Cold chain challenged by new
vaccines:
How Effective Vaccine
Management helps
4th A nnual Global Im m unization M eeting
N ew - York, 17 - 19 February 2009
S. K one – W H O/IV B/E PI
Osm an D avid M ansoor – U N ICE F
Patrick Lydon - W H O/IV B/E PI
Cold Chain & Logistics for EPI:
Essential Health System Infrastructure
Established in 1980s
-Needs updating for new challenges
Inadequate cold chain constraint for vaccine delivery
Integrate vaccine logistics with other essential health commodities
Demands from new vaccines
100
- Increased volume
75
60
63
40
44
49
52
68
71 70 70
73 73 72 72 72 71 73 73 73 75
77 78 79
56
38
20
20
24 26
UCI
Global
Eastern Mediterranean
Western Pacific
African
European
American
South East Asian
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
0
1980
% coverage
80
- Value of vaccines
Current & anticipated vaccines volumes per child
New target
for Pneumo
& Rota
Todays'
requirements
TV + Penta_liq + PCVUniject + Rota
20
41
TV + Penta + PCV-2dose vial + Rota
20
41
TV + Penta + PCV-7
20
41
TV + Penta
20
41
Tradi Vax
35
Initial target
for Pneumo
& Rota
36
21
240
177
240
32
0
Traditional Vax
50
100
150
dtp/hepB/Hib combo
200
PCV
Rota
250
300
350
Volumes, cm3
400
Gross cold-chain capacity of national vaccine store (cm3/child)
National vaccine store capacity, by region
400
350
5/9
countries
TV+Penta+PCV+Rota (300 cm3/child)
300
250
200
150
356
4/6
countries
TV+Penta+PCV+Rota (150 cm3/child)
2/6
countries
357
497
397
3/8
countries
TV+Penta+PCV (100 cm3/child)
100
50
135
98
32/35
countries
4/6
countries
0
EMR
TV+Penta (61.0 cm3/child
cm3/child))
AFR
AMR
WPR
EUR
SEAR
Source: Country cold chain data are from GAVI applications, EVSM assessment reports, Stock Management Tools
Upgrading cold chain takes Time!
Assessing the need
–
–
Central & intermediate
Intermediate & service
3 months
1-2 months
2-3 months
Preparing & ordering
6-9 months
Receiving and installation
3-6 months
It can take at least 12 months to upgrade needed
cold chain capacity for new vaccines introduction
And money: rough estimate $5-10 per birth
Increasing complexity of EPI operations
New vaccine products with non standard characteristics
emerging
–
–
–
Challenging existing simple rules (MDVP, VVM)
Waste disposal (increased qty & diversity)
Service delivery strategies (expanded age groups)
Increase the quantity & volume of safe injection supplies
stored at ambient
–
Need for adequate storage & bundled distribution to matched
with vaccines
Radical implication for training & supportive supervision:
–
–
Increasing complexity and costs of logistics will require serious
qualification improvement of logistics managers at all levels!
Health workers training and supportive supervision…
Efforts to address challenge
Vaccine Presentation and Packaging Advisory
Group (VPPAG): Input to future presentation
development
[see http://sites.google.com/site/vppagp]
Development of electronic tools
–
For country decision-making, planning &
implementation
•
•
•
•
–
Vaccine volume calculator
Stock management tool (Access and Excel Based)
Equipment inventory tools (Access and Excel Based)
Scenario analysis & Multiyear forecasting of needs
For assessment & identification of gaps
What is the EVM ?
Effective Vaccine Store Management (EVSM) started in
2002 and officially launched in 2004 by WHO and
UNICEF
National level assessment leading to certification
Vaccine Management Assessments (VMA)
Covers all levels and no certification
Effective Vaccine Management (EVM) initiative
Currently under development
Combines best features of both EVSM and VMA
National and sub-national levels
Self-management tool - modular
Why vaccine management ?
The vaccine supply chain is the most critical element of an
immunization system
Poor vaccine management and supply chain practices
and/or equipment failure can cause loss of large quantities
of vaccine
Financial loss can run to millions of dollars and children
can miss being immunized
Growing concern with new more costly and more bulky
vaccines
The problem ?
No incentive for countries to undertake vaccine management
assessments and re-assessment to improve their cold chain and
logistics systems for vaccines
Why?
Not promoted enough by immunization partners
WHO-UNICEF joint statement has been forgotten
GAVI and IRC not enforcing this requirement
Logistics and good supply chain management in low income
countries tends to be a second order priority
Yet
We are sending more and more vaccines and more costly
vaccines into poor performing national cold chain and logistics
systems!
Analysis of EVSMs
•
Overall scores on the measure
indicators below acceptable
80% best practice rate
•
Lowest overall scores relate to
– Vaccine arrival
– Storage capacity for
vaccines and supplies
– Distribution and
transportation of vaccines
down the national supply
chain
– Managing vaccine stocks
100
70
75
62
67
70
61
56
59
50
25
23
17
Distribution
Build, Equip &
Transp
Storage Capacity
7
Temp Control
0
23
Stock Control
19
Maintenance
36
Vaccine Arrival
EVSM Score [0% - 100%]
Certification [80%]
Average Score (43)
Minimum Score
Value of Re-assessments
In AFR (3)
Distribution System
Vaccine Arrival
100
•
All countries that did an
assessment and a reassessment improved on
all vaccine management
indicators
•
The process catalyzed
80
60
Temperature Control
40
20
0
Stock control
Storage capacity
Equip Maintenance
In EMR (3)
Build.Eqpt& Transport
Vaccine Arrival
100
80
Distribution System
60
Temperature Control
40
20
0
Stock control
Storage capacity
– Improvements in vaccine
management practices
– National investment in cold
chain and logistics systems
– The preparation for new
vaccine introduction
Re-Assessment
Certification
Baseline Assessment
Equip Maintenance
Build.Eqpt& Transport
Next steps for EVM
•
Raise awareness of the value of
EVM
–
–
–
•
Work with GAVI
–
–
•
CCL Taskforce
Optimize (WHO-PATH)
Promote Strategy 6 of the GIVS
To enforce the EVM requirement
To encourage countries to do
EVM assessments using the
NUVI grant monies (~$10,000
per assessment)
Provide
–
–
–
–
Updated and streamlined tools
more training
roster of consultants
timely technical assistance to
countries
Thank you !
Hib Liq
Hep B
Pneumo
conj
Rotavirus
Cholera/
Typhoid
Live
Men conj
Men PS
Hep A
Rubella
Hib Lyo
JE mouse
brain
Varicella
DTaP +
combos
IPV
Measles
OPV
DT/TT/Td
Influenza
JE PHK
MMR
Yellow
Fever
DTP-HepB
DTP
Rabies
Influenza
Cholera/
Typhoid
Killed
BCG
HPV