Exploring new packaging and delivery options for the immunization supply chain

Mitigation themes in supply chain research during the COVID-19 pandemic: a systematic literature review

Purpose

The purpose of this paper is to understand the themes and direction of supply chain mitigation and resilience research during the COVID-19 pandemic by conducting a systematic literature review (SLR) of supply chain mitigation literature since pandemic.

Design/methodology/approach

This study uses the Web of Science (WoS) Database to analyze the contribution in supply chain mitigation literature by authors, themes in supply chain mitigation and the citing articles. An investigation based on bibliometric approach for the SLR represents the bibliographic data of over 530 publications between the years 2020–2021. Additionally, the article also develops graphical visualizations of the bibliographic data analyzed using the R-program Bibliometrix to ascertain the top sources, authors, keywords and conceptual themes.

Findings

Most strategies in the existing literature focused on reactive approaches to supply chain disruption and current mitigation literature has not evolved in parallel to the changing macro environment leaving a wide gap in considering vaccines as a supply chain mitigation strategy. Hence, this study identifies the potential need to focus on building proactive supply chain mitigation strategies preferably by studying the role of vaccines in mitigating supply chains.

Practical implications

This article helps the reader to understand the scientific research in terms of contributions in supply chain mitigation research since pandemic. Though, the time frame considered limits the connection the findings to previous work on supply chain disruptions and mitigation, it offers an understanding of the various mitigation themes evolved in light of mitigating the supply chain disruptions as one caused by the current pandemic. Further, this research helps us understand how businesses can help reduce the social consequences by preventing the disruptions and helping life normalize during this ongoing COVID-19 pandemic.

Originality/value

This is the first of its kind contribution offering a SLR of supply chain mitigation strategies during the COVID-19 pandemic identifying the focal themes in current literature and establishing the need for future venues of research studying the role of vaccines in supply chain mitigation strategies.

A fuzzy decision framework of lean-agile-green (LAG) practices for sustainable vaccine supply chain

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.

A method for estimating the impact of new vaccine technologies on vaccination coverage rates

Vaccines are one of the most cost-effective tools for improving human health and well-being. The impact of a vaccine on population health is partly determined by its coverage rate, the proportion of eligible individuals vaccinated. Coverage rate is a function of the vaccine presentation and the population in which that presentation is deployed. This population includes not only the individuals vaccinated, but also the logistics and healthcare systems responsible for vaccine delivery. Because vaccine coverage rates remain below targets in many settings, vaccine manufacturers and purchasers have a shared interest in better understanding the relationship between vaccine presentation, population characteristics, and coverage rate. While there have been some efforts to describe this relationship, existing research and tools are limited in their ability to quantify coverage rate changes across a broad set of antigens, vaccine presentations, and geographies. In this article, we present a method for estimating the impact of improved vaccine technologies on vaccination coverage rates. It is designed for use with low- and middle-income country vaccination programs. This method uses publicly available data and simple calculations based on probability theory to generate coverage rate values. We first present the conceptual framework and mathematical approach. Using a Microsoft Excel-based implementation, we then apply the method to a vaccine technology in early-stage development: micro-array patch for a measles-rubella vaccine (MR-MAP). Example outputs indicate that a complete switch from the current subcutaneous presentation to MR-MAP in the 73 countries ever eligible for Gavi support would increase overall vaccination coverage by 3.0-4.9 percentage points depending on the final characteristics of the MR-MAP. This change equates to an additional 2.6-4.2 million children vaccinated per year. Our method can be readily extended to other antigens and vaccine technologies to provide quick, low-cost estimates of coverage impact. As vaccine manufacturers and purchasers face increasingly complex decisions, such estimates could facilitate objective comparisons between options and help these decision makers obtain the most value for money.

