POST 00311 : ESTIMATING VACCINE WASTAGE FACTORS

Post00311 Estimating Vaccine Wastage Factors 15 January 2001 CONTENTS 1. DISCUSSION ON ESTIMATING VACCINE WASTAGE FACTORS It is important to monitor vaccine wastage in national immunization programs and to use wastage data as a routine program planning and management tool. Vaccine wastage has an important bearing on the non-salary and non-capital costs of immunization programs, and ultimately on the sustainability of routine immunization services. During 2 recent EPI assessments both it was clear to the moderator that the estimation of wastage factors AND the use/interpretation of wastage data was poorly understood by many of the international consultants and by health workers and managers. In order to improve the management of immunization program supplies and to manage program costs a simple method of estimating vaccine wastage must be in use. While it is possible to identify and quantify various causes of vaccine wastage as an aid in developing vaccine management interventions, the routine recording and reporting of disaggregated wastage data may be onerous for health workers. In discussion of wastage it is important to remember that in some settings wastage rates for some vaccines are lower than is practical or safe and may indicate poor operational practices. Pressure staff to achieve reduced wastage without using the Opened Multi-dose Vial Policy and VVM labeled vaccines may be counterproductive. In some localities DTP vaccine wastage was lower than is possible, suggesting under-dosing. Deaths in recent years from toxic shock syndrome following injection of contaminated multi-dose vials of measles vaccine retained for use past one immunization session should serve as a warning to us all. During two recent EPI assessments I've been a participant in, the estimation of vaccine wastage AND the use/interpretation of wastage data was poorly understood by many of the international consultants and by health workers and managers. * In todays posting, John Lloyd, PATH/CVP, Robert Steinglass, BASICS, Mark Weeks, DELIVER[Formerly BASICS], Alan Brooks, PATH/CVP, discuss Estimating vaccine wastage factors in response to John Lloyd's draft methodology posted below. Opinion, comments and additions please: [[email protected]][email protected][/email] or use your reply button ___________________________________________________________________________ From "John Lloyd" 11/24 I have attached my suggested text on estimating vaccine wastage rates. If anyone objects to these definitions, let them speak immediately!! All the best, John ___________________________________________________________________________ Estimating Vaccine Wastage FACTORS 1. Using National (or Subnational) Records of Doses Administered Existing language would need to be modified Formula is: Wastage factor = ((B + C) x D)/ A Where : A = the number of doses administered B = the number of vials opened for use C = the number of closed vials discarded due to cold chain failure or VVM indication D = the number of doses per vial 2. Using Stock Records Again modify the existing language. Formula would be : Wastage factor = ((B + C - D) x E)/A Where : A = the number of doses administered B = the number of usable* vials in stock at the start of the year C = the number of vials issued from the store for use D = the number of usable* vials in stock at the end of the year E = the number of doses per vial This could then be followed by a simple conversion from wastage factor to wastage rates, since people are still accustomed to report their wastage rates. * Vials of vaccine which are still permitted to be used. ___________________________________________________________________________ From: Robert Steinglass Sent: 26 November 2000 To: [[email protected]][email protected][/email]; [[email protected]][email protected][/email] Cc: [[email protected]][email protected][/email]; [[email protected]][email protected][/email]; [[email protected]][email protected][/email]; [email protected] Subject: Re: Estimating vaccine wastage John, These formula do NOT give wastage rates. Work them out. For example, you might get 300 doses administered (numerator) divided by 1000 doses opened/used/issued, but this works out arithmetically to 30%. Whereas, 700 doses were not used. Wastage should be 70%, not 30%. Also the "x100" should not appear in the denominator in either of the top two formula. Maybe that was not your intention, but that is how it looks. By the way, vaccine is often not discarded (whether frozen DPT or VVM past discard point). It hangs around until some auditor allows it to be stricken from the books. For that reason, I prefer a definition which includes the terms "usable" vaccine in stock at start of year, and "usable" vaccine in stock at the end of the year. I don't think the first definition is practical in all "points of use" as many of them do not count vials used. Then there is the issue that vials can be of different sizes. This would need to be mentioned. Robert Robert Steinglass Immunization Team Leader BASICS 1600 Wilson Blvd., Suite 300 Arlington, VA. 22209 USA voice: 1-703-312-6800 fax: 1-703-312-6900 e-mail: [[email protected]][email protected][/email] --- Date: Tue, 28 Nov 2000 From: "Robert Steinglass" To: [[email protected]][email protected][/email],[email protected], [[email protected]][email protected][/email] Cc: [[email protected]][email protected][/email],[email protected], [[email protected]][email protected][/email] Subject: RE: Estimating vaccine wastage I have attached much simplified formulas for estimating wastage factors. (I fear that the very appearance of the current formula for calculating wastage rates are correct but daunting to arithmetically- challenged staff!) Someone would still need to add the introductory sentences for each method (counting vials, or using stock records) of calculating the wastage factors, as opposed to wastage rates. It would be interesting to hear TECHNET's perspectives concerning practicalities, as they have on-the- ground experience in the NIS (and elsewhere) with the