Measles/measles-rubella vial optimisation (10-dose to 5-dose) for routine immunization: Resources for switch decision-making and implementation

Healthcare workers (HCWs) may be hesitant to open measles and measles-rubella (MR) 10-dose vaccine vials during routine immunization (RI) due to concerns about vaccine wastage or future stockouts. This hesitation can lead to missed opportunities to vaccinate, including turning caregivers away unless a minimum number of children are present for a session. Transitioning to a 5-dose measles/MR vial reduces this barrier by enabling smaller, more frequent vaccination sessions and increasing overall coverage.

While specific steps vary by country context, most countries follow a common set of core phases to successfully implement the transition to the 5-dose vial presentation for RI:

1. Switch assessment and decision-making
2. Development of tools and guidance
3. Socialization and health worker training
4. Logistical and system readiness
5. Implementation, monitoring, and evaluation

This page provides resources tailored for each phase of the switch process. It is designed to assist national decision-makers, EPI teams, and technical partners in planning and implementing the switch effectively. Across all phases, the focus is on deliberate planning, strengthening routine immunization systems, improving data quality, building health-worker capacity, and ensuring a smooth and successful transition.

Lessons learned from the 5-dose switch can also inform broader immunization optimization efforts in countries (e.g., transitioning from pentavalent vaccine + IPV to hexavalent vaccines, from yellow fever 10-dose to 5-dose vials, switching rotavirus vaccine products, and adjusting PCV and HPV dosing schedules).

Phase 1: Switch Assessment and Decision-Making

In Phase 1, EPI teams assess whether introducing the 5-dose measles/MR vial is an appropriate and cost-effective intervention within their immunization context and priorities. Using routine data and decision-support tools, countries examine the drivers of coverage gaps and compare expected impacts across coverage, wastage, cold chain capacity, supply needs, and program costs. Findings are reviewed with national decision-makers and aligned with immunization strategies to determine whether and when to implement the switch.

Key outputs of this phase include:

• A data-informed assessment comparing 10-dose and 5-dose vial options
• A clear understanding of programmatic, logistical, and cost implications
• Stakeholder alignment on the decision and timing of the switch

Phase 2: Tools and Guidance Development

In Phase 2, countries use the lead time before product delivery to prepare immunization systems for effective implementation of the 5-dose measles/MR vial. National policies, guidance, and tools are updated to clearly communicate the rationale for the switch, reinforce open-vial practices, and provide practical instructions for health workers. The goal is to ensure service delivery, stock management, supervision, and monitoring systems are fully aligned before the product reaches facilities.

Key outputs of this phase include:

• Updated national policies and guidance reflecting the 5-dose presentation and correct use
• Formal notifications and communication materials to inform and prepare stakeholders at all levels
• Revised stock management, recording, and reporting tools (e.g., stock cards, tally sheets, order forms, DHIS2)
• Updated session-planning guidance to support more frequent and flexible service delivery
• Supervisory checklists and job aids to reinforce adherence to revised policies and procedures

Adapted monitoring and evaluation tools to track early switch indicators

Phase 3: Socialization and Health Worker Training

In Phase 3, countries equip health workers and supervisors with the knowledge, confidence, and practical skills to correctly implement the 5-dose measles/MR vial. Socialization and training are integrated into existing platforms and focus on consistent application of open-vial policy, vaccinating every eligible child, and accurate stock management. Supportive supervision and refresher activities reinforce key messages and translate updated guidance into sustained facility-level practice.

Key outputs of this phase include:

• Standardized training packages covering the rationale, benefits, and operational implications of the switch
• Scenario-based learning and practical exercises grounded in real service delivery contexts
• Job aids and visual materials to support correct use (e.g., vial and diluent differentiation)
• Cascade training implementation (national → regional → district → facility) to ensure consistent reach
• Supportive supervision, real-time problem-solving, and accountability through district review mechanisms
• Planned refresher sessions and targeted follow-up for facilities with persistent gaps

Phase 4: System Readiness

In Phase 4, countries align logistics, supply management, and service delivery systems to ensure a smooth transition to the 5-dose measles/MR vial. The focus is on confirming delivery timelines, sequencing distribution, and coordinating across levels to minimize disruption. Real-time stock visibility and close supervision are critical to prevent stockouts, avoid misuse, and maintain uninterrupted vaccine availability.

Key outputs of this phase include:

• Confirmed delivery timelines and distribution plans for 5-dose vials
• Clear SOPs for 10-dose stock depletion, ordering thresholds, and transition-period practices
• Sequenced distribution to minimize overlap and wastage of remaining 10-dose stock
• Enhanced supervisory support at district and facility levels during the transition

Phase 5: Implementation Monitoring and Evaluation

In Phase 5, countries monitor early implementation of the 5-dose measles/MR vial and use data to strengthen performance and guide ongoing adjustments. A targeted set of early indicators is tracked to assess adherence to updated policies, service delivery performance, wastage, and stock availability. As implementation matures, post-switch assessments help identify system-wide effects, inform corrective actions, and support longer-term optimization of ordering and supply planning.

Key outputs of this phase include:

• Monitoring of early implementation indicators aligned with national M&E frameworks (i.e., tracking compliance with open-vial policy and updated session-planning guidance; analysis of MR coverage, timeliness, MOVs, and dropout rates [e.g., between MR1 and MR2]; and wastage monitoring disaggregated by vial presentation)
• Ongoing assessment of stock availability and resupply intervals
• Use of wastage and usage data to refine dose ordering and improve system efficiency over time
• Post-switch assessment findings to inform targeted improvements and longer-term strategy