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Injectable influenza vaccination (this article
focuses only on injectables; intranasal inﬂuenza
vaccine [Flu-mist™] has an important role in
inﬂuenza vaccination but is not considered here)
in the USA is currently distributed in three main
presentations: vials, which can be single or multi-
dose (MDV), and preﬁlled syringes (PFSs). The
USA predominantly uses MDVs, but PFSs have
gained market share over the last few years .
We estimate that, currently, PFSs hold approxi-
mately 30% of the market for inﬂuenza vaccines.
Comparing the two inﬂuenza vaccine preparations
in terms of monetary acquisition, PFSs may cost
slightly more per dose than MDVs, but could offer
advantages in speed, disposal, wastage and patient
safety owing to premeasured accurate doses that
reduce dosing errors [1–3]. PFSs also reduce the
risk of microbial contamination, which can occur
from improper aseptic techniques. Vaccines in
PFSs do not contain the preservative thimerosal,
whereas MDV vaccines do. A drawback of PFSs
is a requirement for more storage space as they
can be heavily packaged by the manufacturer to
prevent damage. Bulkier packaging can increase
refrigeration costs. Production, shipment and stor-
age of MDVs are all cheaper, but using MDVs
can be more time consuming for the healthcare
worker, because each dose must be drawn from
the vial using a needle and an empty syringe, lead-
ing to higher administration costs. Using MDVs
adds operational complexity and more potential
for dosing errors and contamination.
The goal of this article is twofold. First, we
provide a descriptive overview of the current
literature on operational features of MDVs and
PFSs. Second, we report measurements com-
paring the efﬁciency and costs associated with
MDVs and PFSs for inﬂuenza vaccination dur-
ing the 2009/2010 inﬂuenza campaign. Our
measurements emerge from a time-motion study
of the inﬂuenza vaccination process at immuni-
zation clinics. Nurses’ activities related to MDVs
and PFSs were observed and timed using a stop
watch. All relevant usage costs associated with
PFSs and MDVs were identiﬁed and compared.
We also measured the amount of vaccine that
remained in vials after they were deemed empty
by the healthcare worker.
Claudia C Pereira1 and
1Department of Population Family and
Reproduc tive Health, Johns Hopkins
Bloomberg School of Public Health,
615 N. Wolfe Street, Suite 4622,
Baltimore,MD 21205, USA
†Author for correspondence:
Tel.: +1 410 955 7807
Fax: +1 410 955 2303
In the USA, inﬂuenza vaccines are available as parenteral injections or as an intranasal preparation.
Injectable inﬂuenza vaccines are available in either multidose vial (MDV), single-dose vial or
preﬁlled syringe (PFS) presentations. PFSs have gained market share in the USA but have not
yet reached the levels of uptake currently seen in Western Europe. Here, we review the topic of
vaccine presentation in the USA, with a special focus on inﬂuenza vaccines. Second, we present
the results of a time-motion study that measured administration costs of inﬂuenza vaccination
comparing MDVs versus PFSs during the 2009/2010 inﬂuenza campaign. Vaccinating with MDVs
took an average 37.3 s longer than PFSs. The cost of administering 1000 immunizations in 2009
using MDVs were US$8596 versus US$8920.21 using PFSs. In a pandemic situation where 300
million Americans would require vaccination, PFSs would save 3.12 million h in healthcare worker
time, worth US$111.1 million. The higher acquisition costs of PFS vaccines compared with MDVs
are offset by lower administrative costs and increased safety.
Keywor ds: costs • immunization • inuenza vaccine • multidose vials • prelled syringes • time motion
• vaccine administration
Vaccine presentation in the
USA: economics of preﬁlled
syringes versus multidose vials
for inﬂuenza vaccination
Expert Rev. Vaccines 9(11), 1343–1349 (2010)
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Expert Rev. Vaccines 9(11), (2010)
Review Pereira & Bishai
What is the current status of MDV & PFS use in
inﬂuenza vaccination the USA?
