Preliminary results from direct-to-facility vaccine deliveries in Kano, Nigeria

An evaluation of a multi-partner approach to increase routine immunization coverage in six northern Nigerian States

BACKGROUND

Global health partnerships are increasingly being used to improve coordination, strengthen health systems, and incentivize government commitment for public health programs. From 2012 to 2022, the Bill & Melinda Gates Foundation (BMGF) and Aliko Dangote Foundation (ADF) forged Memorandum of Understanding (MoU) partnership agreements with six northern state governments to strengthen routine immunization (RI) systems and sustainably increase immunization coverage. This mixed methods evaluation describes the RI MoUs contribution to improving program performance, strengthening capacity and government financial commitment as well as towards increasing immunization coverage.

METHODS

Drawing from stakeholder interviews and a desk review, we describe the MoU inputs and processes and adherence to design. We assess the extent to which the program achieved its objectives as well as the benefits and challenges by drawing from a health facility assessment, client exit interview and qualitative interviews with service providers, community leaders and program participants. Finally, we assess the overall impact of the MoU by evaluating trends in immunization coverage rates.

RESULTS

We found the RI MoUs across the six states to be mostly successful in strengthening health systems, improving accountability and coordination, and increasing the utilization of services and financing for RI. Across all six states, pentavalent 3 vaccine coverage increased from 2011 to 2021 and in some states, the gains were substantial. For example, in Yobe, vaccination coverage increased from 10% in 2011 to nearly 60% in 2021. However, in Sokoto, the change was minimal increasing from only 4% in 2011 to nearly 8% in 2021. However, evaluation findings indicate that issues pertaining to human resources for health, insecurity that inhibits supportive supervision and vaccine logistics as well as harmful socio-cultural norms remain a persistent challenge in the states. There is also a need for a rigorous monitoring and evaluation plan with well-defined measures collected prior to and throughout implementation.

CONCLUSION

Introducing a multi-partner approach grounded in a MoU agreement provides a promising approach to addressing health system challenges that confront RI programs.

Internet of Things (IoT)-enabled framework for a sustainable Vaccine cold chain management system

Vaccines are a unique category of drugs sensitive to temperature and humidity and whose effectiveness directly impacts public health. There has been an increase in vaccine-related adverse events worldwide, particularly in developing countries, attributed to suboptimal temperatures during transport and storage. At the same time, the Internet of Things (IoT) has ushered in a paradigm shift in vaccine information and storage monitoring, enabling continuous 24/7 tracking. This further reduces the dependence on limited human resources and significantly reduces the associated errors and losses. This paper presents an IoT-driven framework that aims to improve the sustainability of medical cold chain management. The framework promotes trust and transparency in vaccine surveillance data by accessing and authenticating IoT devices. The proposed system aims to improve the safety and sustainability of vaccine management. Moreover, we provide detailed insights into the design and hardware components of the proposed framework. In addition, the specific use of the framework in a particular province is highlighted, covering the design of the software platform and the analysis of the hardware equipment.

Analysis of the impact of COVID-19 pandemic and response on routine childhood vaccination coverage and equity in Northern Nigeria: a mixed methods study

BACKGROUND

Based on 2021 data, Nigeria had the second largest number of zero-dose children globally estimated at over 2.25 million, concentrated in the northern part of the country due to factors some of which are sociocultural. This study analysed the impact of the COVID-19 pandemic and response on childhood vaccination in Northern Nigeria.

METHODS

Using a mixed methods sequential study design in the most populous northern states of Kaduna and Kano, quantitative routine immunisation data for the period 2018-2021 and qualitative data collected through 16 focus group discussions and 40 key informant interviews were used. An adaptation of the socioecological model was used as a conceptual framework. Mean vaccination coverages and test of statistical difference in childhood vaccination data were computed. Qualitative data were coded and analysed thematically.

