Immunization supply chains: Why they matter and how they are changing

Accelerating access for all through research and innovation in immunization: Recommendations from Strategic Priority 7 of the Immunization Agenda 2030

Research and innovation have been fundamental to many of the successes in immunization thus far, and will play important roles in the future success of Immunization Agenda 2030 (IA2030). Strategic Priority 7 (SP7) of IA2030, which addresses research and innovation, is explicitly informed by country needs and priorities, and aims to strengthen the innovation ecosystem through capacity building and collaboration at country, regional, and global levels. SP7 identifies four key focus areas: (1) "needs-based innovation", (2) "new and improved products, services, and practices", (3) "evidence for implementation", and (4) "local capacity". Strategic interventions in these key focus areas apply the lessons of the Global Vaccine Action Plan and the "Decade of Vaccines" to emphasize local innovation, promote the use of research by countries to improve program performance and impact, and encourage capacity building for the development and implementation of innovations. The proposed approach will maintain a focus on the development of new vaccines and the improvement of existing vaccines, and increase attention to innovation in service delivery. Monitoring and evaluation will foster evidence-based priority setting at the country level and help to ground the global research and development (R&D) agenda in the needs of communities. Together, these approaches are intended to harness the power of research and innovation more effectively, to meet the challenges of the future and achieve the ambitious goals of IA2030.

Leveraging Resource Centers for Strengthening Immunization Supply Chain

The efficacy of immunization programs is critically dependent on robust supply chain management, a complex challenge exacerbated by expanding program scopes and evolving vaccine technologies. This comprehensive review underscores the pivotal role of Resource Centers in fortifying the immunization supply chain, presenting a paradigm shift toward enhanced national and global health outcomes. Through a detailed examination of their key activities, the article elucidates how these centers catalyze improvements across various facets of supply chain management - from the integration of suitable technology technologies and specialized training programs to the development of sustainable models and advocacy for policy prioritization. This further explores the multifaceted challenges these centers confront, including funding constraints, capacity building, and infrastructural gaps, alongside the burgeoning opportunities presented by new vaccine introductions, donor interest in health system strengthening, and the potential for broadened scope beyond immunization. By weaving together examples of existing centers worldwide, the review highlights their contributions towards optimizing vaccine logistics, enhancing data management, and ultimately achieving Sustainable Development Goal 3. The insights provided offer valuable guidance for planning and sustaining resource centers, positioning them as indispensable allies in the global pursuit of universal immunization coverage.

Access to DTP-Based Combination Vaccines in Asia-Pacific Countries between 2019 and 2022

The Asia-Pacific countries are highly diverse in health and economic conditions that may impact vaccine access and uptake. Our study aimed to characterize patterns of health access to DTP-based combination vaccines in 10 countries from 2019 to 2022 using the IQVIA-MIDAS database. The availability, affordability, and accessibility were compared across countries by national health and economic performance indicators using Spearman's rank correlation coefficient. Our findings showed that the three aspects of access to DTP-based vaccines varied substantially in the Asia-Pacific region, with higher levels in countries with better health and economic performance. Affected by the COVID-19 pandemic, vaccine accessibility fluctuates significantly in lower-income countries, with DTP coverage rates falling by more than 14% in the Philippines and Indonesia between 2019 and 2021. For availability and affordability, Singapore and Malaysia from high-income groups were largely affected, which may be related to health expenditure as a percentage of gross domestic product (Coefficient = 0.39, p = 0.03). Our study indicates that greater attention needs to be paid to national health expenditure and routine immunization services to improve vaccine disparities and increase the robustness and resilience of the vaccine supply chain during public health emergencies.

Using new cold chain technologies to extend the vaccine cold chain in India: Equipment performance, acceptability, systems fit, and costs

