Questions have emerged over whether the target for Bangladesh’s nationwide measles-rubella vaccination campaign was fundamentally flawed, with one estimate suggesting that nearly 4.6 million children were left outside the official target population. Public health experts say this may help explain why the outbreak remains uncontrolled even four months after it began.
The measles outbreak started in early March this year. On Saturday, the health authorities reported three more child deaths, bringing the total death toll from measles to 753.
To contain the outbreak, the government launched a nationwide measles-rubella vaccination campaign in April. The campaign began on 5 April in 30 upazilas and municipalities across 18 high-risk districts.
It was extended to Dhaka North, Dhaka South, Mymensingh and Barishal city corporations on 12 April, before expanding nationwide—including all upazilas, districts, municipalities and city corporations—on 20 April. The campaign concluded on 20 May.
Under the country’s routine Expanded Programme on Immunization (EPI), children receive the first dose of the measles vaccine at nine months of age and the second dose at 15 months. Before launching the campaign, however, the government decided to vaccinate all children aged six months to under five years.
According to EPI estimates, Bangladesh has 18,015,064 children in that age group, and this figure continued to be used by the Directorate General of Health Services (DGHS) as the campaign target until Friday.
However, after the nationwide Vitamin A campaign began on 28 June, confusion arose over the actual number of children in the same age group. The Vitamin A campaign also targets children aged six months to under five years, but it set its target population at 22.6 million children.
That leaves a discrepancy of 4.6 million children between the two programmes.
Speaking to Prothom Alo on 7 July, EPI Deputy Director Hasanul Mahmud said the number of children in the first 30 upazilas covered from 5 April had been estimated, while the figures for the rest of the country were determined through microplanning.
“Our figures are consistent with those of the Bangladesh Bureau of Statistics. Even so, we are investigating the discrepancy,” he said.
According to the EPI operational guidelines, microplanning includes detailed demographic information for every upazila, municipality and city corporation, including population size, vaccination schedules, previous years’ data and field worker assignments. The target population is determined through field-level data collection for each vaccination centre.
A health official in Bagerhat said the microplanning for the measles-rubella campaign had been carried out in haste, making it unsurprising if some children were left out.
How many children are there?
Although both the vaccination programme and the Vitamin A campaign are run under separate units of the DGHS—and the two offices are located less than 200 yards apart in Mohakhali—their estimates of the child population differ significantly.
The Vitamin A campaign is implemented under the National Nutrition Programme. Programme Director Md Yunus Ali told Prothom Alo that updated child population data are maintained by civil surgeons’ offices across the country.
“Before launching the Vitamin A campaign, we collected updated figures from every district. Based on those reports, we estimated that there are 22.6 million children aged six months to under five years,” he said.
According to Yunus Ali, as of 7 July, 98.67 per cent of the target population—around 22.3 million children—had received Vitamin A capsules, suggesting that at least that many children in the age group exist.
Meanwhile, the Directorate General of Health Services (DGHS) did not include any vaccination figures in the press release issued by its Integrated Control Room on Saturday. However, the previous day's release, issued on 10 July, said that 103 per cent of the target population had been vaccinated against measles—meaning vaccination coverage exceeded the original target by 3 per cent. The campaign target was 18 million (18,015,064) children, while 18.4 million (18,479,359) children ultimately received the vaccine.
Even before the national measles vaccination campaign ended on 20 May, official figures showed that the number of vaccinated children had already surpassed the target. At the time, EPI Deputy Director Hasanul Mahmud and several other DGHS officials said the coverage exceeded 100 per cent because some children older than five years who came for vaccination were not turned away. Those explanations were also published in Prothom Alo.
However, if the Vitamin A campaign's figures are accurate, Bangladesh has 22.6 million children aged six months to under five years. That would mean only 18.4 million children in the target age group received the measles vaccine, leaving about 4.2 million children—or 18 per cent of the target population—still unvaccinated and therefore vulnerable to measles.
Public health experts and immunisation specialists say the vaccination campaign's target population was underestimated.
Former EPI Deputy Director Tajul Islam A Bari told Prothom Alo that the target population during the 2010 national measles-rubella campaign was also around 18 million, similar to this year's target.
However, the eligible age group at that time was nine months to under five years, whereas this year's campaign covered children from six months to under five years.
"With the lower age limit expanded to six months, the target population should naturally have been larger," he said.
Professor Be-Nazir Ahmed, a public health expert and former director of the DGHS Disease Control Unit, said one of the main reasons the outbreak has yet to come under control is that not all eligible children received the vaccine.
"A discrepancy of 4.6 million is enormous. It is quite astonishing. Such a huge difference suggests that those responsible for managing this national public health emergency did not perform their responsibilities properly. The entire matter should be investigated," he said.