RESULTS

Mean Penta 1 coverage declined in Kaduna from 69.88% (SD=21.02) in 2018 to 59.54% (SD=19.14%) by 2021, contrasting with Kano where mean Penta 1 coverage increased from 51.87% (SD=12.61) to 56.32% (SD=17.62%) over the same period. Outreaches and vaccination in urban areas declined for Kaduna state by 10% over the pandemic period in contrast to Kano state where it showed a marginal increase. The two states combined had an estimated 25% of the country's zero-dose burden in 2021. Lockdowns, lack of transport and no outreaches which varied across the states were some of the factors mentioned by participants to have negatively impacted childhood vaccination. Special vaccination outreaches were among the recommendations for ensuring continued vaccination through a future pandemic.

CONCLUSION

While further interrogating the accuracy of denominator estimates for the urban population, incorporating findings into pandemic preparedness and response will ensure uninterrupted childhood vaccination during emergencies. Addressing the identified issues will be critical to achieving and sustaining universal childhood vaccination in Nigeria.

Cost analysis of an innovative eHealth program in Nigeria: a case study of the vaccine direct delivery system

INTRODUCTION

Vaccine stockout is a severe problem in Africa, including Nigeria, which could have an adverse effect on vaccination coverage and even health outcomes among the population. The Vaccine Direct Delivery (VDD) program was introduced to manage vaccine stockouts using eHealth technology. This study conducts a cost analysis of the VDD program and calculates the incremental costs of reaching an additional child for vaccination through the VDD program.

METHODS

We used the expense reports from eHealth Africa, an NGO which implemented the VDD program, to calculate the VDD program's overall operating costs. We also used the findings from the literature to translate the effect of VDD on the reduction of vaccine stockouts into its effect on the increase in vaccination coverage. We calculated the incremental costs of reaching an additional child for vaccination through the VDD program.

RESULTS

We calculated that implementing the VDD program cost USD10,555 monthly for the 42 months that the VDD program was operating in Bauchi state. This figure translates to an incremental cost of USD20.6 to reach one additional child for vaccination.

DISCUSSION/CONCLUSIONS

Our study is one of the first to conduct a cost analysis of eHealth technology in Africa. The incremental cost of USD20.6 was within the range of other interventions that intended to increase vaccine uptake in low- and middle-income countries. The VDD program is a promising technology to substantially reduce vaccine stockout, leading to a reduction of over 55% at a reasonable cost, representing 26% of the total budget for routine immunization activities in Bauchi state. However, there is no comparable costing study that evaluates the cost of a supply chain strengthening intervention. Future studies should investigate further the feasibility of eHealth technology, as well as how to minimize its costs of implementation while keeping the efficacy of the program.

Vaccine distribution with drones for less developed countries: A case study in Vanuatu

Drones (uncrewed aerial vehicles or UAVs) introduce new opportunities to improve vaccine distribution systems, particularly in regions with limited transportation infrastructure where maintaining the cold chain is challenging. This paper addresses the use of drones to deliver vaccines to hard-to-reach populations using a novel optimization model to strategically design a multimodal vaccine distribution network. The model is illustrated in a case study for distributing routine childhood vaccines in Vanuatu, a South Pacific island nation with limited transportation infrastructure. Our research incorporates multiple drone types, recharging of drones, a cold chain travel time limit, transshipment delays for switching transport modes, and practical limits on the vaccine paths and drone trips. The goal is to locate facilities (distribution centers, drone bases, and relay stations) and design vaccine paths to minimize transportation costs, including the fixed costs for facilities and transportation links and variable costs for transportation through the network. Results show large potential cost savings and improved service quality provided by incorporating drones in a multimodal vaccine distribution system. Results also show the impact of introducing drones on the usage of other more expensive or slower transport modes.

