboration has been preferred.
How much money is needed
In the first phase, COVAX will supply vaccines for 20% of the population at a cost of $1.6 per dose. For the next phase, Bangladesh will have to pay nearly $6 per dose.
As per the COVAX allocation, Bangladesh expects to receive vaccine doses equal to 20% of its population (3.4 crore) followed by additional doses equal to at least 40% of its population based on availability of vaccine.
A total of $290.3m is required for vaccine and operational cost for the first 20% of the population, the plan says. Bangladesh will share the vaccine cost of $2 per dose with COVAX. It is estimated that the cost will be $2 per person to support the operation.
Apart from this, the government plans to purchase vaccines from manufacturing companies and countries. A total of $150m and $37.5m is required for vaccine and operational costs for 8.68% of the population ($5 per dose).
To support the vaccine preparedness and deployment activities, a budget of $196.7million is estimated, excluding the vaccine cost and cost for technical assistance to cover the 80% population in the country.
The actual cost of the vaccine cannot be calculated because of the varying options.
Bangladesh is exploring various funding sources to support Covid vaccine deployment in the country.
Where the money is coming from
The World Bank, the Asian Infrastructure Investment Bank (AIIB), the Asian Development Bank and the Korea International Development Corporation are funding the vaccination mission – from purchase to cold chain to skill training.
In June, the government undertook a Tk1,127 crore "Covid-19 emergency response and pandemic preparedness project" with Tk850 crore support from the World Bank. The Washington-based lender is giving an additional amount of Tk4,250 crore while Tk850 crore is coming from the AIIB – prompting the government to revise the project size upward to Tk6,815 crore. The revised project, expected to get Ecnec approval next month, includes Tk4,313 crore for vaccine purchase alone.
The rest of the amount will be spent for cold chain maintenance, hiring human resources and training. Setting up central oxygen plants in 30 hospitals and installation of 10-bed ICUs with ventilators in all district general hospitals will also be done under this project.
"An agreement has already been signed with the Korean International Development Corporation for $50m. We are expecting $100m to $200m more from the AIIB. Besides, France and Japan are also willing to finance vaccination programmes. We are in talks with them," says additional secretary Helal Uddin.
Earlier this month, USA and Europe launched their vaccination drives to check further spread of the pandemic with new strain adding to the worries.
Russia has initiated the drive with its own Sputnik V after voluntary online registration, while China administered its own vaccines to at least one million people after approval for "emergency use." China plans to start opening its vaccination programme to members of the public in February.
The EU began its marathon mass vaccine rollout for 446 million people in 27 countries. They have chosen the Pfizer-BioNTech vaccine to start with.
The EU has secured contracts for more than two billion vaccine doses from a range of drug companies. The bloc, badly hit by the Covid-19 second wave, plans to complete distribution of 200 million doses across all member countries by next September.
USA also initiated its largest ever immunisation campaign and aimed to reach 100 million people by April, while more than 130,000 people were vaccinated in the first week of the UK's vaccination programme in the second week of this month.
Pfizer / BioNTech jab has been the common choice in both US and UK so far.
India expects to begin vaccinating people against Covid-19 in January, with a target to apply to 300 million people by early August. The Covishield, also known as Oxford vaccine and India's own Covaxin have been among their key choices.