Vaccine innovation prioritisation strategy: Findings from three country-stakeholder consultations on vaccine product innovations

As part of the Vaccine Innovation Prioritisation Strategy (VIPS), three immunization-stakeholder consultations were conducted between September 2018 and February 2020 to ensure that countries' needs drove the prioritization of vaccine product innovations. All consultations targeted respondents with immunization program experience. They included: (1) an online survey to identify immunization implementation barriers and desired vaccine attributes in three use settings, (2) an online survey to identify and evaluate the most important immunization challenges for ten exemplar vaccines, and (3) in-depth interviews to better understand the perceived programmatic benefits and challenges that could be addressed by nine innovations and to rank the innovations that could best address current challenges. The first consultation included responses from 442 participants in 61 countries, representing 89% of the 496 respondents who correctly completed at least one section of the online survey. For facility-based settings, missed opportunities for vaccination due to reluctance to open multidose vaccine vials was the barrier most frequently selected by respondents. In community-based (outreach) and campaign settings, limited access to immunization services due to geographic barriers was most frequently selected. Multidose presentations with preservative or single-dose presentations were most frequently selected as desired vaccine attributes for facility-based settings while improved thermostability was most frequently selected for outreach and campaign settings. The second online survey was completed by 220 respondents in 54 countries. For the exemplar vaccines, vaccine ineffectiveness or wastage due to heat or freeze exposure and missed opportunities due to multidose vial presentations were identified as the greatest vaccine-specific challenges. In-depth interviews with 84 respondents in six countries ranked microarray patches, dual-chamber delivery devices, and heat-stable/controlled temperature chain qualified liquid vaccines as the three innovations that could have the greatest impact in helping address current immunization program challenges. These findings informed the VIPS prioritization and provided broader application to designing immunization interventions to better meet country needs.

Polymeric Nanoparticle-Based Vaccine Adjuvants and Delivery Vehicles

As vaccine formulations have progressed from including live or attenuated strains of pathogenic components for enhanced safety, developing new adjuvants to more effectively generate adaptive immune responses has become necessary. In this context, polymeric nanoparticles have emerged as a promising platform with multiple advantages, including the dual capability of adjuvant and delivery vehicle, administration via multiple routes, induction of rapid and long-lived immunity, greater shelf-life at elevated temperatures, and enhanced patient compliance. This comprehensive review describes advances in nanoparticle-based vaccines (i.e., nanovaccines) with a particular focus on polymeric particles as adjuvants and delivery vehicles. Examples of the nanovaccine approach in respiratory infections, biodefense, and cancer are discussed.

Technical product attributes in development of an oral enteric vaccine for infants

Development of an oral enteric vaccine for infants is important for Shigella and enterotoxigenic Escherichia coli (ETEC) vaccine development. At a recent workshop titled "Technical Product Attributes in Development of an Oral Enteric Vaccine for Infants," at the 2nd International Vaccines Against Shigella and ETEC Conference (VASE Conference), the preferred product attributes for development were discussed for these vaccines. The aims of this workshop were to identify gaps and gather opinions from key experts from preclinical, process development, manufacturing, regulatory, and clinical areas to fine-tune and refine key target product attributes for infant oral vaccine development. The workshop used some examples of marketed oral infant vaccines to discuss potential improvements that can be made, such as inclusion of preservatives, multidose vials, and antacid buffer presentation (liquid or lyophilized) in novel oral enteric vaccine development.

Biocompatible near-infrared quantum dots delivered to the skin by microneedle patches record vaccination

Accurate medical recordkeeping is a major challenge in many low-resource settings where well-maintained centralized databases do not exist, contributing to 1.5 million vaccine-preventable deaths annually. Here, we present an approach to encode medical history on a patient using the spatial distribution of biocompatible, near-infrared quantum dots (NIR QDs) in the dermis. QDs are invisible to the naked eye yet detectable when exposed to NIR light. QDs with a copper indium selenide core and aluminum-doped zinc sulfide shell were tuned to emit in the NIR spectrum by controlling stoichiometry and shelling time. The formulation showing the greatest resistance to photobleaching after simulated sunlight exposure (5-year equivalence) through pigmented human skin was encapsulated in microparticles for use in vivo. In parallel, microneedle geometry was optimized in silico and validated ex vivo using porcine and synthetic human skin. QD-containing microparticles were then embedded in dissolvable microneedles and administered to rats with or without a vaccine. Longitudinal in vivo imaging using a smartphone adapted to detect NIR light demonstrated that microneedle-delivered QD patterns remained bright and could be accurately identified using a machine learning algorithm 9 months after application. In addition, codelivery with inactivated poliovirus vaccine produced neutralizing antibody titers above the threshold considered protective. These findings suggest that intradermal QDs can be used to reliably encode information and can be delivered with a vaccine, which may be particularly valuable in the developing world and open up new avenues for decentralized data storage and biosensing.

