Over half of vaccines are wasted globally for these simple reasons

Vaccines are biological initiators that boost immunity (protection) against pathogens. In addition to single immunity, vaccines also minimize the spread of diseases through herd immunity. An example of the benefits of vaccines to humanity was the eradication of smallpox (declared in 1980), which killed over 300 million people in the twentieth century alone, and left millions cripple or blind. Smallpox, like most preventable diseases, affected mainly poor countries. The elimination of smallpox was a result of a decade-long World Health Organisation (WHO) led the global vaccination campaign that

All over the world vaccines have saved millions of children from diseases like polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), smallpox, mumps, tetanus, and rotavirus. A century ago, these life-saving weren’t possible much less delivering them those in need. Thanks to modern technologies, people are living healthier.

The World Health Organisation estimates that more than 50% of vaccines are wasted all over the world every year because of temperature control, logistics, and shipment-related issues.

Most government guidelines recommend that vaccines that have potentially been compromised should be discarded. This can be costly. In 2011, according to UNICEF, an estimated USD$ 1.5 million worth of vaccines were lost in five months, often due to difficulties maintaining cold chain vaccine supply to their remote location.

But despite all these achievements, there are still people who have no access to these medicines. Almost 20 million are in danger of getting preventable diseases because they are under-vaccinated. This results in 1.5 million children dying every year that otherwise could have been prevented.

The reason why

The underlying reason is that their area has no power supply that can keep the vaccines refrigerated. Without refrigeration, the integrity of these vaccines is questionable. They need to be stored at between 2°C and 8°C (36°F and 46°F) temperature until administered to the patients. A power loss can destroy this cold chain and may result in vaccine spoilage.

Vaccines are very effective in providing individual and community immunity against a range of diseases. In addition to protection against most diseases, vaccines also have social and economic benefits. However, for vaccines to do its job, routine immunization programs must be constant to safeguard individual and community protection.

But in many countries in Africa, vaccination coverage is almost non-existing because governments are facing obstacles to bring vaccines to the most remote areas, thus failing to abate the constant outbreaks of vaccine-preventable diseases.

The governments cannot make its promise to deliver the vaccines to a majority of the target population due to problems in policy setting, program management, and financing, cold chain facilities, global vaccine market, research, and production of vaccines.

According to the latest research, three million children die every year in Africa and approximately 24% of these deaths are due to preventable diseases such as measles, tetanus, diphtheria, meningitis, yellow fever, certain types of pneumonia, and diarrhea.

In 2011 alone, diarrhea killed 700,000 deaths, while pneumonia caused 1–3 million deaths in infants. Deaths due to vaccine-preventable pneumonia were mainly caused by Streptococcus pneumoniae (33%), the influenza virus (7%), and Haemophilus influenzae type b (16%).

In addition to the resulting deaths, preventable diseases are also a socio-economic problem because governments have to spend a significant portion of their country’s budget on high treatment costs, children’s educational programs, and general development. National progress and work is severely affected due to parents missing production to look after their children.

Development and production increased

The development and production of vaccines’ research has doubled over the last 30 years. There are more life-saving vaccines available to cure a wider array of diseases. To effectively prevent the spread of preventable diseases and ensure population protection from these, routine immunization programs must be implemented to make sure that all the children are fully immunized. Countries with successful routine immunization programs designate resources every year to ensure easy access to these vaccines, the effective management of immunization programs, and the inclusion of adequate and appropriate support services.

Surveys have revealed that immunization coverage is low in rural and hard to reach areas. In these areas, children are more prone to diseases because they are exposed to many other risk factors, such as limited or no access to clean water, malnutrition, poor healthcare facilities, and filthy surroundings.

With new vaccines being introduced to the market. These vaccines require different storage specifications (high-capacity freezers and refrigerators) and increasing volume of product that needs to be transported, tracked, and stored. This increases the burden of the financial and managerial pressure on an already overworked service. The costs that come with the cold chains include walk-in cold and freezer rooms at the national level, refrigerators, ice-packs, cold boxes, vaccine carriers, kerosene for absorption refrigerators, fuel, trucks, and cars.

Another underlying reason why only one in five children are not vaccinated is because of lack of or substandard delivery of the vaccine to remote areas, the high cost of new vaccines, poor healthcare systems, and ill-prepared routine immunization programs. The key to an effective routine immunization can be divided into four critical areas: management and financing, supply chain, vaccine market, and research and development.

The Global Alliance for Vaccines and Immunization indicates that only 10% of health care facilities in the world’s poorest countries have a dependable electricity supply. For example in Uganda, over 70% of health care facilities have poor access to mains power.

Guidelines by the WHO

The WHO developed a set of guidelines for governments in a bid to lessen the effect of high temperatures on the cold chain storage if a power outage happens.

Cold chain supply

Governments, UNICEF, and GAVI have bought more vaccines in over the last decade to protect the people in third world countries against a multitude of diseases including measles, meningitis, and polio. Once the vaccines reach their destination countries, they depend on the local cold chain supply to get them from their main storage areas to the most isolated communities.

Outbreaks of preventable diseases are often caused by due inefficiency in the immunity program, which are the result of the under-vaccination of the vulnerable population. Under-vaccination is due to vaccines not reaching to their final destination, or the vaccines being damaged due to exposure to less than ideal conditions temper. As a matter of fact, the WHO and UNICEF report most African countries are lacking the minimum standards for effective vaccine cold chain storage, distribution, handling, and stock management.

Vaccine storing

Governments not being able to find enough funds for fuel, maintain the cold chain, and implementing an integrated system of tracking the needed products can lead to vaccine stock-outs and the wastage of vaccines due to substandard storage and transportation problems.

