Connecting the Dots

How to Get Vaccines to More Kids

Vaccines work when supply chains do.

Vaccines are widely recognized as one of the biggest success stories in public health and are responsible for a large portion of the dramatic decline in child mortality observed over the past two decades. Today, thanks to the development of new vaccines, we can protect children everywhere against 12 deadly and debilitating diseases. But the fact that vaccines exist does not mean they reach every child who needs them. One reason: inadequate immunization supply chains to deliver them.

Supply chain challenges are complex, but solvable. For the first time, “Building Next Generation Immunization Supply Chains,” a special edition of Vaccine, compiles the latest evidence on opportunities and challenges facing these systems. This evidence will allow governments and their partners to connect the dots between knowledge and action to invest in reliable, efficient, supply chains that deliver vaccines to all.

Vaccines only work when supply chains work. Improving the immunization supply chain—the network of staff, equipment, vehicles, and data needed to get vaccines safely from the manufacturer to health clinics—plays a critical part in strengthening immunization programs and reaching the one in five children who do not receive the vaccines they need.

To defeat more diseases and save even more lives, we need to improve immunization supply chains by:

  • Strengthening management Supply chain personnel, like any other technical staff, need to improve their skills and expand their capabilities to keep health facilities well stocked.
  • Keeping cool Vaccines must be stored in cold facilities. Monitoring the temperature in these facilities is critical. If they get too warm—or freeze—they can lose effectiveness.
  • Harnessing data Government agencies need innovative strategies and technologies to track vaccines and related supplies so that no child has to wait for a shot or a few drops.
  • Boosting Political Will Governments must be the champions for the delivery of vaccines, as both a public health and economic priority.

Effective managers drive the supply chains that deliver lifesaving vaccines to children everywhere.

Every new vaccine is an exciting technological breakthrough in protecting people from disease. However, administering more doses in more locations creates an increasingly complex situation for the supply chain managers who serve as the backbone of worldwide immunization efforts. Health professionals face a daily struggle to safely and reliably manage, store, transport, and deliver vaccines to everyone, especially those living in remote communities. Technological advances are crucial, but only people can drive the supply chains that deliver these lifesaving vaccines to children around the world.

A survey of 40 health staff in 32 countries mostly in Africa and South Asia, revealed substantive gaps in how the personnel managing immunization supply chains are supported:

  • Two-thirds of these countries had a supply chain manager in place, but the scope of her/his budget and authority were unclear.
  • Only half of the respondents said that the current organizational structure in their government’s health agency supported the supply chain function.
  • More than half of the respondents felt that supply chain staff in their country lacked appropriate certification and training.

Investments in training supply chain personnel have proven successful. In Mono, Benin, a pilot program to replace four vaccine storage facilities with one centralized warehouse included support to management personnel. While the pilot program led to expected improvements in the storage and transportation logistics, the staff training also provided immediate impact. Health workers throughout this district became more familiar with best practices in immunization supply chain management and were more empowered and motivated to implement these best practices.

Investments in training supply chain managers can have an immediate impact.

The need to support immunization supply chain management has increasingly gained recognition. The World Health Organization and partner organizations have established international, professional development networks, regional training centers, academic degree programs in health supply chain management, and other initiatives that help strengthen the capacities of management personnel overseeing immunization supply chains. These efforts add well-deserved prestige to a critically important yet mostly obscure role in public health.

Vaccines work best when delivered at the right temperature—cold, but not freezing, and never warm or hot.

Vaccines have to be delivered wherever children are, no matter how remote the location. Since vaccines are biological products, they are much more temperature sensitive than other drugs and can lose effectiveness if they become too warm or too cold.

“Keeping cool”—maintaining a storage temperature between 2° and 8° Celsius—is essential yet it remains a challenge all over the world. While many people are familiar with the need to keep vaccines cool, many are not aware that freezing is also problematic. Accidental freezing of vaccines occurs in 37 percent of facilities in lower income countries, and it also takes place in 33 percent of facilities in wealthier countries.

Rugged, portable, and sustainable cold chain equipment—the technology that keeps vaccines in the right temperature range despite outside conditions—is essential to ensure vaccine temperatures remain stable from the point of production to administration. Purchasing and maintaining new equipment, and training staff to use the devices effectively, is a worthy investment given the importance of delivering potent vaccines.

Properly functioning cold chain equipment is essential to vaccine delivery, since its failure can compromise vaccine potency. But when refrigerators fail it’s not always for the same reason. A survey of cold chain equipment in Uganda and Mozambique revealed that, when investigated, solutions to common refrigeration failures can be easy to identify and address.

PATH collaborated with Uganda’s National Expanded Program of Immunization (UNEPI) to examine equipment failures in four districts across the country. Looking across the national warehouse, 15 health centers and four district vaccine stores, they found 59 failed refrigerators and freezers. Of the 59 failed refrigerators, 44 of the malfunctions were due to a faulty cooling unit in the same model of equipment. Better data collection and sharing could have revealed this flaw earlier and been communicated to the manufacturer to quickly rectify.

