1. Expert Review Committee Meeting March 2012

2.  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 Number of doses per vial Type Target wastage rate BCG 20lyophilized30% OPV 20liquid15% DTP 10liquid15% Hep B 10liquid15% Measles 10lyophilized30% Yellow Fever 10liquid15% TT 10liquid15%

4.  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. 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.  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.  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.  >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. 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)

10.  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

11.  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.  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.  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. 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

15.  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. Local levelNational 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)

17. Questions?