Two decades of vaccine innovations for global public good: Report of the Developing Countries' Vaccine Manufacturers Network 20th meeting, 21-23 october 2019, Rio de Janeiro, Brazil

The Developing Countries' Vaccine Manufacturers Network, joined by global health organizations, held its 20th meeting celebrating two decades of vaccine innovations for global public good. Health leaders from industry, academia and global health organizations reviewed efforts to accelerate innovation, improve access to vaccines, overcome inequalities and strengthen technological and public-health management capabilities. Discussion topics included World Health Organization's immunization strategy, Pan American Health Organization's system-strengthening efforts, Gavi's evaluation of vaccine coverage in middle income countries and developments on public-market intelligence. Health market trends, delivery gaps, integration of system-wide needs, costs and benefits, and implications for stakeholder decision-making were areas of focus. Novel thinking was discussed on integration of policy, financing, regulatory pathways and alignment of innovation priorities to improve efficiency in vaccine development pathways. The Vaccine Innovation Prioritization Strategy collaboration presented nine global innovation priorities, and many other partners and members presented updates on their priorities. Novel technologies and platforms, such as RNA-based vaccines, adenoviral vectors, bioconjugation, blow-fill-seal and two-dimensional barcodes, provided opportunities to accelerate vaccine innovations. Challenges in planning and operations at global level included those in health security, polio eradication, re-emergence of diseases, disparities between forecasts and orders and heterogeneous regulatory requirements. Manufacturers were urged to accelerate innovation and prequalification of high-impact vaccines, such as pneumococcal, human papillomavirus and rotavirus vaccines, to strengthen immunization globally.

Roadmap for strengthening the vaccine supply chain in emerging countries: Manufacturers' perspectives

Manufacturers have a significant stake in the vaccine supply chain as their reputations rest on the effectiveness of their vaccines at the point of vaccination. The risks of low performing supply chains are detrimental for the safety and effectiveness of vaccines, with potential consequences to future supply in the case of adverse events. For this reason, a study was set up to explore the involvement of developing country manufacturers in the vaccine supply chain over the next decade to determine the areas where innovations could have a positive impact on the supply chain, focusing on the secondary stages of production where formulation, filling and packaging take place. An expert desk review identified eight areas of interest for the vaccine supply chain and informed the development of a survey to assess the relevance of the areas identified. The review also conjectured whether the overall effect of the identified areas is cost-neutral or resulting in net savings to countries. Overall, respondents identified five areas as of highest interest and subsequently an expert working group of representative manufacturers prioritized three of them. Specifically, traceability in the context of global digital health initiatives, stockpiling in the context of addressing vaccine shortages, stock-outs, outbreaks and epidemic prevention, and new packaging technologies are discussed in this report. It is important that vaccine manufacturers be actively engaged in global stakeholders' forums, as equal partners in determining the best ways for improving the vaccine supply chain.

New immunization strategies: adapting to global challenges

Immunization has made an enormous contribution to global health. Global vaccination coverage has dramatically improved and mortality rates among children due to vaccine-preventable diseases have been significantly reduced since the creation of the Expanded Programme of Immunization in 1974, the formation of Gavi, the Vaccine Alliance, in 2000, and the development of the Global Vaccine Action Plan in 2012. However, challenges remain and persisting inequities in vaccine uptake contribute to the continued occurrence and outbreaks of vaccine-preventable diseases. Inequalities in immunization coverage by geography, urban-rural, and socio-economic status jeopardize the achievement of global immunization goals and call for renewed immunization strategies. These should take into account emerging opportunities for building better immunization systems and services, as well as the development of new vaccine products and delivery technologies. Such strategies need to achieve equity in vaccination coverage across and within countries. This will require the participation of communities, a better understanding of vaccine acceptance and hesitancy, the expansion of vaccination across the life course, approaches to improve immunization in middle-income countries, enhanced use of data and possible financial and non-financial incentives. Vaccines also have an important role to play in comprehensive disease control, including the fight against antimicrobial resistance. Lessons learned from disease eradication and elimination efforts of polio, measles and maternal and neonatal tetanus are instrumental in further enhancing global immunization strategies in line with the revised goals and targets of the new Immunization Agenda 2030, which is currently being developed.

