Bangladesh: Stopping polio a routine achievement
While the world applauded when India stopped transmission of polio in 2011, little fanfare was given to Bangladesh, its Eastern neighbor, when it quietly achieved the feat at the turn of the century, some 14 years ago. Yet this achievement was an enormous factor in the South-East Asia Region’s ability to stop transmission of polio, and to be certified polio-free.
Bangladesh and India faced many of the same challenges: a hot, humid monsoon season when it is easiest for the virus to thrive and spread, a large population often living in crowded, unsanitary conditions, and mobile and migrant groups such as brick kiln workers travelling across the country in search of work. It was these factors that saw an estimated 11,500 children crippled or killed by polio every year in Bangladesh until 1986.
So how did Bangladesh stop transmission, and when they did get an importation of polio across its long and porous border with India (as it did in 2006) how did it stop the outbreaks so quickly?
The answer is a strong and well-functioning routine immunization (RI) system, which has maintained high immunity to not only polio but all nine vaccine-preventable childhood diseases. This commitment to full routine immunization coverage has not only seen Bangladesh dramatically reduce its child mortality rate over the past three decades, but sets the example for India to follow in how to protect itself from polio from its own western neighbors – polio-endemic Pakistan and Afghanistan.
UNICEF South Asia’s Regional Director Karin Hulshof believes that the work of tens of thousands of health and family planning workers in helping to ensure that more than 92% of Bangladesh’s children were protected against polio was the shield that both protected Bangladesh, and provided a gift to the global polio programme.
“Routine immunization is the first defence in preventing the reintroduction of polio in any country,” Ms Hulshof said, “and Bangladesh’s incredible investment and achievement has saved the polio programme millions of dollars in importations that it didn’t have to tackle.”
Bangladesh’s routine Expanded Programme of Immunization (EPI) grew exponentially from 1985, when it reached just 25% of children with the first antigen, BCG, to 1994, when it achieved almost universal access to immunization services, reaching 95%. However, the challenge remained: while the first antigen was warmly embraced at birth, full RI coverage against all nine antigens rose from just 50% to 63% between 1994 and 2003.
This, coupled with the importation of poliovirus from India in 2005-06, meant that the polio programme could not rely on RI alone to stop transmission of the virus and so the Government of Bangladesh launched National Immunization Days, where 46,000 Health and Family Planning volunteers would cover the country across four days, immunizing 22 million children under five at 140,000 sites located in health facilities and health centers, schools and mobile sites, such as bus, boat and train stations.
To ensure no child was left out, a further four-day Child-to-Child Search was conducted by mobile teams, targeting the children of migrant workers or nomads. To date, 21 high-quality NIDs have been held, with >95% of all children immunized in each campaign.
UNICEF Bangladesh Representative Pascal Villeneuve said that by proving it could reach most children with polio vaccine in routine and supplementary immunization campaigns, Bangladesh was ready to go the extra mile to immunize every child, everywhere with all nine life-saving vaccines. “We are delighted that Bangladesh has been certified polio-free and that we have won the fight against this potentially deadly and paralyzing disease.”
Indeed, while polio was able to be stopped in the year 2000, only two-thirds of children were being fully immunized against all antigens by the mid-2000s. RI coverage across the country was uneven and inequalities existed between different groups and geographical regions – particularly among the poorest, most uneducated women.
To tackle this, the Government of Bangladesh, with the support of UNICEF, WHO and GAVI HSS, evaluated its highest-risk populations and difficult-to-reach groups, and identified low-performing districts for an intensified ‘Reaching Every District’ (RED) approach. ‘RED Microplanning’ proved a powerful tool in ensuring the equity of health delivery across the country. Partnerships with local NGOs and other service providers played a complementary role in meeting the gaps in logistics and human resources.
With GAVI support, the Government of Bangladesh recruited District Medical Immunization Officers (DMIO) for the lowest-performing districts – the role designed to specifically raise full routine immunization coverage. Implementation of supervision and monitoring plans further helped to improve the coverage.
The capacity development focus provided by successive introductions of new vaccines helped to enhance delivery and annual Coverage Evaluation Surveys provided strong evidence of progress. Broad community awareness programmes helped to build demand and to reduce drop-outs of children falling out of the full RI schedule due to either a lack of awareness, ‘no felt need’ to immunize by the parent or caregiver, or concerns about Adverse Events Following Immunization (AEFI). High-performing and quickly improving districts/City Corporations were given awards by the Ministry of Health as an incentive for further improvement.
While still not perfect, full routine immunization coverage has risen across the country, to 81% by 2013 (by comparison, India’s national average is 61% coverage). The number of children who have received all three doses of oral polio vaccine in RI is above 92%.
Mr Villeneuve warns that while the progress is encouraging, inequalities still remain across different socio-economic groups and geographical locations. “We need to do more to ensure that no child is left behind,” he said, “particularly those living in hard-to-reach areas and deprived communities such as children living in urban slums.”