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Bangladesh Journal of Bioethics 2018; 9(3): 11-15 

 

 

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Mass Vaccination Programme: Public Health Success and Ethical Issues – 

Bangladesh Perspective 
 

Abu Sadat Mohammad Nurunnabi1, Miliva Mozaffor2, Mohammad Akram Hossain3, Sadia 

Akther Sony4 

 
1. Internationally Trained Medical Doctors (ITMD) Bridging Program, The G. Raymond Chang School of 

Continuing Education, Ryerson University, Toronto, ON, Canada. Email: abu.nurunnabi@ryerson.ca   

(corresponding author) 

2. Clinician Researcher, Biomedical Research Foundation (BRF), Dhaka, & Laboratory Consultant and Lecturer, 

Department of Biochemistry, Medical College for Women & Hospital, Uttara, Dhaka-1230, Bangladesh. 

3. Professor and Head, Department of Microbiology and Mycology, National Institute of Preventive and Social 

Medicine (NIPSOM), Dhaka-1212, Bangladesh. 

4. Program Manager, Department of Public Health and Informatics, Bangabandhu Sheikh Mujib Medical University 

(BSMMU), Dhaka-1000, Bangladesh. 

Abstract: Vaccines are responsible for many global public health successes, such as the 

eradication of smallpox and significant reductions in other serious infections like diphtheria, 

pertussis, tetanus, polio and measles. However, mass vaccination has also been the subject of 

various ethical controversies for decades. Several factors need to be considered before any vaccine 

is deployed at national programme like the potential burden of disease in the country or region, 

the duration of the protection conferred, herd immunity in addition to individual protection, 

vaccine-related risks, financing and the logistical feasibility of the large-scale vaccination. 

Moreover, several ethical dilemmas revolve around authority and mandates for vaccination, 

informed consent, benefits vs. risks, and disparities in access to vaccination. This review paper 

aims to elaborate the ethical issues involved in mass vaccination programme and present some 

additional challenges in the context of a resource-poor settings of public health in Bangladesh. 

Keywords: Ethical issues, vaccine, mass vaccination, immunization, EPI, public health, 

Bangladesh. 

 

Introduction: The invention of the vaccine 

is unarguably one of the greatest medical 

achievements in the past century. Vaccines 

have saved millions of lives, prevented 

significant morbidity and suffering, and even 

eradicated smallpox and significantly 

reduced other serious infections like 

diphtheria, pertussis, tetanus, polio and 

measles around the globe1. For an example, 

measles deaths decreased by 60% worldwide 

between 1999 and 2005, and polio, although 

missing the goal of eradication by 2005, has 

decreased significantly as there were fewer 

than 2,000 cases in 20062. Vaccines have 

become readily available in most parts of the 

world, yet debates continue as to the 

appropriateness of requirements for mass 

vaccinations, including legal mandates of 

vaccinations in public health practice and 

public health emergencies and more routinely 



Bangladesh Journal of Bioethics 2018; 9(3): 11-15 

 

 

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for school entry3. Vaccine ethics can be 

conceptualized as a set of issues at the 

intersection of public health policy, clinical 

ethics, and professional ethics4,5. Several 

factors need to be considered before any 

vaccine is deployed at national programme 

like the potential burden of disease, the 

duration of the protection conferred, herd 

immunity in addition to individual protection, 

vaccine-related risks, cost, and the logistical 

feasibility of the large-scale vaccination5. 

Moreover, several ethical and value-based 

debates revolve around authority and 

mandates for vaccination, informed consent, 

benefits vs. risks, and disparities in access to 

vaccination4. This review paper aims to 

elaborate those ethical issues involved in 

mass vaccination programme and present 

some of the additional challenges in the 

context of a resource-poor settings of public 

health sector in Bangladesh. 