A variety of factors have led to a growing number of manufac-
turers of vaccines and other injectables offering PFS platforms
for their products. Over the last decade, the US market for PFSs
grew at a rate of approximately 20% per year . For vaccines,
efﬁciency and perceived safety drive the growth of PFS presenta-
tions. Despite the lack of evidence of toxic effects of thimerosal,
the public perception of risk owing to this preservative has shifted
many providers away from MDVs towards preservative-free PFSs.
In 2004, the Institute of Medicine’s Immunization Safety Review
committee rejected any causal link between thimerosal and
autism . Despite such information, many parents and patients
still exhibit concerns over the use of vaccines in general [5,6] , and
from MDVs in particular.
Inﬂuenza vaccines have traditionally been delivered in clinical
settings, but recent years have seen a shift towards more vaccines
being offered in workplaces, retail centers and at schools. In
all of these settings, efﬁciency and streamlining are extremely
important . Patients with wavering interest in inﬂuenza vac-
cination and consumers are likely to be deterred by long waiting
times. Efﬁciency is especially important in mass vaccination
settings where the goal is to deliver vaccines as quickly as pos-
sible . The success of mass inﬂuenza vaccination clinics relies
on the ability to offer rapid access to low-cost inﬂuenza vaccina-
tions in a safe and organized manner. This is particularly impor-
tant in the USA at present because the Advisory Committee
on Immunization Practices (ACIP), which advises the CDC
on vaccine use and policy, voted unanimously to recommend
universal seasonal inﬂuenza vaccination for all Americans aged
6 months and older, starting in the 2010/2011 season .
Prior studies comparing MDVs and PFSs have been conducted
in Canada, Japan and countries in Europe. A study conducted
by Scheifele and colleagues in Canada concluded that PFSs
could save nurses’ time in mass immunization clinics. Authors
noted that PFSs reduced nursing service time by 9–12 person-
hours per 1000 doses, depending on the PFS packaging (indi-
vidual or trays), thus reducing labor costs by 25–33% . An
earlier study in 1996 conducted in European hospitals compared
preﬁlled disposable syringes with conventional vial-based sys-
tems for parenteral injections and demonstrated that PFSs led
to a cost reduction of 1.5 French Francs (or 1996 GB£0.15) per
injection . A study conducted in a hospital in Japan demon-
strated that for PFSs, the operation time during the preparation
of vaccination was reduced by 31.7% in comparison with vial
preparations . The authors emphasized that PFSs are especially
important in inﬂuenza vaccination, because vaccinations for
large numbers of people are concentrated into a few months
of the year. Safety and convenience become more critical with
high throughput vaccination. According to the Japanese study,
healthcare professionals in Japan are eager for further develop-
ment of PFSs for vaccines and medications not yet available and
support increased availability of the products currently available
in PFSs . No published studies for the USA have addressed
efﬁciency in inﬂuenza vaccination, hence the rationale for the
study presented here.
Safety is a top concern in vaccination. Paradoxically, there is idio-
syncratic variation in the way vaccines are administered, reﬂecting
peculiarities in the way a task can be performed from practice
to practice. Although the CDC has issued guidelines for best
practices in vaccine administration [102 ,103], it is left to individual
practices to achieve guideline adherence. Unsafe injection-related
practices may not be recognized, but when observed should be
obvious and the magnitude of the consequences of unintended
deviant practices may not always be understood . According to
research conducted at the CDC, improper handling of injectable
medications can lead to infections and other severe outcomes in
patients . The research from the CDC presented at the Fifth
Decennial International Conference on Healthcare-Associated
Infections 2010 showed that nosocomial infections can result
from inadequate injection safety practices, and such events could
be prevented by safer practices. Some of the unsafe practices were
related to hygiene and improper storage and labeling. For instance,
the CDC identiﬁed as safety breaches the use of multidose medi-
cations that were accessed multiple times with nonsterile syringes
and needles .
