expert review committee meeting march 2012. recent nigeria cold chain assessments and epi committee...
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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?