Trends of infant vaccination timeliness and completion in selected urban slum communities in Ibadan, Southwestern Nigeria: A four-year review

BACKGROUND

Suboptimal infant vaccination is common in Nigeria and multiple interventions have been deployed to address the situation. Child health indicators are reported to be worse in urban slums compared with other urban areas, but urban data are usually not disaggregated to show these disparities. Examining the timeliness and completion of infant vaccination in urban slums is important to determine the effectiveness of existing interventions in improving infant vaccination among this vulnerable population. This study explored the trends of infant vaccination in selected urban slum communities in Ibadan, Southwest Nigeria between November 2014 and October 2018.

METHODS

This was a cross sectional study where infant vaccination data were extracted from the immunization clinic records of six primary health care centers that were providing infant vaccination services for seven urban slum communities. Data was analyzed using descriptive statistics and Chi square test at α = 05.

RESULTS

A total of 5,934 infants vaccination records were reviewed, 2,895 (48.8%) were for female infants and 3,002(50.6%) were from Muslim families. Overall, only 0.6% infants had both timely and complete vaccination during the four years under study. The highest number of infants with timely and complete vaccination were seen in 2015(12.2%) and least in 2018(2.9%). Regarding timeliness of the vaccines, BCG, was the least timely among the vaccines given at birth and the pentavalent and oral polio vaccines' timeliness reduced as the age of the infants increased. Both yellow fever and measles vaccines were timelier than the pentavalent vaccines. Vaccines were most timely in 2016(31.3%) and least timely in 2018(12.1%). Those from Muslim families significantly had delayed and incomplete vaccinations compared with those from Chrisitan families (p = 0.026).

CONCLUSION

Infant vaccinations were significantly delayed and incomplete in the study communities during the years reviewed. More focused interventions are required to ensure optimal vaccination of the infants.

Improving the availability of vaccines in primary healthcare facilities in South Africa: is the time right for a system redesign process?

An uninterrupted supply of vaccines at different supply chain levels is a basic component of a functional immunization programme and care service. There can be no progress toward achieving universal health coverage and sustainable development without continuous availability of essential medicines and vaccines in healthcare facilities. Shortages of vaccines, particularly at health facility level is an issue of grave concern that requires urgent attention in South Africa. The causes of vaccine stock-outs are multifactorial and may be linked to a broader systems issue. These factors include challenges at higher levels such as delays in the delivery of stock from the pharmaceutical depot; health facility level factors, which include a lack of commitment from healthcare workers and managers; human resource factors, such as, staff shortages, and lack of skilled personnel. Therefore, there is a compelling need to address the factors associated with shortages of vaccines in health facilities. This paper highlights the challenges of vaccine availability in South Africa, the associated factors, the available interventions, and recommended interventions for the expanded programme on immunization in South Africa. We propose a system redesign approach as a potentially useful intervention.

Availability of the Yellow Fever Vaccine in Primary Health Care Services in Brazil

Objectives

To analyze the availability of the Yellow Fever (YF) vaccine at Primary Health Care (PHC) services located in areas with vaccine recommendation in Brazil between two different periods.

Methods

Secondary data from the Program for Improving Access and Quality in PHC, with 13,666 services in 2013-14, and 19,125 in 2017-18, were used. A structured questionnaire was used for the data collection. Pearson’s chi-square and thematic cartographic maps were used to analyze the frequency of the YF vaccine, and Poisson regression with robust variances was used to analyze the associated factors.

Results

The overall frequency of PHC facilities with YF vaccine always available increased from 87.0% (CI 95%; 86.4-87.5) in 2013-14 to 89.7% (CI 95%; 89.2-90.1) in 2017-18. Facilities located in the South, Southeast, Midwest and Northern regions and in non-state capitals, as well as centers that had adequate facilities for vaccination actions, as well as an adey -50quate cold chain network, showed a greater prevalence of YF vaccine always available.

