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Vaccine stockouts around the world: Are essential vaccines always available when needed?

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Introduction: As countries rise to the challenge of implementing the priorities of this "Decade of Vaccine" and their commitments delineated in the Global Vaccine Action Plan (GVAP), many continue to face important challenges of securing a continuous supply of essential vaccine for their national immunization programme. This study provides evidence on the incidence of vaccine stockouts in countries, their root causes and their potential impact on service delivery. Methods: Vaccine stockout indicators collected from the WHO-UNICEF Joint Reporting Form (JRF) and UNICEF's Vaccine Forecasting Tool were analysed for the years covering the first half of the GVAP (2011 to 2015) and using 2010 as the baseline year. While the JRF collects annual information on national and subnational stockouts by vaccine, the UNICEF Vaccine Forecasting Tool has the advantage of requesting UNICEF procuring countries to report on the reasons underpinning any stockouts. Results: Every year on average, one in every three WHO Member States experiences at least one stockout of at least one vaccine for at least one month. The incidence is most pronounced in Sub-Saharan Africa where 38% of countries in this area of the world report national-level stockouts. The vaccines most affected are DTP containing vaccines (often combined with HepB and Hib) and BCG. They account for respectively 43% and 31% of stockout events reported. While national level vaccine stockouts occur in countries of all income groups, middle income countries are the most affected. In 80% of cases, national level stockouts were due to reasons internal to countries. More specifically, 39% of stockouts were attributable to government funding delays, 23% were caused by delays in the procurement processes, and poor forecasting and stock management at country level accounted for an additional 18%. When a national level stockout of vaccines occurs, there is an 89% chance that a subnational stockout will occur at district level. More concerning is that if a district level stockout occurs, this will lead to an interruption of vaccination services in 96% of cases. Discussion: There continues to be important challenges of ensuring a continuous availability of essential vaccines. The global community, together with countries, urgently need to design effective interventions aimed at reducing the frequency and mitigating the impact of stockouts.
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Vaccine stockouts around the world: Are essential vaccines always
available when needed?
q
Patrick Lydon
a,
, Benjamin Schreiber
b
, Aurelia Gasca
c
, Laure Dumolard
a
, Daniela Urfer
a
, Kamel Senouci
a
a
World Health Organization, Expanded Programme on Immunization, Geneva, Switzerland
b
UNICEF Programme Division, New York, USA
c
UNICEF Supply Division, Copenhagen, Denmark
article info
Keywords:
Vaccines
Stockouts
Supply chain
GVAP
abstract
Introduction: As countries rise to the challenge of implementing the priorities of this ‘‘Decade of Vaccine”
and their commitments delineated in the Global Vaccine Action Plan (GVAP), many continue to face
important challenges of securing a continuous supply of essential vaccine for their national immuniza-
tion programme. This study provides evidence on the incidence of vaccine stockouts in countries, their
root causes and their potential impact on service delivery.
Methods: Vaccine stockout indicators collected from the WHO-UNICEF Joint Reporting Form (JRF) and
UNICEF’s Vaccine Forecasting Tool were analysed for the years covering the first half of the GVAP
(2011 to 2015) and using 2010 as the baseline year. While the JRF collects annual information on national
and subnational stockouts by vaccine, the UNICEF Vaccine Forecasting Tool has the advantage of request-
ing UNICEF procuring countries to report on the reasons underpinning any stockouts.
Results: Every year on average, one in every three WHO Member States experiences at least one stockout
of at least one vaccine for at least one month. The incidence is most pronounced in Sub-Saharan Africa
where 38% of countries in this area of the world report national-level stockouts. The vaccines most
affected are DTP containing vaccines (often combined with HepB and Hib) and BCG. They account for
respectively 43% and 31% of stockout events reported. While national level vaccine stockouts occur in
countries of all income groups, middle income countries are the most affected. In 80% of cases, national
level stockouts were due to reasons internal to countries. More specifically, 39% of stockouts were attri-
butable to government funding delays, 23% were caused by delays in the procurement processes, and
poor forecasting and stock management at country level accounted for an additional 18%. When a
national level stockout of vaccines occurs, there is an 89% chance that a subnational stockout will occur
at district level. More concerning is that if a district level stockout occurs, this will lead to an interruption
of vaccination services in 96% of cases.
Discussion: There continues to be important challenges of ensuring a continuous availability of essential
vaccines. The global community, together with countries, urgently need to design effective interventions
aimed at reducing the frequency and mitigating the impact of stockouts.
Ó2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creative-
commons.org/licenses/by/4.0/).
