A quick jab

Three months ago, Fatema Khatun's son Hossain died in her arms. Hossain was one of the nearly 20,000 Bangladeshi children who die every year from measles, the fifth-leading cause of death for children under five-years-old in Bangladesh.

Hossain was also just three months short of being vaccinated through the Measles Catch Up Campaign (MCUC), one of the largest public-health campaigns ever conducted. On 25 February, Bangladesh began the three-week vaccination campaign, in which an estimated 33.5 million children, aged nine months to 10 years, will get their 'catch up' measles vaccine, regardless of whether they have had the disease or the vaccine before. Another 1.5 million were vaccinated in the campaign's first phase, in September last year. About one-in-four children miss out on routine measles vaccines in Bangladesh. About 40 percent of children in each age group are left vulnerable to measles, because the vaccine only has an 85 percent efficacy when given to children aged nine months.

Hossain had been out playing as usual, Fatema says, when he first got sick with a fever that lasted three days. When it started, she took him to a doctor who prescribed paracetamol and rest. After the third day, when the measles rash came, Fatema's neighbours said there was no need to go to the doctor again. "Then he got a bit better, and the rash went down for three days," she says. Fatema had left for work early the morning that Hossain died. She earns between BDT 500-600 per month sorting rubbish and recycling, which is about the same as the rent for the family's small bamboo hut in their Dhaka slum. The family relies on the eldest daughter Khadeza's monthly earnings of BDT 700 as a child domestic worker to survive.

When Fatema arrived home, she found Hossain lying on the floor of their hut. "I came back and held him in my lap to give him a little bit of water," she recalls. "He drank one sip and died. I was holding him when he died." Hossain was one of the 15 percent for whom the vaccine proved useless. But the MCUC safety net, the 'catch up', could save other children from a similar fate. Fatema is certainly making sure her three under-10 children are getting their catch up vaccination. She is also alerting her neighbours in the slum — many of whom had children infected in the outbreak that took Hossain — about the service that is arriving on their doorsteps.

Government success

In order to reach those children excluded from mainstream centres through their extreme poverty, the Measles Catch Up Campaign is going beyond its springboard of the government's expanded programme on immunisation (EPI). Rather than simply working from schools and the government EPI sites, MCUC vaccination teams are also visiting railway and bus stations, parks, jails and slums to reach as many excluded children as possible.

The campaign's estimated USD 15 million cost has been donated by the American Red Cross (ARC). The Bangladeshi government itself is contributing 25 percent of operating costs. However, the MCUC is largely the government's baby, with ministry staff organising and implementing the campaign through the EPI networks. Additional partners include a host of international and national organisations from around the world. Logistically, the campaign has required 40 million vaccines, 40 million syringes, 50,000 skilled vaccinators, 750,000 volunteers, 100,000 schools and 150,000 EPI fixed sites. The vaccines themselves, which need to be kept in cold storage at all times, have been procured by UNICEF with the ARC funds.

The government's work on the measles campaign has been buoyed by its previous success with the EPI programme, through which an estimated 4 million children are saved every year. It has been largely thanks to EPI that coverage against the six preventable childhood diseases — diphtheria, tetanus, tuberculosis, whooping cough, polio and measles — increased from 2 percent in 1971 to 73 percent in 2005.

If not building on past EPI successes, the new campaign is at least filling in the gaps, says Dr Zahid Hossain, the dean of Dhaka University's medical faculty and secretary-general of the Bangladesh Medical Association. Over the past two decades, EPI successes have paved the way for the Bangladeshi focus to shift now to measles. Despite EPI's original focus, measles had largely dropped off the parental radar as the country tackled the more-lethal whooping cough and the more-crippling polio. The last case of polio was recorded in August 2000. "We had to address our primary issues first," Dr Hossain says, "and now we're addressing our secondary issues and have started the measles and hepatitis vaccines. For measles, though, we haven't had this type of mass mobilisation before."

Fighting measles has the extra benefit of combating pneumonia. Measles is a respiratory disease and it can lead to pneumonia, the second-biggest killer of children aged 1 to 17 years, according to the 2004 Bangladesh Health and Injury Survey. "If we can control measles, through this one campaign, we will be able to control the incidence of pneumonia," Dr Hossain explains. "Pneumonia takes a lot of lives in our country, especially in the rural areas and for those that are living under the poverty line."

The MCUC's ripple effects in advocacy will also save lives, says Dr Hossain. At a minimum, it will jumpstart more than an estimated 10 million caregivers into talking about the free measles vaccines. And if caregivers can be made aware of the vaccine's availability, he says, "hopefully for the next few years this country will remain free of measles." Realistically, while the MCUC is hoping to control measles, eradicating the disease is still a long way off.

In fact, for this reason, the second MCUC has already been pencilled in for 2009. Because the vaccine has an 85 percent efficacy only when given to children at nine months, when combined with the number of Bangladeshi children already missing out on the vaccine, this leaves about two-in-five children vulnerable to measles. Given this dropping rate in efficacy and those newborns that will miss their nine-month dose, the need for a second catch up is already evident. Still, this first MCUC will be the most concerted swipe at measles in Bangladesh yet. Those involved hope that success in this campaign will mean the next one will only need to target children aged nine months to five years.

Above politics

For its resounding 70 percent jump in vaccination coverage, Bangladesh's EPI programme is now seen as an international success story for universal childhood immunisation. In addition, however, Dr Hossain believes that the programme itself has also broken ground in the Bangladeshi political arena. The politics of measles might seem incongruous at a time when national headlines scream about the country's security situation and upcoming elections. But the consistent political support EPI has enjoyed over its 20-year lifespan has made it a beacon for other areas of Bangladesh's turbulent political life.

"If we see the history of the last 30 years of Bangladesh, we will see a lot of difference in opinion regarding national issues," Dr Hossain says modestly. "But regarding the EPI programme, all the political parties, all the governments have shown their keen interest, as the programme has a very good relation with the local people, the rural people." It is those levels of trust on local, national and international levels that now allow many to be optimistic that the MCUC measles effort will see success similar to past vaccination drives. The most prominent of these drives, the polio National Immunisation Days, ended in 2004. Every six months, as 18 million children and parents line up for Vitamin A supplements across the country, many still say they are coming for their "polio medicine". Such is the level of recognition, and adoption, of the vaccination campaigns by the people.

That critical local support has been particularly bolstered by EPI's identity-blind approach and high visibility. Seeing their local MP at a vaccination site leads people to assume that that person — regardless of politics — is responsible for saving their child's life, Dr Hossain says. Rather than kissing babies in election campaigns, it is the life-saving EPI jabs that have won the people's support, for the politicians as well.

While the visibility of vaccinations helps in attracting aid money, Dr Hossain also emphasises that Bangladesh cannot stay reliant on aid forever. He says that the level of responsibility the government has taken in running the measles campaign is just one positive sign of such change; he expects Bangladesh will shoulder more of these costs in the future. As a region, the rate of routine measles vaccinations in Southasia is the second-worst in the world — at 61 percent, it is ahead of only western and central Africa. On this matter, Bangladesh is no longer a basket-case, and is providing an anti-measles template for its neighbours.