5-dose vials of measles vaccine for routine immunization programs?

Rationale for introducing 5-dose vials of measles vaccine for routine immunization programs. Robert Steinglass of JSI/MCHIP challenges each of us to give our opinion on our preferences for measles vaccine vial size. At the just-completed Measles Partnership Annual Meeting at the American Red Cross (September 13-14, 2011) in Washington, DC, several speakers stressed the need to do things better for more effective measles mortality control and eventual measles elimination. We were encouraged to examine what we have become accustomed to doing to see if we can do it better. The EPI managers and health workers that I have met over a long career have consistently stated their preference that measles vaccine for routine programs should have fewer than 10 doses per vial, since the reconstituted vaccine must be discarded after six hours or at the end of the session, whichever comes first. At all levels, health staff point to the disconnect between the stated policy of opening a vial even for one child and the reality that they do not receive enough vaccine to operationalize that policy. A health worker who does open vials for just a few children will certainly run out of vaccine before the next supply. And they may be blamed for high wastage. The MOH or its partners would have to supply much more vaccine to support the policy. As a result, it is common to see all vaccines except measles in use at routine sessions. We often blame hard-working health workers for not following the policy of opening a vial for even one child. But can’t those of us in senior positions identify simpler solutions to make their difficult job easier? Making measles vaccine available in 5-dose vials would help to overcome the psychological barrier that health workers face when considering whether or not to open a vial for just one or a few children. What are the consequences of the current supply policy? The investigation of the current Zanzibar measles outbreak concludes that “Most children missed the measles vaccine because health workers are worried of wastage.” This is not the first time that we have heard this. Use of 5-dose measles vials would lead to higher and more timely measles vaccination coverage, reduced mortality, and less vaccine wastage. Would that benefit be worth the extra cost per dose of the monovalent measles vaccine (from about 22 cents to about 30 cents) and the possible extra cost of cold chain storage owing to a doubling of storage volume per dose? Most discouraging is that, after over 30 years of immunization operations, we still don’t know the answers to these relatively simple questions? And would other operational issues and non-vaccine health system costs associated with such a change be so difficult to solve? Under what conditions should 10-dose vaccine continue to be used? The vaccine is available. Five-dose monovalent measles vaccine from at least one manufacturer has been pre-qualified by WHO since 1993 and 5-dose MR (measles-rubella) since 2000. It is interesting that India, whose vaccine manufacturers export the great majority of measles vaccine supplied worldwide by the UNICEF Supply Division – all of it in 10-dose vials – has itself been using 5-dose vials domestically for at least a decade. There is a lot of welcome focus now on preferred presentations, formulations and packaging of newer, more expensive vaccines. We should also consider the preferred presentation of an older vaccine like measles. What is the policy pathway to make monovalent measles vaccine available in 5-dose vials? Does it require gathering evidence? (How much evidence went into the decision to present it in 10-dose vials in the first place?) And do we need a better feedback loop to learn how to support country programs better?[/size] Robert Steinglass Immunization Senior Advisor, JSI/MCHIP, Washington, DC