1. Introduction
One of the cornerstones of an effective national immunization
programme is for its supply chain to ensure a continuous and unin-
terrupted availability of essential vaccines up to the point of vacci-
nation. If vaccine availability is interrupted for any reason, missed
opportunities to vaccinate will occur and populations run the risk
of not being protected against deadly preventable diseases. Unfor-
tunately, recent evidence has shed light on the fact that vaccine
supply chain systems have gradually outgrown their ability to
ensure uninterrupted availability of vaccine and to manage this
current Decade of Vaccine priorities and commitments as delin-
eated in the Global Vaccine Action Plan (GVAP 2011–2020) [1–4].
As part of the GVAP monitoring and accountability framework, a
global vaccine availability indicator is being monitored yearly with
an overarching objective of a 2/3 reduction goals in the number of
countries with national level vaccine stockouts by 2020 [5,6].
In this study we present the findings from an in-depth analysis
of the GVAP vaccine stockout indicator in 194 WHO Member
States. The metric of vaccine availability used is the incidence
http://dx.doi.org/10.1016/j.vaccine.2016.12.071
0264-410X/Ó2017 Published by Elsevier Ltd.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
q
Open Access provided for this article by the Gates Foundation.
Corresponding author.
E-mail address: lydonp@who.int (P. Lydon).
Vaccine 35 (2017) 2121–2126
Contents lists available at ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
and duration of vaccine stockouts reviewed for the years covering
the first half of the GVAP (2011–2015) together with a 2010 base-
line reference year. These indicators, while imperfect, are proxy
measures of a stressed vaccine supply chain and indicative of sys-
tems unable to ensure that essential vaccines are available when
needed. Disruptions in vaccine availability, places national immu-
nization programme at risk of not reaching their own targets and
goals of protecting their populations from vaccine preventable dis-
eases. The findings from this research will contribute to the limited
evidence on trends and performance of vaccine supply chain sys-
tems worldwide and serve as a first step towards understanding
the root causes of vaccine stockouts. We hope that awareness of
the challenges will be raised in order for the global community,
together with countries, to design effective interventions aimed
at reducing the frequency and mitigating the impact of stockouts.
2. Methods
2.1. Data sources and years
The analysis was based on two main data sources. The first is
the WHO-UNICEF Joint Reporting Form (JRF) [7]. Since 2005 the
JRF collects data on the frequency of national level vaccine stock-
outs among a comprehensive set of systems indicators designed
to measure immunization performance and trends in member
state countries. Initially, three indicators were being reported by
WHO Member States as follows:
Was there any stockout of vaccine at national level? (Yes-No)
If ‘‘Yes”, please specify the duration of the stockout in months?
(duration in months or N/A)
Was there any stockout of vaccine at district level? (Yes-No)
In 2014, two indicators were added:
If ‘‘Yes” to the district level stockout question, was the district
level stockout caused by the national level stockout? (Yes-No
or N/A)
If district level stockouts occurred, were vaccination services
interrupted because vaccines were unavailable? (Yes-No
or N/A)
Countries respond to these five indicators
1
by vaccine as per
their national immunization schedule.
The second data source is the UNICEF Vaccine Forecasting Tool
[8]. Countries that purchase vaccines through the UNICEF procure-
ment mechanism submit requested data in this tool as part of the
annual vaccine forecasting exercise managed by UNICEF Supply
Division. One of the reporting sections concerns the previous year’s
vaccine forecast and any occurrence of a stockout. While the initial
two indicators collected through the JRF mechanism are also
reported in the Vaccine Forecasting Tool,
2
the latter has the advan-
tage that it requests countries to report on the reasons for and causes
of the stockouts (Table 1).
For the first two indicators related to stockouts occurrence at
national level and the causes of the stockouts, the periods covered
in this analysis are the baseline year of 2010 and the first half of the
GVAP included between 2011 and 2015. The period of analysis for
the sub-national stockout indicators were the years 2014 and
2015.
2.2. Definitions and adjustments
In order to go deeper in the analytics than simply presenting
figures on the number of countries that report ‘‘Yes” to a vaccine
stockout, the notion of a stockout event becomes useful to define
when a stockout is reported for a specific vaccine. In other words,
if country reports ‘‘Yes” to experiencing a stockout for two separate
vaccines in the same reporting year, these are considered as two
separate stockout events. Likewise, if a country reports multiple
stockouts for the same vaccine in the same reporting year, each
is considered as a separate stockout event in the analysis and
quantified as such. Moreover, to be considered a full vaccine stock-
out, a minimum duration of 30 days (or 1 complete month) was
set. Given the global recommendation to maintain a 3 month buf-
fer stock of vaccines at national level at all times, a stockout would
indicate that these safety stocks have been depleted and vaccine
availability for the national immunization programme could be
compromised. If the reported duration of a stockout was less than
a month, this was not considered as a stockout event and was
excluded from the analysis.
