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  1. Michelle Seidel
  2. Vaccines and delivery technologies
  3. Tuesday, 19 February 2019

Dear Technet 21 Community,

We are glad to share the Measles and Measles-Rubella (MR) Vaccine Five-dose vial presentations Facts sheet.

This Facts Sheet informs of the availability of Measles vaccine and combined Measles-Rubella (MR) vaccine in both a 10-dose vial and a 5-dose vial presentations through (or via) UNICEF procurement. The 5-dose vial presentation has the potential of reducing open vial wastage in some country settings compared to the 10-dose vial presentation.

Please find the link : https://www.technet-21.org/en/?option=com_sobipro&sid=5050&pid=57&Itemid=2586

On behalf of UNICEF and WHO, I wish you an insightful reading and look forward to interesting and fruitful discussions with the TechNet-21 community!

Michelle Seidel

Immunization Supply Chain, Programme Division, UNICEF 

In India the MR vaccine has been supplied in 10 doses vials which is being gradually replacing 5 doses of measles after MR campaign
Kirstin Krudwig Accepted Answer

Thank you, David, for your continued interest in this work. We agree with you that there are definitely further areas to explore including more around changes in practice due to a change in DPC. In JSI's research in Zambia, we did gather monthly monitoring data to look at a change in the frequency of offering MR between facilities using 5 and 10 dose vials and were surprised to not find a difference. This differed from what we heard from HCWs who felt that they were providing vaccinations more frequently and also from the coverage survey that did show an intervention effect. Of course, this was just one piece of research and findings may be different in another setting. 

In addition to the resources which will be shared on TechNet shortly, I'd like to mention that our finished case studies are available at: www.jsi.com/dpcp

David Brown Accepted Answer

Thank you, Wendy. Great info and look forward to seeing the DPCP results in the coming weeks.

On HCW behaviour, it would be great if DPCP can be supported (if this is not already built in) to check back with HCWs to observe whether their stated willingness translates into short-term and long-term actual change in their practices with respect to opening the vial consistent with policy. As we all know, to say it is one thing, to translate into practice is often quite another. I hope the funder will allow a thoughtful Phase 2 for DPCP.

On vial size tailoring, I am hopeful efforts will continue to better understand and address the concerns of national EPI and HCWs rather than allowing the story to end there. Surely the saga will continue, perhaps in practical case studies tied to application of the decision making resource guide for multi-dose vial presentation. 

Hopefully DPCP will continue on as a stream of work for the purposes of replication studies and continuted knowledge generation. I expect the DPCP team would agree that you have only scratched the surface in spite of the immense amount fo work that has been put in already.

Wendy Prosser Accepted Answer

These are great questions, David. It is great to see the availability of 5-dose measles and MR as it could address many concerns about wastage and missed opportunities to vaccinate that have been expressed over the years. 

You are correct that the Dose Per Container Partnership (www.jsi.com/dpcp) has been looking into these questions. All resources and research results will be available on TechNet in the next weeks, but a few thoughts and responses to your questions here:

  1. Vocabulary: The term 'wastage' does have a negative connotation for healthcare workers. What about "vaccine utilization rate" instead of wastage? It's a different way of looking at it but may provide a different perspective.
  2. HCW behavior: In Zambia, as part of DPCP, we have just finished a study looking at the impact of introducing 5-dose MR instead of 10-dose MR. HCWs reported that with 10-dose measles or MR, they would typically wait until at least 5 children were present before opening a vial in order to reduce wastage (or improve vaccine utilization). This was similarly noted in Senegal. And in both cases, the MOH policy states a vial should be opened for every child, yet the reality of high wastage or fear of stockout drives a different practice. After the introduction of 5-dose MR in Zambia, HCWs reported they were willing to open a vial for every child. 
  3. Introduction of 5-dose: As mentioned, the study in Zambia was recently finalized, as well as DPCP research from other countries documenting the decision making process for vial size as well as the impact of different vial sizes on coverage (including timeliness), wastage, safety, cost, supply chain, and HCW behavior. Results showed that MCV1 coverage increased by 3 percentage points and MCV2 by 10 percentage points, while wastage decreased from 31% with 10 dose vials to 16% with 5 dose vials. The final report will be available shortly.
  4. Tailoring vial size: One area of research in the DPCP was determining the level of interest in multiple vial sizes in order to tailor to session size or urban/rural settings. Modeling showed there would be financial benefits to this approach (in terms of less doses required for procurement), but there were concerns from national level EPI as well as HCWs on the actual implementation of this approach.

DPCP has developed a Decision Making Resource Guide to help decision makers consider the different trade-offs related to presentation. As I mentioned, it will be available in the next couple of weeks. And for those going to the EPI Manager's Meeting in Eritrea at the end of March, the full results of the Zambia study will be presented as well as the Decision Making Resource Guide.

It's great to see this conversation. I look forward to other contributions.

Wendy (and the DPCP team)

 

David Brown Accepted Answer

Thank you for this information. Very useful.

In parallel, what activities are ongoing towards addressing the following (anyone with an answer should jump in, please):

1. Let us please change the vocabulary for the new generations of healthcare workers that are coming into service (as well as trying to change the mindset of current HCWs). We messed up from the beginning by allowing use of the term "open vial wastage" to prevail, and it continues. I much prefer reference to "sacrificed vaccine doses", but I recognize that this may not resonate in all settings. Perhaps a vocabulary change can help address the negative stigma attached to "sacrificing" vaccine doses (whether that be 9 in a 10 dose vial or 4 in a 5 dose vial).

2. What are the results of behavioural change intervention studies with regards to re-orienting HCW mindset that "sacrificing" vaccine doses (perhaps, within some reasonable bounds over time) is in fact part of good performance practice? Sharing these results alongside the factsheet would also be useful. If the results of these studies are mixed or fall short in rigor, then let's highlight this too.

3. Has anyone conducted any studies on the short-, medium- and long-term practical effect(s) of introducing a 5-dose vial into communities that have been using 10-dose vials? I thought this had been done as part of the Dose Per Container Partnership (DPCP) activities, but there is no reference to these in the fact sheets (or, perhaps I missed the reference). To really test the influence, a case crossover study would introduce the 5-dose vial size into a community currently using 10-dose vial size, observe HCW behaviour and then remove the 5-dose vial size with a revert to 10-dose vial size to see if HCW behaviour has indeed been influenced or whether HCWs return to old habits.

4. Is there a reason that tailoring or targeting the use of 5-dose vials is not mentioned in the factsheet? Again, I thought the DPCP had explored this area, but perhaps those results are still being reviewed.

Cheers.



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