wastage factor calculations. By the way, if you decide to stick with the current formula for calculating wastage rates (not wastage factors), then I have one suggested edit to footnote C on the second method (using stock records): C = the number of vials issued from the store for use DURING THE YEAR Robert --- From: Lloyd, John Sent: Monday, November 27, 2000 To: Robert Steinglass; [[email protected]][email protected][/email] Cc: [[email protected]][email protected][/email]; Brooks, Alan; [[email protected]][email protected][/email]; [[email protected]][email protected][/email] Subject: RE: Estimating vaccine wastage Thanks very much Robert. I have attached a version which should be correct now. - the formulae are corrected, they were incorrect. - the x 100 would work at the end or the beginning, but the start may be less worrying - good idea re 'usable', although I have never seen that before - I guess that countries which monitor the number of vials discarded and opened for use, there are some, would be able to establish a more accurate wastage rate than those which do not...maybe an average over those which report? - the text already states that the formulae only relate to a single presentation of a single vaccine. Shame it is so complicated.....reduces the likelihood that anyone will make the calculation. Perhaps someone else can come up with alternatives? Thanks again Robert, Yours, John --- >>> "Brooks, Alan" 11/27 >>> John: This looks great. I've added a couple of thoughts for you: -- Suggest using "totaled" as opposed to "aggregated" - easier word. -- Since We're asking for district level coverage, why not ask for district level wastage in addition to national wastage? --Added Titles and some formatting to make it easier to read. See what you think. --Formula look correct. Depending on how this is distributed, to make it easier could add a second page with small Excel Spreadsheets embedded in the Word document where one could insert numbers for A, B, C, etc and the calculation would automatically be done. --I added a description and use of Wastage Factor. See if you think it makes it too complex. --Suggest we include a contact person if people have questions. Alan --- From: Mark Weeks Sent: 28 November 2000 To: [[email protected]][email protected][/email] Cc: [[email protected]][email protected][/email] Subject: Fwd: Re[2]: RE: Estimating vaccine wastage The measurement of vaccine usage which Kyrgyzstan and Ukraine use (perhaps other countries as well) is very simple. You merely divide the number the total doses used according to the supply records by the total number of vaccinations given according to the time period being monitored, usually a month. This gives the vaccine usage ratio of doses per vaccination (immunization). For example, if a health unit gave 20 vaccinations but records showed that 30 doses of vaccine had been used, then the vaccine usage ratio is 1.5 doses per vaccination. 20 vaccinations and 40 doses used = a ratio of 2.0 doses per immunization. In all my years working with health workers from clinic to national levels, this approach has had more impact on getting people to more fully appreciate and understand and monitor their vaccine "wastage." In Kyrgyzstan, having this clear information routinely available and visual resulted in a significant decline in vaccine "wastage." Of course one of the most important factors for getting the health workers to better focus on wastage in the above countries was that they developed the indicator themselves. It was not given to them like orders from above or as some training exercise developed in some far off land. Cheers, Mark Weeks --- From: "John Lloyd" To: "Mark Weeks" , Cc: , Subject: RE: Estimating vaccine wastage Date: Wed, 29 Nov 2000 I like the simplicity of this method, but it is not generalized outside the NIS and would take some retraining. I am also skeptical of "total doses used according.... maybe "distributed for use... might be better. The method ignores the stock at the start and the end of the period, assuming that they are the same. Simple but perhaps not correct? The method also bundles together administrative wastage of vials opened for use with cold chain wastage of closed vials. With the arrival of VVMs, we need more than ever to monitor the discard rate of closed vials due to VVM colour change. Administrative wastage should progressively be limited to freeze dried vaccine if the Opened Vial policy is brought into full use. I think that the VVMs will help make the monitoring of wastage more graphic for health workers. John --- Date: Thu, 30 Nov 2000 From: "Mark Weeks" To: [[email protected]][email protected][/email], [[email protected]][email protected][/email], [[email protected]][email protected][/email] Subject: RE: Estimating vaccine wastage Having worked in both, I can assure you that the NIS AFRO difference does not apply concerning supply management. Anyway, I'm not marketing any methodologies or entering into any geographical debates (AFRICA vs NIS). A global formula for calculating wastage factors/rates/ratios/whatever is not the critical issue. The fundamental issue is better supply management practices, which "EPI" has always neglected. Primarily because all of the emphasis for the past 25 years has been placed on vaccines and refrigerators, both of which have been for the most part available in unlimited supply from donors. If challenged and prompted, the immunization programs can figure out how to improve their supply management (including ADs with safe disposal these days), to monitor vaccines and other supplies and, ultimately, reduce their wastage. Cheers, Mw --- Date: Wed, 29 Nov 2000 From: "Robert Steinglass" To: [[email protected]][email protected][/email], [[email protected]][email protected][/email], [[email protected]][email protected][/email] Cc: [[email protected]][email protected][/email] Subject: RE: Estimating vaccine wastage John, Desegregating the types of wastage is a good idea but I do not know how practical it is. First things first. Let's encourage people to monitor wastage from all causes. Robert