Multi-dose Vaccine Containers Offer Many Benefits, But What About the Trade-offs?

The widespread use of multi -dose vaccine containers in low- and middle-income countries’ immunization programs is assumed to offer benefits and efficiencies for health systems, such as reducing the purchase price per vaccine dose and easing cold chain requirements. Yet the broader impacts on the trade-offs among immunization coverage, costs, health worker behavior, and safety are still not well understood. It is also unclear what processes governments typically go through to determine their choices about dose per container (DPC), and what information decision makers have or use when determining DPC.

As initially described in the April 2016 issue of the IPAC Bulletin, JSI has been leading efforts to build the evidence base on this topic through the Dose Per Container Partnership (DPCP). Since its launch in 2015, this partnership has undertaken a series of activities to explore current decision-making on DPC options and better understand the relationship between DPC and immunization systems, including operational costs, timely coverage, safety, product costs/wastage, supply chain, and policy/correct use.

Through the Partnership, decision making for DPC at the country level has been explored through key informant interviews and implementation and observational research at national, district, and facility level in Ghana, Zambia, Senegal, and Vietnam. The Partnership has analyzed and is documenting the broader decision points at a global and national country level, as well as decision-drivers in routine immunization for the frontline health worker. A few key findings have emerged to date:

Often the decision to change DPC is due to external forces and organizational preferences, not necessarily based on Ministry of Health preference. Ghana provides a good example of dose per container changes in yellow fever and pentavalent in 2012 where global market availability dictated DPC change, which was then successfully managed by Ghana’s Ministry of Health (MOH).

The healthcare worker (HCW) preference of DPC is often not considered at national or global levels. Evidence from qualitative research in Zambia, Senegal, and Vietnam indicated that HCW would prefer smaller vial sizes of BCG and measles in order to reduce wastage.

In lieu of smaller vial sizes, HCW sometimes create workarounds to reduce wastage, such as offering specific vaccines on specific days, having selected immunization days, or waiting until a specific number of children present before opening a vaccine vial sizes, HCWs would be more willing to open a vial during scheduled sessions or opportunistically on any day to improve timely and higher vaccination coverage. This has been evident through the implementation and observational research in Zambia, Senegal, and Vietnam.

Currently there is not a decision support tool that can help a MOH decide what DPC to use, although there are planning tools that could be adapted to respond to this question. The DPCP reviewed 10 immunization planning tools with user feedback on the DPC applicability.

When pressed with this DPC question, MOH staff often consider only some variables, such as purchase price per dose and cold chain capacity, and may not factor in the need for timely vaccination. The DPC issues is considered mostly during annual forecasting and ordering processes, new vaccine introduction application, and when developing the Comprehensive Multi-Year Plan (cMYP).

As countries’ immunization programs are growing and more DPC option are becoming available from manufacturers, there is an opportunity to inform and support key decision makers at the country level when deciding on product choice and close the information gap between country preference, procurement agents such as UNICEF, and manufacturers.

The DPCP is synthesizing research findings to develop guidance to help countries weight the complexity of the trade-offs of DPC. For example, a 5-dose vial of measles may cost more in purchase price per dose (although considerably less per vial) but would reduce the anxiety of health workers to open vial when only a few children present –and lead to higher and more timely coverage rates. Each country context is different, and this DPC decision must be based on evidence that is applied to that context. The Partnership is generating the evidence and will share the results by the end of 2018.

This blog was cross-posted from the April 2018 IPAC Bulletin.

Written by Craig Burgess