The next adjustment was made in order to improve cross-
country comparisons and to improve reporting completeness. On
the former, an inclusion criteria was set for the analysis to focus
on a subset of vaccines that are common to all national immuniza-
tion schedules. Only stockouts reported for BCG, DTP, Measles con-
taining vaccines (ex: DTP-HepB-Hib or MMR), and Polio were
included in the analysis.
3
To improve reporting completeness and
ensure that the analysis can include all 194 WHO Member States, sev-
eral approaches were used to estimate missing information. The first
method was to cross-check all indicators reported by each country in
a given year. In some instances, it was not uncommon for a country to
report on the duration of a stockout for a given vaccine but to forget
to respond ‘‘Yes” to the question of whether or not a stockout
occurred. This backward induction process was used to improve
the reporting completeness. The second method was to crosscheck
the vaccine product that is used in the country using the vaccine
schedule information from the JRF [7]. The reason is that a country
may report a stockout for Hib vaccine, but not report it for HepB or
DTP. Yet the vaccine product used in their national immunization
programme is the pentavalent combination (DTP-HepB-Hib). As a
result, a retrofitting adjustment was performed so that other antigens
are included as part of the reported stockout event. The third method
was for WHO Regional Office focal points to liaise back with the 25 to
30 countries that did not complete any information, and to solicit
responses to their JRF. For those that followed-up with the request,
it was to confirm that no stockouts occurred in the reporting year.
Since most cases of a non-response by a country was to indicate that
no stockouts occurred, this was assumed for the remaining countries
that didn’t follow-up with WHO Regional Office requests.
The reporting to UNICEF on the reasons for a national level
stockout needed were standardized and coded according to major
groups of root-causes. The reasons reported by countries were
grouped according to the following categories: (1) Financing
(delays in releasing funds to purchase vaccines), (2) Forecasting
and stock management (inaccurate forecast or poor stock manage-
ment), (3) Procurement (delays in the national procurement pro-
cess), (4) Product availability (shortages of vaccines on the global
market), (5) Quality (if a vaccine product was taken off the WHO
prequalification list because of a quality concern and no longer
available), and (6) Other (all other causes specific to a country or
not identified/reported on).
1
The stockout indicator reference code for the JRF are Immunization System
Indicators [6280–6380 A-E].
2
The fact that both mechanisms requests the same information allows for
consistency checks to be made for the countries in common for both reporting
systems.
3
Newer vaccines that are not introduced in all countries (ex: Pneumococcal
conjugate or Rotavirus) or that are specific to certain regions of the world (ex: Yellow-
Fever or Japanese Encephalitis) were excluded in order to analyse countries across a
common set of vaccines used.
2122 P. Lydon et al./ Vaccine 35 (2017) 2121–2126
2.3. Analytical approach
The findings for this study cover three interrelated analytical
questions. This first was to analyse how common vaccine stockout
events occur at national level and what vaccines are most affected.
The second was to understand the root-causes of these national
stockouts. The third was an attempt to shed light on the potential
impact of national level stockouts vaccine availability for service
delivery. The baseline year is set at 2010 – the year prior to the
start of the GVAP (2011–2020). The reference year for the analysis
is 2015 representing the mid-point to the 2020 GVAP goals (2011–
2015). The findings are presented in the aggregates, compared
across WHO regional groups, and looking at differences between
income groups. Figures are presented as simple averages.
3. Results
3.1. National level stockouts around the world
At the mid-point in the GVAP, a total of 65 countries (34% of all
countries) reported at least one national-level stockout event for at
least one vaccine and for at least one month during 2015 (Table 2).
Since the 2010 baseline year, the situation improved very little
despite a promising downward trend during 2011–2014 and
where all progress was offset in 2015 – a year marking a setback
to reaching the GVAP target of a two-thirds reduction in the num-
ber of countries reporting national-level stockouts by 2020.
In countries reporting national-level stockouts, multiple events
often occur within the year when one or more vaccines are
affected. In some cases more than 4 stockout events are reported
by countries for a given year (Fig. 1). For the GVAP mid-point year
of 2015 a total of 113 stockout events were reported in the 65
countries - an average of 1.74 stockout events a year per country
reporting national level stockouts. The average stockout duration
was 44 days. The trend since 2013 indicates that the average dura-
tion of a stockout event is on the increase.
A review by groupings of countries uncovers the following addi-
tional findings:
During the first half of the GVAP (2011–2015), 46% of countries
reported a maximum of 1 stockout event in any given reporting
year. For the mid-point year of 2015 this proportion reached
60% and indicates a slight trend away from multiple stockout
events reported by countries within a given year. An average
of 30% of countries reported more than 3 stockout a year with
a maximum reported in a country ranging between 6 and 7
stockout events in a single year.
