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Bhutan's Experience with COVID-19 Vaccination in 2021

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Bhutan's Experience with COVID-19 Vaccination in 2021 Commentary Bhutan’s experience with COVID-19 BMJ Glob Health: first published as 10.1136/bmjgh-2021-005977 on 18 May 2021. Downloaded from vaccination in 2021 1 2 Thinley Dorji , Saran Tenzin Tamang To cite: Dorji T, Tamang ST. INTRODUCTION Summary box Bhutan’s experience with As of April 2021, COVID-19 cases continue COVID-19 vaccination in 2021. BMJ Global Health to rise globally and in the South Asia region ► COVID-19 has caused a major socioeconomic im- 2021;6:e005977. doi:10.1136/ causing devastating morbidity, mortality and pact on the lives of people in Bhutan, a landlocked bmjgh-2021-005977 disruption of socioeconomic life. Apart from nation situated in the eastern Himalayas. public health measures to prevent spread of ► The pandemic has led to the closure of its inter- national border, restriction on cross- border trade, Received 11 April 2021 COVID-19, significant investment has been closure of businesses, schools and colleges, and Revised 20 April 2021 made to develop, test and roll out vaccines. Accepted 23 April 2021 Modelling studies predict significant reduc- restrictions on social gatherings. tion in overall attack rates by SARS- CoV-2 ► Bhutan has reported 957 cases of COVID-19 with one death as of 18 April 2021. through use of effective COVID-19 vaccines, ► Despite limitations of resources and experiences, with the highest relative reduction among Bhutan has achieved good control of the pandemic older adults (aged 65 years and older), reduc- through its unique public health approaches. 1 tion of intensive care admissions and deaths. ► Bhutan vaccinated 94% of its adult population with As of 18 April 2021, 14 vaccines have COVID-19 vaccine within a span of two weeks in been approved for human use by at least April 2021. one country2 and 890 million doses of ► This achievement comes at the backdrop of Bhutan’s COVID-19 vaccines have been adminis- well- established primary healthcare and vaccination tered globally.3 In the South Asia region, the systems. Oxford- AstraZeneca (COVISHIELD) vaccine ► However, the country now faces the daunting task of preventing complacency in physical distancing mea- manufactured in India has been made avail- 2 sures, hand washing and use of face mask by the able through the COVAX Facility. As of 18 public in a background of the rapid spread of new http://gh.bmj.com/ April 2021, 122 million doses (7.9% of the strains of SARS- CoV-2. population) have been administered in India, 6.6 million doses (3.5%) in Bangla- desh, 0.9 million doses (4.3%) in Sri Lanka, 0.8 million doses in Pakistan, 0.3 million doses continues to worsen globally and in the South (54%) in Maldives and 0.1 million doses Asia region, Bhutan has managed to control 3 the spread of the disease with an array of on October 1, 2021 by guest. Protected copyright. (0.3%) in Afghanistan. Bhutan, a country 5 6 with a population of 0.72 million, has vacci- unique public health measures. Despite nated 472 139 individuals with the first dose challenges in the availability of human and © Author(s) (or their of COVISHIELD covering 94% of the eligible financial resources, vaccinating the entire employer(s)) 2021. Re- use population (18 years and older) within a span population to achieve effective herd immu- permitted under CC BY-NC. No 7 of 2 week.4 nity was yet another bold move. The country commercial re- use. See rights vaccinated 94% of eligible adult population and permissions. Published by Bhutan has reported a total of 957 cases BMJ. of COVID-19 up till 18 April 2021 with one within a span of 2 weeks from 27 March 2021 1 4 to 9 April 2021. This article describes the chal- Department of Internal death. The country has seen two nation- Medicine, Jigme Dorji wide lockdowns and disruption of public lenges and enablers that allowed Bhutan to Wangchuck National Referral services, schools and colleges.5 6 The phys- achieve the highest COVID-19 vaccination Hospital, Thimphu, Bhutan coverage of adults. 2Department of Emergency ical distancing measures and the closure of Medicine, Central Regional international borders has impacted almost Referral Hospital, Gelegphu, all sectors of socioeconomic activities in the BHUTAN’S HEALTH AND VACCINATION SYSTEM Bhutan country with the major brunt on the tourism, Bhutan is situated in the eastern Himalayas Correspondence to entertainment and export–import indus- with its population scattered across mountains Dr Thinley Dorji; tries leading to an all-time high unemploy- making physical access a major challenge. dorji. thinleydr@ gmail. com ment rate. While the scenario of COVID-19 The country, since becoming a signatory Dorji T, Tamang ST. BMJ Global Health 2021;6:e005977. doi:10.1136/bmjgh-2021-005977 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2021-005977 on 18 May 2021. Downloaded from Table 1 Coverage of childhood and maternal vaccines in remarkable step in the vaccination programme, the Bhutan in 20208 and COVID-19 vaccine in 2021 country rolled out the COVID-19 vaccine in March 