Conclusion

The frequency of a steady supply of YF vaccine available at PHC facilities, located in Areas with Routine Vaccination Recommendations, increased between 2013-14 and 2017-18. Geographical and structural characteristics related to vaccine actions at PHC facilities influenced access. The effective supply chain networks for the YF vaccine, together with adequate services at PHC facilities are essential to ensuring that the YF vaccine is always available.

Factors affecting recommended childhood vaccine demand

Reaching a high vaccination coverage level is of vital essence when preventing epidemic diseases. For mandatory vaccines, the demand can be forecasted using some demographics such as birth rates or populations between certain ages. However, it has been difficult to forecast non-mandatory vaccine demands because of vaccine hesitation, alongside other factors such as social norms, literacy rate, or healthcare infrastructure. Consequently, the purpose of this study is to explore the predominant factors that affect the non-mandatory vaccine demand, focusing on the recommended childhood vaccines, which are usually excluded from national immunization programs. For this study, fifty-nine factors were determined and categorized as system-oriented and human-oriented factors. After a focus group study conducted with ten experts, seven system-oriented and eight human-oriented factors were determined. To reveal the cause and effect relationship between factors, one of the multi-criteria decision-making methods called Fuzzy-DEMATEL was implemented. The results of the analysis showed that “Immunization-related beliefs”, “Media/social media contents/messaging”, and “Social, cultural, religious norms” have a strong influence on non-mandatory childhood vaccine demand. Furthermore, whereas “Availability and access to health care facilities” and “Political/ financial support to health systems” are identified as cause group factors, “Quality of vaccine and service delivery management” is considered an effect group factor. Lastly, a guide was generated for decision-makers to help their forecasting process of non-mandatory vaccine demands to avoid vaccine waste or shortage.

Optimized supply chain model reduces health system costs in DRC

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After implementing optimized model, we observed 34% reduction in supply chain costs.

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Costs increased for Provincial store but decreased for Zones and health facilities.

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Streamlined distribution practices supported cost reductions for transportation.

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After implementing optimized model, costs increased in control Zones and facilities.

Objective

In 2017, an optimized immunization supply chain (iSC) model was implemented in Equateur Province, Democratic Republic of the Congo. The optimized model aimed to address iSC challenges and featured direct deliveries to service delivery points (SDPs), longer replenishment intervals and increased cold chain capacity. This assessment examines iSC costs before and 5 months after implementing the optimized model.

Materials & Methods

We used a nonexperimental pre-post study design to compare iSC costs before and after implementation. We applied an activity-based costing approach with a comparison arm to assess procurement, management, storage and transportation costs for three iSC tiers: Province (n = 1); Zone (n = 4) and SDP (n = 15). We included data from 3 treatment Zones and 11 treatment SDPs; 1 control Zone and 4 control SDPs. We used sample and population data to estimate iSC costs for the entirety of Equateur Province.

Results

In the period immediately before implementing the optimized model, estimated annual iSC costs were $974,237. Following implementation, estimated annual iSC costs were $642,627—a 34% ($331,610) reduction. This change in costs was influenced by a 43% ($180,313) reduction in SDP costs, a 67% ($198,092) reduction in Zonal costs and an 18% ($46,795) increase in Provincial costs. After implementing the optimized model, average iSC costs for treatment Zones was $6,895 (SD: $6,072); for the control Zone was $21,738; for treatment SDPs was $989 (SD: $969); and for control SDPs was $1,356 (SD: $1,062).

Conclusions

We observed an absolute reduction in iSC costs in treatment Zones while control Zone post-implementation iSC costs remained the same or increased. The greatest cost reductions were for storage and transport at Zones and SDPs. Although cost implications of this model must continue to be evaluated over time, these findings are promising and will inform decisions around project expansion.

Redesigning immunization supply chains: Results from three country analyses

INTRODUCTION

Immunization supply chains (iSC) are essential for ensuring access to vaccines that prevent diseases. Guinea, Madagascar, and Niger initiated iSC system design efforts to conduct analysis of alternative supply chain scenarios to identify areas for improvement.