Accidental vaccine freezing occurs in more than ⅓ of countries, regardless of income.

A second survey in Mozambique’s Gaza Province identified the most common causes for refrigerator failure: solar powered batteries that were not holding a charge and improperly adjusted thermostats. Simply replacing the faulty batteries and properly adjusting the thermostats restored the refrigerators to working order. Monitoring cold chain equipment is essential to diagnosing and fixing refrigerator failures and can ensure these technologies are able to reliably keep the vaccines at the right temperature. However, no technology provides a fail-safe solution without trained staff to make sure it works.

Delivering vaccines in the right condition to the right place at the right time requires reliable data.

Vaccines work—when they are available. Too often, they are not. Every year, approximately one-third of United Nations member states report running out of a vaccine for at least a month. One of the primary culprits is unreliable or unavailable data needed for decision-making. Ensuring vaccine availability requires timely and accurate insight into vaccine demand and current inventory in each location.

The state of Uttar Pradesh has the largest number of under-immunized children in India. Less than two-thirds of the state’s children receive their third dose of the diphtheria, tetanus toxoids, and pertussis (DTP) vaccine, a common benchmark for system strength.

Coverage rates are even worse in the urban districts of Bareilly and Shahjahanpur. Until recently, vaccine inventories were recorded in handwritten registers with no data-sharing procedures, most staff lacked appropriate training, and stock replenishment was ad-hoc. Stockouts—when a distribution facility runs out of one or more vaccines—were common.

A simple tracking system was devised that standardized vaccine supply and demand data collection on just about any communications device—from a desktop computer, to a tablet, and to an old-fashioned flip phone—and just about any operating system and wireless connection.

Setting up this system and training staff to use it took over 19 months. However, once the system was established, the time it took to replenish stock after a reported stockout decreased from an average of about five days in the first year of implementation to under two and a half days in the second year.

With a more reliable data flow, health workers in Bareilly and Shahjahanpur maintained a more consistent supply of vaccine stock, which led to an increase in immunized children. In 2016, this pilot project transitioned from 41 immunization facilities to 27,000 immunization facilities in 12 of India’s 29 states, providing decision-makers with a more stable data management system for their immunization programs.

We can only transform vaccine supply chains with leadership from all levels of government.

Training classes that empower supply-chain managers. High tech refrigerators. Software that collects and organizes data and also works with any device that sends a signal. Although these are all important interventions, translating evidence to action is a challenge, particularly in budget-constrained settings. Sustained political commitment is needed to ensure supply chain investments are made, not as incremental improvements, but as part of a strategic vision for equitable vaccine coverage.

Vaccines are the best protector of human life. They also provide a quantifiable economic value—every US$1 spent on delivering and administering vaccines returns up to US$16 in economic benefit. Yet, an estimated 19.4 million infants worldwide do not receive all of their vaccinations. Of these, 1.5 million children will die from a vaccine-preventable disease. Saving their lives needs to be a political priority.

In January 2017, heads of state from across Africa endorsed the Addis Declaration on Immunization, pledging to ensure the full benefits of immunization to everyone in Africa, regardless of where they live. The declaration calls for countries to commit to political and financial investments in their immunization programs. Among the ten commitments in the declaration are increasing vaccine-related funding and strengthening supply chain and delivery systems. This high-level support for immunization should catalyze national stakeholders to accelerate progress on the ground.

Every $1 spent on vaccine delivery returns $16 in economic benefits.

Progress within specific countries has also been noted. For example, despite historic vaccine delivery challenges, including insufficient equipment and lack of coordination between different supply chains, the Democratic Republic of Congo (DRC)—the largest country in sub-Saharan Africa by land area—is showing political leadership to ensure vaccines are available to all.

Through Vision 2020, leaders within the Ministry of Health have enshrined in policy a commitment to strengthen logistics management capacity and ensure vaccine availability at all levels through investments in the people, systems, and equipment delivering vaccines. In recent years, the Ministry of Health received support from Gavi, the Vaccine Alliance, to acquire 1,600 new refrigerators, increasing the number of facilities with cold chain capacity from one-third to one-half, yet there is still more to do. The government is also planning to build regional warehouses so that all provinces do not rely solely on Kinshasa’s central warehouse. This decentralization will increase transportation options for vaccines, which are all currently delivered to health facilities around the country by air.

The high-level political commitment made to immunization (including supply chains) through the Addis Declaration on Immunization should help fuel the political action needed to mobilize resources and drive the vision forward. By better supplying DRC’s nearly 9,000 health centers, the country will make strides toward saving more lives through improved vaccine coverage for the three million children born each year.

Vaccines work when supply chains do. Now is the time to take action to strengthen supply chains.

Immunizing every child requires connecting the dots between innovation, investment, and support for strong supply chains, from vaccine discovery through delivery. So what can you do?

Read “Building Next Generation Immunization Supply Chains” to investigate immunization supply chain solutions—related to data, equipment, and human resources—that can be implemented where you are.

Champion adequately resourced supply chains as part of all immunization programs.

Consider vaccine delivery needs during product development.