Does the Size of a Vaccine Vial Create Missed Opportunities for Vaccination?

In a Devex article, Chris Elias of the Bill & Melinda Gates Foundation summarized what we know about vaccines and how they are saving lives and improving our world. Yes, coverage rates have been increasing, including for measles-containing vaccines, but we are still a long way from reaching 95 percent coverage which is needed for elimination.

Through the Dose Per Container Partnership (DPCP), we have learned that health workers are turning children away because of the vial size and a fear of wasting vaccine. This issue has not been widely explored, but we have gathered evidence to show that it is a factor that needs to be considered as countries explore ways to increase coverage and reduce missed opportunities for vaccination.

In low-resource settings, program managers must consider patients, wastage, cost, cold-chain storage capacity, and the logistics of transporting vaccines when selecting vial sizes. Data collection efforts on practices related to the effects of vaccine dose per container on coverage have been sporadic. We set out to better understand whether smaller vaccine vial sizes could affect immunization coverage, timely coverage, and other factors in 14 districts of Zambia’s Central and Luapula Provinces.

What We Learned

In Zambia, and many other low- and middle-income countries, health care workers (HCWs) face tough choices when just a few children come for vaccination. The measles vaccine must be discarded six hours after reconstitution or at the end of the vaccination session, whichever comes sooner. Do they open the 10-dose vial of measles vaccine and waste part of it, or do they ask the parents to come back later, knowing that the children may miss out on receiving their immunization?

“Sometimes the child comes, but we refer them to the next visit to avoid opening a vial,” said one health worker I spoke with in Zambia. “I’m not sure if they were brought back and unfortunately we do not have a way to track them.”

The 12-month study, implemented by JSI Research & Training Institute, Inc., began with a baseline survey in mid-2017 and will end in May 2018. The study looks at the effects of changing the measles-rubella vaccine from 10-dose to 5-dose vials and explores HCW preferences and behavior to understand the factors that enable and prevent the use of various vial sizes. Additional aspects of the study include vaccine wastage, logistics, safety, and cost.

Here is a snapshot of what we uncovered:

1. According to Zambia’s national health guidance, all children must be vaccinated regardless of how many show up at a session. However, most of the 32 HCWs interviewed during the baseline survey said their practice was to wait for a minimum of five children before opening a vial of measles vaccine. Their decision was influenced by concerns about wastage.
2. The baseline also included a household survey of almost 8,000 children aged 12 to 35 months, who would be eligible for either the first or second dose of measles vaccine. The survey revealed that 23 percent of respondents had taken a child to a health facility for vaccination but the child did not get vaccinated. The top two reasons were stockouts (70 percent) and not enough children present to open a vial of vaccine (27 percent). We were surprised to hear that even the parents understood that their children were turned away to preserve vaccine.
3. Changing the presentation of vaccines—and not just measles vaccine—to different vial sizes has the potential to increase vaccination coverage and improve health outcomes for thousands of children across the developing world. HCWs would no longer have to choose between wasting vaccines and immunizing a child.

The DPCP study provides a starting point for procuring agencies, manufacturers, and the World Health Organization to develop new recommendations for vaccine dose per container. The study will give insight into programmatic decisions beyond the measles vaccine and will potentially address this question for more expensive and thus economically riskier vaccines.

The study’s baseline, as well as the forthcoming endline report, will enable valuable information from HCWs and patients to be shared among country-level decision makers to support better-informed analysis for weighing the trade-offs related to dose per container.

Written by Kristin Krudwig