Table 1
Summary table of the key data sources.
Data source First/last year
of data
Reporting
Frequency
No. of reporting
countries
Stockout indicator scope Duration of
the stockouts
Reporting on causes
of stockouts
WHO-UNICEF Joint Reporting Form 2005–2015 Annual 194 National level by vaccine Months No
WHO-UNICEF Joint Reporting Form 2014–2015 Annual 194 Sub-national level by vaccine Months No
UNICEF Supply Division Vaccine
Forecasting Tool
2002–2015 Annual 93 National level by vaccine Months Yes
Table 2
National-level stockouts – Percent of countries by region, income and population.
2010 2011 2012 2013 2014 2015 Avg. 2011–15
Summary indicators
No. countries reporting stockouts 67 66 57 54 50 65 58
% of countries 35% 34% 29% 28% 26% 34% 30%
No. of stockout events 153 148 120 112 110 113 121
Average duration of stockouts (days) 42 33 32 29 45 44 37
No. UNICEF procuring countries reporting stockouts 44 39 28 52 36 22 35
% of UNICEF procuring countries 49% 43% 31% 58% 40% 24% 39%
% countries by stockout frequency
One stockout event 43% 39% 40% 41% 50% 60% 46%
Two stockout events 19% 24% 25% 31% 18% 20% 24%
Three stockout events 13% 19% 24% 13% 12% 9% 15%
Four or more stockout events 25% 18% 11% 15% 20% 11% 15%
% stockout events by WHO Region
a
Americas (AMR = 35) 19% 18% 16% 17% 32% 17% 20%
Sub-Saharan Africa (AFR = 47) 39% 38% 38% 46% 32% 34% 38%
East Mediterranean (EMR = 21) 7% 11% 5% 6% 6% 9% 7%
Europe (EUR = 53) 18% 17% 18% 7% 14% 26% 16%
South-East Asia (SEA = 11) 4% 2% 5% 7% 4% 5% 5%
Western Pacific (WPR = 27) 13% 14% 18% 17% 12% 9% 14%
% stockout events by Income
b
Low income (n = 31) 21% 23% 23% 26% 26% 20% 24%
Lower-Middle income (n = 50) 36% 29% 35% 41% 24% 28% 31%
Upper-Middle income (n = 58) 33% 32% 32% 29% 36% 27% 31%
High income (n = 55) 10% 16% 10% 4% 14% 25% 14%
% stockout events by Vaccine
BCG 33% 28% 34% 33% 25% 34% 32%
DTP containing vaccine 47% 45% 42% 35% 40% 51% 42%
Measles containing vaccine 7% 14% 9% 14% 14% 5% 11%
Polio 13% 13% 15% 18% 21% 10% 15%
*
Numbers in brackets indicate the total number of WHO Member States for each region respectively.
**
According to the World Bank classification of countries. The middle income group includes countries that are classified as lower-middle income countries and upper-
middle income countries. Numbers in bracket indicate the number of WHO Member States in each income group.
P. Lydon et al. / Vaccine 35 (2017) 2121–2126 2123
The incidence of national-level stockouts is most pronounced in
Sub-Saharan Africa (AFR) where 38% of the 47 countries in this
region are affected. The next region most affected is the Amer-
icas. On the other hand, the South-East Asia and Western Pacific
regions seem to be the least impacted by vaccine stockouts.
Stockouts at national level occur in countries of all income
groups. Both lower and upper middle income countries
reported the majority of stockouts – 31% on average for each
group between 2011 and 2015.
A deeper analysis by vaccine uncovers that during the first half
of the GVAP, 43% of stockouts events concerned DTP-containing
vaccines – this proportion peaked in 2015 when 51% of all reported
stockouts events included DTP-containing vaccines (often com-
bined with HepB and Hib vaccine). The second vaccine most
affected by stockouts is BCG and represents another 31% of stock-
out events reported at national level.
3.2. Causes of national level stockouts
The analysis of the UNICEF Supply Division information uncover
that in 80% of cases, national level stockouts in the first half of the
GVAP period were endogenous in nature. In other words, the rea-
sons were internal to the countries reporting stockouts rather than
due to exogenous, or external reasons outside of a country’s con-
trol. More specifically, 39% of stockouts were attributable to gov-
ernment funding delays (Fig. 2). Since UNICEF is unable to ship
vaccines to a country unless payment is received upfront, the com-
mon delays in government releasing funds to pay UNICEF for the
purchasing of vaccines invariably leads to a stockout. While vac-
cine financing is the single largest root cause of stockouts, delays
in the procurement processes, poor forecasting and stock manage-
ment at country level accounted for a significant share of internal
reasons for stockouts – respectively 23% and 18%.