The National Center for Immunization and Respiratory
Diseases (NCIRD) of the CDC strongly recommends that health-
care workers draw the vaccine only at the time of administration
to reduce errors and ensure that the cold chain is maintained and
that vaccine is not inappropriately exposed to light . Problems
noted by the NCIRD in regard to the practice of drawing vac-
cine at times other than immediately prior to patient injection
(e.g., ‘predrawing’) include:
• Misidentiﬁcation of the contents of an unlabeled syringe;
• Vaccine wastage;
• Bacterial contamination, especially of vaccines from single-dose
vials that do not contain bacteriostatic agents;
• Possible reductions in potency from interaction between the
plastic syringe and vaccine components;
• Inability of the person administering the dose to be sure of the
composition and sterility of the product.
One example of a medication-switch error happened in January
of 2010 in Massachusetts (USA) where several staff members at
an elementary school had to be taken to a hospital after being
injected with insulin rather than the H1N1 vaccine . In addi-
tion, during observation of the clinics for this study, numerous
guidelines were not adhered to (further details of these obser-
vations are discussed in the results section). Better vaccine and
medication labeling, as well as the use of antigens that cannot be
predrawn in advance and left in refrigerators with no labeling,
would be key factors to counter such events. Furthermore, ade-
quate recording of lot numbers would ensure proper information
Vaccine presentation in the USA
in the case of adverse events. Recording the correct lot number
in the medical record and/or in the patient vaccination card is a
task made easier by PFSs in comparison with MDVs because PFSs
have a detachable label in the package.
The results of a qualitative survey conducted at ﬁve European
hospitals showed that approximately 95% of participating hospi-
tal workers found PFSs more convenient to use and handle than
vials or ampoules, and that PFSs saved time during injections.
Furthermore, 67% found PFSs more convenient to discard. Other
aspects of PFSs that were highlighted by healthcare professionals
were: decreased risk of dosing errors, smaller risk of microorganism
transmission to the patient and lower risk of injuries for nurses .
The study by Hirayama and Kuroyama in Japan showed that PFSs
avoided wastage, made inventory control easier, lowered the risks
of nurses making a mistake and also enabled quicker responses in
emergency situations . In summary, current literature indicates
that PFSs have the potential to be safer and more efﬁcient than
vials. But there have been no studies from the USA to support a
systematic comparison. This was our rationale for studying the
time required to administer vaccines via vials versus PFSs.
Efﬁciency & costs: Baltimore study
The efﬁciency, costs and safety practices related to inﬂuenza
vaccination were evaluated in a time-motion study. Seven
practices in Baltimore (MD, USA) and the metropolitan area
participated in the study. The practices included hospitals,
clinics and private medical centers. The sites varied in their
location; three were urban and four suburban. Five practices
provided both seasonal and H1N1 inﬂuenza vaccines, whereas
two only provided the seasonal inﬂuenza vaccine. We observed
31 immunization professionals (Ta bl e 1) , all of whom were reg-
istered nurses with various years of experience, ranging from
3 to 39 years (mean: 18.1; SD: 11.7). The practices sampled
were selected based on their willingness to participate in the
study and permission was obtained from each healthcare pro-
vider to have their immunization-related activities observed and
timed. Observations and data collection took place between
October 2009 and March 2010.
We collected time and cost data on all activities related to immu-
nization with MDVs and PFSs for both seasonal and H1N1
inﬂuenza vaccines. The time spent by immunization profession-
als on their vaccination-related activities was recorded using a
stopwatch. We observed tasks in the vaccine preparation process,
from the time of removal of the vial or the syringe package from
the refrigerator until the time it was ready to be administered to
a patient. Often during the observations it was not possible to
observe all tasks involved in one vaccine preparation process as a
whole, as there was no standardized way of executing the tasks.
For instance, sometimes nurses attached needles to syringes in
bulk, so they were readily available when needed. That may have
happened hours or days before they actually drew vaccine from
a vial, so that the observer was not able to observe that step, but
could observe the other steps of the sequence. We assumed that
the time to actually inject the patient would be the same for
both methods, so we did not measure the time it took to inject.