METHODOLOGY

Key stakeholders from Ministries of Health and immunization programs identified bottlenecks in the current iSC and prioritized five general design scenarios to model in each country. Scenarios included aspects of integration, changing supply chain levels and delivery frequency, ignoring administrative boundaries, and direct delivery. Primary and secondary data were collected and cleaned. Analysis was completed using Supply Chain Guru (Madagascar and Niger) and AnyLogistix (Guinea) modeling software to build a virtual representation of the iSC physical components and operating policies.

RESULTS

Modeling results were compared using both quantitative and qualitative criteria (total operating costs, cost per dose, cold chain capacity, risk of mishandling, logistics burden on healthcare workers, feasibility to implement, and equity). Using a Stop Light Analysis for user-friendly understanding of positive, negative or minimal impact on scenarios, cost savings were realized in most scenarios in Madagascar (except using autonomous aerial vehicles); proposed scenarios in Guinea increased costs or had minimal impact; in Niger, eliminating regional tiers reduced costs. Facility level cold chain was sufficient in all countries. Effect on qualitative indicators largely depended on the scenario and country context.

DISCUSSION

Similarities in scenarios selected were seen across the three countries. Results suggest that efficiencies can be found through changes to the iSC design, but the benefits of each scenario must be considered in the country context. Results of the analysis do not provide "the right answer" but rather options and guidance which then must be grounded in the country context and used as evidence for decision making to ensure reliable availability of vaccines.

Effect of Vaccine Direct Delivery (VDD) on vaccine stockouts and number of vaccinations: Case study from Bauchi State, Nigeria

OBJECTIVE

Vaccine stockouts are prevalent in Africa. Despite the importance of this as a barrier to universal vaccination coverage, rigorous studies looking at ways to reduce vaccine stockouts have been limited. We causally evaluated the effect of Vaccine Direct Delivery (VDD), an intervention to ensure the vaccine stock availability at health facilities, on the reduction of stockouts in Bauchi state, Nigeria.

METHODS

Employing the interrupted time-series method, we evaluated the change in the occurrence of vaccine stockouts before and after the introduction of VDD in July 2015. We used health facility level data from January 2013 to December 2018 among 175 facilities in Bauchi state, collected through the District Health Information Software 2 (DHIS2) for monthly information on stockouts and stock balances in all the health facilities in Nigeria. Data were analyzed using Stata 15 SE. To validate the causal relationship between VDD and vaccine stockouts, we conducted two sets of robustness checks. First, we evaluated the effect of VDD on the stockouts of other commodities. Second, we compared the trend of the prevalence of vaccine stockouts among health facilities between Bauchi state where VDD was introduced and another state (Adamawa state) where VDD was never introduced.

RESULTS

After the introduction of VDD, vaccine stockouts in Bauchi state decreased by 9 percentage points on average, and they have been decreasing monthly by 0.4 percentage points more than pre-VDD. In Adamawa state, where VDD was never introduced, the prevalence of vaccine stockouts did not change over time. In Bauchi state after VDD introduction, the stock balances of target vaccines all increased, and the number of vaccinations carried out increased in neighboring health facilities.

CONCLUSIONS

VDD intervention resulted in a significant reduction of vaccine stockouts as well as in an increase in the number of vaccinations performed. However, we should consider how to improve the system to provide vaccination service to the population in a sustainable way.

Vaccine stockouts and vaccination rate: examination of unique administrative data from Nigeria

BACKGROUND

Universal access to vaccines is crucial in protecting the population from deadly diseases. This study presents the prevalence of vaccine stockouts in Nigeria and examines the correlation between the vaccine stockouts and vaccine take-up.

METHODS

We use the unique administrative data of monthly vaccine stockouts at each health facility in Nigeria. To evaluate the correlation between the stockouts and the vaccine take-up, the administrative data were merged with the Nigeria Demographic and Health Survey conducted in 2013. We used logistic regression for the correlational study.