This study evaluated the performance, acceptability, costs, and systems fit of three new cold chain devices in India: a second-generation ice-lined refrigerator (ILR), a solar direct drive (SDD) refrigerator, and a long-term passive device (LTPD). The evaluation was conducted over 15 months during 2016-2017. Sites were selected for their diversity in climate, terrain, and grid electrical supply, and 31 cold chain devices were deployed, 1 to each site. Results showed that all three technologies maintained correct temperatures. The SDD refrigerators had no malfunctions, whilst the ILRs had at least one malfunction, mostly due to the printed circuit board's sensitivity to the erratic power supply. The LTPD temperature display panel caused challenges initially that required replacement of all solar panels with lithium batteries. Yet the devices' long holdovers helped ensure vaccine potency. One challenge, particularly with the ILRs and SDD refrigerators, was condensation. The passively cooled LTPD was valued in settings with smaller populations and unreliable or no power; however, some its features, including the need to condition ice blocks, made it challenging to operate. In addition, the acceptable temperature range for the LTPD, as for all passively cooled devices (greater than 0 °C and less than + 10 °C), was confusing for some health workers due to the decades-long emphasis on maintaining temperatures at + 2 °C to + 8 °C. The greatest system-related benefit was establishment of new cold chain points (CCPs) at locations with intermittent or no grid electricity, bringing immunisation services closer to hard-to-reach areas. A key limitation of all three devices was the inability to freeze ice packs, which are required for vaccine carriers, somewhat restricting the potential of these technologies to reach underserved populations. Moreover, establishing new CCPs added costs to the health system. Results from this study, including costing data, can help guide decision-making.

A reliable vaccine tracking and monitoring system for health clinics using blockchain

Vaccines are delicate biological substances that gradually become inactive over time and must be kept under a recommended temperature range of 2-8 °C for both short and long-term storage. Exposure to heat or freezing temperatures can highly affect the immunological properties of these vaccines and make them completely ineffective. Research shows that vaccine exposure to temperatures outside the recommended range is 33% in developed countries and 37.1% in developing countries. In practice, vaccines are stored in refrigerators, while thermometers and data loggers are used to record and monitor temperatures. However, traditional systems are unreliable due to lack of battery backup, human error, periodic logging of temperatures, etc. Therefore, an effective and reliable vaccine tracking and monitoring system is urgently needed. This paper proposes a blockchain-based, smart contract enabled solution that ensures an enhanced level of security, transparency, and traceability of stored vaccines in a health clinic, and enables the complete history of every vaccine to be checked from the day the vaccine is received by the health clinic to the date it is used or expires. We also formally analyze the resiliency of the proposed system against several attacks and compare the system with existing blockchain and non-blockchain-based solutions.

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.

Strengthening the immunization supply chain through EVM assessment: Comparing India's two successive national assessments

Background

Effective immunization supply chain (iSC) is crucial for safe and timely transport of potent vaccines to the beneficiary. India's iSC, with a network of ~29,000 cold chain points (CCP), measures its quality standards using the World Health Organization-United Nations International Children's Emergency Fund (WHO-UNICEF) global tool on effective vaccine management (EVM). The two national EVM assessments (EVMA) were conducted in 2013 and 2018. This study helps to see the impact of policies and practices through EVMA in maintaining an efficient iSC for effective implementation of immunization program.

Materials and Methods

We conducted a desk analysis using EVMA reports to summarize and compare the findings of the two studies. Cut-off of 80% was considered ideal for each category/criteria score.

Results

Both EVMA 2013 and 2018 were conducted using Android-based global EVM tool, though across a wider sample of CCP. Maximum and minimum changes in scores were sub-national and lowest distribution (16% each) and national buffer stores (7%), respectively. Maximum and minimum improvements were seen in vaccine management (29%) and MIS and supportive functions (3%), respectively. The improvement was statistically significant for the overall scores (P = 0.02), primary (P = 0.01), subnational (P = 0.02), and lowest distribution stores (P = 0.03). Among the 36 recommendations of 2013 assessment, 78% and 22% were fully and partially implemented (or ongoing), respectively.

Conclusion

Implementation of EVM recommendations has significantly led to improvement and continues to provide a benchmark for iSC and its processes. Follow-up assessments every 3-5 years can further help to evaluate iSC and ascertain the impact of recommendations.

Vaccine production and supply need a paradigm change

We discuss the impact of COVID‐19, the journey towards developing vaccines against the disease, and how biomanufacturing should evolve in order to meet similar challenges in the future.

Designing supply chains to meet the growing need of vaccines: evidence from four countries

Background

Immunization supply chains (iSCs) move vaccines from manufacturer to point of use with the added complexities of requiring cold chain and an increasing need for agility and efficiency to ensure vaccine quality and availability. Underperforming iSCs have been widely acknowledged as a key constraint to achieving high immunization coverage rates in low- and middle-income countries. This paper details the system design approach used to analyze the iSC network in Sierra Leone, Madagascar, Niger and Guinea and documents six lessons.

