A Shortened Supply Threatens Child Health

In July 2023, Ethiopia’s Ministry of Health (MOH) received alarming news of an unanticipated rotavirus vaccine (RVV) supply issue due to manufacturer related challenge. Without the vaccine, rotavirus, a diarrheal disease, was responsible for approximately 28,000 child deaths annually in Ethiopia prior to the introduction of the vaccine. This sudden product shortage created an urgent need for an unplanned, compulsory vaccine product switch.

 In August 2023, recognizing the remaining stock of the current vaccine, ROTARIX, would only last for up to six months, the MOH accepted the switch. The replacement product identified, ROTASIIL-Liquid (ROTASIIL), presented enormous practical implications for the tens of thousands of vaccinators and caregivers across the country. Specifically, ROTARIX uses a two-dose formula, whereas ROTASIIL requires a three-dose schedule, in packages of two doses per vial. Administering ROTASIIL meant changing from a dropper to adapter. 

Strategic Technical Support and Adaptive Systems

To facilitate the switch, JSI, with Gates Foundation support, deployed a senior immunization technical assistance provider to the MOH that closely worked with the national immunization technical working group. Additional technical assistance providers were seconded at regional level. The national immunization technical working group developed RVV switch training materials, reporting tools, and readiness assessments. RVV switch monitoring was integrated into regular immunization meetings in order to simplify coordination, enable teams to identify opportunities for integration, and leverage existing resources for a more unified rollout. A RVV training-of-trainers was rolled out, built into an already planned HPV switch and IPV2 introduction, leveraging resources and saving valuable health worker time. 

The national reporting system for all health services in Ethiopia needed revision due to ROTASIL’s three-dose schedule, while existing routine immunization recording tools (including tally sheet, registration book and vaccination cards) required re-printing to accommodate the third dose. These systems could not be finalized before the transition. The MOH implemented interim recording solutions, which included using available blank spaces in existing reporting forms. This interim reporting solution was used for about 6 months. Monthly feedback to identify and target struggling facilities and districts for on-the-job training and supervision was monitored through performance indicators collected. Virtual re-orientation, job-aids, and close follow-up helped resolve initial recording, reporting, and administration challenges.

Building a Resilient Immunization Framework

Despite the compressed timeline and complexity of the transition, the switch was executed successfully. JSI documented the success through a four-part series, The Switch Series: 

• Preparing for an Unplanned Product Switch focuses on the initial phase, detailing the strategic planning and assessments required to pivot the national program in a compressed timeline.
• Implementing the RVV Switch at Scale provides a deep dive into how technical support at national and subnational levels facilitated the physical rollout across a vast network of facilities.
• Integration Lessons from the Frontline focuses on how MOH used service integration as a core strategy, coordinating the RVV switch alongside other health interventions.
• Comprehensive Process Lessons gives an overview of the entire lifecycle of the switch and offers best practices for health systems facing unplanned product transitions.

The outcome

In the end, our collaboration ensured 98% of health facilities nationwide had successfully transitioned to ROTASIIL within four months. ROTASIIL forecasting and procurement was optimized to meet national demand without overextending the supply chain. This collaboration ultimately enabled Ethiopia to maintain and even increase rotavirus coverage from 63% in 2021 to 73% in 2024. Ultimately, Ethiopia’s experience offers a global roadmap for maintaining immunization stability through adaptive management and strategic resource optimization.