For some children, measles arrives before they are old enough for their first routine vaccine. For others, it comes after they have moved beyond the age covered by the emergency campaign.
That gap is becoming increasingly difficult to ignore as Bangladesh’s outbreak enters its 179th day of official reporting.
A large share of the children who have died are under 6 months old. Three were more than 5.
Neither group is covered by the routine vaccination programme. Neither was included in this year’s special campaign.
So as infections continue to rise, a troubling question remains unanswered: how will these children be protected?
Experts say measles will be difficult to bring under control without a decision on both age groups.
Under the routine programme, children receive one dose of measles-rubella vaccine at 9 months and another at 15 months. When the outbreak intensified, the government expanded vaccination to children aged 6 to 59 months.
But the expected decline in infections has not materialised. Instead, measles has shown an upward trend since August, prompting questions over vaccination coverage, implementation and weaknesses in healthcare.
Experts say inadequate coverage, poor public awareness and mismanagement of health services are stretching the death toll further.
More than 1,000 Deaths
Although reports of a measles outbreak emerged early this year, the government began publishing data from Mar 15.
By Wednesday, 1,002 people had died with measles or its symptoms -- an average of more than five deaths a day.
By then, 167,580 patients with measles symptoms had arrived at hospitals. Of them, 147,393 were admitted and 141,819 discharged after treatment.
Confirmed measles infections stood at 19,904. But not every hospital patient is tested.
Under National Immunization Technical Advisory Group (NITAG) guidelines, testing is no longer necessary because measles has spread to all 64 districts and almost every Upazila.
Patients admitted with symptoms are therefore considered measles-infected.
DGHS data show that around 2,500 patients were admitted to hospitals nationwide during the first 30 days of the outbreak. Admissions remained around 4,000 over the following three months.
On Jul 31, 4,128 patients were in hospitals. By Wednesday, the figure had risen to 5,574 -- more than twice the number recorded during the outbreak’s first 30 days.
The Numbers behind ‘100 per cent Coverage’
After the outbreak triggered criticism and protests, the government began vaccinating children in 30 high-risk upazilas on Apr 5.
The campaign expanded to four city corporation areas on Apr 12, before the nationwide drive ran from Apr 20 to May 20.
On May 14, a DGHS bulletin reported 100 percent coverage.
But the numbers did not quite add up.
The measles campaign targeted children aged 6 to 59 months -- the same group covered by the Vitamin A Plus programme.
According to the National Nutrition Institute, 22.36 million children received Vitamin A Plus capsules on Jun 28.
The health directorate said 18.48 million children had received measles vaccines.
That left a difference of 3.88 million children.
After questions were raised, the government said children left out would be vaccinated.
The latest DGHS bulletin says more than 19.7 million children have now received vaccines against a target of 18 million -- 109 percent of the target.
But public health experts say the real test is whether enough children have acquired protection.
Tajul Islam A Bari, former programme manager of the Expanded Programme on Immunization and a public health expert, told bdnews24.com: “Vaccination coverage is not correct, which is why deaths are not stopping. Because measles cannot be controlled until at least 95 percent of the population is brought under vaccination.”
Even after the subsequent vaccinations, the gap with the Vitamin A programme remains about 2.6 million children.
DGHS Director General Prof Pravath Chandra Biswas said vaccination was continuing.
“40 lakh (4 million) doses of vaccines have been ordered anew. When these vaccines arrive, we will conduct another campaign for those who were left out. Then, hopefully, measles will decrease.”
At a Bangladesh Shishu Hospital and Institute event on Aug 19, Health State Minister MA Muhith said: “There is no scope for giving unrealistic assurances about measles. Even if the pace of vaccination is increased by 100 percent, it will take another two to three months to bring measles under complete control.
“However, efforts are under way to reduce child deaths during this period through the highest level of treatment and stronger surveillance at the field level.”
Outside the Vaccination Net
The mortality figures reveal the scale of the vulnerability.
The DGHS provided bdnews24.com detailed information on 252 measles deaths on Aug 4, a month after the request was made. The data contained no dates.
Among the dead were 67 children under 6 months old, or 26.6 percent. Three were older than five, accounting for 1.2 percent.
WHO data from August tell a similar story. Ninety percent of those who died had received no measles vaccine. Another 7.9 percent had received one dose, while 2.19 percent died despite receiving two.
The age breakdown is stark: 20 percent of deaths were among children under 6 months, while 31 percent involved children aged 6 to under 9 months.
In other words, 51 percent of those who died were younger than 9 months -- an age when many have not yet reached their first routine vaccination.
Epidemiologist Prof Mahmudur Rahman, chairman of the National Verification Committee for Measles and Rubella Elimination, says the two groups outside the current vaccination strategy cannot be ignored.
“One in 10 of the measles patients we currently have is under 6 months old. And there is another group whose age is above 5. There is no vaccination decision for these two age groups.”
Unless they are protected, he says, transmission will not stop.
“We have long been analysing infection rates by age and calling for decisions on vaccination and on those who cannot be vaccinated. But although people listen, no one is giving it importance.”
He says: “We need intensive research to determine how protection can be ensured for children under 6 months.”
Prof Pravath says the government is considering the issue.
“We have thought about the issue. IEDCR and icddr,b are working on research.”
Closing the Gaps
Experts say vaccination must be only the beginning.
Prof Mahmudur says Bangladesh first needs to achieve adequate coverage, followed by a nationwide awareness campaign and a properly functioning routine immunisation programme.
A decision must also be made about the age groups currently left outside the programme.
Public health expert Lelin Choudhury points to another vulnerability among children.
“A huge number of children in the country have remained outside vaccination. As a result, herd immunity has not developed in their bodies. On the other hand, children under six months are also becoming infected with measles. Why are they becoming infected? Because their mothers did not receive measles vaccines. As a result, immunity against measles has not developed in the children either.”
He calls for screening and vaccination among people of marriageable age, greater emphasis on breastfeeding and efforts to reach street children, children in brothels and other disadvantaged groups.
“If you cannot bring 95 percent of children under vaccination, it will not be possible to prevent children from becoming infected or dying,” he says.
Public health expert Mushtuq Husain says the health system itself must also improve.
“If the health system were better, some deaths could have been prevented, but this aspect is not good either. Because even now, it has not been possible to make everyone in the country aware.”
He urges families to isolate children as soon as they develop fever and seek care at local health centres if it persists.
“The quality of primary healthcare in the country must be improved. In other words, there needs to be a healthcare centre between the ICU and the home. This will save patients’ lives as well as reduce pressure on hospitals in cities. Poor people in the country must be prioritised so that they can receive care at home.”
The government says another campaign will begin after new vaccines arrive this month.
Prof Pravath says infection patterns and antibody levels will first be assessed in areas already targeted for vaccination, with the Institute of Public Health, IEDCR and other institutions involved.
“Hopefully, measles infections will decline after vaccination is completed this time.”
For now, however, the outbreak continues to expose the limits of a campaign measured in percentages.
Behind every coverage figure are children who remain outside it -- some too young to have received their first dose, others already beyond the age the campaign was designed to reach.
Until Bangladesh finds a way to protect them, the gaps in its vaccination strategy will remain an obstacle to bringing measles under control.