For a remaining 11%, the cause of the stockout are exogenous
and independent to the country. In 9% of cases, the stockouts were
due to a global supply shortages. In rare cases, a quality issue on
certain vaccines caused countries to experience stockouts. This
would happen if a certain vaccine is no longer prequalified by
the WHO. In which case, UNICEF can no longer purchase this vac-
cine on behalf of countries and this can lead to a stockout.
3.3. Impact at subnational level and service delivery levels
In and of itself, a national level stockout does not necessarily
translate into a countrywide stockout of vaccines. There may be
instances where there is enough vaccines at subnational levels to
buffer against the effects of a national level stockout. In such case,
29
39
13 13
8
6
17
7
0
5
10
15
20
25
30
35
40
45
2010 2011 2012 2013 2014 2015
No. of countries reporng stockout events
One stockout
Two stockouts
Three stockouts
Four or more stockouts
Fig. 1. Frequency of national level stockouts.
Funding
delays
39%
Poor forcasng &
stock management
23%
Procurement
delays
18%
Global shortage
9%
Quality issues
2%
Other/Not idenfied
9%
Reasons
endogenous
to the
country
80%
Reasons
exogenous
to the
country
11%
Other
Causes
9%
Fig. 2. Root cause of national level vaccine stockouts in 90 UNICEF procuring countries (2011–15).
2124 P. Lydon et al. / Vaccine 35 (2017) 2121–2126
vaccination services are not interrupted by the lack of vaccines and
the national immunization programme is unaffected. That said, to
what extent do we know if this is the case? To shed light on the
potential impact of a national level stockout on subnational avail-
ability of vaccines and potential interruption in vaccination ser-
vices, a deeper analysis was conducted for the years 2014 and
2015.
The results indicate in 2015 a total of 58 countries reported
subnational-level stockouts at district level (Fig. 3). This represents
89% of the 65 countries that reported national level stockouts. Of
these 58 countries reporting subnational level stockouts, 86% (or
49 countries) indicated that the subnational level stockout was
caused by the national-level stockout. In other words, both
reported events were interlinked. For the remaining 14% of coun-
tries, the subnational-level stockout were caused by factors unre-
lated to the national-level stockout – a breakdown of the
distribution system or poor stock management at lower levels of
the supply chain for instance.
More concerning is that 47 of the 49 countries reported that the
district level stockout resulted in an interruption of vaccination
services. This implies that there is an 96% chance that a stockout
at district level will cause an interruption of immunization ser-
vices. In reviewing the trend over the two years of data, the situa-
tion deteriorated between 2014 and 2015 with more countries
reporting district-level stockouts and interruptions of vaccination
services.
4. Discussion
As the findings revealed, essential vaccines are not always avail-
able when needed and stockouts occur on a regular basis at both
national and subnational levels. Countries in all regions of the world
and of all income groups experience regular stockouts of key vacci-
nes, and in many cases these cause an interruptions of immuniza-
tion services. Results from an immunization coverage analysis in
17 countries that reported stockouts at all levels of the system
and interruptions in vaccination services suggest that stockouts
can potentially reduce DTP3 coverage by 7–10% points [9]. In the
Philippines for instance, repeated stockouts of DTP-HepB-Hib vacci-
nes is estimated to have contributed to a 15% point reduction in the
national coverage estimate [10]. Given the size of the population in
the Philippines, large segments became unprotected. It is no sur-
prise that Diphtheria cases were on the rise in 2015.
While this study has uncovered the ongoing challenges in
ensuring vaccine availability in countries, the interpretation of
these finding needs to be made with some understanding of the
key limitations. A first set relate to the methodology that under-
pins the analysis and the need to make certain adjustments to
improve the reporting completeness or to improve cross-country
comparisons. Given that a national stockout of vaccine could be
an embarrassing situation for a country to report on, one would
expect that the incentive to under-report a stockout and/or its
duration would outweigh any reasons to over-report. Considering
further that some vaccines were excluded from the analysis, we
suspect that the findings presented in the analysis are likely to
underestimate the full magnitude of the problem at hand. This
underreporting potential was raised by the Strategic Advisory
Group of Experts (SAGE) for immunization in 2014 [6].
The second set of limitations relate to the indicators collected to
track subnational-level stockouts and whether these lead to an
interruption of vaccination services. While these indicators provide
valuable insights, the magnitude of the problem is difficult to
gauge without a complete understanding of how many districts
were affected, or the extend of the interruption on vaccination ser-
vices and coverage performance. The third key limitation touches
on the root causes of stockouts – an analysis based on approxi-
mately 90 low and middle income countries that procure their vac-
cines through UNICEF and making the assumption that the root
cause results are generalizable. That said, it’s likely that exogenous
factors would play a greater role in explaining stockouts in middle
income countries that are self-procuring and often have difficulty
securing access to timely and affordable vaccines on the global
market.
