Nigeria vaccine wastage assessment

1. Nigeria vaccine wastage assessment Expert Review Committee Meeting March 2012

2. Assessment rationale in Nigeria • 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

3. Vaccine presentation types and target wastage rates – Nigeria, 2010

4. Global vaccination policies and their relationship to wastage • 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)

5. 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.

6. Study objectives • 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

7. Study methods: Data collection activities • 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 Field data collection period: 22-26 August, 2011 Assessment partners: NPHCDA, UNICEF, WHO, CDC

8. Facility results: Low quality data for calculating wastage rates • >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

9. Facility results: Calculated wastage rates 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 HF sessions (from HF session summary forms) median wastage rate across months (from HF monthly reporting form) Note: 55 health facilities were visited in survey. Number of health facilities used in calculation of vaccine-specific wastage rate given in parentheses.

10. Facility results: Immunization policies • 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 (currentpolicy) • 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

11. Facility results: Stock management • 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

12. Facility results: Session planning & implementation • 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

13. Example : Measles vaccination • 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

14. LGA level wastage-related knowledge & practices • 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 Reported reasons for vaccine wastage by LGA immunization staff

15. Conclusions • 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

16. Recommendations • Distribute standardized forms • Review/reaffirm policies • MDVP • Vaccination age ranges • When vial is opened • Stock management training (using forms) • Microplan updation exercise including session-type assessment for villages • Assess vaccine supply • Funding availability • Sufficient doses ordered • Sufficient supply available • Account for policy decisions • Intradistrict knowledge sharing exercise (supervisor-led) • Immunization policies training (MDVP) Local level National level • Wastage training: targets, calculations, types

17. Thank You! Questions?