 

Expanded Programme on Immunization 

(EPI) in Bangladesh: 

The World Health Organization (WHO) 

initiated the Expanded Programme on 

Immunization (EPI) in May 1974 with the 

objective to vaccinate children throughout 

the world. Ten years later, in 1984, the WHO 

established a standardized vaccination 

schedule for the original EPI vaccines for six 

serious infectious and fatal diseases: Bacillus 

Calmette-Guérin (BCG) for tuberculosis, 

DPT for diphtheria, pertussis and tetanus, 

oral polio vaccine (OPV) for polio myelitis, 

and measles for measles6. Since EPI was 

launched in Bangladesh on 7th April of 1979, 

in 1999, the Global Alliance for Vaccines and 

Immunization (GAVI) was created with the 

sole purpose of improving child health in the 

poorest countries by extending the reach of 

the EPI. The GAVI brought together a grand 

coalition, including the UN agencies and 

institutions (WHO, UNICEF, the World 

Bank), public health institutes, donors and 

implementing countries, the Bill and Melinda 

Gates Foundation and The Rockefeller 

Foundation, the vaccine industry, non-

governmental organizations (NGOs) to 

accomplish the mission7. The creation of the 

GAVI has helped to renew interest and 

maintain the importance of immunizations in 

battling the world’s large burden of infectious 

diseases7.  

Some important update on EPI8: i) TT5 dose 

for WCBA started in 1993, ii) HepB vaccine 

introduced in 2003, iii) AD syringes 

introduced in 2004, iv) Pentavalent vaccine 

introduced in 2009, v) MR vaccine and 

measles vaccine second dose introduced in 

2012, vi) PCV introduced in 2015, vii) tOPV 

to bOPV switched on 23 April 2016 and IPV 

to fIPV switched on November 2017, viii) 

HPV demonstration projects launched on 16 

April 2016 in 4 upazillas and 1 zone under 

Gazipur district which is being completed in 

2017, ix) TT switched to Td on March 2019. 

As a result of outstanding performance in 

improving the child immunization status, 

Bangladesh achieved GAVI Alliance Award 

in 2009 and 2012, which is given as a 

recognition to achieving the Millennium 

Development Goals (MDG), particularly in 

reducing child mortality9. 

 

Other mass vaccination programmes: 

There are several special mass vaccination 

programme launched and done through EPI 



Bangladesh Journal of Bioethics 2018; 9(3): 11-15 

 

 

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authority. Recently, the Human Papilloma 

Virus (HPV) vaccine has been introduced for 

the first time in Bangladesh in 2016 by the 

Ministry of Health and Family Welfare 

(MOHFW), with support from the GAVI10. 

This programme has run in a pilot basis for 

two years in Gazipur district and as it has 

become successful. Then the GAVI has 

become interested to provide support for 

national introduction of HPV vaccine soon10. 

Moreover, several mass vaccination 

programmes are arranged yearly, e.g. special 

measles campaign, mass vaccination in 

disaster and during humanitarian crisis, e.g. 

in Rohingya refugee camps, etc.8, as per 

decision of the Ministry of Health and Family 

Welfare, Government of the people’s 

Republic of Bangladesh. 

 

Ethical issues in mass vaccination: 

In spite of demonstration of individual and 

collective benefit and cost effectiveness of 

vaccination, one of the contemporary 

challenges in providing medical care for 

children is the increasing proportion of 

vaccination refusal, especially in the Western 

world11; however, vaccination rates in 

developing countries like Bangladesh are 

very impressive9. It is not a surprise that 

parents’ refusal to vaccinate their children 

can cause collective harm by raising 

unprotected, susceptible individuals in the 

community. Besides, with herd immunity 

compromised, devastating disease outbreaks 

may occur. In these settings, individuals are 

morally obligated to accept vaccination to 

prevent harm to others12. Apart from this, in 

a specific humanitarian crisis or in disaster, 

failure to provide a vaccine violates the 

principle of non-maleficence5. Moreover, 

only vaccines having proven effectivity and 

safety are to be considered for mass 

administration5. Such vaccines confer 

additional benefit through herd immunity 

apart from protecting people against specific 

diseases when administered on a large 

scale5,11. Looking at a long term investment 

in health care, the statistics illustrate the 

benefits and economics of vaccines and 

disease eradication. For an example, 

smallpox eradication has saved millions of 

lives over the decades, and millions of dollars 

in terms of quarantine and treatment13. From 

a human rights perspective, vaccination 

equitably promotes and protects public health 

which satisfy the notion of the Article 25 of 

the Universal Declaration of Human Rights 

as stated: “Everyone has the right to a 

standard of living adequate for the health and 

well-being of himself and his family … … … 

by progressive measures, national and 

international, to secure [its] universal and 

effective recognition.”5 However, access to 

vaccination is still not achievable universally. 