These limitations aside, this paper was an opportunity to assess
the situation half way through the GVAP and the trend is not mov-
ing towards the goal of a 2/3rd reduction in the number of coun-
tries experience at least one stockout of at least one vaccine for
at least one month. The target by 2020 is to have 25 countries or
less reporting national level vaccine stockouts. Yet, we remain far
from this target with 67 countries reporting stockouts in 2010
and 65 countries reporting stockouts in 2015.
Few would argue against the moral imperative to make vacci-
nes widely available on an equitable basis. This is especially true
for the poorest countries where the burden of vaccine preventable
diseases is the greatest. We see however, that many countries con-
tinue to face challenges of accessing an uninterrupted supply of
vaccines. Unless a concerted and coordinated effort is made to
address this problem, stockouts of life saving vaccines will con-
tinue to be commonplace. Effective interventions aimed at reduc-
ing the frequency and mitigating the impact of stockouts are
critically needed especially to address the root-causes of 75% of
national level stockouts namely: (1) addressing delays in releasing
national funds to purchase vaccines on time and ensure vaccine
financing, (2) improving forecasting accuracy, stock management
practices and data systems for managing vaccines, (3) addressing
cumbersome national procurement processes and delays, espe-
cially in self-procuring countries. Recent discussion at global level
on these issues hold the promise for a change [11,12]. In the mean-
time, we hope that this analysis serves to raise awareness on the
vaccine stockouts situation worldwide and initiate interventions
aimed at reducing and eliminating causes of future ones.
Conflict of interest
All authors declare no conflict of interest.
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44
38
33
65
58
49 47
0
25
50
75
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2126 P. Lydon et al. / Vaccine 35 (2017) 2121–2126
... The regular immunization program has a successful history in developing countries like India. But it also faces issues like stock-out (Chandra and Kumar, 2018a;Lydon et al., 2017), damaged quality due to improper handling and temperature variance (Robertson et al., 2017), vaccine wastage due to expiry and open vial waste (Brown et al., 2014b;Duijzer et al., 2018b;Heaton et al., 2017;Patel et al., 2016). The mismanagement of vaccine waste can also Improving VSC using LAG practices contribute to the outbreak of drug-resistant infectious diseases (Hsu et al., 2008;Makajic-Nikolic et al., 2016). ...
... Also, it explored the use of operation research and operation management techniques as the intervention of these issues and challenges. Lydon et al. (2017) analyzed the availability of required vaccines around the world with the help of previous data and concluded that stock-out of vaccines occurs very frequently at national level stocks. Cernuschi et al. (2018) documented the programmatic challenges of the countries moving from GAVI (The Global Alliance for Vaccines and Immunizations) association to self-dependency and revealed that independent decision-making and financial stability along with timely supply of vaccines are the major problems in such countries. ...
... Frequent stock-out of vaccines in regular immunization programs is a major problem . The study of Lydon et al. (2017) also shows that Improving VSC using LAG practices every year about one out of every three WHO member states has at least one basic vaccination stock-out that lasts at least one month. Thus, reducing the number of stock-outs becomes an important criterion for LAG practices selection in SVSC. ...
Purpose The already-strained vaccine supply chain (VSC) of the expanded program for immunization (EPI) require a more robust and structured distribution network for pandemic/outbreak vaccination due to huge volume demand and time constraint. In this paper, a lean-agile-green (LAG) practices approach is proposed to improve the operational, economic and environmental efficiency of the VSC. Design/methodology/approach A fuzzy decision framework of importance performance analysis (IPA)–analytical hierarchy process (AHP)–technique for order for preference by similarity in ideal solution (TOPSIS) has been presented in this paper to prioritize the LAG practices on the basis of the influence on performance indicators. Sensitivity analysis is carried out to check the robustness of the presented model. Findings The derived result indicates that sustainable packaging, coordination among supply chain stakeholders and cold chain technology improvement are among the top practices affecting most of the performance parameters of VSC. The sensitivity analysis reveals that the priority of practices is highly dependent on the weightage of performance indicators. Practical implications This study's finding will help policymakers reframe strategies for sustainable VSC (SVSC) by including new management practices that can handle regular immunization programs as well as emergency mass vaccination. Originality/value To the best of the authors' knowledge, this is the first study that proposes the LAG framework for SVSC. The IPA–Fuzzy AHP (FAHP)–Fuzyy TOPSIS (FTOPSIS) is also a novel combination in decision-making.
