At a time when the world is grappling with the health and economic impacts of Covid-19, vaccination is the most effective way to overcome the pandemic.
But, even if a vaccine is available, a lack of an effective cold chain system coupled with scarce efficient manpower will get in the way of immunisation against the virus in Bangladesh.
While there are challenges to address, the efforts for Covid vaccination may push the government to move to a sustainable energy solution, train its healthcare workers and adopt an advanced mechanism for waste management, thus rendering a lasting legacy, said speakers at a webinar on Thursday.
The webinar on "Understanding the cold chain challenge for a Covid-19 vaccine" was organised by the British High Commission Dhaka in partnership with The Business Standard.
A team of researchers from the University of Birmingham, Heriot-Watt University, BRAC University, and Buet has been trying to design how the challenges can be met in the most sustainable and financially efficient way in Bangladesh.
Toby Peters, professor of cold economy at the University of Birmingham, said, "We are leading a fast-track programme to design noble methods and instruments to assist policymakers in developing the most sustainable interventions to support cold chain for Covid-19 vaccines."
An effective vaccine will be the best thing to outdo the pandemic; that is why governments, agencies and private sectors have come together to invest heavily in researching and developing vaccines, he added.
However, achieving herd immunity requires vaccinating 60-70% of the population, which equals 5-6 billion people worldwide. And if the vaccine requires two doses, 11-12 billion doses of vaccines will have to be delivered, Toby pointed out.
Since vaccines will be temperature sensitive, achieving successful immunisation will depend on a robust cold chain, he said.
Given the speed at which the immunisation has to be done and the volume, "I think this is the single biggest logistic challenge we have ever faced," he a
Universal access to vaccines is already a challenge mainly because of a lack of integrated functioning cold chain, especially in lower- and middle-income countries.
Equitable distribution of Covid-19 vaccines globally will prevent 61% of subsequent deaths but there is a concern that vaccines will be distributed in high-income countries first, and in that case only 33% of the deaths could be avoided.
The challenges include insufficient capacity, inadequate equipment and the lack of access to energy, said Toby Peters.
Cold chains are energy intensive and they have the potential to cause high global warming. Therefore, the rapid expansion must not be based on technology that is environmentally harmful. This is an opportunity to deploy a sustainable vaccine solution to fight Covid-19, which will have a lasting legacy.
To give a glimpse of the gap between the existing vaccination system and what is needed, Tomoo Hozumi, Unicef country director in Bangladesh, said Bangladesh immunises yearly 3.9 million children, equivalent to 2.4% of the population.
Under the Covid-19 vaccination programme, 29% of the population needs to be immunised, including 3% front-line workers and social workers and 17% vulnerable groups, by the alliance of Covid-19 vaccine called COVAX led by Gavi, the coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organisation (WHO).
In addition, the government is planning to cover its 9% more population by purchasing vaccines being produced by Oxford University.
This vaccination programme will concurrently go on with the regular immunisation programme for children, which cannot be compromised. So, the government has to scale up the immunisation system to an unprecedented level, Tomoo Hozumi said.
Cold chain is the fundamental part of the immunisation system.
Acquisition of substantial number of additional cold chain facilities and equipment at central, district and upazila levels, deploying a system of maintenance of a big number of cold chain equipment, transportation of vaccines, storage and handling of those, training additional human resources and monitoring the actual functional status of the cold chain equipment are just some of the challenges to overcome, Hozumi said.
Unicef, Gavi and WHO have been working closely with the ministry of health and family welfare to strengthen the cold chain system in Bangladesh.
Referring to a primary assessment, Hozumi said if 5% of the population is to be covered by two doses of a vaccine and if the vaccine is of the kind developed by Oxford that can be preserved at -2 to -8 degrees Celsius, the country needs to double the current storage capacity.
Bangladesh also has the technology to store vaccines such as Moderna that will require the maintenance of -15 to -20 degrees Celsius but that technology is very limited. The government will have to invest substantially to widen the system but the vaccines, like those developed by Pfizer and BioNTech needing ultra-cold temperatures like -70 degree Celsius, will be out of reach for Bangladesh.
The need for data
Products like Covid-19 vaccines have to be delivered in a set of time and it will be temperature sensitive.
