AWAY WITH THE DOGMA 1 ! Closed Vial Wastage

Hi John:

Thanks for continuing the discussion post-TechNet. Vaccine Utilization rate (VUR) could be a good substitute for closed vial wastage (CVW) as a high-level indicator in systems that rely on simple reporting systems (paper in particular) at the last mile. The challenge with this is that it mixes closed and open vial wastage and prevents disaggregation. I certainly understand the disincentive for the HCW to report wastage.

However, as digital reporting systems penitrate to the last mile, and especially in situations where a vender managed inventory (VMI) system (aka "informed push" or delivery truck top-up system) is used, we can offer pre-dertermined reason codes for any reported CVW, which can mitigate the disincentive. In the VMI scenario, the data are gathered by the delivery person and not the HCW, removing the onous of self-reporting/self-incrimination of CVW at the HF.

We know that CVW has many potential causes, from poor (over) forecasting, to poor storage condidtions, to heat or freeze exposure during transport, to poor inventory management (FEFO). Enabling the HCW to report a reason for the wastage not only lifts some of the onous from the HCW, it also informs decisions about how to address the problem by getting to (or closer to) and addressing root causes of CVW. Also, it's really important to monitor CVW incidents and causes at intermediate storage levels and during transport, since that is indicative of a potentially much larger risk than CVW loss at HF level.

Finally, my preference is to keep CVW distnct from VUR in digital systems since we can then compare reported coverage at each HF with reported SKUs opened/used in order to derive and monitor true OVW on a facility-by-facility basis. This data could then inform optimization of container size for each antigen best suited to each HF's service delivery profile. As barcoding technology also gets adapted and extended to the last mile, all of this becomes not only possible, but essential for enabling iSCs to evolve to greater maturity.

I look forward to reading responses amd seeing where this discussion goes!

What an interesting discussion! I am jumping in here because I see that my first posting was misleading and possibly confusing?.

Can I try again?

Discarding closed vaccine vials is indeed an important function of vaccine stock adjustment at all stores and Health Facilities. There is no dogma to discard here. As Chris says, we should welcome a multi choice option to record the reason for discard in stock control ledgers or databases (eg. expiry, coldchain failure, breakage etc.). But, in addition to accounting for stock adjustment, this record is to flag a local investigation, a supervisory question at the site of the problem. To avoid recurrence, the truth about the cause needs to be accurate. but using the statistic as part of the performance assessment or as part of estimating vaccine needs at any level is questionable.

Where the 'Dogma' applies is in the calculation  of vaccine needs which have to take account of vaccine doses consumed, including those administered and those not administered. The consumption rate of vaccine, also called the vaccine utilisation rate (VUR) is simply the doses of vaccine used to adminster a given number of doses to the client - including doses that were 'lost' whatever' the reason. The VUR can be applied at any level, at any store that uses or distributes for use as long as the number of doses used, consumed is serving the same target population. 

The value of the VUR will vary from area to area due to many complex factors, some due to the size of immunization sessions and the choice of multi-dose vials. Targets can be set to minimize wastage but if vaccine dsitrubution follows the target, not the reported VUR, the immunization coverage may drop. So, a low VUR mamy signal the need for further investigation of vaccine wastge in particular stores visited, but cannot apply as a norm, country wide to vaccine supply.