Our time measurements end from the moment the vaccine was
considered ready to inject.
Table 1. Characteristics of the sample of registered
1 37 2 80
2 7 2 69
3 28 2 23
4 8 2 42
5 23 2 90
6 6.5 3 1
7 5 3 2
8 7.5 3 17
9 6 3 47
10 39 3 12
11 17 3 13
12 7 3 7
13 3 3 19
14 15 3 34
15 31 3 5
16 30 3 2
17 12 3 25
18 23 3 7
19 37 3 8
20 9 4 7
21 23 4 3
22 11 1 10
23 8 1 6
24 25 1 1
25 27 1 5
26 9 1 6
27 34.5 1 3
28 30 1 2
29 10 1 4
30 31 5 4
31 3 5 1
Total = 555
†Years of experience as a nurse.
‡Sites six and seven provided empty vials and participated in interviews about
preﬁlled syringes and multidose vials.
§Number of times a nurse was o bserved performing multiple tasks, w hich could
be the preparation of one or multiple vaccines to be administered.
Expert Rev. Vaccines 9(11), (2010)
Review Pereira & Bishai
Healthcare professionals’ salaries were obtained through the US
Bureau of Labor Statistics website, statistics for the year 2009 .
We utilized mean wages for registered nurses in the state of
Monthly storage costs were estimated by obtaining the average
market price of medical-use refrigerators of 4 cubic feet capac-
ity, assuming a 10-year useful life and a discount rate of 5%.
Consumer price inﬂators were used to adjust prices for inﬂa-
tion. The average volume for a package of ﬁve doses of PFSs was
52.6 cm3 and of ten doses of MDVs or one vial was 5.4 cm3.
Disposal/waste cost difference was assumed to be negligible, as
we pressumed that hospitals and clinics already have a contracted
waste service and the choice of MDVs or PFSs would not lead to
additional waste disposal collection visits.
The prices for syringes, needles, alcohol pads and gloves for
the brands and models we observed were obtained from the 2009
Red Book™ Drug Reference . The prices for vaccines were
obtained from the IMS MIDAS database .
In order to account for uncertainty and to take into account
the relatively small number of practices we investigated, we per-
formed a set of one-way sensitivity analyses, using the lowest and
highest costs we identiﬁed in the 2009 Red Book for vaccines,
needles, gloves and alcohol. For storage we calculated the lower
bound by multiplying the smallest storage unit cost by 0.8, and
likewise we multiplied the largest storage cost for PFSs by 1.2.
In a similar fashion, for the lower bound of healthcare worker
wages, we multiplied the national average salary of a medical
assistant by 0.8. For the upper bound, we used the mean salary
for a registered nurse.
Statistical analyses: time use estimation
All analyses were made using STATA SE 10 . The process to
prepare a vaccine for injection is composed of several individual
subtasks. Some subtasks were timed individually. Most were
timed as part of a continuum of sequential subtasks. Stop watch
episodes commonly represented more than one single subtask,
but the duration of each episode was always accompanied by
data on which subtasks had occurred in the inter val. In our
dataset we had up to seven subtasks represented in one single
time measurement. The dataset was arranged so that the length
of each measured episode was attached to a list of up to seven
subtasks that occurred during that interval. Getting a vaccine
ready from MDVs could take up to 16 subtasks and up to ten
for PFSs (F igur e 1).
To estimate time per subtask we used random-effects regres-
sion models to take into account the effects of healthcare profes-
sionals. The model assumed clinic-speciﬁc and worker-speciﬁc
random effects. We were able to estimate individual weighted
average times for each of the 21 subtasks that could possibly
be performed. From our observations and from the literature,
we listed all practice steps to vaccinate using MDVs and PFSs,
although sometimes none of these steps were performed by a
nurse. Finally, we estimated total time required to complete all
subtasks for either MDVs or PFSs. The coefﬁcients in the models
were interpreted as the incremental number of seconds required
to conduct each corresponding subtask. After estimating the
average time required for each of the subtasks we observed, we
estimated the total time to conduct the entire sequence of sub-
tasks ( Figur e 1) . We conducted that separately for vial-only tasks
(13 tasks), common tasks for both MDVs and PFSs (six tasks)
and PFS-only tasks (ﬁve tasks).