2021. Guided by its development philosophy of Gross Vaccine Coverage (%) National Happiness, Bhutan has a state-sponsored BCG BCG 100 healthcare system that provides free basic healthcare to OPV OPV0 96.3 all. Vaccines in the national immunisation schedule are OPV1 99.2 funded through the Bhutan Health Trust Fund estab- lished in 1998. Additionally, the funding of vaccines from OPV2 99.0 international development partners has played a crucial OPV3 97.4 role as reported in the polio eradication and measles Pentavalent DTP- HepB- Hib1 99.6 elimination efforts.9 11 With the COVID-19 pandemic DTP- HepB- Hib2 99.1 incurring huge amounts of government spending, it DTP- HepB- Hib3 98.7 came as a relief when the Government of India donated 550 000 doses of COVID-19 vaccine through its Vaccine HPV vaccine HPV1 90.5 Maitri initiative in January 2021 and March 2021. (quadrivalent) HPV2 TT for pregnant women TT1 97.9 COVID-19 vaccine COVISHIELD 1 94.0 CHALLENGES IN COVID-19 VACCINE DELIVERY Planning stage BCG, Bacilus Calmette- Guerin; DTP- HepB- Hib, Diphtheria, tetanus, pertusis, hepatitis B, Haemophilus influenzae b; HPV, The country’s national vaccination programme is run human papillomavirus; OPV, oral polio vaccine; TT, tetanus toxoid. by the EPI Unit, Department of Public Health, Ministry of Health. During this pandemic, all efforts against COVID-19 were implemented through the National to the Alma- Ata Declaration in 1978, has expanded its COVID-19 Task Force working in coordination with the primary healthcare network to include 48 hospitals, 186 Health Emergency Management Committee (HEMC) primary health centres, three thromde (municipality) established at the Ministry of Health.5 The HEMC set up health centres and 542 outreach clinics in 2021.8 This the National Immunisation Technical Advisory Group network covers >95% of the population within 3 hours of (NITAG), which worked closely with the Department of travel. Public Health in planning and rolling out the vaccine. The other major constraint has been the shortage of During the planning phase, members of NITAG and trained health human resources. A health school was the Health Minister made extensive field visits covering established in 1974 and has trained almost all of its districts in the east that were 2 days drive away from the primary health workers that include district health offi- capital city. The government mapped the volume of cers, health assistants, nurses, midwives, technicians and adult population in each district through the Bhutan village health workers. In 2012, the school was incorpo- Vaccination System (BVS) portal that allowed registra- http://gh.bmj.com/ rated as the Faculty of Nursing and Public Health under tion, follow- up and generation of vaccine certificate. the Khesar Gyalpo University of Medical Sciences of Mapping out of volume of expected recipients of vaccine Bhutan, the only medical university in the country. As of was important to identify facilities that would serve as 2020, there were 620 health assistants, 1364 nurses and vaccination centres such as schools, monasteries, public 1187 technologists and technicians with only 376 doctors sheds, etc. Identification of vaccination centres were (including 129 specialist doctors).8 key in the placement of cold chain storages at central on October 1, 2021 by guest. Protected copyright. Bhutan’s primary healthcare workers have contributed locations catering to several vaccination centres in the significantly in establishing the Expanded Programme catchment area. Online conferences were conducted on Immunisation (EPI) in 1973, expanding it to include with stakeholders at the district level (dzongdas) and at all 20 districts by 1980, achieving Universal Childhood the village level (gups) that enabled identification of chal- Immunisation by 1991 and maintaining childhood vacci- lenges including logistics for the vaccine delivery team. nation coverage of >95%.8 9 Bhutan has achieved major In the months leading up to the vaccine roll out, multiple successes in vaccine- preventable diseases with poliomy- batches of health workers were trained on the manage- elitis eradicated in 1988,9 measles eliminated in 201710 and ment and monitoring of vaccine cold chain, organisation rubella verified to be under control.11 Bhutan continues of vaccination booths, delivery of vaccine and post- to maintain high coverage of both childhood vaccines vaccination monitoring. and adult vaccines (table 1). In the recent years, Bhutan has introduced the following vaccines into the national Infrastructure and delivery immunisation schedule: pentavalent (DPT-HepB- Hib) Physical transportation is still a major concern especially in 2009, human papillomavirus (HPV) vaccine in 2010, when the cold chain of the vaccine is concerned. With recent inactivated polio vaccine in 2015, pneumococcal vaccine improvement in air connectivity, domestic flights oper- (PCV13) in 2019,12 influenza vaccine in 20205 and ated by the Royal Bhutan Airlines and helicopter services gender-neutral HPV vaccine since 2020.13 In yet another run by the Royal Bhutan Helicopter Services, otherwise 2 Dorji T, Tamang ST.
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