Academic journal article Journal of Health Population and Nutrition

Introducing Hepatitis B Virus Vaccine into the Expanded Programme on Immunization in Bangladesh: A Proposed Method to Evaluate Whether the Existing Infrastructure Has the Capacity

Academic journal article Journal of Health Population and Nutrition

Introducing Hepatitis B Virus Vaccine into the Expanded Programme on Immunization in Bangladesh: A Proposed Method to Evaluate Whether the Existing Infrastructure Has the Capacity

Article excerpt

INTRODUCTION

In developing countries, over 11 million children, aged less than five years, die each year, and nearly three-quarters of these deaths result from infectious diseases. The World Health Organization (WHO) estimates that the death of at least four million of these children is linked to their lack of access to vaccines (1). Vaccines are highly effective against childhood diseases preventing an estimated three million deaths a year (2). Although, since the mid-1970s, the global immunization coverage for the six preventable diseases--diphtheria, measles, pertussis, polio, tetanus, and tuberculosis--originally targeted by WHO, has improved significantly, the rates of coverage of children in the poorest countries are still low.

The Expanded Programme on Immunization (EPI) in Bangladesh was launched nationwide in 1974 aimed at reducing morbidity, mortality, and disability associated with tuberculosis, tetanus, diphtheria, measles, pertussis, and poliomyelitis. The EPI experienced four phases of development. Phase one was started in 1979; phase two, learning and experimentation, lasted from 1985 to 1993; phase three, carried out during 1993-1995, expanded the coverage of the EPI at a rapid rate; and phase four is characterized by well-established infrastructure and knowledge of mothers about the need for childhood and maternal immunizations. The national EPI coverage remained stable during the 1990s. A survey in June 2001 reported a coverage of 93.7% for BCG, 65.4% DPT3, 65.5% OPV3, and 64.2% measles.

A general concern is that, while the coverage rates have not declined, they appear to have reached a plateau. Despite the extensive infrastructure of the EPI, especially in the rural areas, and the heavy use of outreach activities, an estimated 53% of children are fully immunized by 12 months of age. This is because many children do not complete their vaccination series--dropout rates have been rising since 1995 and are currently estimated at 25% from DPT1 to measles and 15% from DPT1 to DPT3 (3,4). However, as shown by the high BCG coverage rate, access to the EPI is quite good.

The Government of Bangladesh is currently preparing a proposal to both improve the overall EPI and introduce the hepatitis B virus (HBV) vaccine into the EPI, aimed at increasing the EPI coverage from the current 68% for DPT3 to 90% by 2006 and to introduce the HBV vaccine in phases reaching nationwide coverage by 2004. Improving the coverage for the six basic vaccines--tuberculosis (Bacillus Calamette Guerin, BCG), diphtheria, pertussis, tetanus (DPT3), measles, and poliomyelitis (OPV3)--is fundamental because an estimated 20,000 deaths per year still occur each from neonatal tetanus and measles. A related priority is, thus, to improve the cold-chain system. The burden that a new vaccine places on the EPI in terms of cold-chain requirements and procurement was mentioned by several policy-makers as an important factor in deciding whether to consider the introduction of the vaccine. Some mentioned it as the second most important constraint, after cost, to the introduction of new vaccines (3).

According to the priorities of the Government of Bangladesh, there is a need to assess whether the existing infrastructure has the capacity to sustain the expansion of the EPI.

Based on the introduction of the HBV vaccine and the proposed increase in the coverage of measles and DPT vaccines in the existing EPI, the study describes a technique employed to quantify current EPI resources and assesses their capacity to determine whether they will be sufficient in sustaining the implementation of the EPI in these circumstances. Capacity is discussed in terms of use-rate of the required resources, such as personnel, equipment, infrastructure, etc., to accommodate the delivery of additional vaccines and supplies. The study focuses on cold-chain equipment, as an example, with the following specific objectives: (a) develop an instrument to assess the capacity-use rate of cold-chain equipment; (b) measure the capacity-use rate of cold-chain equipment in selected vaccine-storage centres; (c) evaluate the capacity of cold-chain equipment to accommodate the introduction of the HBV vaccine; (d) measure the capacity of cold-chain equipment to accommodate an increase in the coverage of measles and DPT vaccines; and (e) analyze the quality of cold-chain equipment. …

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