We observed a total of 555 multitasking activities performed
by 31 different registered nurses. We estimated that the total
time in seconds to get a vaccine ready to be administered per
patient was 87 s for MDVs and 49.71 s for PFSs, a difference of
37.29 s ( Figu re 1).
After adding all relevant administration costs, which included
nurses’ time, syringes for MDVs only, needles, storage, alcohol
and gloves per 1000 injections, the total administration costs
Remove vial from box 2.07
Unpack syringe 11.43
Split needle packs 1.77
Attach fill needle 4.20
Expose stopper 0.36
Sterilize vial 4.32
Fill/measure from vial 6.81
Unwrap new needle 2.27
Affix new needle 4.20
Write tracking number 1.49
Vial tasks (time [s])
Don gloves 0.87
Retrieve vaccine from fridge 1.25
Open box of needles 1.15
Split needle packs 1.77
Unwrap one needle 2.27
Tidy up 1.33
Common tasks (time [s])
Open PFS box (five or ten) 1.61
Remove tracking number 1.19
Attach PFS to needle 4.20
Prefilled tasks (time [s])
Total: 49.71 s (A) Difference between MDVs and PFSs
(A–B) = 37.29 s
Total: 12.42 s (B)
Figure 1. Estimated time in seconds for tasks associated with multidose vial and preﬁlled syringe use.
MDV: Multidose vial; PFS: Preﬁlled syringe.
Vaccine presentation in the USA
in 2009 were US$ 8596 for MDVs and US$8920.21 for PFSs, a
difference of US$324.21 (Ta ble 2) or US$0.32 per dose adminis-
tered. These numbers exclude the acquisition cost of the vaccine.
Our estimates thus suggest a ‘breakeven’ PFS price differential of
US$0.32. At this price, the savings in vaccination administration
costs would exactly offset the higher PFS purchase price.
We conducted a series of univariate sensitivity analyses to
explore the impact of varying all costs that were common to
MDVs and PFSs (Figure 2). Our results indicate that vaccine acqui-
sition price is the main source of uncertainty in the analyses. The
total administration costs varied from US$7456 to US$10,010
in 2009 dollars.
A number of clinical practice adaptations during vaccine
preparation were obser ved and documented. At times, for
instance, the same alcohol swab was repeatedly used to sterilize
the vial, without being exchanged or receiving more alcohol.
This was especially true when nurses were predrawing a batch
of vaccines at once in preparation for a big inﬂuenza clinic day,
so they had to act quickly. The observer
noted instances where nurses pooled vac-
cine remainders from multiple spent vials
in order to assemble a full dose, which
does not adhere to safe injection practices.
In many clinics, vaccines were predrawn
many hours in advance to expedite the vac-
cination process, especially in inﬂuenza clin-
ics that need to minimize patient waiting
time. With predrawing there was potential
confusion about vaccine lot number, since
there was no place on the syringe to write the
lot number. In instances of predrawing, we
frequently observed incorrect forecasts of the
number of vaccines that would be needed.
Leftover vaccines that were predrawn from
vials would remain in the plastic syringe for
the following day.
When vaccines were predrawn, nurses often relied on memory
for entering vaccine lot numbers in patient records. A very com-
mon practice was to memorize one relevant lot number for a
day or session and enter the memorized number on the patient’s
paperwork, without referencing the original packaging. Some
nurses wrote the vial lot numbers on pieces of paper that they
could later refer to and some even wrote the number on their
skin, as a way of being able to refer to it at any time. During one
session the lot number had changed between the syringes for that
session and a nurse was still writing the previous lot number.
