Vaccine Stock-outs Research Articles

Reasons for defaulting from childhood immunization program: a qualitative study from Hadiya zone, Southern Ethiopia.

BackgroundReduction of mortality and morbidity from vaccine-preventable diseases in developing countries involves successfully implementing strategies that ensure high coverage and minimize drop-outs and missed opportunities. Achieving maximum coverage, however, has been a challenge due to many reasons, including high rates of defaulters from the program. The objective of this study was to explore the reasons behind defaulting from the immunization program.MethodsA qualitative study was conducted in two districts of Hadiya zone, Southern Ethiopia between November 2014 and April 2015. A total of twenty-six in-depth interviews were held with mothers of defaulted children aged 6-11months old and key informants from the communities, health centers, and health offices. Observations and review of relevant documents were also conducted. Thematic analysis was used to analyze the data.ResultsIn this study, the main reason for defaulting from the immunization was inadequate counseling of mothers that led to a lack of information about vaccination schedules and service arrangements, including in unusual circumstances such as after missed appointment, loss of vaccination card and when the health workers failed to make home visits. Provider-client relationships are poor with mothers reporting fear of mistreatment and lack of cooperation from service providers. Contrary to what health workers and managers believe, mothers were knowledgeable about the benefits of vaccination. The high workload on mothers compounded by the lack of support from male partners was also found to contribute to the problem. Health system factors that contributed to the problem were poorly arranged and coordinated immunization services, vaccine and supplies stock outs, and lack of viable defaulter tracking systems in the health facilities.ConclusionsThe main reasons for defaulting from the immunization program are poor counseling of mothers, unsupportive provider-client relationships, poor immunization service arrangements, and lack of systems for tracking defaulters. Efforts to reduce defaulter rates from the immunization program need to focus on improving counseling of mothers and strengthening the health systems, especially with regards to service arrangements and tracking of defaulters.

Evaluation of medicine retail outlets for sale of typhoid fever vaccine among adults in two urban and rural settings in western Kenya: a proof-of-concept study

BackgroundPrivate sector medicine outlets are an important provider of health services across the developing world, and are an untapped means of distributing and selling vaccines outside of childhood immunization programs. The present study assessed the viability of medicine outlets (chemists and pharmacies) as potential channels for sale of vaccines.MethodsTo evaluate the viability of the medicine outlet model, we partnered with nine outlets across urban and rural communities in western Kenya to sell a nurse-administered typhoid vaccine. Purchasers were surveyed to reveal market demographic characteristics, reasons for vaccine purchase, and sources of information about the program. Key informant interviews and focus group discussions defined acceptability, demand, and additional suggestions for improving this mechanism of selling and distributing vaccines.ResultsThere was a higher than expected demand for the vaccine that resulted in stock-outs. Previous instance of typhoid, desire to prevent disease, affordable price and convenience were cited by most participants as main reasons for purchase of vaccine at the local outlet. The most common source of information on the vaccine sale was word-of-mouth and referral from friends. Longer vaccine sale duration, adequate stocking of vaccines and extended hours of administration in the evening to allow working individuals to buy vaccines were cited by participants as ways for improved participation in the future.ConclusionsThis study demonstrated a high demand for vaccines at community medicine outlets. Important insights on how to improve and sustain such a program included extension of distribution time, education of outlet keepers, and minimizing vaccine stockouts. With improved social marketing, infrastructure mapping, education and pricing schemes, medicine outlets could become a sustainable avenue for selling adult vaccines in emerging markets for both routine and pandemic vaccines.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1788-5) contains supplementary material, which is available to authorized users.

Acceptance of multiple injectable vaccines in a single immunization visit in The Gambia pre and post introduction of inactivated polio vaccine

BackgroundAs the World Health Organization (WHO) currently recommends that children be protected against 11 different pathogens, it is becoming increasingly necessary to administer multiple injectable vaccines during a single immunization visit. In this study we assess Gambian healthcare providers’ and infant caregivers’ attitudes and practices related to the administration of multiple injectable vaccines to a child at a single immunization visit before and after the 2015 introduction of inactivated polio vaccine (IPV). IPV introduction increased the number of injectable vaccines recommended for the 4-month immunization visit from two to three in The Gambia. MethodsWe conducted a cross-sectional questionnaire-based survey before and after the introduction of IPV at 4months of age in a representative sample of all health facilities providing immunizations in The Gambia. Healthcare providers who administer vaccines at the selected health facilities and caregivers who brought infants for their 4month immunization visit were surveyed. FindingsPrior to IPV introduction, 9.9% of healthcare providers and 35.7% of infant caregivers expressed concern about a child receiving more than 2 injections in a single visit. Nevertheless, 98.8% and 90.9% of infants received all required vaccinations for the visit before and after IPV introduction, respectively. The only reason why vaccines were not received was vaccine stock-outs. Infant caregivers generally agreed that vaccinators could be trusted to provide accurate information regarding the number of vaccines that a child needed. ConclusionHealthcare providers and infant caregivers in this resource limited setting accepted an increase in the number of injectable vaccines administered at a single visit even though some expressed concerns about the increase.

