Supplying the vaccine

18 World Health • 48th Yeor, No. 1, Jonuary-Februory 1995 Supplying the vaccine David Halliday & Julie Milstien To ensure that vaccines ore available for both routine and supplemental needs, WHO and UNICEF ore exploring new procurement strategies, new suppliers, better forecasting and planning, and improvements to the vaccine. Large shipments of vaccine arriving at a distribution centre in A frica . 5 ince the Expanded Programme on Immunization began in 1974, oral poliomyelitis vaccine (OPV) has been given to millions of children around the world. UNICEF's vast supply system has procured and delivered over 2500 million doses of OPV to more than 100 developing countries in the Americas, Africa, Asia, and the Middle East, helping to immunize over 100 million children each year. Besides supplying the vaccine, UNICEF has worked with WHO to ensure that vaccine arrives safely at the health centre. The vaccine "cold chain" is a logistics system to keep the vaccine cold from the moment it is bottled until it is finally given to a child. The UNICEF Supply Division and WHO have standardized both the vaccine and the cold chain equip- ment specifications. Because of this coordination, all OPV purchased through UNICEF is of guaranteed quality and can be maintained in tested, approved equipment. The standardized dosage and model wording for leaflets and labels have also made possible the interchange- able use of vaccine from different manufacturers. The polio eradication goal calls for huge amounts of OPV to be delivered through routine and supplemental strategies. Routine strategies use OPV in a predictable fashion throughout the year. National immunization days are re- garded as a supplemental strategy and are intended to deliver OPV simultaneously over a wide epi- demiological area, so it is critical to have large quantities of vaccine available at a particular moment. Since national immunization days might require tens of millions of doses of OPV at a time- China recently delivered 83 million doses of OPV in one day- the need for advance planning is clear. To ensure that vaccines are available for both routine and supplemental needs, WHO and UNICEF are exploring new procurement strategies, new suppliers, better forecasting and planning, and improvements to the vaccine. Procurement strategies To ensure a steady vaccine supply, UNICEF periodically evaluates and modifies its procurement strategies. For example, to meet a large increase in demand for vaccines after 1985, UNICEF lengthened to two years its period for receiving price tenders so as to enable manufacturers to plan better for these volumes. The two- year tendering process provided producers with a reasonable assurance of demand during the next two to four years. UNICEF is currently discussing new procurement strategies with its suppliers. For example, a five-year tender period may encourage manu- facturers to invest in additional capacity or to lower their prices. New suppliers Although much of the world 's supply World Health • 48th Year, No. l, Jonuory-Februory 1995 From the producer's premises to the vaccination posts, polio vaccine has to be transported under refr1gerated cond1t1ons. of OPV is purchased from five major suppliers located in the industrialized world, local production of vaccines meets the need in several large devel- oping countries. For OPV, about half of the vaccine used is manufactured within the country of use. But many countries are not making enough vaccine locally to meet their needs, and the supply must be supplemented in some other way. One method of doing this is called production shar- ing: the importation of bulk vaccine which is mixed and filled into vials in the country. Countries such as India, Egypt, Pakistan and Brazil thus use their local resources and in- dustry while still optimizing capacity and quality. Working with UNICEF and WHO, countries and the indus- trial producers of bulk OPV have entered into contracts which faci li- tate this process. Forecasting and planning When the EPI began, the emphasis was on getting as much vaccine as possible to the children who needed it. Strategies for ordering and deliv- ering vaccines were not focused on economy. However, as the demand increased, it became clear that better planning was needed. Not only must UNICEF pay more for vaccines bought at the last minute, but inaccu- rate forecasts tend to damage the relationship and confidence existing between UNICEF and the manufac- turers. WHO and UNICEF are developing new tools to assist coun- tries to make accurate forecasts. In future, countries will be rewarded for better planning. Vaccine vial indicators Vaccine wastage- the amount of vaccine which is delivered to the im- munization centre but is unused and thrown away at the end of the day- has become a serious concern as greater attention is focused on vac- cine supply. Traditionally, discard- ing unused vaccine at the end of the session was recommended to ensure that the fragile vaccine was not com- promised by exposure to too much heat. Vaccine wastage can be as high as 50% of the supply in some circumstances. The search is continu- ing for vaccine which will retain its potency at high temperature for a longer period of time. This increased stability, combined with the use of new time-temperature indicators, will let the health worker know whether vaccine still left in the vac- cine vial has received an excessive exposure to heat. Paying for the vaccine While OPV is not very expensive- about US$ 0.08 a dose at current prices - other factors have an impact on the price. More than 20% of the cost of the delivered vaccine is the cost of air freight to get the vaccine from the manufacturer to the starting-point of the country's cold chain. Providing two extra doses every year for each child under five 19 years of age adds considerably to the immunization budget available to a country. Many countries have found it too expensive to launch polio eradication activities. Rotary International has been a major donor, with UNICEF, of polio vaccine for the eradication initiative, and many bilateral donors have also been involved in vaccine purchase. But donations alone are not the answer. An important change in the polio eradication effort has been that governments are beginning to plan more carefully and take more responsibility for funding their own vaccine needs, rather than relying on donors. Governments are developing stronger, more sustainable systems for vaccine supply, procurement and production which will assure the availability of high quality vaccine. These efforts will increase the governments' ability to obtain not only OPV but all vaccines, even long after polio has disappeared as a global threat. • Mr David Halliday is Director, Supply Division, UNICEF, Unicef Plods, Freeport, 2 l 00 Copenhagen, Denmark, and Or julie Milstien is Scientist, Global Programme for Vaccines, World Health Organization, I 21 I Geneva 27, Switzerland. Other members of the WHO/UNICEF Vaccine Supply Team who contributed to the article are Mr Peter Evans and Ms Amie Batson, of the same WHO pro- gramme, and Or Terrel Hill, Principal Advisor, CSU Program Division, UNICEF, 3 United Nations Plaza, New York, NY I 00 17, USA. Supplying every individual child with the vaccine is the key to polio eradication.