Although MDVs require less cold storage and may have lower
acquisition costs, their use imposes higher staff time burdens
and higher task complexity. Practices related to predrawing vac-
cine into unmarked plastic syringes were observed that could
impact patient safety and reduce vaccine potency. PFS packaging
makes them bulkier to store but none of the clinics observed
7000 7500 8000 8500 9000 9500 10,000 10,500 11,000 11,500
Staff wage price
Figure 2. Tornado diagram of univariate analyses. This tornado diagram shows the
degree to which uncertainty in prices affects estimates.
Table 2. Costs associated with vaccination using multidose vials and preﬁlled syringes in 2009 in the USA.
Units Price (US$) Total (US $) Units Price (US$) Total (US$)
Staff time (person h) 13.81 14.16/h†195.55 3.45 14.16/h†48.85
Syringe‡1000 0.39 /unit 390.00 NA NA NA
Needles‡2000 0.31/unit 310.00 1000 0.31/unit 310.00
Alcohol‡1000 0.03/unit 30.00 1000 0.03/unit 30.00
Gloves‡1000 0.08/unit 80.00 1000 0.08/unit 80.00
Vaccine‡1000 7.59/dose§7590.00 1000 8.44/dose§8440.00
Storage‡1000 doses/month 0.00045/unit 0.45 1000 doses /month 0.0114/unit 11.36
†From the US Bureau of Labor Statistics for wages of a medical assistant .
‡From the 2009 Red Book™ .
§Average price – I MS MIDA S – Price differential is individually negotiated by distributors and dynamically changing in time.
¶The differences between PFSs and MDVs (per 1000 doses) is 324.21.
MDV: Multidose vial; N A: Not available; PFS: Preﬁlled syringe.
Expert Rev. Vaccines 9(11), (2010)
Review Pereira & Bishai
had cold storage constraints that would impede their ability to
use PFSs. By the same token, none of the clinics were at a point
where they could reduce tota l clinic staff if they could save
37.29 s per patient vaccinated based on the patient volumes the
days we observed.
Nevertheless, in the broad scheme of things, the 37.29-s gap
between MDVs and PFSs may have important implications.
Considering the American birth cohort of 4 million infants, with
each infant typically encountering approximately 15 shots before
1 year of age, the use of PFSs would save 621,500 person-hours
worth US$22.2 million in healthcare worker time in 1 year of
infant vaccination. In a pandemic situation where 300 million
Americans would require vaccination, PFSs would save 3.12 mil-
lion h, worth US$111.1 million in healthcare worker time. The
economic decision rests on whether there are better uses for the
precious resource of healthcare worker time, especially of nurses.
This work shows that the costs of vaccine administration using
PFSs are lower than using MDVs. These costs primarily reﬂect
the longer average time required to prepare a dose of vaccine
from a MDV.
Given the current US scenario and system of reimbursement
from health plans, the small price gap between MDVs and PFSs
and storage requirements are likely to be the main reasons that
practices have not yet completely switched to PFSs in the case
of inﬂuenza vaccines. Furthermore, from the perspective of the
clinics, those that receive most of their supplies through the
Vaccines for Children Program would beneﬁt the most from the
time and convenience of PFSs compared with MDVs, as they
are not incurring the expense of the vaccines. Mass vaccination
clinics would need to weigh the relative convenience of PFSs in
relation to MDVs, versus the full cost of both.
There are strong indications that the growth of PFS penetra-
tion into the market for vaccines will continue as American con-
sumers and providers become more familiar with the advantages
of these products.
Expert commentary & ﬁve-year view
Inﬂuenza vaccination in the USA still predominantly uses MDVs,
but PFSs offer many advantages over MDVs in terms of efﬁciency
and safety, especially considering the many opportunities for errors
and contamination that the use of MDVs creates in vaccination.