... This might be due to the lack of training for vaccinators in Tanzania, particularly in the Morogoro region. This observation might be linked to the common knowledge of healthcare [31]. ...
Article
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Background Effective vaccine management is essential to maintain the quality of vaccines, minimise wastages, and prevent missed opportunities for vaccination at service delivery points. Objectives This study aims to assess vaccine management practices among vaccinators at health facilities in the Morogoro region, Tanzania. Methodology A descriptive cross-sectional study design involved health workers from 77 health facilities offering vaccination services. The study population consisted of vaccine handlers and vaccinators working in public health facilities in the Morogoro region. The vaccine management practices were assessed using data collected from ledgers and the Vaccine Information Management System (VIMS). The temperature records were downloaded from the Fridge-tag® 2 and Coldtrace5 devices. Results The findings indicated that 65 (84%) health facilities had functional refrigerators and are using power from 26 (34%), 28 (36%), and 23 (30%) of grid electricity, solar, and Liquefied Petroleum Gas (LPG), respectively. Besides, 27 (35%) health facilities have an alternative energy source as a backup. In general, healthcare workers had a good knowledge of cold chain management, including the World Health Organization recommended storage temperatures for vaccines. Furthermore, vaccine stockout was found in 12 (15.6%) health facilities for at least one antigen and 4 (5.1%) health facilities for all five antigens under observation. This current study also revealed that the average calculated vaccine wastage rates for DTP, Measles–Rubella and Rotavirus vaccines were 7%, 19%, and 15%, respectively. More than half of health workers did not perform monthly temperature data reviews. In addition, poor performance led to high wastage rates, including the Rotavirus vaccines, and a change in VVM to discard points. Finally, a small number of 5 (6.5%) health facilities consecutively reported temperature exposure beyond + 8 Celsius (between 5.9 and 281 h). Conclusions Healthcare workers’ vaccine and cold chain management knowledge were good for temperature data reading and documentation. However, the practices were poor for some health facilities. The gaps observed in this study inform health managers and policymakers toward establishing interventions to improve health workers' knowledge and practice, including mentorships, supervision, and training to guarantee that each child in all communities reaps the benefits of immunisation services.
... Streamlined, efficient processes based on accurate data and long-term planning support timely procurement, forecasting, and stock management. [4] A demand-side that functions effectively, is well-resourced, and recognizes the farreaching value of vaccination, continues to signal the need for ongoing investment in vaccine innovation. ...
... Phase 3 determines how efficient the vaccine is, and the dose to verify its effectiveness is given to volunteers. Phase 4 is the approval of the regulations and licencing (Lydon et al., 2017). ...
Article
Purpose Immunization is one of the most cost-effective ways to save lives while promoting good health and happiness. The coronavirus disease 2019 (COVID-19) pandemic has served as a stark reminder of vaccines' ability to prevent transmission, save lives, and have a healthier, safer and more prosperous future. This research investigates the sustainable development (SD) of the COVID-19 vaccine supply chain (VSC). Design/methodology/approach This study investigates the relationship between internal process, organizational growth, and its three pillars of SD environmental sustainability, economic sustainability and social sustainability. Survey-based research is carried out in the hospitals providing COVID-19 vaccines. Nine hypotheses are proposed for the study, and all the hypotheses got accepted. The survey was sent to 428 respondents and received 291 responses from health professionals with a response rate of 68%. For the study, the healthcare professionals working in both private and public hospitals across India were selected. Findings The structural equation modelling (SEM) approach is used to test the hypothesis. All nine hypotheses are supported. This study examines a link between internal processes and organizational learning and the three sustainability pillars (environmental sustainability, economic sustainability and social sustainability). Practical implications This study will help the management and the policymakers to think and adopt SD in the COVID-19 VSC. This paper also implies that robust immunization systems will be required in the future to ensure that people worldwide are protected from COVID-19 and other diseases. Originality/value This paper shows the relationship between organizational learning and internal process with environmental sustainability, economic sustainability and social sustainability for the COVID-19. Studies on VSC of COVID-19 are not evident in any previous literature.
... As reported to GAVI, 65 countries reported at least one national-level stock-out in 2015, and 73 countries reported 131 stock-out events in 2016. Whereas stockouts were mostly attributed to funding delays [29], in China, limited production, limited governmental batch release testing capacities, and delays in procurement were also considered important obstacles [30]. To avoid constraints and delays, the EU system builds on release of vaccines by Official Member State Control Laboratories (OMCL) [31] and parallel testing by OMCL and manufacturers. ...