Racial or ethnic disparities in immunization 

programme is an ethical concern4,5,13. For 

example, in the United States, Blacks and 

Hispanics were significantly less likely to 

report receipt of nearly all preventive services 

like vaccination12,13. Even a few years back, 

immunization coverage in the hilly regions 

and some areas of our country (hard to reach 

areas) was below national average8. 

However, we could overcome the situation in 

a very short time. A new round of polarizing 

debates started up with the steps taken to 

make the HPV vaccine mandatory. Some 

religious conservatives were worried with the 

programme and they thought that the 



Bangladesh Journal of Bioethics 2018; 9(3): 11-15 

 

 

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availability of a vaccine against a sexually 

transmitted disease would threaten 

abstinence-based prevention messages before 

the vaccine was licensed, this concern created 

argument for the vaccine10,14. Abstinence is 

one of the approaches to HIV prevention 

taken by the Physicians’ organizations. 

Preventive measures include abstinence-

based prevention massages like counseling 

adolescents and their families for being more 

responsible on sexual decision making 

including abstinence13,15. Some religious 

conservatives thought that the availability of 

the vaccine could affect the promotion of 

these messages10,13. Some advocacy groups 

agreed availability of the vaccines in public 

health systems; however, they did not agree 

on making the vaccine mandatory4,10,12,13. 

Their perspective was this decision of the 

state may lead to force a child to undergo an 

intervention that may be incompatible with 

her family’s religious values and beliefs15. 

The huge expense of vaccines starting from 

research to introduce a successful product in 

the market along with maintenance of its 

safety and efficacy is a debatable concern in 

public health in terms cost – as most of the 

developing countries have some other 

priorities like pure water supply or 

sanitation13. Moreover, just as a vaccine that 

works in one population might not be as 

effective in another population, so might 

adverse effects of a vaccine be specific to one 

population13. This raises another concern 

about hidden exploitation by the vaccine 

manufacturers. Once again, parental attitudes 

and concerns, as most parents expressed the 

desire for more information about the vaccine 

before they agree to vaccinate their children, 

is an essential topic to address16. Physicians 

and health authority should discuss openly 

and transparently about necessity of 

vaccination with parents – as the ultimate 

decision should be taken by their parents to 

ensure parental autonomy17,18. However, 

where the threat of widespread, serious 

infectious disease is imminent, individual 

liberties may be justifiably curtailed5,19. In 

such situation, national health authorities are 

morally obligated to do all that they 

reasonably can to implement evidence-based 

guidelines to avert preventable harm13,15. 

 

Conclusion:  

The benefits of vaccination extend beyond 

prevention of specific diseases in individuals. 

Vaccination makes good economic sense, as 

well as meets the need to care for the weakest 

members of societies. There may be 

situations where there is an ethically valid 

public health justification for restricting 

individual rights – both in circumstances 

where such actions benefit the community 

and in situations where the actions only 

benefit the individual. However, restrictions 

should only be placed after meeting certain 

conditions to ensure judicious use of this 

power. We conclude that a comprehensive 

vaccination programme is a cornerstone of 

good public health and will reduce inequities 

and poverty especially in a developing 

country like Bangladesh. 

 

References: 

1. Andre FE, Booy R, Bock HL, Clemens J, Datta 

SK, John TJ, et al. Vaccination greatly reduces 

disease, disability, death and inequity worldwide. 

Bull World Health Organ. 2008;86(2):140-146. 