It is estimated that over a third of vaccine doses are wasted due to conditions like contamination from the outside environment, exceeding the expiration period of the vaccines in warehouses, or by misuse in poor countries

The biggest hurdle in remote areas where electricity is unavailable or not stable, cold chain facilities are inadequate, and problems in transporting vaccine to the target population remotely living from the health centers.

Between 2011 and 2020, immunization cost for each child will increase by 40% because developing countries needs to increase their storage capacity and transportation capability. Aside from that, health care workers administering the program will deploy six time more doses per person.

It is estimated that around US$25.4 billion is needed to cover non-vaccine costs which is approximately 70% to be invested in human resources and the supply chain.

Vaccine demand forecast and distribution

During the last century, vaccines were cheap and so vaccine wastage was often ignored. Today, there are more vaccines that are administered per person, development and production costs are increasing along with population growth and higher distribution costs. Hence, vaccine wastage cannot be ignored.

The cold chain supply is essential for routine immunization programs and countries must guarantee that they can store, transport, and deliver vaccines effectively to the needed population.

Cold chain managers at the national and local levels must estimate the quantities of each vaccine, monitor local vaccine levels, and sustain systematic preventive maintenance and repairs. By accurately predicting the needs for each region, managers can maintain minimum stock levels and reduce the steps of the vaccine cold chain.

In developing countries, data gathered from Demographic and Health Surveys (DHS) are analyzed to make informed decisions on the quantity and requirements of vaccines needed to be sent to each health center. However, these surveys are costly and require a system that is not readily available to most of the countries. Due to these problems, a number of countries in Africa did not achieve completing the DHS every 5 years, as recommended by the WHO. Therefore, raising difficulties for program managers to accurately forecast the number of vaccines to be allocated.

A solution would be that governments can reduce the complexity and financial problem of the vaccine cold chain by integrating it with other health products, working with national transportation services to distribute the vaccines to health centers across the country in cold storage containers. In 57 GAVI-eligible countries, cold chains could be lowered from the standard 4 levels to a simple model in which vaccines are transported from a central location directly to immunization locations with a limited number of stopovers in between, thus saving money and improving efficiency.

Another solution is to outsource the distribution process to the private enterprises, this would lighten the burden of the government in terms of storage and transportation costs. A study in Cape Town (South Africa) found that outsourcing vaccine logistics to the private sector reduced delivery and inventory costs, improved obedience to temperature monitoring procedures, eliminate delivery delays, improved handling protocols, and allowed greater volume flexibility.

Another advantage of outsourcing the cold chain is that it would free up resources, healthcare workers, and more storage space for other primary care services.

Vaccine stock management and monitoring

Cooperative work between GAVI, pharmaceutical companies, governments, and the private sector can solve solving a multitude of problems in the cold chain in Africa.

 A good example of such cooperation is contributing to efficient cold chain management is the mVacciNation pilot program that is ongoing in Nampula (Mozambique) in 2015. The program formed a partnership between the pharmaceutical company GSK and the mobile services provider Vodafone and is funded by GAVI and USAID. GSK’s vaccine expertise and resources are merged with Vodafone‘s innovative mobile technology to help manage vaccination and supply chain.

The program, which currently has around 35.000 children registered, primarily started with 17 healthcare facilities, expanding to 76 by December 2015. Each facility has a smartphone with an app that allows health workers to manage different stages of infant vaccination (register caregivers, record vaccination histories, and schedule vaccination appointments through automatic SMSs), and regular reporting on vaccine stock supply and refrigerator temperatures. It provides important information that helps manage the supply chain and increase adherence to mass vaccination campaigns in remote and rural areas.

The use of IT technology to monitor vaccine stock nationwide and solar-powered refrigerators have aided governments to control vaccine levels in remote areas. In Nigeria, effective vaccine stock monitoring has enabled a steady flow of supply shipments that fulfill local needs and, when necessary, air shipments are also deployed.

Possible solutions

Transporting vaccines during the cold chain delivery system can be a logistical nightmare with thousands of people and equipment involved in moving it to remote locations. A number of variables could happen to the vaccines while in transit. None of it good, if the cargo is compromised it will have to be replaced, adding more costs.

Steps that can be taken include:

• Better guidelines: The creation of better guidelines for health professionals. These should be based on testing the stability and potency of vaccines and other medicines under a variety of conditions.

• Better equipment: acquiring alternative equipment that can maintain temperature during a power outage. These include solar-powered refrigeration cabinets, backup generators and refrigerators, and data loggers. This will protect temperature-sensitive medicines and vaccines.

• New vaccines: Innovative vaccines that don’t require continued refrigeration from manufacture to distribution. These vaccines are already here, including thermostable vaccines which can be stored for extended periods above 8°C. Changing the standard vaccines with heat-stable versions would lower costs and still keep their efficacy even in challenging conditions.

Some existing vaccines, such as hepatitis A&B, inactivated poliomyelitis, diphtheria, tetanus, and HPV and rotavirus vaccines, have good heat-stability capabilities. Efforts are underway to allow them to be used outside the regular cold chain.

The advantages of thermostable vaccines are significant. But there’s still the compliance of technical and regulatory rules. For example, time and experiment are needed to prove that a vaccine is still effective after exposure to high temperatures, and manufacturers need to be sure that investing the necessary resources to generate this data is needed.

The development of thermostable vaccines – and the relabelling of some existing vaccines to be effective even when stored outside the cold chain for a limited time – will lessen the instability of the delivery of additional vaccines. It will also make substantial savings in wasted vaccines and logistics, including cold chain equipment.

Conclusion

The challenge of lowering the incidence of vaccine wastage is monumental. But technology is advancing rapidly to slow down the wastage. With improved temperature monitoring, better transportation modes, and thermostable vaccines will significantly reduce, if not eliminate, the vaccine wastage and save more lives in the long run.