David W Brown, Brown Consulting Group International, LLC, North Carolina, USA
Marta Gacic-Dobo, World Health Organization, Geneva, Switzerland
The WHO and UNICEF recommend that immunization programmes order and supply vaccines bundled with safe-injection equipment (e.g., diluents, auto-disable syringes, reconstitution syringes and safety boxes) to better ensure that AD syringes along with other safe-injection equipment are available together with vaccines in appropriate corresponding quantities at the point of delivery, thereby promoting overall safe injection practice . Overall, the use of bundling vaccines with safe-injection equipment appears to be a success story.
As children receive recommended immunization services necessary to be protected from vaccine-preventable diseases, it is important for healthcare workers to deliver and caregivers to keep legibly completed records of the vaccinations that the child receives, particularly given recent increases in the number of vaccinations in recommended immunization schedules and mixed results of caregiver’s ability to accurately recall their child’s vaccination history.
Home-based records (HBRs) (e.g., vaccination card, maternal/child health book) are used by health authorities alongside facility-based records, to document an individual’s vaccination history (as well as other primary care services in some countries) and as a communication and information resource to encourage a partnership in the care of the child between the healthcare worker and the caregiver. Not only do HBRs serve as a vehicle for health education to empower caregivers about which primary healthcare services have been received and those which remain outstanding, HBRs (when available and complete), also enhance health professionals’ ability to make appropriate clinical decisions (e.g., which vaccinations have been received already and which vaccinations remain outstanding) and improve continuity of care across providers in the absence of other health records and support public health monitoring efforts, such as in vaccination coverage surveys .
However, HBRs are currently unable to fulfil their intended purpose in many communities either because the HBR is not functionally well-designed to serve the needs above, not made available, not fully adopted and/or not appropriately utilized by caregivers and/or health workers. Of particular concern are the occurrence of HBR stock-outs in many countries.
According to data reported by national immunization programmes to the WHO and UNICEF, of the more than 140.2 million estimated births during 2015, roughly 9% or estimated 12.4 million children were born in 22 countries reporting a national level HBR stock-out that year. Two-thirds (or 8.3 million) of these children resided in one of 12 countries in the WHO African Region, and more than half (4.8 million) of these children resided in the Democratic Republic of Congo or Kenya. DRC along with Chad, Guinea Bissau and Venezuela has reported HBR stock-outs during 2013, 2014 and 2015. Other countries with large (>500,000) birth cohorts reporting national level stock-outs during 2015 included Philippines, Ghana, Cameroon, Malawi, Chad and Venezuela (overall, five countries reporting HBR stock-outs were from the Western Pacific Region, three from the Region of the Americas and one each from the Eastern Mediterranean and South-East Asia Regions). Two-thirds of the countries reporting HBR stock-outs during 2015 were Gavi-eligible. Information on HBR stock-outs was either not available or not reported by 53 (11 were Gavi-eligible) countries for 2015.
These HBR stock-outs are quietly occurring against a back-drop of increased attention to the immunization supply chain [3,4] and need to improve availability and use of data for decision making at all levels of the immunization programme. Unfortunately, there appears to be little attention towards exploring the root causes for why these HBR stock-outs are occurring and what practical steps can be taken to prevent them. Make no mistake, each and every one of these HBR stock-outs — not unlike stock-outs of vaccines — is an avoidable event with proper planning.
So, similar to the initial proposal for bundling AD syringes with vaccines, we propose further exploration and consideration of the bundling concept for HBRs to better ensure that HBRs are available at the point of delivery for recording of vaccines delivered. We have previously posted to TechNet to get feedback from our colleagues with expertise in market shaping for vaccines and safe-injection equipment. We reach out again to our colleagues in immunization supply chain to solicit feedback on the feasibility of implementing a bundling policy inclusive of HBRs alongside the vaccines and safe-injection equipment. We see potential benefits, but we also realize that there may be risks and practical challenges, all of which we hope to identify, understand and address. We look forward to learning from our logistician colleagues and your responses!
1. World Health Organization. Training for mid-level managers (MLM). Module 1. Cold chain, vaccines and safe-injection equipment management. Geneva, Switzerland: World Health Organization, 2008. Available online at http://whqlibdoc.who.int/hq/2008/WHO_IVB_08.01_eng.pdf Accessed 21 October 2016.
2. World Health Organization. Practical Guide for Home-based Records in Immunization Programmes. Geneva, Switzerland: World Health Organization, 2015. Available online at http://apps.who.int/iris/bitstream/10665/175905/2/WHO_IVB_15.05_eng.pdf . Accessed 21 October 2016.
3. UNICEF. Immunization Supply Chain Strengthening. October 2015. Available online at http://www.unicef.org/supply/files/1_-_iSC_Introduction_20151026.pdf . Accessed 21 October 2016.
4. Gavi, the Vaccine Alliance. Gavi Immunization Supply Chain Strategy. Available online at http://www.gavi.org/library/publications/gavi-fact-sheets/gavi-supply-chain-strategy/ . Accessed 21 October 2016.