Potential use of microarray patches for vaccine delivery in low- and middle- income countries

Microarray patches (MAPs), also referred to as microneedle patches, are a novel methodology that have the potential to overcome barriers to vaccine delivery in low- and middle-income countries (LMICs), and transform the way that vaccines are delivered within immunization programs. The World Health Organization's Initiative for Vaccine Research and its partners are working to understand how MAPs could ease vaccine delivery and increase equitable access to vaccines in LMICs. Global stakeholders have been engaged to evaluate technical, economic, and programmatic challenges; to validate assumptions where possible; and to propose areas of focus to facilitate future vaccine-MAP product development. This report summarizes those learnings.

Immunogenicity and safety of intradermal delivery of hepatitis B booster vaccine using the novel drug delivery device VAX-ID™

BACKGROUND

Although intramuscular (IM) injection is still the most preferred method for vaccination, intradermal (ID) delivery may have several advantages over intramuscular and subcutaneous (SC), including an improved immune response and antigen dose sparing effect. However it is currently limited due to the difficulty in standardizing the injection technique often based on the Mantoux technique. Difficulties encountered using the Mantoux technique could be overcome by the use of alternative ID delivery systems that confer more uniform and standardized procedures. The aim of this study was to evaluate the performance of a newly developed intradermal injection device, VAX-ID™, via a proof-of-concept to assess the immunogenicity of a commercially available hepatitis B booster vaccination in healthy hepatitis B pre-immunised subjects. Additionally, device safety and tolerability was evaluated.

MATERIALS AND METHODS

Three different routes of administration were compared over 4 groups, each receiving hepatitis B vaccine antigen: (1) standard IM injection in the deltoid region (HBVAXPRO® 10 µg/1 ml), (2) ID injection in the proximal posterior area of the forearm according to the Mantoux technique, (3) with VAX-ID™ in one forearm, or (4) with VAX-ID™ in both forearms. For ID injections 0.11 cc, of which 0.01 cc is overfill, was drawn from a vial containing HBVAXPRO® 40 µg/1 ml. Immunogenicity and safety were followed-up at day 0, 14, 30 and 210.

RESULTS

A total of 48 subjects were included. All subjects showed an anamnestic response at 14 days post booster vaccination. Elevated titres persisted until end of follow-up at day 210. For the ID groups a 3 fold higher immune response at day 14 and day 30 was recorded compared to IM group. Local adverse events were more reported for ID compared to IM.

CONCLUSIONS

The investigated ID injection device VAX-ID™ proves to be a good alternative to offer ID vaccination.

Protamine Nanocapsules for the Development of Thermostable Adjuvanted Nanovaccines

One of the main challenges in the development of vaccine has been to improve their stability at room temperature and eliminate the limitations associated with the cold chain storage. In this paper, we describe the development and optimization of thermostable nanocarriers consisting of an oily core with immunostimulating activity, containing squalene or α tocopherol surrounded by a protamine shell. The results showed that these nanocapsules can efficiently associate the recombinant hepatitis B surface antigen (rHBsAg) without compromising its antigenicity. Furthermore, the freeze-dried protamine nanocapsules were able to preserve the integrity and bioactivity of the associated antigen upon storage for at least 12 months at room temperature. In vitro studies evidenced the high internalization of the nanocapsules by immunocompetent cells, followed by cytokine secretion and complement activation. In vivo studies showed the capacity of rHBsAg-loaded nanocapsules to elicit protective levels upon intramuscular or intranasal administration to mice. Overall, our data indicate that protamine nanocapsules are an innovative thermostable nanovaccine platform for improved antigen delivery.