Although there are unknown issues surrounding policy and
market strateg y related to inﬂuenza vaccines, we expect to con-
tinue to see growth in the market share of PFSs for inﬂuenza
vaccines in the USA. We anticipate that this market will grow
from the current 30 % to 80 – 85% in the next 5 years. Our
projection is based on interviews with important stakeholders
from this industry and from our understanding of the mar-
ket dynamics over the last few years. As the demand for PFSs
increases, manufacturers are expected to increase production
capacity and drive costs down. This has already been seen to
a certain extent in the past decade. We expect to see the price
gap between PFSs and MDVs diminish over the next 5 years.
The authors would like to thank the practices and nurses who kindly
allowed us to observe their work and routine. They also acknowledge the
helpful comments received from Brian Lynch, Nuphar Rozen-Adler,
Justin Wright and Jennifer Zolot.
Financial & competing interests disclosure
The study was funded by a grant from Becton, Dickinson & Company. The
authors have received a grant from Becton, Dickinson and Company. The
authors have no other relevant afﬁliations or ﬁnancial involvement with
any organization or entity with a ﬁnancial interest in or ﬁnancial conﬂict
with the subject matter or materials discussed in the manuscript. This
includes employment, consultancies, honoraria, stock ownership or options,
expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.
The authors state that the study received IRB exempt status from the Johns
Hopkins Bloomberg School of Public Health Internal Review Board. Even
though the IRB declared the study to be exempt, the investigators obtained
consent from each participant.
• Preﬁlled syringes (PFSs) have gained market share in the USA, growing at approximately 20% a year, but have not yet reached levels of
uptake currently seen in Western Europe.
• In inﬂuenza vaccination, PFSs may cost more per dose than multidose vials (MDVs), but could offer advantages in speed, disposal, wastage
and patient safety owing to premeasured accurate doses that reduce dosing errors.
• Efﬁciency and safety are the two key aspects for different stakeholders in inﬂuenza vaccination.
• A time-motion study conducted in Baltimore, MD, USA during the 2009/2010 inﬂuenza vaccination campaign estimated that the total time
to get a vaccine ready to be administered per patient was 87 s for MDVs and 49.71 s for PFSs, a difference of 37.29 s.
• The total administration costs for MDVs in 2009 were US$8596 and US$8920.21 for PFSs, a difference of US$324.21 per 1000 doses or
US$0.32 per each dose administered. These numbers exclude the acquisition cost of vaccination.
• MDVs require less cold storage and may have lower acquisition costs, but their use imposes higher staff time burdens and higher task
complexity. Practices related to predrawing the vaccine into unmarked plastic syringes were observed that could impact patient safety and
reduce vaccine potency.
• If we consider the American birth cohort of 4 million infants, with each infant typically encountering approximately 15 shots before 1 year of
age, the use of PFSs would save 621,500 person-hours, worth US$22.2 million in healthcare worker time in 1 year of infant vaccination.
• In a pandemic situation, where 300 million Americans would require vaccination, PFSs would save 3.12 million h, worth US$111.1 million, in
healthcare worker time.
Vaccine presentation in the USA
Papers of special note have been highlighted as :
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usefulness of pre-ﬁlled syringe containing
inﬂuenza vaccine preparations. Japan
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Evaluation of ready-to-use and multi-dose
inﬂuenza vaccine formats in large clinical
settings. Can. J. Public Health 91(5),
329–332 (2000 ).
3 Detournay B, Aden G, Fabregas Z,
Lattarulo M, Lebouvier G. Preﬁlled
disposable syringes vs conventional
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Pharm. 4 (4), 109–112 (1998).
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Academies. Immunization Safety Review
Committee, Board on Health Promotion
and Disease Prevention. Immunization
Safety Review: Vaccines and Autism. The
National Academies Press, Washington,
DC, USA, 214 (2004).
5 Shetty P. Experts concerned about
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6 Kimmel SR. Adolescent vaccination:
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practices. Pediatrics. 124(5 Suppl.), S492–
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10 US Agency for International Development.
Immunization Essentials: a Practical Field
Guide. US Agency for International
Development, Washington, DC, USA
11 US Department of Labor, Bureau of Labor
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