Data is imperative to enhance the ability to manage the risk within the supply chain and transportation, said Amy Shortman, director of product marketing, Overhaul that provides real-time supply chain integrity technology to detect and correct non-compliance.
Data should also give a visibility of what is happening.
It has to be made sure that no counterfeit materials enter into the supply chain.
"We have logistics system that are working very independently and different parts of the products go through different transportation system and different people are in charge," Amy Shortman said.
"The chain of custody and the data we will be getting is to ensure that the products will be safe, valid and effective when administered to patients," he said adding, "When the shipment will be moving, we will have to use the data to manage the risk in real time and ensure protection of both goods and people."
Being able to provide time and temperature related data when the shipments are moving is imperative to prevent any wastage of vaccines.
As a supplier of leading cold chain equipment like vaccine refrigerators, Nigel Saunders, chief executive officer of the Sure Chill Labs, said, "We believe we have the duty to deliver cold chain in partnership with the governments."
Pharmaceutical companies are at race to develop vaccines but for those to be successful, a cold chain system has to be in place since vaccines have to reach every person in perfect condition.
From the industry perspective, there is a mounting pressure on the supply chain.
Some countries, like Bangladesh, have already started working on that, which is positive.
"When the vaccines are ready to be rolled out, we have to make sure that the cold chain is in place," Nigel Saunders said.
People often think that vaccines need to be cool but in outreach programmes "you need to make sure that you do not freeze the vaccines". That will also destroy the efficacy of the vaccines.
So, the authorities will rely on health workers following clear procedures. Millions of cool boxes will be required along with ice packs. Generating ice will be very challenging.
One of the innovations that Sure Chill Labs came up with is micro chiller that provides the benefit of a vaccine fridge on the move. "We will be launching this early next year and it is designed to provide perfect cooling," he informed.
The device will stay cold inside for two days without power in an outside temperature of 43 degree Celsius.
Where Bangladesh stands
"If the authorities have to handle vaccines which need to be stored in -70 or -80 degree Celsius, we will need extensive support," said ABM Khurshid Alam, director general of the Directorate General of Health Services.
The government is yet to learn which vaccines will prove effective, how many people have to be vaccinated and the scale of expansion of the vaccination needed, he also said.
Bangladesh has 26,000 health assistants in rural areas but they may need to be trained to administer Covid vaccines.
If a vaccine is ready by January, it will be difficult to get it in here because the storage system is filled with Measles and Rubella and other vaccines. Uninterrupted power supply is another big challenge, he added.
HE Robert Chatterton Dickson, British high commissioner in Dhaka, said the UK is one of the leading countries trying to find a solution to immunisation problems. It is contributing 1.3 million pounds to stop the spread of Covid-19 and to fund and ensure equitable distribution of Covid vaccines.
"We are trying to support Bangladeshi government in its response to Covid in testing, setting up hand-washing centres in Rohingya refugee camps and capacity building of medical colleges" he also said.
A wider support for vaccination is the best public health intervention. Therefore, the UK is taking into consideration that when there is a vaccine available, it should be distributed everywhere, regardless of the challenges, remoteness and a lack of prosperity, he added.
Why vaccination is important
The economy will see a qualitative growth only when people can overcome the fear for the unknown. And vaccination is the key to that, said Farzana Munshi, a professor of Economics at the School of Humanities and Social Sciences at Brac University.
Lockdown is not really enforceable in a country where more than 80% of the workforce is engaged in the informal sector. Social distancing is not feasible either because Bangladesh is a densely populated country, she said.
A robust cold chain will also open up new opportunities for employment, improve the storage capacity of agricultural products and reduce the incentive for urban migration, Farzana added.
If vaccines are to be transported from the airport to remote parts of the country, the authority will have to mitigate many issues, said Dr Ijaz Hossain, a professor of chemical engineering at Buet, who is a member of the research team assessing the existing cold chain.
A large part of the country still lacks access to electricity. In those areas vaccination is a challenge, he said.
"We want a sustainable solution. Important part of our work is bringing renewable energy to remote areas of Bangladesh."
Tomoo Hozumi said the pandemic offers scope to move to clean energy through embracing sustainable solution for vaccination.
Another issue that would require attention is waste management. The vaccination can usher in a positive development in terms of waste management if proper technology is put in place to dispose of waste like syringes, he added.