28.05.2012
Immunization session attendance,
vaccine wastage and coverage
Study conducted by AMP in Burkina Faso in 2009
P. Jaillard, AMP
www.amp-vaccinology.org
www.logivac.org
Agenda
Study objectives
Burkina Faso presentation
Method and material
Results
frequency of sessions
attendance at session
vaccine wastage
immunization coverage
Conclusion
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28.05.2012
Objectives
• To measure immunization session attendance of EPI routine
program for different strategies in urban and rural areas
• To calculate vaccine wastage rate during immunization sessions
• To measure attendance by girls in primary and secondary
schools in urban and rural areas (HPV vaccine)
WHO commissioned and funded the study (to support VPPAG
activities)
AMP developped the protocole and implemented the study in
Burkina Faso in 2009
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Plan
Study objectives
Burkina Faso presentation
Method and material
Results
frequency of sessions
attendance at session
vaccine wastage
immunization coverage
Conclusion
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Presentation
• ~ 15 M. hab;
47%<15yrs
Burkina Faso
National
immunization
program - overview
Vaccine presentation
• Schedule: 8, 12, 16 wks
• Systematic EPI : Fixed posts and out reach sessions.
• Campaign : + door to door
• 20 doses / vial
• 10 doses / vial
• 1 dose / vial
BCG (lyo), OPV (liq), TT (liq)
MCV (lyo), YF (lyo)
Penta (liq)
Imm. Coverage
(WHO/UNICEF, 2008)
Vaccine management
(WHO, 2008)
•Penta 3 = 95%;
MCV =94%
•Wastage :
BCG = 36%;
MCV = 19%
•No stock out in 2008 (central and district level)
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Presentation – Burkina Faso
Vaccine management performance at service
delivery level (2009 EPI review
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Plan
Study objectives
Burkina Faso situation
Method and material
Results
frequency of sessions
attendance at session
vaccine wastage
immunization coverage
Conclusion
7
Method
• Retrospective study (Jan(Jan-Dec 2008)
• Routine immunization: fixed post and out reach strategy
• Four sites selected in Burkina Faso: Two rural, Two urban
Name of facility
Population
Settings Distance from
Cold chain
Total / 0-11 months
vaccine store
equipment
(district) (km)
Medical Center Kossodo
9 829 / 414
Urban
0
1 fridge (Sibir *)
Health Center Secteur 23
86 919 / 3 659
Urban
9
2 fridges (Sibir)
1 freezer
Medical Center Tanghin Dassouri
20 006 / 842
Rural
25
2 fridges (Sibir)
Health Center Yaoghin
3 060 / 128
Rural
50
1 fridge (Sibir)
• Source of data
•
•
Daily immunization register
Vaccine stock register
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Method – Immunization sessions and coverage
Frequency
Number of immunization session by
•Health facility
•Strategy
•Vaccine
For the all year 2008
Coverage
Attendance
Number of attendees by
•Health facility
•Immunization session
•Strategy
•Vaccine
For the all year 2008
• Calculation based on the number of doses reported in the tally
records (numerator), and the target population of the area of each
health facility, provided by the Ministry of Health (denominator).
• Limits :
• Not possible to affirm that each dose was administered to a
beneficiary residing in the area of the health facility.
• Data of target population issues from 2006 population census
Method - Vaccine wastages calculation
Health facility level
Immunization sessions
Unopened vials + opened vials
Opened vials only
Include losses due to services and
losses due to the program.
include only losses due to the program.
Measured on the full year 2008 for all
vaccines
Calculated from the number of doses
reported in the tally register and the
number of vaccine vials taken out of
the stock of the facility, reported on the
vaccine stock register.
Measured :
1. on the full year 2008 for all vaccines.
2.for each session only for vaccines not
covered by the open vial policy (BCG, MCV
and YF) and vaccine in single dose (penta).
Calculated from the number of doses and
the number of vaccine vials opened during
the session, reported in the tally register
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Plan
Study objectives
Burkina Faso presentation
Method and material
Results
frequency of sessions
attendance at session
vaccine wastage
immunization coverage
Conclusion
11
Results – immunization session frequency - 2008
Distribution of immunization sessions and Distribution of immunization sessions (n=839)
doses
60%
Fixed post
Out reach
50%
sessions
doses
40%
24.40
%
32.3
0%
30%
20%
66.7
0%
10%
73.60
%
Urban
0%
Kossodo Secteur
23
Urban set.