Vaccination coverage and timely vaccination with valid doses in Malawi

IntroductionA cluster vaccination coverage survey was conducted in two districts, Dowa and Ntchisi, in Malawi to measure the vaccination coverage of children 12–23months old and identify factors impacting the utilization of vaccination service. MethodsA cross-sectional descriptive cluster survey with 30 clusters and 10 children per cluster was administered in each district including a total of 601 children surveyed. 57 village heads and 60 health surveillance assistants (HSAs) were also interviewed. FindingsThe vaccination card availability was very high in both districts (94%). Vaccination coverage by card plus history of mothers was very high, above 93% for all antigens, and the coverage by card alone was also high with a range of pentavalent1 coverage of 91% in Ntchisi and 83% in Dowa to measles coverage of 81% and 83% in Dowa and Ntchisi respectively. However, the percentage of valid doses administered to fully immunized children was low (60% in Dowa and 49% in Ntchisi). About 10% of the pentavalent1 doses in Dowa and 9% in Ntchisi were administered before six weeks of age and 7% and 8% of the pentavalent3 doses in Dowa and Ntchisi districts respectively were administered in less than 28days after pentavalent2. Similarly, 15% of measles doses in both Dowa and Ntchisi districts were administered before 270days. The main reason for no vaccination was vaccine stock outs at health facility level. The majority of village heads are satisfied with the vaccination service in their communities. Health surveillance assistants (HSAs), village heads and religious leaders all play major roles in mobilization for vaccination service in the two districts. ConclusionDowa and Ntchisi districts have high vaccination coverage, however many children receive invalid doses. This finding calls for immediate action to educate the service providers on administration of valid doses.

The acceptability of three vaccine injections given to infants during a single clinic visit in South Africa.

BackgroundThe Expanded Programme on Immunisation (EPI) has increased the number of antigens and injections administered at one visit. There are concerns that more injections at a single immunisation visit could decrease vaccination coverage. We assessed the acceptability and acceptance of three vaccine injections at a single immunisation visit by caregivers and vaccinators in South Africa.MethodsA mixed methods exploratory study of caregivers and vaccinators at clinics in two provinces of South Africa was conducted. Quantitative and qualitative data were collected using questionnaires as well as observations of the administration of three-injection vaccination sessions.ResultsThe sample comprised 229 caregivers and 98 vaccinators. Caregivers were satisfied with the vaccinators’ care (97 %) and their infants receiving immunisation injections (93 %). However, many caregivers, (86 %) also felt that three or more injections were excessive at one visit. Caregivers had limited knowledge of actual vaccines provided, and reasons for three injections. Although vaccinators recognised the importance of informing caregivers about vaccination, they only did this sometimes. Overall, acceptance of three injections was high, with 97 % of caregivers expressing willingness to bring their infant for three injections again in future visits despite concerns about the pain and discomfort that the infant experienced. Many (55 %) vaccinators expressed concern about giving three injections in one immunisation visit. However, in 122 (95 %) observed three-injection vaccination sessions, the vaccinators administered all required vaccinations for that visit. The remaining seven vaccinations were not completed because of vaccine stock-outs.ConclusionsWe found high acceptance by caregivers and vaccinators of three injections. Caregivers’ poor understanding of reasons for three injections resulted from limited information sharing by vaccinators for caregivers. Acceptability of three injections may be improved through enhanced vaccinator-caregiver communication, and improved management of infants’ pain. Vaccinator training should include evidence-informed ways of communicating with caregivers and reducing injection pain. Strategies to improve acceptance and acceptability of three injections should be rigorously evaluated as part of EPI’s expansion in resource-limited countries.