Bangladesh Journal of Bioethics 2018; 9(3): 11-15 

 

 

15 

 

2. Greenwood B. The contribution of vaccination to 

global health: past, present and future. Philos 

Trans R Soc Lond B Biol Sci. 

2014;369(1645):20130433. 

3. Amin ANE, Parra MT, Kim-Farley R, Fielding 

JE. Ethical issues concerning vaccination 

requirements. Public Health Rev. 2012;34:14. 

4. Isaacs D. An ethical framework for public health 

immunisation programs. NSW Public Health 

Bull. 2012;23(5-6):111-115. 

5. Moodley K, Hardie K, Selgelid MJ, Waldman RJ, 

Strebel P, Rees H, et al. Ethical considerations for 

vaccination programmes in acute humanitarian 

emergencies. Bull World Health Organ. 

2013;91(4):290-297. 

6. Hadler S, Cochi S, Bilous J, Cutts F. Vaccination 

Programs in Developing Countries. Chapter 55: 

Vaccines, 4th ed. Philadelphia: Elsevier; 2004. 

7. Global Alliance for Vaccines and Immunizations 

(GAVI). Global immunization challenges 

[Internet]. Accessed May 15, 2018. Retrieved 

from: 

http://www.vaccinealliance.org/reference/globali

mmchallenges.html 

8. World Health Organization (WHO). HPV vaccine 

introduced in Bangladesh WHO South-East Asia 

Regional Office. 2017. [Internet]. Accessed May 

16, 2018. Retrieved from: 

http://www.searo.who.int/bangladesh/HPVvacci

nelaunch/en/ 

9. Directorate General of Health Services (DGHS). 

Bangladesh EPI Coverage Evaluation Survey 

2013. Dhaka: Expanded Programme on 

Immunization, DGHS; 2013:33. 

10. Haseen F, Sony SA. Cervical cancer and ethical 

issues in HPV vaccination. Bangladesh J 

Bioethics. 2017;8(2):31-37. 

11. Salmon DA, Omer SB. Individual freedoms 

versus collective responsibility: immunization 

decision making in the face of occasionally 

repeating values. Emerg Themes Epidemiol. 

2006;3(1):1-3. 

12. Dawson A. Vaccination and the prevention 

problem. Bioethics. 2004;18(6):515-530. 

13. Ulmer JB, Liu MA. Ethical issues for vaccines 

and immunization. Nat Rev Immunol. 

2002;2(4):291-296. 

14. Salmon DA, Haber M, Gangarosa EJ, Phillips L, 

Smith N, Chen RT. Health consequences of 

religious and philosophical exemptions from 

immunization laws: individual and societal risks 

of measles. JAMA. 1999, 282(1):47-53. 

15. Jacobs AJ, Arora KS. When may government 

interfere with religious practices to protect the 

health and safety of children? Ethics Med Public 

Health. 2018;5:86-93. 

16. Holman DM, Benard V, Roland KB, Watson M, 

Liddon N, Stokley S. Barriers to human 

papillomavirus vaccination among US 

adolescents: a systematic review of the literature. 

JAMA Pediatrics. 2014;168(1):76-82. 

17. Feikin DR, Lezotte DC, Hamman RF, Salmon 

DA, Chen RT, Hoffman RE. Individual and 

community risks of measles and pertussis 

associated with personal exemptions to 

immunization. JAMA. 2000;284(24):3145-3150. 

18. Leask J, Kinnersley P, Jackson C, Cheater F, 

Bedford H, Rowles G. Communicating with 

parents about vaccination: a framework for health 

professionals. BMC Pediatr. 2012;12:154. 

19. Gostin LO. Influenza A(H1N1) and pandemic 

preparedness under the rule of international law. 

JAMA. 2009;301(22):2376-2378. 

 

Author contributions: ASM Nurunnabi and M 

Mozaffor were involved in concept and design of the 

paper; ASM Nurunnabi, M Mozaffor, MA Hossain 

and SA Sony were equally involved in the literature 

search, review, compilation, manuscript writing and 

revision. 

Conflict of interest: There is no conflict of interest 

relevant to this paper to disclose. 

 

 

 