RESULTS

The prevalence of vaccine stockouts in Nigeria is high: 82.7% between 2012 and 2013. We find a negative correlation between vaccine stockouts and vaccine take-up. However, we observe the differential correlational pattern depending on the regional vaccine coverage, which we consider as the proxy of the level of demand for vaccines.

CONCLUSIONS

We find that, while vaccine stockouts are correlated with the low vaccine take-up on average, this negative correlation between stockouts and vaccination rate is observed only in regions with low demand for vaccines. Reducing vaccine stockouts in regions with the low vaccination coverage might be an effective way to increase the overall vaccination rate.

Interventions to increase the distribution of vaccines in Sub-Saharan Africa: a scoping review

Achieving universal access to immunization, as envisioned in the global vaccine action plan continues to be a challenge for many countries in Sub-Saharan Africa. Weak immunization supply chain (iSC) has widely been recognized as a key barrier, hindering progress towards vaccination targets in this region. These iSCs, which were designed in the 1980s, have become increasing fragile and are now considered outdated. The objective of this review was to assess the effectiveness of system redesign and outsourcing to improve outdated iSC systems in sub-Saharan Africa. We searched the following electronic databases from January 2007 to December 2017: Medline, EMBASE (Excerpta Medica Database), the Cochrane Library, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), WHOLIS (World Health Organization Library Database), LILACS (Latin American and Caribbean Literature on Health Sciences) and contacted experts in the field. Our search strategy yielded 80 records and after assessment for eligibility, seven papers met the inclusion criteria. Five studies evaluated the experiences of system redesign in three countries (Nigeria, Benin and Mozambique), two assessed outsourcing vaccine logistics to the private sector in Nigeria and South Africa. According to these studies, system redesign improved vaccine availability at service delivery points and reduce the cost of distributing vaccines. Similarly, outsourcing vaccine logistics to the private sector reduced the cost of vaccines distribution and improve vaccine availability at service delivery points.

Evaluating scenarios of locations and capacities for vaccine storage in Nigeria

Many developing countries still face the prevalence of preventable childhood diseases because their vaccine supply chain systems are inadequate by design or structure to meet the needs of their populations. Currently, Nigeria is evaluating options in the redesign of the country's vaccine supply chain. Using Nigeria as a case study, the objective is to evaluate different regional supply chain scenarios to identify the cost minimizing optimal hub locations and storage capacities for doses of different vaccines to achieve a 100% fill rate. First, we employ a shortest-path optimization routine to determine hub locations. Second, we develop a total cost minimizing routine based on stochastic optimization to determine the optimal capacities at the hubs. This model uses vaccine supply data between 2011 and 2014 provided by Nigeria's National Primary Health Care Development Agency (NPHCDA) on Tuberculosis, Polio, Yellow Fever, Tetanus Toxoid, and Hepatitis B. We find that a two-regional system with no central hub (NC2) cut costs by 23% to achieve a 100% fill rate when compared to optimizing the existing chain of six regions with a central hub (EC6). While the government's leading redesign alternative - no central three-hub system (Gov NC3) - reduces costs by 21% compared with the current EC6, it is more expensive than our NC2 system by 3%. In terms of capacity increases, optimizing the current system requires 42% more capacity than our NC2 system. Although the proposed Gov NC3 system requires the least increase in storage capacity, it requires the most distance to achieve a 100% coverage and about 15% more than our NC2. Overall, we find that improving the current system with a central hub and all its variants, even with optimal regional hub locations, require more storage capacities and are costlier than systems without a central hub. While this analysis prescribes the no central hub with two regions (NC2) as the least cost scenario, it is imperative to note that other configurations have benefits and comparative tradeoffs. Our approach and results offer some guidance for future vaccine supply chain redesigns in countries with similar layouts to Nigeria's.