Article
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Background Unavailability of vaccines endangers the overall goal to protect individuals and whole populations against infections. Methods The German notification system includes the publication of vaccine supply shortages reported by marketing authorisation holders (MAH), information on the availability of alternative vaccine products, guidance for physicians providing vaccinations and an unavailability reporting tool to monitor regional distribution issues. Aim This study provides a retrospective analysis of supply issues and measures in the context of European and global vaccine supply constraints. Results between October 2015 and December 2020, the 250 notifications concerned all types of vaccines (54 products). Most shortages were caused by increased demand associated with immigration in Germany in 2015 and 2016, new or extended vaccine recommendations, increased awareness, or changes in global immunisation programmes. Shortages of a duration up to 30 days were mitigated using existing storage capacities. Longer shortages, triggered by high demand on a national level, were mitigated using alternative products and re-allocation; in a few cases, vaccines were imported. However, for long lasting supply shortages associated with increased global demand, often occurring in combination with manufacturing issues, few compensatory mechanisms were available. Nevertheless, only few critical incidents were identified: (i) shortage of hexavalent vaccines endangering neonatal immunisation programmes in 2015;(ii) distribution issues with influenza vaccines in 2018; and (iii) unmet demand for pneumococcal and influenza vaccines during the coronavirus disease (COVID)-19 pandemic. Conclusion Vaccine product shortages in Germany resemble those present in neighbouring EU states and often reflect increased global demand not matched by manufacturing capacities.
Article
Full-text available
Abstract Supply Chain Management (SCM) is the active management of supply chain activities to maximize customer value and achieve sustainable competitive advantage and in the most effective, and efficient ways possible. Nigeria is a developing economy with poor healthcare indices coupled with poor socioeconomic developmental status with a dire need for a robust SCM platform to drive her economy and the already weak healthcare system. The study explored the dynamics of supply chain management for commodities as a growing need for healthcare sector development in Nigeria. We critically explored studies and articles related to the SCM and healthcare sector development in Nigeria. SCM is a growing and largely untapped aspect of healthcare sector development in Nigeria.
Article
Purpose Each individual needs to be vaccinated to control the spread of the COVID-19 pandemic in the shortest possible time. However, the vaccine distribution with an already strained supply chain in low- and middle-income countries (LMICs) will not be effective enough to vaccinate all the population in stipulated time. The purpose of this paper is to show that there is a need to revolutionize the vaccine supply chain (VSC) by overcoming the challenges of sustainable vaccine distribution. Design/methodology/approach An integrated lean, agile and green (LAG) framework is proposed to overcome the challenges of the sustainable vaccine supply chain (SVSC). A hybrid best worst method (BWM)–Measurement of Alternatives and Ranking According to COmpromise Solution (MARCOS) methodology is designed to analyze the challenges and solutions. Findings The analysis shows that vaccine wastage is the most critical challenge for SVSC, and the coordination among stakeholders is the most significant solution followed by effective management support. Social implications The result of the analysis can help the health care organizations (HCOs) to manage the VSC. The effective vaccination in stipulated time will help control the further spread of the virus, which will result in the normalcy of business and availability of livelihood for millions of people. Originality/value To the best of the author's knowledge, this is the first study to explore sustainability in VSC by considering the environmental and social impact of vaccination. The LAG-based framework is also a new approach in VSC to find the solution for existing challenges.
Article
National immunisation programmes require an adequate supply of vaccines to function properly but many countries, globally and in Europe, have reported vaccine shortages. A comprehensive view of vaccine shortages and stockouts in the EU/EEA is missing in the published literature. This study was conducted in the framework of the European Joint Action on Vaccination (EU-JAV). Twenty-eight countries, including 20 EU-JAV consortium member states and an additional 8 EU/EEA countries, were invited to participate in a survey aimed at collecting information on vaccine shortages and stock-outs experienced from 2016 to 2019, their main causes, actions taken, and other aspects of vaccine supply. Twenty-one countries completed the survey (response rate 75%), of which 19 reported at least one shortage/stock-out event. Overall, 115 events were reported, 28 of which led to a change in the national immunisation programme. The most frequently involved vaccines were DT- and dT-containing combination vaccines, hepatitis B, hepatitis A, and BCG vaccines. The median duration of shortages/stock-outs was five months (range <1 month–39 months). Interruption in supply and global shortage were the most frequently indicated causes. Only about half of countries reported having an immunization supply chain improvement plan. Similarly, only about half of countries had recommendations or procedures in place to address shortages/stockouts. The survey also identified the occurrence of shortages/stockouts of other biological products (e.g. diphtheria antitoxin in 12 countries). Public health strategies to assure a stable and adequate vaccine supply for immunization programmes require coordinated actions from all stakeholders, harmonized definitions, strengthening of reporting and monitoring systems, the presence of an immunization supply chain improvement plan in all countries, and procedures or recommendations in place regarding the use of alternative vaccines or vaccination schedules in case of shortages/stockouts.
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