From factory floors to Rohingya refugee children: The journey of a vaccine

COX’S BAZAR, Bangladesh, 19 July 2018 – At the Balukhali refugee camp health centre in Cox’s Bazar, a mother and her baby enter the vaccination room, separated from the waiting area by a large white sheet. The vaccinator peels the cap off the vaccine vial and tears open a plastic bag containing a syringe. She is preparing a pentavalent shot for six-week-old Rachal.

The vaccine took several years to manufacture, travelled at carefully controlled temperatures for up to 4,300 km, was stored in seven different cold rooms and was carried by at least 17 people before it reached the Rohingya refugee camp.

Every day, cool boxes filled with vaccines make their way through the dusty lanes of the Rohingya refugee camps in Cox’s Bazar, Bangladesh. Since August 2017, about 706,000 Rohingya refugees – almost 400,000 of them children – fled Myanmar for camps over the Bangladesh border. Crowded living conditions, poor sanitation and low vaccination coverage rates among children make them vulnerable to disease.

In late 2017, a diphtheria outbreak swept through the sprawling expanse of tarpaulin and bamboo shelters in the hilly area close to the border with Myanmar. The Government of Bangladesh, with the support of UNICEF, WHO, GAVI – the Vaccine Alliance – and healthcare partners launched three campaigns to vaccinate close to half a million children in the camps, temporary settlements and surrounding areas.

Now that the campaigns are over, Rohingya children are receiving routine immunization vaccines, including the pentavalent.

This vaccine protects against five potentially fatal infections in one shot: hepatitis B, pertussis, diphtheria, tetanus and Haemophilus influenzae type b. It is one of 10 vaccines included in Bangladesh’s routine immunization programme.

The pentavalent vaccine’s journey to the refugee camp is a formidable one.

Logistical challenges

A trolley carrying hundreds of cold ice packs rumbles as it is pushed across the factory floor towards the packaging area. A worker scrambles to get out of its way. In the vaccine manufacturing plant, packaging is serious business.

Pentavalent vaccines procured by UNICEF are manufactured in South Korea and India. To get to the Rohingya refugee camps in Cox’s Bazar, they fly between 1,400 and 3,800 km to Dhaka, the capital of Bangladesh, before hitting the country’s winding roads.

For high quality vaccines to reach children around the world, it’s not enough to produce them without addressing the logistical problems that arise from making sure they reach their destination. The rule is that vaccines need to be kept between 2^o–8^o C up to the point of delivery, or they may lose effectiveness. In countries facing emergency crises, poor roads, unreliable electricity and high temperatures, it is a daunting challenge.

“It is timed so that the vaccines arrive at the airport only a few hours before the plane takes off,” says the Logistics Director of one of UNICEF’s six pentavalent suppliers.

The vaccines are put in polyurethane cartons with cool packs conditioned at 4^o C. A monitoring tag, dropped in each box, indicates variations in temperature. Workers dressed in blue overalls bustle around the room, filling boxes with vaccines and loading them on a truck waiting to head to the airport.

Travelling through Bangladesh

Vaccines earmarked for Bangladeshi and Rohingya refugee children land in Dhaka, the capital city of Bangladesh. At the airport, they are put in dark blue cool boxes surrounded by ice packs, and then whisked off to the central warehouse of the Expanded Programme on Immunization (EPI) located in the city centre.

The truck makes its way along Gulshan Lake through the brightly coloured bicycle rickshaws and the gridlocked roads of the city. The warehouse is a four storey white building with boxes of disposable syringes stacked in the corridors. “Vaccines are usually stored in the EPI central warehouse cold rooms for up to three or four months,” says Subodh Chandrah Banik, the Logisitics Officer at the EPI in Dhaka.

When the time comes to send vaccines to the refugee camps, they are once again taken out of the cold room and packed in cool boxes with ice packs. Banik helps load them onto an open truck that will head south, to the town of Cox’s Bazar.

After the vaccine lands in Bangladesh, the trip from the capital to the refugee camps takes 12 to 13 hours. The truck drives carefully past 400 kilometres of green fields, woods, boggy marshlands and cities before reaching Cox’s Bazar district’s warehouse.

A second truck is on standby in case the first one breaks down. At the warehouse, vaccines are once again unloaded and stored in a cold room to ensure that their temperature or the ‘cold chain’ is maintained.

“We have a single truck leaving every week for the Rohingya refugees, and every month for routine immunization of local populations in the district,” says Mohammed Saiful, Cox’s Bazar’s warehouse superintendent, while he loads cool boxes onto a smaller truck. The truck travels farther south to the last stop of the cold chain: the Ukhiya sub-district health centre, approximately 40 km away. From there, the pentavalent vaccines set out on an ambulance destined for the Balukhali health centre.

Rachal lies cradled in his mother’s arms, his cheek pressed against her collarbone. He is still fast asleep. His mother, in her late twenties, sits on a green plastic chair in the vaccination room. She brought her six-week-old son to the health centre closest to the shelter she shares with her family so that he could be vaccinated. She left Myanmar’s Rakhine state after her village was burned down. It took her and her family over 10 days to walk to Bangladesh. She was pregnant with Rachal at the time.

The young mother waits as a nurse prepares a pentavalent shot for her son, which was delivered a few minutes earlier. Rachal receives a vaccine that will protect him against five potentially fatal diseases and help him survive in some of the most difficult conditions in the world today.