Predictors of Uptake and Timeliness of Newly Introduced Pneumococcal and Rotavirus Vaccines, and of Measles Vaccine in Rural Malawi: A Population Cohort Study

BackgroundMalawi introduced pneumococcal conjugate vaccine (PCV13) and monovalent rotavirus vaccine (RV1) in 2011 and 2012 respectively, and is planning the introduction of a second-dose measles vaccine (MV). We assessed predictors of availability, uptake and timeliness of these vaccines in a rural Malawian setting.MethodsCommencing on the first date of PCV13 eligibility we conducted a prospective population-based birth cohort study of 2,616 children under demographic surveillance in Karonga District, northern Malawi who were eligible for PCV13, or from the date of RV1 introduction both PCV13 and RV1. Potential predictors of vaccine uptake and timeliness for PCV13, RV1 and MV were analysed respectively using robust Poisson and Cox regression.ResultsVaccine coverage was high for all vaccines, ranging from 86.9% for RV1 dose 2 to 95.4% for PCV13 dose 1. Median time delay for PCV13 dose 1 was 17 days (IQR 7–36), 19 days (IQR 8–36) for RV1 dose 1 and 20 days (IQR 3–46) for MV. Infants born to lower educated or farming mothers and those living further away from the road or clinic were at greater risk of being not fully vaccinated and being vaccinated late. Delays in vaccination were also associated with non-facility birth. Vaccine stock-outs resulted in both a delay in vaccine timeliness and in a decrease in completion of schedule.ConclusionDespite high vaccination coverage in this setting, delays in vaccination were common. We identified programmatic and socio-demographic risk factors for uptake and timeliness of vaccination. Understanding who remains most vulnerable to be unvaccinated allows for focussed delivery thereby increasing population coverage and maximising the equitable benefits of universal vaccination programmes.

Catching-up with pentavalent vaccine: Exploring reasons behind lower rotavirus vaccine coverage in El Salvador

Rotavirus vaccine was introduced in El Salvador in 2006 and is recommended to be given concomitantly with DTP–HepB–Haemophilus influenzae type b (pentavalent) vaccine at ages 2 months (upper age limit 15 weeks) and 4 months (upper age limit 8 months) of age. However, rotavirus vaccination coverage continues to lag behind that of pentavalent vaccine, even in years when national rotavirus vaccine stock-outs have not occurred. We analyzed factors associated with receipt of oral rotavirus vaccine among children who received at least 2 doses of pentavalent vaccine in a stratified cluster survey of children aged 24–59 months conducted in El Salvador in 2011. Vaccine doses included were documented on vaccination cards (94.4%) or in health facility records (5.6%). Logistic regression and survival analysis were used to assess factors associated with vaccination status and age at vaccination. Receipt of pentavalent vaccine by age 15 weeks was associated with rotavirus vaccination (OR: 5.1; 95% CI 2.7, 9.4), and receipt of the second pentavalent dose by age 32 weeks was associated with receipt of two rotavirus vaccine doses (OR: 5.0; 95% CI 2.1–12.3). Timely coverage with the first pentavalent vaccine dose was 88.2% in the 2007 cohort and 91.1% in the 2008 cohort (p=0.04). Children born in 2009, when a four-month national rotavirus vaccine stock-out occurred, had an older median age of receipt of rotavirus vaccine and were less likely to receive rotavirus on the same date as the same dose of pentavalent vaccine than children born in 2007 and 2008. Upper age limit recommendations for rotavirus vaccine administration contributed to suboptimal vaccination coverage. Survey data suggest that late rotavirus vaccination and co-administration with later doses of pentavalent vaccine among children born in 2009 helped increase rotavirus vaccine coverage following shortages.

Estimating the costs of the vaccine supply chain and service delivery for selected districts in Kenya and Tanzania

Having data on the costs of the immunization system can provide decision-makers with information to benchmark the costs when evaluating the impact of new technologies or programmatic innovations. This paper estimated the supply chain and immunization service delivery costs and cost per dose in selected districts in Kenya and Tanzania. We also present operational data describing the supply chain and service delivery points (SDPs).To estimate the supply chain costs, we collected resource-use data for the cold chain, distribution system, and health worker time and per diems paid. We also estimated the service delivery costs, which included the time cost of health workers to provide immunization services, and per diems and transport costs for outreach sessions. Data on the annual quantities of vaccines distributed to each facility, and the occurrence and duration of stockouts were collected from stock registers. These data were collected from the national store, 2 regional and 4 district stores, and 12 SDPs in each country for 2012. Cost per dose for the supply chain and immunization service delivery were estimated.The average annual costs per dose at the SDPs were $0.34 (standard deviation (s.d.) $0.18) for Kenya when including only the vaccine supply chain costs, and $1.33 (s.d. $0.82) when including immunization service delivery costs. In Tanzania, these costs were $0.67 (s.d. $0.35) and $2.82 (s.d. $1.64), respectively. Both countries experienced vaccine stockouts in 2012, bacillus Calmette-Guérin vaccine being more likely to be stocked out in Kenya, and oral poliovirus vaccine in Tanzania. When stockouts happened, they usually lasted for at least one month.Tanzania made investments in 2011 in preparation for planned vaccine introductions, and their supply chain cost per dose is expected to decline with the new vaccine introductions. Immunization service delivery costs are a significant portion of the total costs at the SDPs.