Methodology

Between 2018 and 2020, these countries implemented the system design approach, involving four key steps: (1) advocate and introduce to engage stakeholders and prioritize identification of modeling scenarios; (2) collect data and plan analysis through document review and key informant interviews; (3) analyze system design scenarios using computer software modeling tools (LLamasoft’s Supply Chain Guru and AnyLogic's AnyLogistix) for optimization and simulation modeling as well as further analysis with Excel, Google maps, and OpenStreetMap; and (4) build consensus on optimized model and implementation roadmap using the Traffic Light Analysis tool and building on stakeholder input.

Findings

Key lessons include the following: (1) define system design objectives based on country priorities; (2) establish consensus with stakeholders on scenarios to model; (3) modeling provides the evidence but not the answer; (4) costs should not be weighted above other decision criteria; (5) data collection—work smarter, not harder; (6) not all questions can be answered with a computer model.

Discussion

A system design approach can identify changes to the design of the supply chain that can introduce efficiencies and improve reliability. This approach can be more effective when these lessons and principles are applied at the country level. The lessons from these four countries contribute to global thinking and best practices related to system design. The modeling and system design approach provides illustrative results to guide decision-makers. It does not give a "final answer", but compares and contrasts.

A fuzzy multi-criteria framework to identify barriers and enablers of the next-generation vaccine supply chain

Purpose

Due to the introduction of new vaccines in the child immunization program and inefficient vaccine supply chain (VSC), the universal immunization program (UIP), India is struggling to provide a full schedule of vaccination to the targeted children. In this paper, the authors investigate the critical factors for improving the performance of the existing VSC system by implementing the next-generation vaccine supply chain (NGVSC) in India.

Design/methodology/approach

The authors design a fuzzy multi-criteria framework using a fuzzy analytical hierarchical process (FAHP) and fuzzy multi-objective optimization on the basis of ratio analysis (FMOORA) to identify and analyze the critical barriers and enablers for the implementation of NGVSC. Further, the authors carry out a numerical simulation to validate the model.

Findings

The outcome of the analysis contends that demand forecasting is the topmost supply chain barrier and sustainable financing is the most important/critical enabler to facilitate the implementation of the NGVSC. In addition, the simulation reveals that the results of the study are reliable.

Social implications

The findings of the study can be useful for the child immunization policymakers of India and other developing countries to design appropriate strategies for improving existing VSC performance by implementing the NGVSC.

Originality/value

To the best of the authors’ knowledge, the study is the first empirical study to propose the improvement of VSC performance by designing the NGVSC.

Stability Studies of the Vaccine Adjuvant U-Omp19

Unlipidated outer membrane protein 19 (U-Omp19) is a novel mucosal adjuvant in preclinical development to be used in vaccine formulations. U-Omp19 holds two main properties, it is capable of inhibiting gastrointestinal and lysosomal peptidases, increasing the amount of co-administered antigen that reaches the immune inductive sites and its half-life inside cells, and it is able to stimulate antigen presenting cells in vivo. These activities enable U-Omp19 to enhance the adaptive immune response to co-administrated antigens.

To characterize the stability of U-Omp19 we have performed an extensive analysis of its physicochemical and biological properties in a 3-year long-term stability study, and under potentially damaging freeze-thawing and lyophilization stress processes. Results revealed that U-Omp19 retains its full protease inhibitor activity, its monomeric state and its secondary structure even when stored in solution for 36 months or after multiple freeze-thawing cycles. Non-enzymatic hydrolysis resulted the major degradation pathway for storage in solution at 4 °C or room temperature which can be abrogated by lyophilization yet increasing protein tendency to form aggregates.

This information will play a key role in the development of a stable formulation of U-Omp19, allowing an extended shelf-life during manufacturing, storage, and shipping of a future vaccine containing this pioneering adjuvant.

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.

Prioritizing the vaccine supply chain issues of developing countries using an integrated ISM-fuzzy ANP framework

Purpose

Delivering vaccines to the children who need them requires a supply chain that is efficient and effective. In most of the developing countries, however, the unknown and unresolved supply chain issues are causing inefficiencies in distributing vaccines. There is, therefore, a great need in such countries to recognize the issues that cause delays in vaccine delivery. With this purpose, the present study aims to identify and analyze the key issues in the supply chain of basic vaccines required to immunize children in developing countries.

Design/methodology/approach

Based on a field survey of three states of India, in-depth review of relevant literature and experts’ opinions, 25 key issues were recognized as factors of the vaccine supply chain (VSC) and categorized into five main domains. Using integrated interpretive structural modeling and fuzzy analytic network process approaches, the issues have been prioritized to determine their relative importance in the VSC. In addition, a sensitivity analysis has been performed to investigate the priority stability of the issues.