Tanghin
Yaoghin
Rural
14.8
%
Rural setting
40.5
%
• Total number of sessions conducted = 839
• Total number of doses administered = 42 805
Urban setting
Rural setting
• Urban setting : 67% of immunization sessions; 77% of doses administered
• All health structure offered both fixed and out reach immunization services
• Out reach strategy more frequent in rural (40,5%) than urban (14,8%)
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Results – immunization session frequency
Frequency of session offering
MCV
Frequency of session offering
vaccines
40.0%
35.0%
100.0%
30.0%
80.0%
MCV
25,5%
60.0%
25.0%
MCV
37,2%
20.0%
MCV
21,9%
15.0%
40.0%
10.0%
20.0%
5.0%
0.0%
0.0%
BCG
Penta
MCV
Urban
TT
Rural
Fixed post Out reach
• Liquide vaccines offered at most of immunization sessions
• Lyophilized vaccines :
•
•
•
twice a week to once a month in fixed post
Depend on attendance in out reach sessions
Follow instruction given by regional health authorities
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Results - Vaccination session attendance
Distribution of sessions by attendance
Attendance
30
25
BCG
20
• BCG = 20 doses/vial:
• More sessions with attendances 11-20 and
31-40 to limit wastage
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• Pentavalent = 1 dose/vial
10
5
• Average attendance lower than BCG (5
time more session with pentavalent)
0
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70
Attendance
70
number of sessions
• No “vial effect”
60
Pentavalent
Pentavalent
50
40
30
20
10
• Average attendance BCG=24,1;
Penta=12,5;
• Minimum : BCG=7:
Penta= 0
• Maximum: BCG= 70;
Penta=98
0
1
4
7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73
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Results - Vaccination session attendance
Attendance
Distribution of sessions by attendance
• Measles = 10 doses/vial:
40
35
30
• More sessions with attendances 6-10
and 16-20 to limit wastage
Measles
25
20
15
• TT = 20 doses/vial
10
5
• No “vial effect” because of multi dose vial
policy application
0
1
3
5
7
9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41
number of sessions
• Average attendance lower than MCV (5
time more session with TT)*
Attendance
80
70
60
Tetanos Toxoid
50
• Average attendance :
40
MCV=14,9
30
TT=9,6;
20
10
0
1 3 5 7 9 1113151719212325272931333537394143454749515355575961
• Minimum : MCV=1
TT= 0
• Maximum : MCV = 71
TT=88
Results – Vaccine wastage
30%
• 41% of MCV wastage happened at
store level
Vaccine Wastage rate in 2008
25%
20%
Health facility
15%
Imm. sessions
10%
5%
0%
BCG
35%
OPV
Penta
measles
YF
TT
Vaccine Wastage rate in 2008
Immunization sessions
30%
• Difference between wastage rates
during immunization sessions and
at health facility store due to
expiration, broken vial, VVM switch,
reporting error, ...
25%
Fixed post
20%
Out reach strategy
15%
• wastages in outreach sessions
more important than in fixed post,
especially for lyophilized vaccines.
• Wastages lower than planed in
cMYP for all antigens
10%
5%
0%
BCG
OPV
Penta
measles
YF
TT
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Results – Immunization coverage - 2008
2000
Immunization
Card
Valid dose
Penta 1
92,2%
90,0%
MCV
87,5%
72,9%
FIC
81,5%
64,0%
Drop-out rate
penta1-MCV
5,09%
1800
1600
1400
1200
Penta 1
1000
MCV
800
600
400
200
Vaccination Coverage in the
Region (EPI review 2009)
0
Kossodo
Secteur 23
Tanghin
Yaoghin
Number of children receiving a vaccine
dose - 2008
• Low difference in number of children vaccinated with penta 1 and measles
• Measles offered in one out of 4 immunization sessions (average)
• At region level (2009 EPI review)
•
Low drop ou rate Penta 1 – MCV (5,09%)
•
1,4% of MCV doses administrated were not valid
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Plan
Study objectives
Burkina Faso situation
Method and material
Results
frequency of sessions
attendance at session
vaccine wastage
immunization coverage
Conclusion
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Conclusion
• Diversity of immunization session organization according to setting (strategy,
frequency, attendance…)
• Vaccine vials presentation drives the immunization sessions planning
• Strategies to limit vaccine wastage without significative impact on coverage (following
instruction given by health authorities) : limited wastage with high coverage
• Vaccine vial size as an adjustment parameter for immunization program
implementation; health services adapt strategy to gain efficiency in immunization
• Possible impact of vaccine vial size on quality of immunization (high number of unvalid
doses)
• Recommandation ; Maintain/developp country’s decision making capacity based on
evidence, country specificity, immunization multi year plan…
•
•
•
Assesment tools, Simulation tools, Decison tree
Policy and Improvement plan development and implementation
HR skills development
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Conclusion
• Needs further documentation on :
•
•
•
•
•
•
•
Cause of wastage at store and immunization session
Missed opportunities due to limited number of session (vaccines excluded
by MDVP)
Role of vaccine presentation in the validity of immunization
Age of immunization
Quality of immunization (immunization safety, vaccine efficacy…)
Cost / Affordability (cost per dose at district store; cost per dose
administered, cost of losses at various level; cost of AEFI, unprotected
children, contamination…)
…
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Aknowledgement
•
•
•
•
Césaire Ahanhanzo (AMP)
Aristide Aplogan (AMP)
Souleymane Koné (WHO)
Prosper Djiguemdé (MoH Burkina Faso)
Thank you for your attention
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