Nigeria vaccine wastage assessment

Expert Review Committee MeetingMarch 2012

Recent Nigeria cold chain assessments and EPI committee recommendations ◦ Review wastage rates and further determine

weaknesses in stock management / monitoring

Forthcoming introduction of pentavalent and pneumococcal vaccines in Nigeria

Anecdotal evidence health workers do not follow immunization policies meant to increase coverage for fear of wasting doses

Assessment rationale in Nigeria

Vaccine Number of doses per vial Type Target wastage

rate

BCG 20 lyophilized 30%

OPV 20 liquid 15%

DTP 10 liquid 15%

Hep B 10 liquid 15%

Measles 10 lyophilized 30%

Yellow Fever 10 liquid 15%

TT 10 liquid 15%

Vaccine presentation types and target wastage rates – Nigeria, 2010

GAVI wastage rate recommendations by year of funding◦ By third year: reduce wastage rate to 15%

WHO Multi-Dose Vial Policy (MDVP) recommendation◦ Opened, multi-dose vials of certain liquid vaccines may be

reused up to 4 weeks if properly stored (may decrease wastage by 30%)

WHO  policy◦ A vial should be opened anytime a child is present for

vaccinations◦ Always administer a measles vaccine to eligible unvaccinated

child, even if >1 year old (WHO recommendation)

Global vaccination policies and their relationship to wastage

Relationship between vaccine usage, wastage, and vial-specific wastage rates

Measuring vial-specific wastage rates allows for determining appropriate strategies to reducing wastage

WHO, Monitoring vaccine wastage at country level. Guidelines for programme managers.

For routine immunization vaccines, measure◦ Vaccine wastage rates (overall, unopened-vial-

specific, open-vial-specific)◦ Proportion of sessions where the vaccine is

given

Assess◦ Vaccine management policies and practices◦ Vaccine session planning and implementation

Study objectives

Sites selected◦ 55 health facilities across 11 LGAs and all 6 Zones

Stock records reviewed◦ Records abstracted for January 1, 2011 to June 30, 2011◦ Data abstracted: monthly starting balance, # of doses opened, # of

persons vaccinated and ending balance

Session records reviewed◦ Records abstracted for 12 sessions prior to June 30, 2011◦ Data abstracted: number of doses received, opened, returned;

population vaccinated

Facility staff surveyed◦ Stock recordkeeping practices, knowledge of national vaccine use

policies, current immunization practices◦ Mothers of infants also interviewed on experiences

Study methods: Data collection activities

Field data collection period: 22-26 August, 2011Assessment partners: NPHCDA, UNICEF, WHO, CDC

>50% of facilities did not have approved stock management forms◦ Were using alternate methods for managing stock data

Overall vaccine wastage rate calculation◦ 30-40% of facilities lacked at least 1 data element (# of doses

received; # of doses opened etc.) needed for calculating wastage rate per antigen

Unable to calculate unopened-vial-specific wastage rates ◦ 0% of facilities recorded number of unopened doses discarded ◦ Yet, 38% of facilities reported they had damaged vials in last 6

months

Facility results: Low quality data for calculating wastage rates

Facility results: Calculated wastage rates

BC

G (

26)

PO

L (3

0)

DTP (

30)

HepB

(30)

Measl

es

(34)

TT (

31)

BC

G (

24)

PO

L (3

0)

DTP (

30)

HepB

(29)

Measl

es

(29)

YF

(28)

TT (

26)

Health facility monthly wastage rate Session wastage rate

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

17%19% 18%

21%19%

24% 24%

35%

10%

14%

10% 10%

19%

Media

n C

alc

ula

ted W

ast

age r

ate

median monthly wastage rates calculated using monthly reporting form data (January-June 2011)

Note: 55 health facilities were visited in survey. Number of health facilities used in calculation of vaccine-specific wastage rate given in parentheses.

Median wastage rates were calculated using session reporting form data from a facility’s last 12 sessions conducted prior to June 30, 2011

30%

15%

median wastage rate across months (from HF monthly reporting form)

median wastage rate across HF sessions (from HF session summary forms)

Multi-dose vial policy◦ 55% reported familiarity with the MDVP; of those:

10% knew opened vials could be reused up to 4 weeks

Eligible age for vaccination policy◦ 12% reportedly vaccinate up to 2 years of age (current

policy) ◦ 58% reportedly vaccinate up to 5 years of age

When to open a vial◦ 24% reportedly open a vial whenever a child shows up at

facility/session◦ 10% of all reviewed sessions had all vaccines given

Facility results: Immunization policies

Stock records◦ 17% of facilities monitored each ILR 2x daily, 7 days/week ◦ 44% of facilities had records on quantity of doses received

Stock supply/forecasting◦ 63% reported stockouts in last 6 months; nearly all believed

wastage caused these stockouts◦ 53% reportedly forecast stock needs based on previous

number of doses used

Wastage knowledge & practices◦ 79% reportedly make an effort to reduce wastage◦ 21% had calculated monthly wastage rates for last 6 months◦ 16% knew all data elements needed to calculate wastage◦ 12% reported receiving wastage targets

Facility results: Stock management

Planning◦ 15% had facility microplan available◦ 26% reported they have hard to reach populations◦ 6% reported receiving a supervision visit in last 3

months

Implementation◦ 30% of interviewed beneficiaries reported being

turned away for at least 1 vaccine◦ 52% of them reported not receiving all vaccines

they had missed

Facility results: Session planning & implementation

Reported use of MDVP◦ 12% incorrectly believed the MDVP applies to measles vaccine◦ 85% reported they should discard opened measles vial within

6 hours

Reported use of open vial policy for Measles vaccine ◦ 2% open measles vial for every eligible infant◦ 98% open measles vial only on certain days or certain number

of children◦ On average, 6 infants must be present before measles vial is

opened

Session planning & implementation◦ 62% of reviewed sessions included measles vaccine◦ Only 1 vial opened in 76% of sessions with measles vaccine

Example : Measles vaccination

LGA level wastage-related knowledge & practices

Poor

clie

nt flow

discar

d 6 h

ours

afte

r rec

onst

itutio

n

expos

ure to

hig

h tem

perat

ure

inab

ility

to g

et a

ll dos

es fr

om v

ial

expiry

dat

e has

pas

sed

spilla

ge

discar

d afte

r open

ing

expos

ure to

free

zing

0

10

20

30

40

50

60

70

80

90

100

Pro

port

ion o

f LG

As

Reported reasons for vaccine wastage by LGA immunization staff

100% of LGAs believed wastage was important topic◦ 25% collected wastage rate data from facilities◦ 39% correctly aware of the required data needed to calculate wastage rates◦ 79% believed wastage rates needed to decrease

Stock management◦ Few monitoring & managing stock well◦ Wastage rates low, but likely driven by stockout

concerns

Policies & session implementation◦ Few knew MDVP ◦ Majority vaccinating up to 5 years

May be impacting stockouts (good policy change though?)

◦ Few opening a vial at every opportunity Tied to high concerns with stockouts

◦ Missed opportunities reported

Conclusions

RecommendationsLocal level National level

Distribute standardized forms Review/reaffirm policies◦ MDVP◦ Vaccination age ranges◦ When vial is opened

Assess vaccine supply◦ Funding availability◦ Sufficient doses ordered◦ Sufficient supply available◦ Account for policy decisions

Stock management training (using forms)

Microplan updation exercise including session-type assessment for villages

Immunization policies training (MDVP)

Wastage training: targets, calculations, types

Intradistrict knowledge sharing exercise (supervisor-led)

Thank You!Questions?