Findings

The results of the analysis show that among the five domains of VSC issues, the economic domain with a weight of 0.4262 is the most important domain, followed by the management (0.2672), operational (0.2222), environmental (0.0532) and social (0.0312).

Research limitations/implications

This study focuses on the prioritization of VSC issues; therefore, the results of the present study can provide direction to the decision-makers of immunization programs of developing countries in driving their efforts and resources on eliminating the most important obstacles to design successful vaccination programs.

Originality/value

To the authors’ knowledge, this paper is first to provide a direction to the decision-makers in identifying and managing important issues through the use of an analytical approach.

A scoping review of interventions for vaccine stock management in primary health-care facilities

One of the challenges facing the success of immunization programs is shortages of vaccines at health facilities, which could result from inadequate vaccine stock management. Several approaches have been designed by countries to improve vaccine stock management. This review summarizes currently available information on interventions for vaccine stock management.We considered both randomized trials and non-randomized studies eligible for inclusion in this review. The following databases were searched: PubMed, Embase, Cochrane Central Register of Controlled Trials, World Health Organization Library Information System, Web of Science, and PDQ-Evidence. We searched the websites of the World Health Organization, Global Alliance for Vaccine and Immunization, PATH's Vaccine Resources Library, and United Nations Children's Fund. The reference lists of all the included studies were also searched. Two authors independently screened search outputs, reviewed full texts of potentially eligible articles, evaluated risk of bias, and extracted data; resolving disagreements through consensus.Four studies met our inclusion criteria (three before-after studies and one randomized trial). Three studies were conducted in low- and middle-income countries while one was conducted in Canada (a high-income country). All the studies had various limitations and were classified as having a high risk of bias. Study findings suggest that the use of digital information systems to improve information and stock visibility, coupled with other interventions (such as training of health-care workers on the use of innovative tools and redesign of the supply chain to tackle certain bottlenecks), has the potential to increase vaccine availability, reduce response times, and improve the quality of vaccine records.

Two-way assessment of key performance indicators to vaccine supply chain system in India

Purpose

The purpose of this paper is to identify the key performance indicators (KPIs) of vaccine supply chain of Universal Immunization Program (UIP) India, and measure their impact on vaccine supply chain performance improvement, so that results of this study can help the decision makers manage the activity and effectiveness of their resources in order to improve vaccine delivery performance and child immunization coverage.

Design/methodology/approach

The 41 KPIs in terms of four dimension of the balanced scorecard (BSC), i.e. financial, customer, internal process and learning and growth have been identified and validated from the literature and expert’s opinions. Further, the impact of internal process and learning and growth performance indicators on the vaccine supply chain performance improvement have been evaluated using two-way assessment. The rankings obtained using two-way assessment are then compared to DEMATEL approach to validate the results.

Findings

The results from the analysis reveal that “Enhancement in employee work satisfaction” (LG3=10.08 percent), “Enhancement in professional vaccine supply chain managers and leaders” (LG2 = 6.70 percent) “Improvement in planning and coordination in the supply chain” (LG9 = 6.57 percent) are the three critical performance indicators having maximum impact on vaccine supply chain performance improvement. The decision makers should give priority to these performance indicators to improve delivery performance and immunization coverage.

Social implications

This study focuses on the improvement in vaccine delivery performance, therefore, analysis and findings can be useful to government immunization programs of India to other developing nations to improve child immunization coverage.

Originality/value

To our knowledge, this paper is first to attempt to provide a direction to improve immunization coverage through vaccine supply chain performance indicators.

A fuzzy MICMAC analysis for improving supply chain performance of basic vaccines in developing countries

INTRODUCTION

In recent years, demand to improve child immunization coverage globally, and the development of the latest vaccines and technology has made the vaccine market very complex. The rise in such complexities often gives birth to numerous issues in the vaccine supply chain, which are the primary cause of its poor performance. Figuring out the cause of the performance problem can help you decide how to address it. The goal of the present study is to identify and analyze important issues in the supply chain of basic vaccines required for child immunization in the developing countries.

RESEARCH DESIGN & METHODS

Twenty-five key issues as various factors of the vaccine supply chain have been presented in this paper. Fuzzy MICMAC analysis has been carried out to classify the factors based on their driving and dependence power and to develop a hierarchy based model. Further, the findings have been discussed with the field experts to identify the critical factors.

RESULTS & CONCLUSION

Three factors: better demand forecast, communication between the supply chain members, and proper planning and scheduling have been identified as the critical factors of vaccine supply chain. These factors should be given special care to improve vaccine supply chain performance.